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Obamacare Monroe County, TN

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Obamacare 2023 Rates for Monroe County

Obamacare > Rates > Tennessee > Monroe 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 Monroe County, TN.

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, 93 Plans and 2023 Rates for Monroe County, Tennessee

Below, you’ll find a summary of the 93 plans for Monroe County, Tennessee 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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BlueCross BlueShield of Tennessee

Local: 1-423-535-5600 | Toll Free: 1-800-565-9140

Toc - Plan #1 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B07S HSA + Free Preventive Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 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 		$357.34
$405.58
$456.68
$638.21
$969.82 		$630.71
$678.95
$730.05
$911.58 		$904.08
$952.32
$1,003.42
$1,184.95 		$1,177.45
$1,225.69
$1,276.79
$1,458.32 		$273.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.68
$811.16
$913.36
$1,276.42
$1,939.64 		$988.05
$1,084.53
$1,186.73
$1,549.79 		$1,261.42
$1,357.90
$1,460.10
$1,823.16 		$1,534.79
$1,631.27
$1,733.47
$2,096.53 		$273.37
Toc - Plan #2 BlueCross BlueShield of Tennessee
Bronze

(EPO) Bronze B08S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321.34
$364.72
$410.67
$573.91
$872.12 		$567.17
$610.55
$656.50
$819.74 		$813.00
$856.38
$902.33
$1,065.57 		$1,058.83
$1,102.21
$1,148.16
$1,311.40 		$245.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.68
$729.44
$821.34
$1,147.82
$1,744.24 		$888.51
$975.27
$1,067.17
$1,393.65 		$1,134.34
$1,221.10
$1,313.00
$1,639.48 		$1,380.17
$1,466.93
$1,558.83
$1,885.31 		$245.83
Toc - Plan #3 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B10S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$6,600 $13,200 Annual Deductible
$8,150 $16,300 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 		$351.79
$399.28
$449.59
$628.30
$954.76 		$620.91
$668.40
$718.71
$897.42 		$890.03
$937.52
$987.83
$1,166.54 		$1,159.15
$1,206.64
$1,256.95
$1,435.66 		$269.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$703.58
$798.56
$899.18
$1,256.60
$1,909.52 		$972.70
$1,067.68
$1,168.30
$1,525.72 		$1,241.82
$1,336.80
$1,437.42
$1,794.84 		$1,510.94
$1,605.92
$1,706.54
$2,063.96 		$269.12
Toc - Plan #4 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B07L HSA + Free Preventive Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 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 		$306.39
$347.75
$391.57
$547.21
$831.54 		$540.78
$582.14
$625.96
$781.60 		$775.17
$816.53
$860.35
$1,015.99 		$1,009.56
$1,050.92
$1,094.74
$1,250.38 		$234.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.78
$695.50
$783.14
$1,094.42
$1,663.08 		$847.17
$929.89
$1,017.53
$1,328.81 		$1,081.56
$1,164.28
$1,251.92
$1,563.20 		$1,315.95
$1,398.67
$1,486.31
$1,797.59 		$234.39
Toc - Plan #5 BlueCross BlueShield of Tennessee
Bronze

(EPO) Bronze B08L Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$275.53
$312.73
$352.13
$492.10
$747.79 		$486.31
$523.51
$562.91
$702.88 		$697.09
$734.29
$773.69
$913.66 		$907.87
$945.07
$984.47
$1,124.44 		$210.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.06
$625.46
$704.26
$984.20
$1,495.58 		$761.84
$836.24
$915.04
$1,194.98 		$972.62
$1,047.02
$1,125.82
$1,405.76 		$1,183.40
$1,257.80
$1,336.60
$1,616.54 		$210.78
Toc - Plan #6 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B13S 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$374.00
$424.49
$477.97
$667.96
$1,015.04 		$660.11
$710.60
$764.08
$954.07 		$946.22
$996.71
$1,050.19
$1,240.18 		$1,232.33
$1,282.82
$1,336.30
$1,526.29 		$286.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748.00
$848.98
$955.94
$1,335.92
$2,030.08 		$1,034.11
$1,135.09
$1,242.05
$1,622.03 		$1,320.22
$1,421.20
$1,528.16
$1,908.14 		$1,606.33
$1,707.31
$1,814.27
$2,194.25 		$286.11
Toc - Plan #7 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B13L 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$320.68
$363.97
$409.83
$572.73
$870.33 		$566.00
$609.29
$655.15
$818.05 		$811.32
$854.61
$900.47
$1,063.37 		$1,056.64
$1,099.93
$1,145.79
$1,308.69 		$245.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.36
$727.94
$819.66
$1,145.46
$1,740.66 		$886.68
$973.26
$1,064.98
$1,390.78 		$1,132.00
$1,218.58
$1,310.30
$1,636.10 		$1,377.32
$1,463.90
$1,555.62
$1,881.42 		$245.32
Toc - Plan #8 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B10L Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$6,600 $13,200 Annual Deductible
$8,150 $16,300 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 		$301.64
$342.36
$385.50
$538.73
$818.65 		$532.39
$573.11
$616.25
$769.48 		$763.14
$803.86
$847.00
$1,000.23 		$993.89
$1,034.61
$1,077.75
$1,230.98 		$230.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.28
$684.72
$771.00
$1,077.46
$1,637.30 		$834.03
$915.47
$1,001.75
$1,308.21 		$1,064.78
$1,146.22
$1,232.50
$1,538.96 		$1,295.53
$1,376.97
$1,463.25
$1,769.71 		$230.75
Toc - Plan #9 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B14S $70 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$326.97
$371.11
$417.87
$583.97
$887.40 		$577.10
$621.24
$668.00
$834.10 		$827.23
$871.37
$918.13
$1,084.23 		$1,077.36
$1,121.50
$1,168.26
$1,334.36 		$250.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.94
$742.22
$835.74
$1,167.94
$1,774.80 		$904.07
$992.35
$1,085.87
$1,418.07 		$1,154.20
$1,242.48
$1,336.00
$1,668.20 		$1,404.33
$1,492.61
$1,586.13
$1,918.33 		$250.13
Toc - Plan #10 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B14L $70 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$280.35
$318.20
$358.29
$500.71
$760.87 		$494.82
$532.67
$572.76
$715.18 		$709.29
$747.14
$787.23
$929.65 		$923.76
$961.61
$1,001.70
$1,144.12 		$214.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560.70
$636.40
$716.58
$1,001.42
$1,521.74 		$775.17
$850.87
$931.05
$1,215.89 		$989.64
$1,065.34
$1,145.52
$1,430.36 		$1,204.11
$1,279.81
$1,359.99
$1,644.83 		$214.47
Toc - Plan #11 BlueCross BlueShield of Tennessee
Bronze

(EPO) Bronze B15S + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$318.12
$361.07
$406.56
$568.16
$863.38 		$561.48
$604.43
$649.92
$811.52 		$804.84
$847.79
$893.28
$1,054.88 		$1,048.20
$1,091.15
$1,136.64
$1,298.24 		$243.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.24
$722.14
$813.12
$1,136.32
$1,726.76 		$879.60
$965.50
$1,056.48
$1,379.68 		$1,122.96
$1,208.86
$1,299.84
$1,623.04 		$1,366.32
$1,452.22
$1,543.20
$1,866.40 		$243.36
Toc - Plan #12 BlueCross BlueShield of Tennessee
Bronze

(EPO) Bronze B15L + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$272.77
$309.59
$348.60
$487.17
$740.30 		$481.44
$518.26
$557.27
$695.84 		$690.11
$726.93
$765.94
$904.51 		$898.78
$935.60
$974.61
$1,113.18 		$208.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$545.54
$619.18
$697.20
$974.34
$1,480.60 		$754.21
$827.85
$905.87
$1,183.01 		$962.88
$1,036.52
$1,114.54
$1,391.68 		$1,171.55
$1,245.19
$1,323.21
$1,600.35 		$208.67
Toc - Plan #13 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S01S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$458.50
$520.40
$585.96
$818.88
$1,244.37 		$809.25
$871.15
$936.71
$1,169.63 		$1,160.00
$1,221.90
$1,287.46
$1,520.38 		$1,510.75
$1,572.65
$1,638.21
$1,871.13 		$350.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.00
$1,040.80
$1,171.92
$1,637.76
$2,488.74 		$1,267.75
$1,391.55
$1,522.67
$1,988.51 		$1,618.50
$1,742.30
$1,873.42
$2,339.26 		$1,969.25
$2,093.05
$2,224.17
$2,690.01 		$350.75
Toc - Plan #14 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S04S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$6,200 $12,400 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 		$452.34
$513.41
$578.09
$807.88
$1,227.65 		$798.38
$859.45
$924.13
$1,153.92 		$1,144.42
$1,205.49
$1,270.17
$1,499.96 		$1,490.46
$1,551.53
$1,616.21
$1,846.00 		$346.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.68
$1,026.82
$1,156.18
$1,615.76
$2,455.30 		$1,250.72
$1,372.86
$1,502.22
$1,961.80 		$1,596.76
$1,718.90
$1,848.26
$2,307.84 		$1,942.80
$2,064.94
$2,194.30
$2,653.88 		$346.04
Toc - Plan #15 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S23S 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$449.30
$509.96
$574.21
$802.45
$1,219.40 		$793.01
$853.67
$917.92
$1,146.16 		$1,136.72
$1,197.38
$1,261.63
$1,489.87 		$1,480.43
$1,541.09
$1,605.34
$1,833.58 		$343.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.60
$1,019.92
$1,148.42
$1,604.90
$2,438.80 		$1,242.31
$1,363.63
$1,492.13
$1,948.61 		$1,586.02
$1,707.34
$1,835.84
$2,292.32 		$1,929.73
$2,051.05
$2,179.55
$2,636.03 		$343.71
Toc - Plan #16 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S23L 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$385.24
$437.25
$492.34
$688.04
$1,045.54 		$679.95
$731.96
$787.05
$982.75 		$974.66
$1,026.67
$1,081.76
$1,277.46 		$1,269.37
$1,321.38
$1,376.47
$1,572.17 		$294.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.48
$874.50
$984.68
$1,376.08
$2,091.08 		$1,065.19
$1,169.21
$1,279.39
$1,670.79 		$1,359.90
$1,463.92
$1,574.10
$1,965.50 		$1,654.61
$1,758.63
$1,868.81
$2,260.21 		$294.71
Toc - Plan #17 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S04L Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$6,200 $12,400 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 		$387.85
$440.21
$495.67
$692.70
$1,052.62 		$684.56
$736.92
$792.38
$989.41 		$981.27
$1,033.63
$1,089.09
$1,286.12 		$1,277.98
$1,330.34
$1,385.80
$1,582.83 		$296.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.70
$880.42
$991.34
$1,385.40
$2,105.24 		$1,072.41
$1,177.13
$1,288.05
$1,682.11 		$1,369.12
$1,473.84
$1,584.76
$1,978.82 		$1,665.83
$1,770.55
$1,881.47
$2,275.53 		$296.71
Toc - Plan #18 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S01L Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.13
$446.20
$502.42
$702.13
$1,066.95 		$693.87
$746.94
$803.16
$1,002.87 		$994.61
$1,047.68
$1,103.90
$1,303.61 		$1,295.35
$1,348.42
$1,404.64
$1,604.35 		$300.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.26
$892.40
$1,004.84
$1,404.26
$2,133.90 		$1,087.00
$1,193.14
$1,305.58
$1,705.00 		$1,387.74
$1,493.88
$1,606.32
$2,005.74 		$1,688.48
$1,794.62
$1,907.06
$2,306.48 		$300.74
Toc - Plan #19 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S24S $35 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,150 $10,300 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.36
$477.11
$537.22
$750.76
$1,140.86 		$741.94
$798.69
$858.80
$1,072.34 		$1,063.52
$1,120.27
$1,180.38
$1,393.92 		$1,385.10
$1,441.85
$1,501.96
$1,715.50 		$321.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.72
$954.22
$1,074.44
$1,501.52
$2,281.72 		$1,162.30
$1,275.80
$1,396.02
$1,823.10 		$1,483.88
$1,597.38
$1,717.60
$2,144.68 		$1,805.46
$1,918.96
$2,039.18
$2,466.26 		$321.58
Toc - Plan #20 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S24L $35 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,150 $10,300 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.43
$409.09
$460.63
$643.73
$978.21 		$636.16
$684.82
$736.36
$919.46 		$911.89
$960.55
$1,012.09
$1,195.19 		$1,187.62
$1,236.28
$1,287.82
$1,470.92 		$275.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.86
$818.18
$921.26
$1,287.46
$1,956.42 		$996.59
$1,093.91
$1,196.99
$1,563.19 		$1,272.32
$1,369.64
$1,472.72
$1,838.92 		$1,548.05
$1,645.37
$1,748.45
$2,114.65 		$275.73
Toc - Plan #21 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S25S $45 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$431.70
$489.98
$551.71
$771.02
$1,171.63 		$761.95
$820.23
$881.96
$1,101.27 		$1,092.20
$1,150.48
$1,212.21
$1,431.52 		$1,422.45
$1,480.73
$1,542.46
$1,761.77 		$330.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.40
$979.96
$1,103.42
$1,542.04
$2,343.26 		$1,193.65
$1,310.21
$1,433.67
$1,872.29 		$1,523.90
$1,640.46
$1,763.92
$2,202.54 		$1,854.15
$1,970.71
$2,094.17
$2,532.79 		$330.25
Toc - Plan #22 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S25L $45 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$370.15
$420.12
$473.05
$661.09
$1,004.59 		$653.31
$703.28
$756.21
$944.25 		$936.47
$986.44
$1,039.37
$1,227.41 		$1,219.63
$1,269.60
$1,322.53
$1,510.57 		$283.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.30
$840.24
$946.10
$1,322.18
$2,009.18 		$1,023.46
$1,123.40
$1,229.26
$1,605.34 		$1,306.62
$1,406.56
$1,512.42
$1,888.50 		$1,589.78
$1,689.72
$1,795.58
$2,171.66 		$283.16
Toc - Plan #23 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,350 $12,700 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 		$548.61
$622.67
$701.12
$979.82
$1,488.93 		$968.30
$1,042.36
$1,120.81
$1,399.51 		$1,387.99
$1,462.05
$1,540.50
$1,819.20 		$1,807.68
$1,881.74
$1,960.19
$2,238.89 		$419.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,097.22
$1,245.34
$1,402.24
$1,959.64
$2,977.86 		$1,516.91
$1,665.03
$1,821.93
$2,379.33 		$1,936.60
$2,084.72
$2,241.62
$2,799.02 		$2,356.29
$2,504.41
$2,661.31
$3,218.71 		$419.69
Toc - Plan #24 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G06L $35 PCP Copay + Free Telehealth + Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,350 $12,700 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 		$470.39
$533.89
$601.16
$840.12
$1,276.64 		$830.24
$893.74
$961.01
$1,199.97 		$1,190.09
$1,253.59
$1,320.86
$1,559.82 		$1,549.94
$1,613.44
$1,680.71
$1,919.67 		$359.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$940.78
$1,067.78
$1,202.32
$1,680.24
$2,553.28 		$1,300.63
$1,427.63
$1,562.17
$2,040.09 		$1,660.48
$1,787.48
$1,922.02
$2,399.94 		$2,020.33
$2,147.33
$2,281.87
$2,759.79 		$359.85
Toc - Plan #25 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G08S $30 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$542.23
$615.43
$692.97
$968.42
$1,471.61 		$957.04
$1,030.24
$1,107.78
$1,383.23 		$1,371.85
$1,445.05
$1,522.59
$1,798.04 		$1,786.66
$1,859.86
$1,937.40
$2,212.85 		$414.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,084.46
$1,230.86
$1,385.94
$1,936.84
$2,943.22 		$1,499.27
$1,645.67
$1,800.75
$2,351.65 		$1,914.08
$2,060.48
$2,215.56
$2,766.46 		$2,328.89
$2,475.29
$2,630.37
$3,181.27 		$414.81
Toc - Plan #26 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G08L $30 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$464.93
$527.70
$594.18
$830.36
$1,261.82 		$820.60
$883.37
$949.85
$1,186.03 		$1,176.27
$1,239.04
$1,305.52
$1,541.70 		$1,531.94
$1,594.71
$1,661.19
$1,897.37 		$355.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.86
$1,055.40
$1,188.36
$1,660.72
$2,523.64 		$1,285.53
$1,411.07
$1,544.03
$2,016.39 		$1,641.20
$1,766.74
$1,899.70
$2,372.06 		$1,996.87
$2,122.41
$2,255.37
$2,727.73 		$355.67
Toc - Plan #27 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B16S $50 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$349.19
$396.33
$446.26
$623.65
$947.70 		$616.32
$663.46
$713.39
$890.78 		$883.45
$930.59
$980.52
$1,157.91 		$1,150.58
$1,197.72
$1,247.65
$1,425.04 		$267.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.38
$792.66
$892.52
$1,247.30
$1,895.40 		$965.51
$1,059.79
$1,159.65
$1,514.43 		$1,232.64
$1,326.92
$1,426.78
$1,781.56 		$1,499.77
$1,594.05
$1,693.91
$2,048.69 		$267.13
Toc - Plan #28 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B16L $50 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$299.41
$339.83
$382.65
$534.75
$812.60 		$528.46
$568.88
$611.70
$763.80 		$757.51
$797.93
$840.75
$992.85 		$986.56
$1,026.98
$1,069.80
$1,221.90 		$229.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.82
$679.66
$765.30
$1,069.50
$1,625.20 		$827.87
$908.71
$994.35
$1,298.55 		$1,056.92
$1,137.76
$1,223.40
$1,527.60 		$1,285.97
$1,366.81
$1,452.45
$1,756.65 		$229.05
Toc - Plan #29 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S26S $40 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$429.21
$487.15
$548.53
$766.57
$1,164.88 		$757.56
$815.50
$876.88
$1,094.92 		$1,085.91
$1,143.85
$1,205.23
$1,423.27 		$1,414.26
$1,472.20
$1,533.58
$1,751.62 		$328.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.42
$974.30
$1,097.06
$1,533.14
$2,329.76 		$1,186.77
$1,302.65
$1,425.41
$1,861.49 		$1,515.12
$1,631.00
$1,753.76
$2,189.84 		$1,843.47
$1,959.35
$2,082.11
$2,518.19 		$328.35
Toc - Plan #30 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S26L $40 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$368.02
$417.70
$470.33
$657.28
$998.81 		$649.56
$699.24
$751.87
$938.82 		$931.10
$980.78
$1,033.41
$1,220.36 		$1,212.64
$1,262.32
$1,314.95
$1,501.90 		$281.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.04
$835.40
$940.66
$1,314.56
$1,997.62 		$1,017.58
$1,116.94
$1,222.20
$1,596.10 		$1,299.12
$1,398.48
$1,503.74
$1,877.64 		$1,580.66
$1,680.02
$1,785.28
$2,159.18 		$281.54
Toc - Plan #31 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S27S $60 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$6,300 $12,600 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 		$414.92
$470.93
$530.27
$741.05
$1,126.09 		$732.33
$788.34
$847.68
$1,058.46 		$1,049.74
$1,105.75
$1,165.09
$1,375.87 		$1,367.15
$1,423.16
$1,482.50
$1,693.28 		$317.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.84
$941.86
$1,060.54
$1,482.10
$2,252.18 		$1,147.25
$1,259.27
$1,377.95
$1,799.51 		$1,464.66
$1,576.68
$1,695.36
$2,116.92 		$1,782.07
$1,894.09
$2,012.77
$2,434.33 		$317.41
Toc - Plan #32 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S27L $60 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$6,300 $12,600 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 		$355.76
$403.79
$454.66
$635.39
$965.53 		$627.92
$675.95
$726.82
$907.55 		$900.08
$948.11
$998.98
$1,179.71 		$1,172.24
$1,220.27
$1,271.14
$1,451.87 		$272.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.52
$807.58
$909.32
$1,270.78
$1,931.06 		$983.68
$1,079.74
$1,181.48
$1,542.94 		$1,255.84
$1,351.90
$1,453.64
$1,815.10 		$1,528.00
$1,624.06
$1,725.80
$2,087.26 		$272.16

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-250-8188 | Toll Free: 1-877-250-8188 | TTY: 1-877-250-8188
Toc - Plan #33 UnitedHealthcare
Silver

(EPO) UHC Silver Value $3,350 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family
$3,350 $6,700 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 		$394.34
$447.58
$503.97
$704.29
$1,070.24 		$696.01
$749.25
$805.64
$1,005.96 		$997.68
$1,050.92
$1,107.31
$1,307.63 		$1,299.35
$1,352.59
$1,408.98
$1,609.30 		$301.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.68
$895.16
$1,007.94
$1,408.58
$2,140.48 		$1,090.35
$1,196.83
$1,309.61
$1,710.25 		$1,392.02
$1,498.50
$1,611.28
$2,011.92 		$1,693.69
$1,800.17
$1,912.95
$2,313.59 		$301.67
Toc - Plan #34 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value $7,500 Deductible 1 (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$303.37
$344.32
$387.70
$541.81
$823.34 		$535.45
$576.40
$619.78
$773.89 		$767.53
$808.48
$851.86
$1,005.97 		$999.61
$1,040.56
$1,083.94
$1,238.05 		$232.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.74
$688.64
$775.40
$1,083.62
$1,646.68 		$838.82
$920.72
$1,007.48
$1,315.70 		$1,070.90
$1,152.80
$1,239.56
$1,547.78 		$1,302.98
$1,384.88
$1,471.64
$1,779.86 		$232.08
Toc - Plan #35 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family
$1,850 $3,700 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 		$523.88
$594.60
$669.52
$935.65
$1,421.80 		$924.65
$995.37
$1,070.29
$1,336.42 		$1,325.42
$1,396.14
$1,471.06
$1,737.19 		$1,726.19
$1,796.91
$1,871.83
$2,137.96 		$400.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,047.76
$1,189.20
$1,339.04
$1,871.30
$2,843.60 		$1,448.53
$1,589.97
$1,739.81
$2,272.07 		$1,849.30
$1,990.74
$2,140.58
$2,672.84 		$2,250.07
$2,391.51
$2,541.35
$3,073.61 		$400.77
Toc - Plan #36 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$574.98
$652.60
$734.83
$1,026.92
$1,560.50 		$1,014.84
$1,092.46
$1,174.69
$1,466.78 		$1,454.70
$1,532.32
$1,614.55
$1,906.64 		$1,894.56
$1,972.18
$2,054.41
$2,346.50 		$439.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,149.96
$1,305.20
$1,469.66
$2,053.84
$3,121.00 		$1,589.82
$1,745.06
$1,909.52
$2,493.70 		$2,029.68
$2,184.92
$2,349.38
$2,933.56 		$2,469.54
$2,624.78
$2,789.24
$3,373.42 		$439.86
Toc - Plan #37 UnitedHealthcare
Gold

(EPO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$558.62
$634.03
$713.92
$997.70
$1,516.10 		$985.97
$1,061.38
$1,141.27
$1,425.05 		$1,413.32
$1,488.73
$1,568.62
$1,852.40 		$1,840.67
$1,916.08
$1,995.97
$2,279.75 		$427.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,117.24
$1,268.06
$1,427.84
$1,995.40
$3,032.20 		$1,544.59
$1,695.41
$1,855.19
$2,422.75 		$1,971.94
$2,122.76
$2,282.54
$2,850.10 		$2,399.29
$2,550.11
$2,709.89
$3,277.45 		$427.35
Toc - Plan #38 UnitedHealthcare
Silver

(EPO) UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.03
$448.35
$504.84
$705.52
$1,072.10 		$697.22
$750.54
$807.03
$1,007.71 		$999.41
$1,052.73
$1,109.22
$1,309.90 		$1,301.60
$1,354.92
$1,411.41
$1,612.09 		$302.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.06
$896.70
$1,009.68
$1,411.04
$2,144.20 		$1,092.25
$1,198.89
$1,311.87
$1,713.23 		$1,394.44
$1,501.08
$1,614.06
$2,015.42 		$1,696.63
$1,803.27
$1,916.25
$2,317.61 		$302.19
Toc - Plan #39 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$394.19
$447.41
$503.78
$704.03
$1,069.84 		$695.75
$748.97
$805.34
$1,005.59 		$997.31
$1,050.53
$1,106.90
$1,307.15 		$1,298.87
$1,352.09
$1,408.46
$1,608.71 		$301.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.38
$894.82
$1,007.56
$1,408.06
$2,139.68 		$1,089.94
$1,196.38
$1,309.12
$1,709.62 		$1,391.50
$1,497.94
$1,610.68
$2,011.18 		$1,693.06
$1,799.50
$1,912.24
$2,312.74 		$301.56
Toc - Plan #40 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.01
$461.95
$520.15
$726.91
$1,104.62 		$718.37
$773.31
$831.51
$1,038.27 		$1,029.73
$1,084.67
$1,142.87
$1,349.63 		$1,341.09
$1,396.03
$1,454.23
$1,660.99 		$311.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.02
$923.90
$1,040.30
$1,453.82
$2,209.24 		$1,125.38
$1,235.26
$1,351.66
$1,765.18 		$1,436.74
$1,546.62
$1,663.02
$2,076.54 		$1,748.10
$1,857.98
$1,974.38
$2,387.90 		$311.36
Toc - Plan #41 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$400.45
$454.51
$511.77
$715.20
$1,086.81 		$706.79
$760.85
$818.11
$1,021.54 		$1,013.13
$1,067.19
$1,124.45
$1,327.88 		$1,319.47
$1,373.53
$1,430.79
$1,634.22 		$306.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800.90
$909.02
$1,023.54
$1,430.40
$2,173.62 		$1,107.24
$1,215.36
$1,329.88
$1,736.74 		$1,413.58
$1,521.70
$1,636.22
$2,043.08 		$1,719.92
$1,828.04
$1,942.56
$2,349.42 		$306.34
Toc - Plan #42 UnitedHealthcare
Silver

(EPO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$395.64
$449.05
$505.63
$706.62
$1,073.77 		$698.31
$751.72
$808.30
$1,009.29 		$1,000.98
$1,054.39
$1,110.97
$1,311.96 		$1,303.65
$1,357.06
$1,413.64
$1,614.63 		$302.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.28
$898.10
$1,011.26
$1,413.24
$2,147.54 		$1,093.95
$1,200.77
$1,313.93
$1,715.91 		$1,396.62
$1,503.44
$1,616.60
$2,018.58 		$1,699.29
$1,806.11
$1,919.27
$2,321.25 		$302.67
Toc - Plan #43 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value $7,500 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$308.55
$350.20
$394.32
$551.06
$837.39 		$544.59
$586.24
$630.36
$787.10 		$780.63
$822.28
$866.40
$1,023.14 		$1,016.67
$1,058.32
$1,102.44
$1,259.18 		$236.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.10
$700.40
$788.64
$1,102.12
$1,674.78 		$853.14
$936.44
$1,024.68
$1,338.16 		$1,089.18
$1,172.48
$1,260.72
$1,574.20 		$1,325.22
$1,408.52
$1,496.76
$1,810.24 		$236.04
Toc - Plan #44 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$314.91
$357.43
$402.46
$562.44
$854.68 		$555.82
$598.34
$643.37
$803.35 		$796.73
$839.25
$884.28
$1,044.26 		$1,037.64
$1,080.16
$1,125.19
$1,285.17 		$240.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.82
$714.86
$804.92
$1,124.88
$1,709.36 		$870.73
$955.77
$1,045.83
$1,365.79 		$1,111.64
$1,196.68
$1,286.74
$1,606.70 		$1,352.55
$1,437.59
$1,527.65
$1,847.61 		$240.91
Toc - Plan #45 UnitedHealthcare
Bronze

(EPO) UHC Bronze Essential $9,100 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$288.29
$327.20
$368.43
$514.88
$782.41 		$508.83
$547.74
$588.97
$735.42 		$729.37
$768.28
$809.51
$955.96 		$949.91
$988.82
$1,030.05
$1,176.50 		$220.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.58
$654.40
$736.86
$1,029.76
$1,564.82 		$797.12
$874.94
$957.40
$1,250.30 		$1,017.66
$1,095.48
$1,177.94
$1,470.84 		$1,238.20
$1,316.02
$1,398.48
$1,691.38 		$220.54
Toc - Plan #46 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$306.04
$347.36
$391.12
$546.59
$830.60 		$540.16
$581.48
$625.24
$780.71 		$774.28
$815.60
$859.36
$1,014.83 		$1,008.40
$1,049.72
$1,093.48
$1,248.95 		$234.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.08
$694.72
$782.24
$1,093.18
$1,661.20 		$846.20
$928.84
$1,016.36
$1,327.30 		$1,080.32
$1,162.96
$1,250.48
$1,561.42 		$1,314.44
$1,397.08
$1,484.60
$1,795.54 		$234.12
Toc - Plan #47 UnitedHealthcare
Bronze

(EPO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$288.32
$327.24
$368.47
$514.94
$782.50 		$508.88
$547.80
$589.03
$735.50 		$729.44
$768.36
$809.59
$956.06 		$950.00
$988.92
$1,030.15
$1,176.62 		$220.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.64
$654.48
$736.94
$1,029.88
$1,565.00 		$797.20
$875.04
$957.50
$1,250.44 		$1,017.76
$1,095.60
$1,178.06
$1,471.00 		$1,238.32
$1,316.16
$1,398.62
$1,691.56 		$220.56
Toc - Plan #48 UnitedHealthcare
Bronze

(EPO) UHC Bronze Essential $6,350 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 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 		$298.50
$338.80
$381.49
$533.13
$810.14 		$526.85
$567.15
$609.84
$761.48 		$755.20
$795.50
$838.19
$989.83 		$983.55
$1,023.85
$1,066.54
$1,218.18 		$228.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.00
$677.60
$762.98
$1,066.26
$1,620.28 		$825.35
$905.95
$991.33
$1,294.61 		$1,053.70
$1,134.30
$1,219.68
$1,522.96 		$1,282.05
$1,362.65
$1,448.03
$1,751.31 		$228.35

ADVERTISEMENT

Ambetter of Tennessee

Local: 1-833-709-4735 | Toll Free: 1-833-709-4735

Toc - Plan #49 Ambetter of Tennessee
Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$265.37
$301.18
$339.13
$473.93
$720.18 		$468.37
$504.18
$542.13
$676.93 		$671.37
$707.18
$745.13
$879.93 		$874.37
$910.18
$948.13
$1,082.93 		$203.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$530.74
$602.36
$678.26
$947.86
$1,440.36 		$733.74
$805.36
$881.26
$1,150.86 		$936.74
$1,008.36
$1,084.26
$1,353.86 		$1,139.74
$1,211.36
$1,287.26
$1,556.86 		$203.00
Toc - Plan #50 Ambetter of Tennessee
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$365.87
$415.25
$467.56
$653.42
$992.93 		$645.75
$695.13
$747.44
$933.30 		$925.63
$975.01
$1,027.32
$1,213.18 		$1,205.51
$1,254.89
$1,307.20
$1,493.06 		$279.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.74
$830.50
$935.12
$1,306.84
$1,985.86 		$1,011.62
$1,110.38
$1,215.00
$1,586.72 		$1,291.50
$1,390.26
$1,494.88
$1,866.60 		$1,571.38
$1,670.14
$1,774.76
$2,146.48 		$279.88
Toc - Plan #51 Ambetter of Tennessee
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$378.51
$429.59
$483.72
$675.99
$1,027.24 		$668.06
$719.14
$773.27
$965.54 		$957.61
$1,008.69
$1,062.82
$1,255.09 		$1,247.16
$1,298.24
$1,352.37
$1,544.64 		$289.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.02
$859.18
$967.44
$1,351.98
$2,054.48 		$1,046.57
$1,148.73
$1,256.99
$1,641.53 		$1,336.12
$1,438.28
$1,546.54
$1,931.08 		$1,625.67
$1,727.83
$1,836.09
$2,220.63 		$289.55
Toc - Plan #52 Ambetter of Tennessee
Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$290.86
$330.12
$371.71
$519.46
$789.37 		$513.36
$552.62
$594.21
$741.96 		$735.86
$775.12
$816.71
$964.46 		$958.36
$997.62
$1,039.21
$1,186.96 		$222.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.72
$660.24
$743.42
$1,038.92
$1,578.74 		$804.22
$882.74
$965.92
$1,261.42 		$1,026.72
$1,105.24
$1,188.42
$1,483.92 		$1,249.22
$1,327.74
$1,410.92
$1,706.42 		$222.50
Toc - Plan #53 Ambetter of Tennessee
Silver

(EPO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$362.17
$411.05
$462.84
$646.82
$982.91 		$639.22
$688.10
$739.89
$923.87 		$916.27
$965.15
$1,016.94
$1,200.92 		$1,193.32
$1,242.20
$1,293.99
$1,477.97 		$277.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.34
$822.10
$925.68
$1,293.64
$1,965.82 		$1,001.39
$1,099.15
$1,202.73
$1,570.69 		$1,278.44
$1,376.20
$1,479.78
$1,847.74 		$1,555.49
$1,653.25
$1,756.83
$2,124.79 		$277.05
Toc - Plan #54 Ambetter of Tennessee
Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$284.71
$323.13
$363.84
$508.47
$772.66 		$502.50
$540.92
$581.63
$726.26 		$720.29
$758.71
$799.42
$944.05 		$938.08
$976.50
$1,017.21
$1,161.84 		$217.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569.42
$646.26
$727.68
$1,016.94
$1,545.32 		$787.21
$864.05
$945.47
$1,234.73 		$1,005.00
$1,081.84
$1,163.26
$1,452.52 		$1,222.79
$1,299.63
$1,381.05
$1,670.31 		$217.79
Toc - Plan #55 Ambetter of Tennessee
Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$320.60
$363.87
$409.71
$572.57
$870.07 		$565.85
$609.12
$654.96
$817.82 		$811.10
$854.37
$900.21
$1,063.07 		$1,056.35
$1,099.62
$1,145.46
$1,308.32 		$245.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.20
$727.74
$819.42
$1,145.14
$1,740.14 		$886.45
$972.99
$1,064.67
$1,390.39 		$1,131.70
$1,218.24
$1,309.92
$1,635.64 		$1,376.95
$1,463.49
$1,555.17
$1,880.89 		$245.25
Toc - Plan #56 Ambetter of Tennessee
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$356.74
$404.89
$455.90
$637.12
$968.16 		$629.64
$677.79
$728.80
$910.02 		$902.54
$950.69
$1,001.70
$1,182.92 		$1,175.44
$1,223.59
$1,274.60
$1,455.82 		$272.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.48
$809.78
$911.80
$1,274.24
$1,936.32 		$986.38
$1,082.68
$1,184.70
$1,547.14 		$1,259.28
$1,355.58
$1,457.60
$1,820.04 		$1,532.18
$1,628.48
$1,730.50
$2,092.94 		$272.90
Toc - Plan #57 Ambetter of Tennessee
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$360.69
$409.37
$460.95
$644.17
$978.88 		$636.61
$685.29
$736.87
$920.09 		$912.53
$961.21
$1,012.79
$1,196.01 		$1,188.45
$1,237.13
$1,288.71
$1,471.93 		$275.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.38
$818.74
$921.90
$1,288.34
$1,957.76 		$997.30
$1,094.66
$1,197.82
$1,564.26 		$1,273.22
$1,370.58
$1,473.74
$1,840.18 		$1,549.14
$1,646.50
$1,749.66
$2,116.10 		$275.92
Toc - Plan #58 Ambetter of Tennessee
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$362.24
$411.14
$462.94
$646.95
$983.11 		$639.35
$688.25
$740.05
$924.06 		$916.46
$965.36
$1,017.16
$1,201.17 		$1,193.57
$1,242.47
$1,294.27
$1,478.28 		$277.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.48
$822.28
$925.88
$1,293.90
$1,966.22 		$1,001.59
$1,099.39
$1,202.99
$1,571.01 		$1,278.70
$1,376.50
$1,480.10
$1,848.12 		$1,555.81
$1,653.61
$1,757.21
$2,125.23 		$277.11
Toc - Plan #59 Ambetter of Tennessee
Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 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 		$416.64
$472.88
$532.46
$744.10
$1,130.74 		$735.36
$791.60
$851.18
$1,062.82 		$1,054.08
$1,110.32
$1,169.90
$1,381.54 		$1,372.80
$1,429.04
$1,488.62
$1,700.26 		$318.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$833.28
$945.76
$1,064.92
$1,488.20
$2,261.48 		$1,152.00
$1,264.48
$1,383.64
$1,806.92 		$1,470.72
$1,583.20
$1,702.36
$2,125.64 		$1,789.44
$1,901.92
$2,021.08
$2,444.36 		$318.72
Toc - Plan #60 Ambetter of Tennessee
Bronze

(EPO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$253.05
$287.20
$323.39
$451.93
$686.76 		$446.63
$480.78
$516.97
$645.51 		$640.21
$674.36
$710.55
$839.09 		$833.79
$867.94
$904.13
$1,032.67 		$193.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$506.10
$574.40
$646.78
$903.86
$1,373.52 		$699.68
$767.98
$840.36
$1,097.44 		$893.26
$961.56
$1,033.94
$1,291.02 		$1,086.84
$1,155.14
$1,227.52
$1,484.60 		$193.58
Toc - Plan #61 Ambetter of Tennessee
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$278.80
$316.43
$356.30
$497.92
$756.64 		$492.08
$529.71
$569.58
$711.20 		$705.36
$742.99
$782.86
$924.48 		$918.64
$956.27
$996.14
$1,137.76 		$213.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.60
$632.86
$712.60
$995.84
$1,513.28 		$770.88
$846.14
$925.88
$1,209.12 		$984.16
$1,059.42
$1,139.16
$1,422.40 		$1,197.44
$1,272.70
$1,352.44
$1,635.68 		$213.28
Toc - Plan #62 Ambetter of Tennessee
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$357.32
$405.55
$456.64
$638.15
$969.74 		$630.66
$678.89
$729.98
$911.49 		$904.00
$952.23
$1,003.32
$1,184.83 		$1,177.34
$1,225.57
$1,276.66
$1,458.17 		$273.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.64
$811.10
$913.28
$1,276.30
$1,939.48 		$987.98
$1,084.44
$1,186.62
$1,549.64 		$1,261.32
$1,357.78
$1,459.96
$1,822.98 		$1,534.66
$1,631.12
$1,733.30
$2,096.32 		$273.34
Toc - Plan #63 Ambetter of Tennessee
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$358.08
$406.41
$457.61
$639.51
$971.80 		$632.00
$680.33
$731.53
$913.43 		$905.92
$954.25
$1,005.45
$1,187.35 		$1,179.84
$1,228.17
$1,279.37
$1,461.27 		$273.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.16
$812.82
$915.22
$1,279.02
$1,943.60 		$990.08
$1,086.74
$1,189.14
$1,552.94 		$1,264.00
$1,360.66
$1,463.06
$1,826.86 		$1,537.92
$1,634.58
$1,736.98
$2,100.78 		$273.92
Toc - Plan #64 Ambetter of Tennessee
Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$275.57
$312.76
$352.17
$492.16
$747.88 		$486.38
$523.57
$562.98
$702.97 		$697.19
$734.38
$773.79
$913.78 		$908.00
$945.19
$984.60
$1,124.59 		$210.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.14
$625.52
$704.34
$984.32
$1,495.76 		$761.95
$836.33
$915.15
$1,195.13 		$972.76
$1,047.14
$1,125.96
$1,405.94 		$1,183.57
$1,257.95
$1,336.77
$1,616.75 		$210.81
Toc - Plan #65 Ambetter of Tennessee
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$379.94
$431.22
$485.55
$678.55
$1,031.13 		$670.59
$721.87
$776.20
$969.20 		$961.24
$1,012.52
$1,066.85
$1,259.85 		$1,251.89
$1,303.17
$1,357.50
$1,550.50 		$290.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$759.88
$862.44
$971.10
$1,357.10
$2,062.26 		$1,050.53
$1,153.09
$1,261.75
$1,647.75 		$1,341.18
$1,443.74
$1,552.40
$1,938.40 		$1,631.83
$1,734.39
$1,843.05
$2,229.05 		$290.65
Toc - Plan #66 Ambetter of Tennessee
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$393.06
$446.12
$502.32
$702.00
$1,066.75 		$693.75
$746.81
$803.01
$1,002.69 		$994.44
$1,047.50
$1,103.70
$1,303.38 		$1,295.13
$1,348.19
$1,404.39
$1,604.07 		$300.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.12
$892.24
$1,004.64
$1,404.00
$2,133.50 		$1,086.81
$1,192.93
$1,305.33
$1,704.69 		$1,387.50
$1,493.62
$1,606.02
$2,005.38 		$1,688.19
$1,794.31
$1,906.71
$2,306.07 		$300.69
Toc - Plan #67 Ambetter of Tennessee
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$302.05
$342.82
$386.01
$539.44
$819.74 		$533.11
$573.88
$617.07
$770.50 		$764.17
$804.94
$848.13
$1,001.56 		$995.23
$1,036.00
$1,079.19
$1,232.62 		$231.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.10
$685.64
$772.02
$1,078.88
$1,639.48 		$835.16
$916.70
$1,003.08
$1,309.94 		$1,066.22
$1,147.76
$1,234.14
$1,541.00 		$1,297.28
$1,378.82
$1,465.20
$1,772.06 		$231.06
Toc - Plan #68 Ambetter of Tennessee
Silver

(EPO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$376.10
$426.87
$480.65
$671.70
$1,020.72 		$663.81
$714.58
$768.36
$959.41 		$951.52
$1,002.29
$1,056.07
$1,247.12 		$1,239.23
$1,290.00
$1,343.78
$1,534.83 		$287.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.20
$853.74
$961.30
$1,343.40
$2,041.44 		$1,039.91
$1,141.45
$1,249.01
$1,631.11 		$1,327.62
$1,429.16
$1,536.72
$1,918.82 		$1,615.33
$1,716.87
$1,824.43
$2,206.53 		$287.71
Toc - Plan #69 Ambetter of Tennessee
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$295.66
$335.56
$377.84
$528.03
$802.39 		$521.83
$561.73
$604.01
$754.20 		$748.00
$787.90
$830.18
$980.37 		$974.17
$1,014.07
$1,056.35
$1,206.54 		$226.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591.32
$671.12
$755.68
$1,056.06
$1,604.78 		$817.49
$897.29
$981.85
$1,282.23 		$1,043.66
$1,123.46
$1,208.02
$1,508.40 		$1,269.83
$1,349.63
$1,434.19
$1,734.57 		$226.17
Toc - Plan #70 Ambetter of Tennessee
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 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 		$332.93
$377.86
$425.47
$594.59
$903.54 		$587.61
$632.54
$680.15
$849.27 		$842.29
$887.22
$934.83
$1,103.95 		$1,096.97
$1,141.90
$1,189.51
$1,358.63 		$254.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.86
$755.72
$850.94
$1,189.18
$1,807.08 		$920.54
$1,010.40
$1,105.62
$1,443.86 		$1,175.22
$1,265.08
$1,360.30
$1,698.54 		$1,429.90
$1,519.76
$1,614.98
$1,953.22 		$254.68
Toc - Plan #71 Ambetter of Tennessee
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$374.56
$425.12
$478.68
$668.95
$1,016.53 		$661.09
$711.65
$765.21
$955.48 		$947.62
$998.18
$1,051.74
$1,242.01 		$1,234.15
$1,284.71
$1,338.27
$1,528.54 		$286.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.12
$850.24
$957.36
$1,337.90
$2,033.06 		$1,035.65
$1,136.77
$1,243.89
$1,624.43 		$1,322.18
$1,423.30
$1,530.42
$1,910.96 		$1,608.71
$1,709.83
$1,816.95
$2,197.49 		$286.53
Toc - Plan #72 Ambetter of Tennessee
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$376.18
$426.95
$480.74
$671.84
$1,020.92 		$663.95
$714.72
$768.51
$959.61 		$951.72
$1,002.49
$1,056.28
$1,247.38 		$1,239.49
$1,290.26
$1,344.05
$1,535.15 		$287.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.36
$853.90
$961.48
$1,343.68
$2,041.84 		$1,040.13
$1,141.67
$1,249.25
$1,631.45 		$1,327.90
$1,429.44
$1,537.02
$1,919.22 		$1,615.67
$1,717.21
$1,824.79
$2,206.99 		$287.77
Toc - Plan #73 Ambetter of Tennessee
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$370.46
$420.46
$473.44
$661.63
$1,005.41 		$653.86
$703.86
$756.84
$945.03 		$937.26
$987.26
$1,040.24
$1,228.43 		$1,220.66
$1,270.66
$1,323.64
$1,511.83 		$283.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.92
$840.92
$946.88
$1,323.26
$2,010.82 		$1,024.32
$1,124.32
$1,230.28
$1,606.66 		$1,307.72
$1,407.72
$1,513.68
$1,890.06 		$1,591.12
$1,691.12
$1,797.08
$2,173.46 		$283.40
Toc - Plan #74 Ambetter of Tennessee
Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 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 		$432.67
$491.07
$552.94
$772.73
$1,174.23 		$763.65
$822.05
$883.92
$1,103.71 		$1,094.63
$1,153.03
$1,214.90
$1,434.69 		$1,425.61
$1,484.01
$1,545.88
$1,765.67 		$330.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$865.34
$982.14
$1,105.88
$1,545.46
$2,348.46 		$1,196.32
$1,313.12
$1,436.86
$1,876.44 		$1,527.30
$1,644.10
$1,767.84
$2,207.42 		$1,858.28
$1,975.08
$2,098.82
$2,538.40 		$330.98

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #75 Cigna Healthcare
Silver

(EPO) Cigna Connect 4100

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 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 		$418.70
$475.23
$535.10
$747.80
$1,136.36 		$739.01
$795.54
$855.41
$1,068.11 		$1,059.32
$1,115.85
$1,175.72
$1,388.42 		$1,379.63
$1,436.16
$1,496.03
$1,708.73 		$320.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.40
$950.46
$1,070.20
$1,495.60
$2,272.72 		$1,157.71
$1,270.77
$1,390.51
$1,815.91 		$1,478.02
$1,591.08
$1,710.82
$2,136.22 		$1,798.33
$1,911.39
$2,031.13
$2,456.53 		$320.31
Toc - Plan #76 Cigna Healthcare
Gold

(EPO) Cigna Connect 1000

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$636.31
$722.21
$813.20
$1,136.44
$1,726.94 		$1,123.08
$1,208.98
$1,299.97
$1,623.21 		$1,609.85
$1,695.75
$1,786.74
$2,109.98 		$2,096.62
$2,182.52
$2,273.51
$2,596.75 		$486.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,272.62
$1,444.42
$1,626.40
$2,272.88
$3,453.88 		$1,759.39
$1,931.19
$2,113.17
$2,759.65 		$2,246.16
$2,417.96
$2,599.94
$3,246.42 		$2,732.93
$2,904.73
$3,086.71
$3,733.19 		$486.77
Toc - Plan #77 Cigna Healthcare
Bronze

(EPO) Cigna Connect 6500

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

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 		$356.28
$404.38
$455.33
$636.32
$966.95 		$628.84
$676.94
$727.89
$908.88 		$901.40
$949.50
$1,000.45
$1,181.44 		$1,173.96
$1,222.06
$1,273.01
$1,454.00 		$272.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.56
$808.76
$910.66
$1,272.64
$1,933.90 		$985.12
$1,081.32
$1,183.22
$1,545.20 		$1,257.68
$1,353.88
$1,455.78
$1,817.76 		$1,530.24
$1,626.44
$1,728.34
$2,090.32 		$272.56
Toc - Plan #78 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 5900

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.37
$420.37
$473.33
$661.48
$1,005.18 		$653.70
$703.70
$756.66
$944.81 		$937.03
$987.03
$1,039.99
$1,228.14 		$1,220.36
$1,270.36
$1,323.32
$1,511.47 		$283.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.74
$840.74
$946.66
$1,322.96
$2,010.36 		$1,024.07
$1,124.07
$1,229.99
$1,606.29 		$1,307.40
$1,407.40
$1,513.32
$1,889.62 		$1,590.73
$1,690.73
$1,796.65
$2,172.95 		$283.33
Toc - Plan #79 Cigna Healthcare
Silver

(EPO) Cigna Connect 3200

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

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 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 		$422.66
$479.71
$540.15
$754.86
$1,147.09 		$745.99
$803.04
$863.48
$1,078.19 		$1,069.32
$1,126.37
$1,186.81
$1,401.52 		$1,392.65
$1,449.70
$1,510.14
$1,724.85 		$323.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.32
$959.42
$1,080.30
$1,509.72
$2,294.18 		$1,168.65
$1,282.75
$1,403.63
$1,833.05 		$1,491.98
$1,606.08
$1,726.96
$2,156.38 		$1,815.31
$1,929.41
$2,050.29
$2,479.71 		$323.33
Toc - Plan #80 Cigna Healthcare
Bronze

(EPO) Cigna Connect 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.11
$401.91
$452.55
$632.44
$961.05 		$625.00
$672.80
$723.44
$903.33 		$895.89
$943.69
$994.33
$1,174.22 		$1,166.78
$1,214.58
$1,265.22
$1,445.11 		$270.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.22
$803.82
$905.10
$1,264.88
$1,922.10 		$979.11
$1,074.71
$1,175.99
$1,535.77 		$1,250.00
$1,345.60
$1,446.88
$1,806.66 		$1,520.89
$1,616.49
$1,717.77
$2,077.55 		$270.89
Toc - Plan #81 Cigna Healthcare
Silver

(EPO) Cigna Connect 5450

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

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,950 $17,900 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 		$420.48
$477.25
$537.38
$750.98
$1,141.19 		$742.15
$798.92
$859.05
$1,072.65 		$1,063.82
$1,120.59
$1,180.72
$1,394.32 		$1,385.49
$1,442.26
$1,502.39
$1,715.99 		$321.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.96
$954.50
$1,074.76
$1,501.96
$2,282.38 		$1,162.63
$1,276.17
$1,396.43
$1,823.63 		$1,484.30
$1,597.84
$1,718.10
$2,145.30 		$1,805.97
$1,919.51
$2,039.77
$2,466.97 		$321.67
Toc - Plan #82 Cigna Healthcare
Silver

(EPO) Cigna Connect 3800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$421.22
$478.09
$538.32
$752.30
$1,143.20 		$743.46
$800.33
$860.56
$1,074.54 		$1,065.70
$1,122.57
$1,182.80
$1,396.78 		$1,387.94
$1,444.81
$1,505.04
$1,719.02 		$322.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.44
$956.18
$1,076.64
$1,504.60
$2,286.40 		$1,164.68
$1,278.42
$1,398.88
$1,826.84 		$1,486.92
$1,600.66
$1,721.12
$2,149.08 		$1,809.16
$1,922.90
$2,043.36
$2,471.32 		$322.24
Toc - Plan #83 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.32
$420.31
$473.27
$661.39
$1,005.04 		$653.61
$703.60
$756.56
$944.68 		$936.90
$986.89
$1,039.85
$1,227.97 		$1,220.19
$1,270.18
$1,323.14
$1,511.26 		$283.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.64
$840.62
$946.54
$1,322.78
$2,010.08 		$1,023.93
$1,123.91
$1,229.83
$1,606.07 		$1,307.22
$1,407.20
$1,513.12
$1,889.36 		$1,590.51
$1,690.49
$1,796.41
$2,172.65 		$283.29
Toc - Plan #84 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7800

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.66
$420.70
$473.71
$662.01
$1,005.98 		$654.22
$704.26
$757.27
$945.57 		$937.78
$987.82
$1,040.83
$1,229.13 		$1,221.34
$1,271.38
$1,324.39
$1,512.69 		$283.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.32
$841.40
$947.42
$1,324.02
$2,011.96 		$1,024.88
$1,124.96
$1,230.98
$1,607.58 		$1,308.44
$1,408.52
$1,514.54
$1,891.14 		$1,592.00
$1,692.08
$1,798.10
$2,174.70 		$283.56
Toc - Plan #85 Cigna Healthcare
Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.53
$477.30
$537.44
$751.07
$1,141.32 		$742.24
$799.01
$859.15
$1,072.78 		$1,063.95
$1,120.72
$1,180.86
$1,394.49 		$1,385.66
$1,442.43
$1,502.57
$1,716.20 		$321.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.06
$954.60
$1,074.88
$1,502.14
$2,282.64 		$1,162.77
$1,276.31
$1,396.59
$1,823.85 		$1,484.48
$1,598.02
$1,718.30
$2,145.56 		$1,806.19
$1,919.73
$2,040.01
$2,467.27 		$321.71
Toc - Plan #86 Cigna Healthcare
Silver

(EPO) Cigna Connect 0B

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$424.98
$482.35
$543.12
$759.01
$1,153.39 		$750.09
$807.46
$868.23
$1,084.12 		$1,075.20
$1,132.57
$1,193.34
$1,409.23 		$1,400.31
$1,457.68
$1,518.45
$1,734.34 		$325.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.96
$964.70
$1,086.24
$1,518.02
$2,306.78 		$1,175.07
$1,289.81
$1,411.35
$1,843.13 		$1,500.18
$1,614.92
$1,736.46
$2,168.24 		$1,825.29
$1,940.03
$2,061.57
$2,493.35 		$325.11
Toc - Plan #87 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect HSA 6000

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.44
$422.72
$475.98
$665.18
$1,010.81 		$657.36
$707.64
$760.90
$950.10 		$942.28
$992.56
$1,045.82
$1,235.02 		$1,227.20
$1,277.48
$1,330.74
$1,519.94 		$284.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.88
$845.44
$951.96
$1,330.36
$2,021.62 		$1,029.80
$1,130.36
$1,236.88
$1,615.28 		$1,314.72
$1,415.28
$1,521.80
$1,900.20 		$1,599.64
$1,700.20
$1,806.72
$2,185.12 		$284.92
Toc - Plan #88 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 0A

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.92
$449.37
$505.98
$707.11
$1,074.52 		$698.80
$752.25
$808.86
$1,009.99 		$1,001.68
$1,055.13
$1,111.74
$1,312.87 		$1,304.56
$1,358.01
$1,414.62
$1,615.75 		$302.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.84
$898.74
$1,011.96
$1,414.22
$2,149.04 		$1,094.72
$1,201.62
$1,314.84
$1,717.10 		$1,397.60
$1,504.50
$1,617.72
$2,019.98 		$1,700.48
$1,807.38
$1,920.60
$2,322.86 		$302.88
Toc - Plan #89 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7600 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 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 		$370.57
$420.59
$473.58
$661.83
$1,005.71 		$654.05
$704.07
$757.06
$945.31 		$937.53
$987.55
$1,040.54
$1,228.79 		$1,221.01
$1,271.03
$1,324.02
$1,512.27 		$283.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.14
$841.18
$947.16
$1,323.66
$2,011.42 		$1,024.62
$1,124.66
$1,230.64
$1,607.14 		$1,308.10
$1,408.14
$1,514.12
$1,890.62 		$1,591.58
$1,691.62
$1,797.60
$2,174.10 		$283.48
Toc - Plan #90 Cigna Healthcare
Bronze

(EPO) Cigna Simple Choice 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.11
$401.91
$452.55
$632.44
$961.05 		$625.00
$672.80
$723.44
$903.33 		$895.89
$943.69
$994.33
$1,174.22 		$1,166.78
$1,214.58
$1,265.22
$1,445.11 		$270.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.22
$803.82
$905.10
$1,264.88
$1,922.10 		$979.11
$1,074.71
$1,175.99
$1,535.77 		$1,250.00
$1,345.60
$1,446.88
$1,806.66 		$1,520.89
$1,616.49
$1,717.77
$2,077.55 		$270.89
Toc - Plan #91 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Simple Choice 7500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$369.03
$418.85
$471.62
$659.09
$1,001.56 		$651.34
$701.16
$753.93
$941.40 		$933.65
$983.47
$1,036.24
$1,223.71 		$1,215.96
$1,265.78
$1,318.55
$1,506.02 		$282.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.06
$837.70
$943.24
$1,318.18
$2,003.12 		$1,020.37
$1,120.01
$1,225.55
$1,600.49 		$1,302.68
$1,402.32
$1,507.86
$1,882.80 		$1,584.99
$1,684.63
$1,790.17
$2,165.11 		$282.31
Toc - Plan #92 Cigna Healthcare
Silver

(EPO) Cigna Simple Choice 5800

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$419.84
$476.52
$536.55
$749.83
$1,139.44 		$741.02
$797.70
$857.73
$1,071.01 		$1,062.20
$1,118.88
$1,178.91
$1,392.19 		$1,383.38
$1,440.06
$1,500.09
$1,713.37 		$321.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.68
$953.04
$1,073.10
$1,499.66
$2,278.88 		$1,160.86
$1,274.22
$1,394.28
$1,820.84 		$1,482.04
$1,595.40
$1,715.46
$2,142.02 		$1,803.22
$1,916.58
$2,036.64
$2,463.20 		$321.18
Toc - Plan #93 Cigna Healthcare
Gold

(EPO) Cigna Simple Choice 2000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$613.47
$696.29
$784.02
$1,095.66
$1,664.97 		$1,082.78
$1,165.60
$1,253.33
$1,564.97 		$1,552.09
$1,634.91
$1,722.64
$2,034.28 		$2,021.40
$2,104.22
$2,191.95
$2,503.59 		$469.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,226.94
$1,392.58
$1,568.04
$2,191.32
$3,329.94 		$1,696.25
$1,861.89
$2,037.35
$2,660.63 		$2,165.56
$2,331.20
$2,506.66
$3,129.94 		$2,634.87
$2,800.51
$2,975.97
$3,599.25 		$469.31

‡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 Monroe County here.

Monroe County is in “Rating Area 3” of Tennessee.

Currently, there are 93 plans offered in Rating Area 3.

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2023 Obamacare Plans for Monroe County, TN

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