Obamacare 2023 Rates for Calumet County

Obamacare > Rates > Wisconsin > Calumet 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 Calumet County, WI.

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, 152 Plans and 2023 Rates for Calumet County, Wisconsin

Below, you’ll find a summary of the 152 plans for Calumet County, Wisconsin and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Together with CCHP

Local: 1-844-201-4672 | Toll Free: 1-844-201-4672 | TTY: 1-844-531-4856

Toc - Plan #1 Together with CCHP

Expanded Bronze

(EPO) Chorus Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

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

$290.28
$329.46
$370.97
$518.43
$787.80

$512.34
$551.52
$593.03
$740.49

$734.40
$773.58
$815.09
$962.55

$956.46
$995.64
$1,037.15
$1,184.61

$222.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$580.56
$658.92
$741.94
$1,036.86
$1,575.60

$802.62
$880.98
$964.00
$1,258.92

$1,024.68
$1,103.04
$1,186.06
$1,480.98

$1,246.74
$1,325.10
$1,408.12
$1,703.04

$222.06

Toc - Plan #2 Together with CCHP

Silver

(EPO) Chorus Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

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

$379.45
$430.67
$484.93
$677.68
$1,029.80

$669.72
$720.94
$775.20
$967.95

$959.99
$1,011.21
$1,065.47
$1,258.22

$1,250.26
$1,301.48
$1,355.74
$1,548.49

$290.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$758.90
$861.34
$969.86
$1,355.36
$2,059.60

$1,049.17
$1,151.61
$1,260.13
$1,645.63

$1,339.44
$1,441.88
$1,550.40
$1,935.90

$1,629.71
$1,732.15
$1,840.67
$2,226.17

$290.27

Toc - Plan #3 Together with CCHP

Silver

(EPO) Chorus Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$346.06
$392.77
$442.25
$618.05
$939.18

$610.79
$657.50
$706.98
$882.78

$875.52
$922.23
$971.71
$1,147.51

$1,140.25
$1,186.96
$1,236.44
$1,412.24

$264.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$692.12
$785.54
$884.50
$1,236.10
$1,878.36

$956.85
$1,050.27
$1,149.23
$1,500.83

$1,221.58
$1,315.00
$1,413.96
$1,765.56

$1,486.31
$1,579.73
$1,678.69
$2,030.29

$264.73

Toc - Plan #4 Together with CCHP

Gold

(EPO) Chorus Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$409.81
$465.12
$523.72
$731.90
$1,112.19

$723.30
$778.61
$837.21
$1,045.39

$1,036.79
$1,092.10
$1,150.70
$1,358.88

$1,350.28
$1,405.59
$1,464.19
$1,672.37

$313.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$819.62
$930.24
$1,047.44
$1,463.80
$2,224.38

$1,133.11
$1,243.73
$1,360.93
$1,777.29

$1,446.60
$1,557.22
$1,674.42
$2,090.78

$1,760.09
$1,870.71
$1,987.91
$2,404.27

$313.49

Toc - Plan #5 Together with CCHP

Expanded Bronze

(EPO) Chorus Bronze HDHP

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

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

$319.50
$362.62
$408.31
$570.61
$867.09

$563.91
$607.03
$652.72
$815.02

$808.32
$851.44
$897.13
$1,059.43

$1,052.73
$1,095.85
$1,141.54
$1,303.84

$244.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$639.00
$725.24
$816.62
$1,141.22
$1,734.18

$883.41
$969.65
$1,061.03
$1,385.63

$1,127.82
$1,214.06
$1,305.44
$1,630.04

$1,372.23
$1,458.47
$1,549.85
$1,874.45

$244.41

Toc - Plan #6 Together with CCHP

Silver

(EPO) Chorus Silver Select

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family

$3,250 $6,500 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

$367.31
$416.88
$469.41
$656.00
$996.85

$648.29
$697.86
$750.39
$936.98

$929.27
$978.84
$1,031.37
$1,217.96

$1,210.25
$1,259.82
$1,312.35
$1,498.94

$280.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$734.62
$833.76
$938.82
$1,312.00
$1,993.70

$1,015.60
$1,114.74
$1,219.80
$1,592.98

$1,296.58
$1,395.72
$1,500.78
$1,873.96

$1,577.56
$1,676.70
$1,781.76
$2,154.94

$280.98

Toc - Plan #7 Together with CCHP

Catastrophic

(EPO) Chorus Catastrophic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

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

$241.33
$273.90
$308.41
$431.01
$654.95

$425.94
$458.51
$493.02
$615.62

$610.55
$643.12
$677.63
$800.23

$795.16
$827.73
$862.24
$984.84

$184.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$482.66
$547.80
$616.82
$862.02
$1,309.90

$667.27
$732.41
$801.43
$1,046.63

$851.88
$917.02
$986.04
$1,231.24

$1,036.49
$1,101.63
$1,170.65
$1,415.85

$184.61

Toc - Plan #8 Together with CCHP

Expanded Bronze

(EPO) Chorus Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

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

$323.29
$366.93
$413.16
$577.38
$877.39

$570.60
$614.24
$660.47
$824.69

$817.91
$861.55
$907.78
$1,072.00

$1,065.22
$1,108.86
$1,155.09
$1,319.31

$247.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$646.58
$733.86
$826.32
$1,154.76
$1,754.78

$893.89
$981.17
$1,073.63
$1,402.07

$1,141.20
$1,228.48
$1,320.94
$1,649.38

$1,388.51
$1,475.79
$1,568.25
$1,896.69

$247.31

Toc - Plan #9 Together with CCHP

Silver

(EPO) Chorus Silver Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

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

$409.81
$465.12
$523.72
$731.90
$1,112.19

$723.30
$778.61
$837.21
$1,045.39

$1,036.79
$1,092.10
$1,150.70
$1,358.88

$1,350.28
$1,405.59
$1,464.19
$1,672.37

$313.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$819.62
$930.24
$1,047.44
$1,463.80
$2,224.38

$1,133.11
$1,243.73
$1,360.93
$1,777.29

$1,446.60
$1,557.22
$1,674.42
$2,090.78

$1,760.09
$1,870.71
$1,987.91
$2,404.27

$313.49

Toc - Plan #10 Together with CCHP

Bronze

(EPO) Chorus Core Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

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

$272.45
$309.22
$348.18
$486.58
$739.40

$480.87
$517.64
$556.60
$695.00

$689.29
$726.06
$765.02
$903.42

$897.71
$934.48
$973.44
$1,111.84

$208.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$544.90
$618.44
$696.36
$973.16
$1,478.80

$753.32
$826.86
$904.78
$1,181.58

$961.74
$1,035.28
$1,113.20
$1,390.00

$1,170.16
$1,243.70
$1,321.62
$1,598.42

$208.42

Toc - Plan #11 Together with CCHP

Silver

(EPO) Chorus Core Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

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

$344.54
$391.04
$440.31
$615.33
$935.06

$608.11
$654.61
$703.88
$878.90

$871.68
$918.18
$967.45
$1,142.47

$1,135.25
$1,181.75
$1,231.02
$1,406.04

$263.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$689.08
$782.08
$880.62
$1,230.66
$1,870.12

$952.65
$1,045.65
$1,144.19
$1,494.23

$1,216.22
$1,309.22
$1,407.76
$1,757.80

$1,479.79
$1,572.79
$1,671.33
$2,021.37

$263.57

Toc - Plan #12 Together with CCHP

Gold

(EPO) Chorus Core Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

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

$393.49
$446.60
$502.87
$702.76
$1,067.91

$694.50
$747.61
$803.88
$1,003.77

$995.51
$1,048.62
$1,104.89
$1,304.78

$1,296.52
$1,349.63
$1,405.90
$1,605.79

$301.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$786.98
$893.20
$1,005.74
$1,405.52
$2,135.82

$1,087.99
$1,194.21
$1,306.75
$1,706.53

$1,389.00
$1,495.22
$1,607.76
$2,007.54

$1,690.01
$1,796.23
$1,908.77
$2,308.55

$301.01

HealthPartners

Local: 1-952-883-5900 | Toll Free: 1-855-813-3887 | TTY: 1-952-883-6060

Toc - Plan #13 HealthPartners

Gold

(PPO) Robin Oak $1,000 w/Copay P-S Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$8,000 $16,000 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

$459.04
$521.01
$586.65
$819.85
$1,245.83

$810.21
$872.18
$937.82
$1,171.02

$1,161.38
$1,223.35
$1,288.99
$1,522.19

$1,512.55
$1,574.52
$1,640.16
$1,873.36

$351.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$918.08
$1,042.02
$1,173.30
$1,639.70
$2,491.66

$1,269.25
$1,393.19
$1,524.47
$1,990.87

$1,620.42
$1,744.36
$1,875.64
$2,342.04

$1,971.59
$2,095.53
$2,226.81
$2,693.21

$351.17

Toc - Plan #14 HealthPartners

Expanded Bronze

(PPO) Robin Oak $6,250 Plus Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family

$6,250 $12,500 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

$322.53
$366.07
$412.19
$576.04
$875.35

$569.27
$612.81
$658.93
$822.78

$816.01
$859.55
$905.67
$1,069.52

$1,062.75
$1,106.29
$1,152.41
$1,316.26

$246.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$645.06
$732.14
$824.38
$1,152.08
$1,750.70

$891.80
$978.88
$1,071.12
$1,398.82

$1,138.54
$1,225.62
$1,317.86
$1,645.56

$1,385.28
$1,472.36
$1,564.60
$1,892.30

$246.74

Toc - Plan #15 HealthPartners

Catastrophic

(PPO) Robin Oak $9,100 Catastrophic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

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

$243.13
$275.95
$310.72
$434.23
$659.85

$429.12
$461.94
$496.71
$620.22

$615.11
$647.93
$682.70
$806.21

$801.10
$833.92
$868.69
$992.20

$185.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$486.26
$551.90
$621.44
$868.46
$1,319.70

$672.25
$737.89
$807.43
$1,054.45

$858.24
$923.88
$993.42
$1,240.44

$1,044.23
$1,109.87
$1,179.41
$1,426.43

$185.99

Toc - Plan #16 HealthPartners

Silver

(PPO) Robin Oak $3,800 Plus Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

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

$411.40
$466.94
$525.77
$734.76
$1,116.54

$726.12
$781.66
$840.49
$1,049.48

$1,040.84
$1,096.38
$1,155.21
$1,364.20

$1,355.56
$1,411.10
$1,469.93
$1,678.92

$314.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$822.80
$933.88
$1,051.54
$1,469.52
$2,233.08

$1,137.52
$1,248.60
$1,366.26
$1,784.24

$1,452.24
$1,563.32
$1,680.98
$2,098.96

$1,766.96
$1,878.04
$1,995.70
$2,413.68

$314.72

Toc - Plan #17 HealthPartners

Expanded Bronze

(PPO) Robin Oak $7,500 HSA Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$312.16
$354.30
$398.94
$557.52
$847.20

$550.96
$593.10
$637.74
$796.32

$789.76
$831.90
$876.54
$1,035.12

$1,028.56
$1,070.70
$1,115.34
$1,273.92

$238.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$624.32
$708.60
$797.88
$1,115.04
$1,694.40

$863.12
$947.40
$1,036.68
$1,353.84

$1,101.92
$1,186.20
$1,275.48
$1,592.64

$1,340.72
$1,425.00
$1,514.28
$1,831.44

$238.80

Toc - Plan #18 HealthPartners

Gold

(PPO) Robin Oak $2,000 w/Copay P-S Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

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

$443.24
$503.08
$566.46
$791.63
$1,202.95

$782.32
$842.16
$905.54
$1,130.71

$1,121.40
$1,181.24
$1,244.62
$1,469.79

$1,460.48
$1,520.32
$1,583.70
$1,808.87

$339.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$886.48
$1,006.16
$1,132.92
$1,583.26
$2,405.90

$1,225.56
$1,345.24
$1,472.00
$1,922.34

$1,564.64
$1,684.32
$1,811.08
$2,261.42

$1,903.72
$2,023.40
$2,150.16
$2,600.50

$339.08

Toc - Plan #19 HealthPartners

Silver

(PPO) Robin Oak $5,800 w/Copay P-S Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

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

$412.61
$468.31
$527.32
$736.92
$1,119.82

$728.26
$783.96
$842.97
$1,052.57

$1,043.91
$1,099.61
$1,158.62
$1,368.22

$1,359.56
$1,415.26
$1,474.27
$1,683.87

$315.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$825.22
$936.62
$1,054.64
$1,473.84
$2,239.64

$1,140.87
$1,252.27
$1,370.29
$1,789.49

$1,456.52
$1,567.92
$1,685.94
$2,105.14

$1,772.17
$1,883.57
$2,001.59
$2,420.79

$315.65

Toc - Plan #20 HealthPartners

Expanded Bronze

(PPO) Robin Oak $7,500 w/Copay P-S Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

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

$324.82
$368.67
$415.12
$580.13
$881.56

$573.31
$617.16
$663.61
$828.62

$821.80
$865.65
$912.10
$1,077.11

$1,070.29
$1,114.14
$1,160.59
$1,325.60

$248.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$649.64
$737.34
$830.24
$1,160.26
$1,763.12

$898.13
$985.83
$1,078.73
$1,408.75

$1,146.62
$1,234.32
$1,327.22
$1,657.24

$1,395.11
$1,482.81
$1,575.71
$1,905.73

$248.49

Toc - Plan #21 HealthPartners

Silver

(PPO) Robin Oak $3,500 HSA Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$7,300 $14,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$407.83
$462.89
$521.21
$728.38
$1,106.85

$719.82
$774.88
$833.20
$1,040.37

$1,031.81
$1,086.87
$1,145.19
$1,352.36

$1,343.80
$1,398.86
$1,457.18
$1,664.35

$311.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$815.66
$925.78
$1,042.42
$1,456.76
$2,213.70

$1,127.65
$1,237.77
$1,354.41
$1,768.75

$1,439.64
$1,549.76
$1,666.40
$2,080.74

$1,751.63
$1,861.75
$1,978.39
$2,392.73

$311.99

Toc - Plan #22 HealthPartners

Silver

(PPO) Robin Select $3,800 Plus Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

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

$366.17
$415.60
$467.97
$653.98
$993.79

$646.29
$695.72
$748.09
$934.10

$926.41
$975.84
$1,028.21
$1,214.22

$1,206.53
$1,255.96
$1,308.33
$1,494.34

$280.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$732.34
$831.20
$935.94
$1,307.96
$1,987.58

$1,012.46
$1,111.32
$1,216.06
$1,588.08

$1,292.58
$1,391.44
$1,496.18
$1,868.20

$1,572.70
$1,671.56
$1,776.30
$2,148.32

$280.12

Toc - Plan #23 HealthPartners

Silver

(PPO) Robin Select $5,800 w/Copay P-S Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

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

$367.22
$416.79
$469.31
$655.85
$996.64

$648.14
$697.71
$750.23
$936.77

$929.06
$978.63
$1,031.15
$1,217.69

$1,209.98
$1,259.55
$1,312.07
$1,498.61

$280.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$734.44
$833.58
$938.62
$1,311.70
$1,993.28

$1,015.36
$1,114.50
$1,219.54
$1,592.62

$1,296.28
$1,395.42
$1,500.46
$1,873.54

$1,577.20
$1,676.34
$1,781.38
$2,154.46

$280.92

Toc - Plan #24 HealthPartners

Expanded Bronze

(PPO) Robin Select $6,250 Plus Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family

$6,250 $12,500 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

$287.04
$325.79
$366.84
$512.65
$779.03

$506.63
$545.38
$586.43
$732.24

$726.22
$764.97
$806.02
$951.83

$945.81
$984.56
$1,025.61
$1,171.42

$219.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$574.08
$651.58
$733.68
$1,025.30
$1,558.06

$793.67
$871.17
$953.27
$1,244.89

$1,013.26
$1,090.76
$1,172.86
$1,464.48

$1,232.85
$1,310.35
$1,392.45
$1,684.07

$219.59

Toc - Plan #25 HealthPartners

Expanded Bronze

(PPO) Robin Select $7,500 w/Copay P-S Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

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

$289.10
$328.13
$369.47
$516.33
$784.62

$510.26
$549.29
$590.63
$737.49

$731.42
$770.45
$811.79
$958.65

$952.58
$991.61
$1,032.95
$1,179.81

$221.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.20
$656.26
$738.94
$1,032.66
$1,569.24

$799.36
$877.42
$960.10
$1,253.82

$1,020.52
$1,098.58
$1,181.26
$1,474.98

$1,241.68
$1,319.74
$1,402.42
$1,696.14

$221.16

Toc - Plan #26 HealthPartners

Silver

(PPO) Robin Select $3,500 HSA Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$7,300 $14,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$362.95
$411.95
$463.85
$648.23
$985.05

$640.61
$689.61
$741.51
$925.89

$918.27
$967.27
$1,019.17
$1,203.55

$1,195.93
$1,244.93
$1,296.83
$1,481.21

$277.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$725.90
$823.90
$927.70
$1,296.46
$1,970.10

$1,003.56
$1,101.56
$1,205.36
$1,574.12

$1,281.22
$1,379.22
$1,483.02
$1,851.78

$1,558.88
$1,656.88
$1,760.68
$2,129.44

$277.66

Toc - Plan #27 HealthPartners

Expanded Bronze

(PPO) Robin Select $7,500 HSA Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$277.84
$315.35
$355.08
$496.22
$754.06

$490.39
$527.90
$567.63
$708.77

$702.94
$740.45
$780.18
$921.32

$915.49
$953.00
$992.73
$1,133.87

$212.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$555.68
$630.70
$710.16
$992.44
$1,508.12

$768.23
$843.25
$922.71
$1,204.99

$980.78
$1,055.80
$1,135.26
$1,417.54

$1,193.33
$1,268.35
$1,347.81
$1,630.09

$212.55

Toc - Plan #28 HealthPartners

Catastrophic

(PPO) Robin Select $9,100 Catastrophic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-813-3887

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

$216.38
$245.59
$276.53
$386.45
$587.26

$381.91
$411.12
$442.06
$551.98

$547.44
$576.65
$607.59
$717.51

$712.97
$742.18
$773.12
$883.04

$165.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$432.76
$491.18
$553.06
$772.90
$1,174.52

$598.29
$656.71
$718.59
$938.43

$763.82
$822.24
$884.12
$1,103.96

$929.35
$987.77
$1,049.65
$1,269.49

$165.53

Quartz

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310 | TTY: 1-800-877-8973

Toc - Plan #29 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$405.64
$460.39
$518.40
$724.46
$1,100.89

$715.95
$770.70
$828.71
$1,034.77

$1,026.26
$1,081.01
$1,139.02
$1,345.08

$1,336.57
$1,391.32
$1,449.33
$1,655.39

$310.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$811.28
$920.78
$1,036.80
$1,448.92
$2,201.78

$1,121.59
$1,231.09
$1,347.11
$1,759.23

$1,431.90
$1,541.40
$1,657.42
$2,069.54

$1,742.21
$1,851.71
$1,967.73
$2,379.85

$310.31

Toc - Plan #30 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$401.83
$456.08
$513.54
$717.67
$1,090.57

$709.23
$763.48
$820.94
$1,025.07

$1,016.63
$1,070.88
$1,128.34
$1,332.47

$1,324.03
$1,378.28
$1,435.74
$1,639.87

$307.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$803.66
$912.16
$1,027.08
$1,435.34
$2,181.14

$1,111.06
$1,219.56
$1,334.48
$1,742.74

$1,418.46
$1,526.96
$1,641.88
$2,050.14

$1,725.86
$1,834.36
$1,949.28
$2,357.54

$307.40

Toc - Plan #31 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$6,000 $12,000 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

$405.18
$459.87
$517.81
$723.63
$1,099.63

$715.14
$769.83
$827.77
$1,033.59

$1,025.10
$1,079.79
$1,137.73
$1,343.55

$1,335.06
$1,389.75
$1,447.69
$1,653.51

$309.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$810.36
$919.74
$1,035.62
$1,447.26
$2,199.26

$1,120.32
$1,229.70
$1,345.58
$1,757.22

$1,430.28
$1,539.66
$1,655.54
$2,067.18

$1,740.24
$1,849.62
$1,965.50
$2,377.14

$309.96

Toc - Plan #32 Quartz

Gold

(HMO) Quartz One with Aurora Health Care Gold I410 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$415.55
$471.64
$531.07
$742.17
$1,127.79

$733.44
$789.53
$848.96
$1,060.06

$1,051.33
$1,107.42
$1,166.85
$1,377.95

$1,369.22
$1,425.31
$1,484.74
$1,695.84

$317.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$831.10
$943.28
$1,062.14
$1,484.34
$2,255.58

$1,148.99
$1,261.17
$1,380.03
$1,802.23

$1,466.88
$1,579.06
$1,697.92
$2,120.12

$1,784.77
$1,896.95
$2,015.81
$2,438.01

$317.89

Toc - Plan #33 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$417.53
$473.89
$533.59
$745.69
$1,133.15

$736.93
$793.29
$852.99
$1,065.09

$1,056.33
$1,112.69
$1,172.39
$1,384.49

$1,375.73
$1,432.09
$1,491.79
$1,703.89

$319.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$835.06
$947.78
$1,067.18
$1,491.38
$2,266.30

$1,154.46
$1,267.18
$1,386.58
$1,810.78

$1,473.86
$1,586.58
$1,705.98
$2,130.18

$1,793.26
$1,905.98
$2,025.38
$2,449.58

$319.40

Toc - Plan #34 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$413.99
$469.88
$529.08
$739.38
$1,123.56

$730.69
$786.58
$845.78
$1,056.08

$1,047.39
$1,103.28
$1,162.48
$1,372.78

$1,364.09
$1,419.98
$1,479.18
$1,689.48

$316.70

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$827.98
$939.76
$1,058.16
$1,478.76
$2,247.12

$1,144.68
$1,256.46
$1,374.86
$1,795.46

$1,461.38
$1,573.16
$1,691.56
$2,112.16

$1,778.08
$1,889.86
$2,008.26
$2,428.86

$316.70

Toc - Plan #35 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

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

$434.36
$492.99
$555.10
$775.75
$1,178.83

$766.64
$825.27
$887.38
$1,108.03

$1,098.92
$1,157.55
$1,219.66
$1,440.31

$1,431.20
$1,489.83
$1,551.94
$1,772.59

$332.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$868.72
$985.98
$1,110.20
$1,551.50
$2,357.66

$1,201.00
$1,318.26
$1,442.48
$1,883.78

$1,533.28
$1,650.54
$1,774.76
$2,216.06

$1,865.56
$1,982.82
$2,107.04
$2,548.34

$332.28

Toc - Plan #36 Quartz

Silver

(HMO) Quartz One with Aurora Health Care Silver I309 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$454.92
$516.33
$581.38
$812.48
$1,234.64

$802.93
$864.34
$929.39
$1,160.49

$1,150.94
$1,212.35
$1,277.40
$1,508.50

$1,498.95
$1,560.36
$1,625.41
$1,856.51

$348.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$909.84
$1,032.66
$1,162.76
$1,624.96
$2,469.28

$1,257.85
$1,380.67
$1,510.77
$1,972.97

$1,605.86
$1,728.68
$1,858.78
$2,320.98

$1,953.87
$2,076.69
$2,206.79
$2,668.99

$348.01

Toc - Plan #37 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$307.91
$349.47
$393.50
$549.92
$835.65

$543.46
$585.02
$629.05
$785.47

$779.01
$820.57
$864.60
$1,021.02

$1,014.56
$1,056.12
$1,100.15
$1,256.57

$235.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$615.82
$698.94
$787.00
$1,099.84
$1,671.30

$851.37
$934.49
$1,022.55
$1,335.39

$1,086.92
$1,170.04
$1,258.10
$1,570.94

$1,322.47
$1,405.59
$1,493.65
$1,806.49

$235.55

Toc - Plan #38 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$310.96
$352.93
$397.40
$555.36
$843.92

$548.84
$590.81
$635.28
$793.24

$786.72
$828.69
$873.16
$1,031.12

$1,024.60
$1,066.57
$1,111.04
$1,269.00

$237.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$621.92
$705.86
$794.80
$1,110.72
$1,687.84

$859.80
$943.74
$1,032.68
$1,348.60

$1,097.68
$1,181.62
$1,270.56
$1,586.48

$1,335.56
$1,419.50
$1,508.44
$1,824.36

$237.88

Toc - Plan #39 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 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

$325.95
$369.94
$416.55
$582.13
$884.61

$575.30
$619.29
$665.90
$831.48

$824.65
$868.64
$915.25
$1,080.83

$1,074.00
$1,117.99
$1,164.60
$1,330.18

$249.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$651.90
$739.88
$833.10
$1,164.26
$1,769.22

$901.25
$989.23
$1,082.45
$1,413.61

$1,150.60
$1,238.58
$1,331.80
$1,662.96

$1,399.95
$1,487.93
$1,581.15
$1,912.31

$249.35

Toc - Plan #40 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$322.62
$366.16
$412.30
$576.18
$875.57

$569.42
$612.96
$659.10
$822.98

$816.22
$859.76
$905.90
$1,069.78

$1,063.02
$1,106.56
$1,152.70
$1,316.58

$246.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$645.24
$732.32
$824.60
$1,152.36
$1,751.14

$892.04
$979.12
$1,071.40
$1,399.16

$1,138.84
$1,225.92
$1,318.20
$1,645.96

$1,385.64
$1,472.72
$1,565.00
$1,892.76

$246.80

Toc - Plan #41 Quartz

Expanded Bronze

(HMO) Quartz One with Aurora Health Care Bronze I206 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$335.90
$381.24
$429.27
$599.90
$911.61

$592.86
$638.20
$686.23
$856.86

$849.82
$895.16
$943.19
$1,113.82

$1,106.78
$1,152.12
$1,200.15
$1,370.78

$256.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$671.80
$762.48
$858.54
$1,199.80
$1,823.22

$928.76
$1,019.44
$1,115.50
$1,456.76

$1,185.72
$1,276.40
$1,372.46
$1,713.72

$1,442.68
$1,533.36
$1,629.42
$1,970.68

$256.96

Toc - Plan #42 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$387.65
$439.98
$495.42
$692.34
$1,052.08

$684.20
$736.53
$791.97
$988.89

$980.75
$1,033.08
$1,088.52
$1,285.44

$1,277.30
$1,329.63
$1,385.07
$1,581.99

$296.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$775.30
$879.96
$990.84
$1,384.68
$2,104.16

$1,071.85
$1,176.51
$1,287.39
$1,681.23

$1,368.40
$1,473.06
$1,583.94
$1,977.78

$1,664.95
$1,769.61
$1,880.49
$2,274.33

$296.55

Toc - Plan #43 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$8,000 $16,000 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

$384.02
$435.86
$490.77
$685.85
$1,042.21

$677.79
$729.63
$784.54
$979.62

$971.56
$1,023.40
$1,078.31
$1,273.39

$1,265.33
$1,317.17
$1,372.08
$1,567.16

$293.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$768.04
$871.72
$981.54
$1,371.70
$2,084.42

$1,061.81
$1,165.49
$1,275.31
$1,665.47

$1,355.58
$1,459.26
$1,569.08
$1,959.24

$1,649.35
$1,753.03
$1,862.85
$2,253.01

$293.77

Toc - Plan #44 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$6,000 $12,000 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

$387.21
$439.48
$494.85
$691.55
$1,050.88

$683.42
$735.69
$791.06
$987.76

$979.63
$1,031.90
$1,087.27
$1,283.97

$1,275.84
$1,328.11
$1,383.48
$1,580.18

$296.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$774.42
$878.96
$989.70
$1,383.10
$2,101.76

$1,070.63
$1,175.17
$1,285.91
$1,679.31

$1,366.84
$1,471.38
$1,582.12
$1,975.52

$1,663.05
$1,767.59
$1,878.33
$2,271.73

$296.21

Toc - Plan #45 Quartz

Gold

(HMO) Quartz One with Aurora Health Care Gold I410 Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$397.13
$450.73
$507.52
$709.26
$1,077.79

$700.93
$754.53
$811.32
$1,013.06

$1,004.73
$1,058.33
$1,115.12
$1,316.86

$1,308.53
$1,362.13
$1,418.92
$1,620.66

$303.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$794.26
$901.46
$1,015.04
$1,418.52
$2,155.58

$1,098.06
$1,205.26
$1,318.84
$1,722.32

$1,401.86
$1,509.06
$1,622.64
$2,026.12

$1,705.66
$1,812.86
$1,926.44
$2,329.92

$303.80

Toc - Plan #46 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$399.02
$452.88
$509.94
$712.63
$1,082.91

$704.26
$758.12
$815.18
$1,017.87

$1,009.50
$1,063.36
$1,120.42
$1,323.11

$1,314.74
$1,368.60
$1,425.66
$1,628.35

$305.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$798.04
$905.76
$1,019.88
$1,425.26
$2,165.82

$1,103.28
$1,211.00
$1,325.12
$1,730.50

$1,408.52
$1,516.24
$1,630.36
$2,035.74

$1,713.76
$1,821.48
$1,935.60
$2,340.98

$305.24

Toc - Plan #47 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$395.64
$449.04
$505.62
$706.60
$1,073.75

$698.30
$751.70
$808.28
$1,009.26

$1,000.96
$1,054.36
$1,110.94
$1,311.92

$1,303.62
$1,357.02
$1,413.60
$1,614.58

$302.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$791.28
$898.08
$1,011.24
$1,413.20
$2,147.50

$1,093.94
$1,200.74
$1,313.90
$1,715.86

$1,396.60
$1,503.40
$1,616.56
$2,018.52

$1,699.26
$1,806.06
$1,919.22
$2,321.18

$302.66

Toc - Plan #48 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

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

$415.10
$471.13
$530.49
$741.36
$1,126.56

$732.65
$788.68
$848.04
$1,058.91

$1,050.20
$1,106.23
$1,165.59
$1,376.46

$1,367.75
$1,423.78
$1,483.14
$1,694.01

$317.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$830.20
$942.26
$1,060.98
$1,482.72
$2,253.12

$1,147.75
$1,259.81
$1,378.53
$1,800.27

$1,465.30
$1,577.36
$1,696.08
$2,117.82

$1,782.85
$1,894.91
$2,013.63
$2,435.37

$317.55

Toc - Plan #49 Quartz

Silver

(HMO) Quartz One with Aurora Health Care Silver I309 Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$434.75
$493.44
$555.61
$776.46
$1,179.90

$767.33
$826.02
$888.19
$1,109.04

$1,099.91
$1,158.60
$1,220.77
$1,441.62

$1,432.49
$1,491.18
$1,553.35
$1,774.20

$332.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$869.50
$986.88
$1,111.22
$1,552.92
$2,359.80

$1,202.08
$1,319.46
$1,443.80
$1,885.50

$1,534.66
$1,652.04
$1,776.38
$2,218.08

$1,867.24
$1,984.62
$2,108.96
$2,550.66

$332.58

Toc - Plan #50 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$294.26
$333.98
$376.06
$525.54
$798.60

$519.36
$559.08
$601.16
$750.64

$744.46
$784.18
$826.26
$975.74

$969.56
$1,009.28
$1,051.36
$1,200.84

$225.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$588.52
$667.96
$752.12
$1,051.08
$1,597.20

$813.62
$893.06
$977.22
$1,276.18

$1,038.72
$1,118.16
$1,202.32
$1,501.28

$1,263.82
$1,343.26
$1,427.42
$1,726.38

$225.10

Toc - Plan #51 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$297.17
$337.28
$379.78
$530.74
$806.51

$524.50
$564.61
$607.11
$758.07

$751.83
$791.94
$834.44
$985.40

$979.16
$1,019.27
$1,061.77
$1,212.73

$227.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.34
$674.56
$759.56
$1,061.48
$1,613.02

$821.67
$901.89
$986.89
$1,288.81

$1,049.00
$1,129.22
$1,214.22
$1,516.14

$1,276.33
$1,356.55
$1,441.55
$1,743.47

$227.33

Toc - Plan #52 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 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

$311.50
$353.54
$398.09
$556.32
$845.39

$549.79
$591.83
$636.38
$794.61

$788.08
$830.12
$874.67
$1,032.90

$1,026.37
$1,068.41
$1,112.96
$1,271.19

$238.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$623.00
$707.08
$796.18
$1,112.64
$1,690.78

$861.29
$945.37
$1,034.47
$1,350.93

$1,099.58
$1,183.66
$1,272.76
$1,589.22

$1,337.87
$1,421.95
$1,511.05
$1,827.51

$238.29

Toc - Plan #53 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$308.31
$349.93
$394.02
$550.64
$836.75

$544.17
$585.79
$629.88
$786.50

$780.03
$821.65
$865.74
$1,022.36

$1,015.89
$1,057.51
$1,101.60
$1,258.22

$235.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$616.62
$699.86
$788.04
$1,101.28
$1,673.50

$852.48
$935.72
$1,023.90
$1,337.14

$1,088.34
$1,171.58
$1,259.76
$1,573.00

$1,324.20
$1,407.44
$1,495.62
$1,808.86

$235.86

Toc - Plan #54 Quartz

Expanded Bronze

(HMO) Quartz One with Aurora Health Care Bronze I206 Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$321.01
$364.34
$410.24
$573.31
$871.19

$566.58
$609.91
$655.81
$818.88

$812.15
$855.48
$901.38
$1,064.45

$1,057.72
$1,101.05
$1,146.95
$1,310.02

$245.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$642.02
$728.68
$820.48
$1,146.62
$1,742.38

$887.59
$974.25
$1,066.05
$1,392.19

$1,133.16
$1,219.82
$1,311.62
$1,637.76

$1,378.73
$1,465.39
$1,557.19
$1,883.33

$245.57

Toc - Plan #55 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I403 HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$3,500 $7,000 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

$411.41
$466.95
$525.78
$734.77
$1,116.56

$726.14
$781.68
$840.51
$1,049.50

$1,040.87
$1,096.41
$1,155.24
$1,364.23

$1,355.60
$1,411.14
$1,469.97
$1,678.96

$314.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$822.82
$933.90
$1,051.56
$1,469.54
$2,233.12

$1,137.55
$1,248.63
$1,366.29
$1,784.27

$1,452.28
$1,563.36
$1,681.02
$2,099.00

$1,767.01
$1,878.09
$1,995.75
$2,413.73

$314.73

Toc - Plan #56 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I304 HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$437.10
$496.11
$558.61
$780.66
$1,186.28

$771.48
$830.49
$892.99
$1,115.04

$1,105.86
$1,164.87
$1,227.37
$1,449.42

$1,440.24
$1,499.25
$1,561.75
$1,783.80

$334.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$874.20
$992.22
$1,117.22
$1,561.32
$2,372.56

$1,208.58
$1,326.60
$1,451.60
$1,895.70

$1,542.96
$1,660.98
$1,785.98
$2,230.08

$1,877.34
$1,995.36
$2,120.36
$2,564.46

$334.38

Toc - Plan #57 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 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

$309.23
$350.97
$395.19
$552.28
$839.25

$545.79
$587.53
$631.75
$788.84

$782.35
$824.09
$868.31
$1,025.40

$1,018.91
$1,060.65
$1,104.87
$1,261.96

$236.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$618.46
$701.94
$790.38
$1,104.56
$1,678.50

$855.02
$938.50
$1,026.94
$1,341.12

$1,091.58
$1,175.06
$1,263.50
$1,577.68

$1,328.14
$1,411.62
$1,500.06
$1,814.24

$236.56

Toc - Plan #58 Quartz

Catastrophic

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE CATASTROPHIC I101

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$227.96
$258.73
$291.33
$407.13
$618.68

$402.35
$433.12
$465.72
$581.52

$576.74
$607.51
$640.11
$755.91

$751.13
$781.90
$814.50
$930.30

$174.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$455.92
$517.46
$582.66
$814.26
$1,237.36

$630.31
$691.85
$757.05
$988.65

$804.70
$866.24
$931.44
$1,163.04

$979.09
$1,040.63
$1,105.83
$1,337.43

$174.39

Toc - Plan #59 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$6,000 $12,000 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

$439.01
$498.27
$561.05
$784.06
$1,191.45

$774.85
$834.11
$896.89
$1,119.90

$1,110.69
$1,169.95
$1,232.73
$1,455.74

$1,446.53
$1,505.79
$1,568.57
$1,791.58

$335.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$878.02
$996.54
$1,122.10
$1,568.12
$2,382.90

$1,213.86
$1,332.38
$1,457.94
$1,903.96

$1,549.70
$1,668.22
$1,793.78
$2,239.80

$1,885.54
$2,004.06
$2,129.62
$2,575.64

$335.84

Toc - Plan #60 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$392.16
$445.09
$501.17
$700.38
$1,064.30

$692.16
$745.09
$801.17
$1,000.38

$992.16
$1,045.09
$1,101.17
$1,300.38

$1,292.16
$1,345.09
$1,401.17
$1,600.38

$300.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$784.32
$890.18
$1,002.34
$1,400.76
$2,128.60

$1,084.32
$1,190.18
$1,302.34
$1,700.76

$1,384.32
$1,490.18
$1,602.34
$2,000.76

$1,684.32
$1,790.18
$1,902.34
$2,300.76

$300.00

Toc - Plan #61 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$8,000 $16,000 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

$388.48
$440.92
$496.47
$693.82
$1,054.32

$685.66
$738.10
$793.65
$991.00

$982.84
$1,035.28
$1,090.83
$1,288.18

$1,280.02
$1,332.46
$1,388.01
$1,585.36

$297.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$776.96
$881.84
$992.94
$1,387.64
$2,108.64

$1,074.14
$1,179.02
$1,290.12
$1,684.82

$1,371.32
$1,476.20
$1,587.30
$1,982.00

$1,668.50
$1,773.38
$1,884.48
$2,279.18

$297.18

Toc - Plan #62 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$391.71
$444.58
$500.60
$699.58
$1,063.09

$691.36
$744.23
$800.25
$999.23

$991.01
$1,043.88
$1,099.90
$1,298.88

$1,290.66
$1,343.53
$1,399.55
$1,598.53

$299.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$783.42
$889.16
$1,001.20
$1,399.16
$2,126.18

$1,083.07
$1,188.81
$1,300.85
$1,698.81

$1,382.72
$1,488.46
$1,600.50
$1,998.46

$1,682.37
$1,788.11
$1,900.15
$2,298.11

$299.65

Toc - Plan #63 Quartz

Gold

(HMO) Quartz One with Aurora Health Care Gold I410 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$401.74
$455.97
$513.42
$717.50
$1,090.31

$709.07
$763.30
$820.75
$1,024.83

$1,016.40
$1,070.63
$1,128.08
$1,332.16

$1,323.73
$1,377.96
$1,435.41
$1,639.49

$307.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$803.48
$911.94
$1,026.84
$1,435.00
$2,180.62

$1,110.81
$1,219.27
$1,334.17
$1,742.33

$1,418.14
$1,526.60
$1,641.50
$2,049.66

$1,725.47
$1,833.93
$1,948.83
$2,356.99

$307.33

Toc - Plan #64 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$403.65
$458.14
$515.86
$720.91
$1,095.49

$712.44
$766.93
$824.65
$1,029.70

$1,021.23
$1,075.72
$1,133.44
$1,338.49

$1,330.02
$1,384.51
$1,442.23
$1,647.28

$308.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$807.30
$916.28
$1,031.72
$1,441.82
$2,190.98

$1,116.09
$1,225.07
$1,340.51
$1,750.61

$1,424.88
$1,533.86
$1,649.30
$2,059.40

$1,733.67
$1,842.65
$1,958.09
$2,368.19

$308.79

Toc - Plan #65 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$400.23
$454.26
$511.49
$714.81
$1,086.22

$706.41
$760.44
$817.67
$1,020.99

$1,012.59
$1,066.62
$1,123.85
$1,327.17

$1,318.77
$1,372.80
$1,430.03
$1,633.35

$306.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$800.46
$908.52
$1,022.98
$1,429.62
$2,172.44

$1,106.64
$1,214.70
$1,329.16
$1,735.80

$1,412.82
$1,520.88
$1,635.34
$2,041.98

$1,719.00
$1,827.06
$1,941.52
$2,348.16

$306.18

Toc - Plan #66 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

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

$419.92
$476.60
$536.65
$749.97
$1,139.65

$741.15
$797.83
$857.88
$1,071.20

$1,062.38
$1,119.06
$1,179.11
$1,392.43

$1,383.61
$1,440.29
$1,500.34
$1,713.66

$321.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$839.84
$953.20
$1,073.30
$1,499.94
$2,279.30

$1,161.07
$1,274.43
$1,394.53
$1,821.17

$1,482.30
$1,595.66
$1,715.76
$2,142.40

$1,803.53
$1,916.89
$2,036.99
$2,463.63

$321.23

Toc - Plan #67 Quartz

Silver

(HMO) Quartz One with Aurora Health Care Silver I309 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$439.80
$499.17
$562.06
$785.48
$1,193.61

$776.24
$835.61
$898.50
$1,121.92

$1,112.68
$1,172.05
$1,234.94
$1,458.36

$1,449.12
$1,508.49
$1,571.38
$1,794.80

$336.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$879.60
$998.34
$1,124.12
$1,570.96
$2,387.22

$1,216.04
$1,334.78
$1,460.56
$1,907.40

$1,552.48
$1,671.22
$1,797.00
$2,243.84

$1,888.92
$2,007.66
$2,133.44
$2,580.28

$336.44

Toc - Plan #68 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$297.68
$337.86
$380.42
$531.64
$807.88

$525.40
$565.58
$608.14
$759.36

$753.12
$793.30
$835.86
$987.08

$980.84
$1,021.02
$1,063.58
$1,214.80

$227.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$595.36
$675.72
$760.84
$1,063.28
$1,615.76

$823.08
$903.44
$988.56
$1,291.00

$1,050.80
$1,131.16
$1,216.28
$1,518.72

$1,278.52
$1,358.88
$1,444.00
$1,746.44

$227.72

Toc - Plan #69 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$300.62
$341.20
$384.19
$536.90
$815.87

$530.59
$571.17
$614.16
$766.87

$760.56
$801.14
$844.13
$996.84

$990.53
$1,031.11
$1,074.10
$1,226.81

$229.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$601.24
$682.40
$768.38
$1,073.80
$1,631.74

$831.21
$912.37
$998.35
$1,303.77

$1,061.18
$1,142.34
$1,228.32
$1,533.74

$1,291.15
$1,372.31
$1,458.29
$1,763.71

$229.97

Toc - Plan #70 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 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

$315.11
$357.65
$402.71
$562.79
$855.21

$556.17
$598.71
$643.77
$803.85

$797.23
$839.77
$884.83
$1,044.91

$1,038.29
$1,080.83
$1,125.89
$1,285.97

$241.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$630.22
$715.30
$805.42
$1,125.58
$1,710.42

$871.28
$956.36
$1,046.48
$1,366.64

$1,112.34
$1,197.42
$1,287.54
$1,607.70

$1,353.40
$1,438.48
$1,528.60
$1,848.76

$241.06

Toc - Plan #71 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$311.89
$353.99
$398.59
$557.03
$846.47

$550.49
$592.59
$637.19
$795.63

$789.09
$831.19
$875.79
$1,034.23

$1,027.69
$1,069.79
$1,114.39
$1,272.83

$238.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$623.78
$707.98
$797.18
$1,114.06
$1,692.94

$862.38
$946.58
$1,035.78
$1,352.66

$1,100.98
$1,185.18
$1,274.38
$1,591.26

$1,339.58
$1,423.78
$1,512.98
$1,829.86

$238.60

Toc - Plan #72 Quartz

Expanded Bronze

(HMO) Quartz One with Aurora Health Care Bronze I206 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$324.73
$368.57
$415.00
$579.97
$881.31

$573.15
$616.99
$663.42
$828.39

$821.57
$865.41
$911.84
$1,076.81

$1,069.99
$1,113.83
$1,160.26
$1,325.23

$248.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$649.46
$737.14
$830.00
$1,159.94
$1,762.62

$897.88
$985.56
$1,078.42
$1,408.36

$1,146.30
$1,233.98
$1,326.84
$1,656.78

$1,394.72
$1,482.40
$1,575.26
$1,905.20

$248.42

Toc - Plan #73 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I403 HSA with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$3,500 $7,000 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

$416.19
$472.37
$531.89
$743.31
$1,129.53

$734.57
$790.75
$850.27
$1,061.69

$1,052.95
$1,109.13
$1,168.65
$1,380.07

$1,371.33
$1,427.51
$1,487.03
$1,698.45

$318.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$832.38
$944.74
$1,063.78
$1,486.62
$2,259.06

$1,150.76
$1,263.12
$1,382.16
$1,805.00

$1,469.14
$1,581.50
$1,700.54
$2,123.38

$1,787.52
$1,899.88
$2,018.92
$2,441.76

$318.38

Toc - Plan #74 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I304 HSA with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$442.18
$501.87
$565.10
$789.73
$1,200.06

$780.44
$840.13
$903.36
$1,127.99

$1,118.70
$1,178.39
$1,241.62
$1,466.25

$1,456.96
$1,516.65
$1,579.88
$1,804.51

$338.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$884.36
$1,003.74
$1,130.20
$1,579.46
$2,400.12

$1,222.62
$1,342.00
$1,468.46
$1,917.72

$1,560.88
$1,680.26
$1,806.72
$2,255.98

$1,899.14
$2,018.52
$2,144.98
$2,594.24

$338.26

Toc - Plan #75 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$444.11
$504.06
$567.56
$793.17
$1,205.29

$783.85
$843.80
$907.30
$1,132.91

$1,123.59
$1,183.54
$1,247.04
$1,472.65

$1,463.33
$1,523.28
$1,586.78
$1,812.39

$339.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$888.22
$1,008.12
$1,135.12
$1,586.34
$2,410.58

$1,227.96
$1,347.86
$1,474.86
$1,926.08

$1,567.70
$1,687.60
$1,814.60
$2,265.82

$1,907.44
$2,027.34
$2,154.34
$2,605.56

$339.74

Toc - Plan #76 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 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

$312.83
$355.05
$399.78
$558.70
$849.00

$552.14
$594.36
$639.09
$798.01

$791.45
$833.67
$878.40
$1,037.32

$1,030.76
$1,072.98
$1,117.71
$1,276.63

$239.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$625.66
$710.10
$799.56
$1,117.40
$1,698.00

$864.97
$949.41
$1,038.87
$1,356.71

$1,104.28
$1,188.72
$1,278.18
$1,596.02

$1,343.59
$1,428.03
$1,517.49
$1,835.33

$239.31

Molina Healthcare

Local: 1-888-560-2043 | Toll Free: 1-888-560-2043

Toc - Plan #77 Molina Healthcare

Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$449.08
$509.71
$573.93
$802.06
$1,218.81

$792.63
$853.26
$917.48
$1,145.61

$1,136.18
$1,196.81
$1,261.03
$1,489.16

$1,479.73
$1,540.36
$1,604.58
$1,832.71

$343.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$898.16
$1,019.42
$1,147.86
$1,604.12
$2,437.62

$1,241.71
$1,362.97
$1,491.41
$1,947.67

$1,585.26
$1,706.52
$1,834.96
$2,291.22

$1,928.81
$2,050.07
$2,178.51
$2,634.77

$343.55

Toc - Plan #78 Molina Healthcare

Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$2,500 $5,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$376.98
$427.87
$481.78
$673.28
$1,023.12

$665.37
$716.26
$770.17
$961.67

$953.76
$1,004.65
$1,058.56
$1,250.06

$1,242.15
$1,293.04
$1,346.95
$1,538.45

$288.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$753.96
$855.74
$963.56
$1,346.56
$2,046.24

$1,042.35
$1,144.13
$1,251.95
$1,634.95

$1,330.74
$1,432.52
$1,540.34
$1,923.34

$1,619.13
$1,720.91
$1,828.73
$2,211.73

$288.39

Toc - Plan #79 Molina Healthcare

Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

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

$458.76
$520.69
$586.29
$819.34
$1,245.06

$809.71
$871.64
$937.24
$1,170.29

$1,160.66
$1,222.59
$1,288.19
$1,521.24

$1,511.61
$1,573.54
$1,639.14
$1,872.19

$350.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$917.52
$1,041.38
$1,172.58
$1,638.68
$2,490.12

$1,268.47
$1,392.33
$1,523.53
$1,989.63

$1,619.42
$1,743.28
$1,874.48
$2,340.58

$1,970.37
$2,094.23
$2,225.43
$2,691.53

$350.95

Toc - Plan #80 Molina Healthcare

Silver

(HMO) Constant Care Silver 8

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

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

$387.69
$440.03
$495.47
$692.42
$1,052.19

$684.27
$736.61
$792.05
$989.00

$980.85
$1,033.19
$1,088.63
$1,285.58

$1,277.43
$1,329.77
$1,385.21
$1,582.16

$296.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$775.38
$880.06
$990.94
$1,384.84
$2,104.38

$1,071.96
$1,176.64
$1,287.52
$1,681.42

$1,368.54
$1,473.22
$1,584.10
$1,978.00

$1,665.12
$1,769.80
$1,880.68
$2,274.58

$296.58

Toc - Plan #81 Molina Healthcare

Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$453.33
$514.52
$579.35
$809.64
$1,230.33

$800.12
$861.31
$926.14
$1,156.43

$1,146.91
$1,208.10
$1,272.93
$1,503.22

$1,493.70
$1,554.89
$1,619.72
$1,850.01

$346.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$906.66
$1,029.04
$1,158.70
$1,619.28
$2,460.66

$1,253.45
$1,375.83
$1,505.49
$1,966.07

$1,600.24
$1,722.62
$1,852.28
$2,312.86

$1,947.03
$2,069.41
$2,199.07
$2,659.65

$346.79

Toc - Plan #82 Molina Healthcare

Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$2,500 $5,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$387.27
$439.55
$494.93
$691.66
$1,051.05

$683.53
$735.81
$791.19
$987.92

$979.79
$1,032.07
$1,087.45
$1,284.18

$1,276.05
$1,328.33
$1,383.71
$1,580.44

$296.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$774.54
$879.10
$989.86
$1,383.32
$2,102.10

$1,070.80
$1,175.36
$1,286.12
$1,679.58

$1,367.06
$1,471.62
$1,582.38
$1,975.84

$1,663.32
$1,767.88
$1,878.64
$2,272.10

$296.26

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1813 | Toll Free: 1-855-748-1813

Toc - Plan #83 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$337.56
$383.13
$431.40
$602.88
$916.14

$595.79
$641.36
$689.63
$861.11

$854.02
$899.59
$947.86
$1,119.34

$1,112.25
$1,157.82
$1,206.09
$1,377.57

$258.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$675.12
$766.26
$862.80
$1,205.76
$1,832.28

$933.35
$1,024.49
$1,121.03
$1,463.99

$1,191.58
$1,282.72
$1,379.26
$1,722.22

$1,449.81
$1,540.95
$1,637.49
$1,980.45

$258.23

Toc - Plan #84 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$327.30
$371.49
$418.29
$584.56
$888.29

$577.68
$621.87
$668.67
$834.94

$828.06
$872.25
$919.05
$1,085.32

$1,078.44
$1,122.63
$1,169.43
$1,335.70

$250.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$654.60
$742.98
$836.58
$1,169.12
$1,776.58

$904.98
$993.36
$1,086.96
$1,419.50

$1,155.36
$1,243.74
$1,337.34
$1,669.88

$1,405.74
$1,494.12
$1,587.72
$1,920.26

$250.38

Toc - Plan #85 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 6550 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$6,550 $13,100 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$321.43
$364.82
$410.79
$574.07
$872.36

$567.32
$610.71
$656.68
$819.96

$813.21
$856.60
$902.57
$1,065.85

$1,059.10
$1,102.49
$1,148.46
$1,311.74

$245.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$642.86
$729.64
$821.58
$1,148.14
$1,744.72

$888.75
$975.53
$1,067.47
$1,394.03

$1,134.64
$1,221.42
$1,313.36
$1,639.92

$1,380.53
$1,467.31
$1,559.25
$1,885.81

$245.89

Toc - Plan #86 Anthem Blue Cross and Blue Shield

Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$304.67
$345.80
$389.37
$544.14
$826.87

$537.74
$578.87
$622.44
$777.21

$770.81
$811.94
$855.51
$1,010.28

$1,003.88
$1,045.01
$1,088.58
$1,243.35

$233.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$609.34
$691.60
$778.74
$1,088.28
$1,653.74

$842.41
$924.67
$1,011.81
$1,321.35

$1,075.48
$1,157.74
$1,244.88
$1,554.42

$1,308.55
$1,390.81
$1,477.95
$1,787.49

$233.07

Toc - Plan #87 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$320.77
$364.07
$409.94
$572.90
$870.57

$566.16
$609.46
$655.33
$818.29

$811.55
$854.85
$900.72
$1,063.68

$1,056.94
$1,100.24
$1,146.11
$1,309.07

$245.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$641.54
$728.14
$819.88
$1,145.80
$1,741.14

$886.93
$973.53
$1,065.27
$1,391.19

$1,132.32
$1,218.92
$1,310.66
$1,636.58

$1,377.71
$1,464.31
$1,556.05
$1,881.97

$245.39

Toc - Plan #88 Anthem Blue Cross and Blue Shield

Gold

(HMO) Anthem Gold Blue Preferred/Broad 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 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

$416.09
$472.26
$531.76
$743.14
$1,129.27

$734.40
$790.57
$850.07
$1,061.45

$1,052.71
$1,108.88
$1,168.38
$1,379.76

$1,371.02
$1,427.19
$1,486.69
$1,698.07

$318.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$832.18
$944.52
$1,063.52
$1,486.28
$2,258.54

$1,150.49
$1,262.83
$1,381.83
$1,804.59

$1,468.80
$1,581.14
$1,700.14
$2,122.90

$1,787.11
$1,899.45
$2,018.45
$2,441.21

$318.31

Toc - Plan #89 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Blue Preferred/Broad 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$401.73
$455.96
$513.41
$717.49
$1,090.30

$709.05
$763.28
$820.73
$1,024.81

$1,016.37
$1,070.60
$1,128.05
$1,332.13

$1,323.69
$1,377.92
$1,435.37
$1,639.45

$307.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$803.46
$911.92
$1,026.82
$1,434.98
$2,180.60

$1,110.78
$1,219.24
$1,334.14
$1,742.30

$1,418.10
$1,526.56
$1,641.46
$2,049.62

$1,725.42
$1,833.88
$1,948.78
$2,356.94

$307.32

Toc - Plan #90 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Blue Preferred/Broad 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$4,100 $8,200 Annual Deductible

$7,250 $14,500 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

$406.56
$461.45
$519.58
$726.12
$1,103.40

$717.58
$772.47
$830.60
$1,037.14

$1,028.60
$1,083.49
$1,141.62
$1,348.16

$1,339.62
$1,394.51
$1,452.64
$1,659.18

$311.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$813.12
$922.90
$1,039.16
$1,452.24
$2,206.80

$1,124.14
$1,233.92
$1,350.18
$1,763.26

$1,435.16
$1,544.94
$1,661.20
$2,074.28

$1,746.18
$1,855.96
$1,972.22
$2,385.30

$311.02

Toc - Plan #91 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Blue Preferred/Broad 5300 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$5,300 $10,600 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

$399.37
$453.28
$510.39
$713.27
$1,083.89

$704.89
$758.80
$815.91
$1,018.79

$1,010.41
$1,064.32
$1,121.43
$1,324.31

$1,315.93
$1,369.84
$1,426.95
$1,629.83

$305.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$798.74
$906.56
$1,020.78
$1,426.54
$2,167.78

$1,104.26
$1,212.08
$1,326.30
$1,732.06

$1,409.78
$1,517.60
$1,631.82
$2,037.58

$1,715.30
$1,823.12
$1,937.34
$2,343.10

$305.52

Toc - Plan #92 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Pathway/Lean 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$287.55
$326.37
$367.49
$513.56
$780.41

$507.53
$546.35
$587.47
$733.54

$727.51
$766.33
$807.45
$953.52

$947.49
$986.31
$1,027.43
$1,173.50

$219.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$575.10
$652.74
$734.98
$1,027.12
$1,560.82

$795.08
$872.72
$954.96
$1,247.10

$1,015.06
$1,092.70
$1,174.94
$1,467.08

$1,235.04
$1,312.68
$1,394.92
$1,687.06

$219.98

Toc - Plan #93 Anthem Blue Cross and Blue Shield

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$293.38
$332.99
$374.94
$523.98
$796.23

$517.82
$557.43
$599.38
$748.42

$742.26
$781.87
$823.82
$972.86

$966.70
$1,006.31
$1,048.26
$1,197.30

$224.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$586.76
$665.98
$749.88
$1,047.96
$1,592.46

$811.20
$890.42
$974.32
$1,272.40

$1,035.64
$1,114.86
$1,198.76
$1,496.84

$1,260.08
$1,339.30
$1,423.20
$1,721.28

$224.44

Toc - Plan #94 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Pathway/Lean 6550 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$6,550 $13,100 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

$288.15
$327.05
$368.26
$514.64
$782.04

$508.58
$547.48
$588.69
$735.07

$729.01
$767.91
$809.12
$955.50

$949.44
$988.34
$1,029.55
$1,175.93

$220.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$576.30
$654.10
$736.52
$1,029.28
$1,564.08

$796.73
$874.53
$956.95
$1,249.71

$1,017.16
$1,094.96
$1,177.38
$1,470.14

$1,237.59
$1,315.39
$1,397.81
$1,690.57

$220.43

Toc - Plan #95 Anthem Blue Cross and Blue Shield

Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$273.15
$310.03
$349.09
$487.85
$741.33

$482.11
$518.99
$558.05
$696.81

$691.07
$727.95
$767.01
$905.77

$900.03
$936.91
$975.97
$1,114.73

$208.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$546.30
$620.06
$698.18
$975.70
$1,482.66

$755.26
$829.02
$907.14
$1,184.66

$964.22
$1,037.98
$1,116.10
$1,393.62

$1,173.18
$1,246.94
$1,325.06
$1,602.58

$208.96

Toc - Plan #96 Anthem Blue Cross and Blue Shield

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$332.36
$377.23
$424.76
$593.59
$902.03

$586.62
$631.49
$679.02
$847.85

$840.88
$885.75
$933.28
$1,102.11

$1,095.14
$1,140.01
$1,187.54
$1,356.37

$254.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$664.72
$754.46
$849.52
$1,187.18
$1,804.06

$918.98
$1,008.72
$1,103.78
$1,441.44

$1,173.24
$1,262.98
$1,358.04
$1,695.70

$1,427.50
$1,517.24
$1,612.30
$1,949.96

$254.26

Toc - Plan #97 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Pathway/Lean 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$4,100 $8,200 Annual Deductible

$7,250 $14,500 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

$336.36
$381.77
$429.87
$600.74
$912.88

$593.68
$639.09
$687.19
$858.06

$851.00
$896.41
$944.51
$1,115.38

$1,108.32
$1,153.73
$1,201.83
$1,372.70

$257.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$672.72
$763.54
$859.74
$1,201.48
$1,825.76

$930.04
$1,020.86
$1,117.06
$1,458.80

$1,187.36
$1,278.18
$1,374.38
$1,716.12

$1,444.68
$1,535.50
$1,631.70
$1,973.44

$257.32

Toc - Plan #98 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Pathway/Lean 5300 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$5,300 $10,600 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

$330.36
$374.96
$422.20
$590.02
$896.60

$583.09
$627.69
$674.93
$842.75

$835.82
$880.42
$927.66
$1,095.48

$1,088.55
$1,133.15
$1,180.39
$1,348.21

$252.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$660.72
$749.92
$844.40
$1,180.04
$1,793.20

$913.45
$1,002.65
$1,097.13
$1,432.77

$1,166.18
$1,255.38
$1,349.86
$1,685.50

$1,418.91
$1,508.11
$1,602.59
$1,938.23

$252.73

Toc - Plan #99 Anthem Blue Cross and Blue Shield

Gold

(HMO) Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 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

$344.22
$390.69
$439.91
$614.78
$934.21

$607.55
$654.02
$703.24
$878.11

$870.88
$917.35
$966.57
$1,141.44

$1,134.21
$1,180.68
$1,229.90
$1,404.77

$263.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$688.44
$781.38
$879.82
$1,229.56
$1,868.42

$951.77
$1,044.71
$1,143.15
$1,492.89

$1,215.10
$1,308.04
$1,406.48
$1,756.22

$1,478.43
$1,571.37
$1,669.81
$2,019.55

$263.33

Toc - Plan #100 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Pathway/Lean 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$293.58
$333.21
$375.20
$524.33
$796.78

$518.17
$557.80
$599.79
$748.92

$742.76
$782.39
$824.38
$973.51

$967.35
$1,006.98
$1,048.97
$1,198.10

$224.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$587.16
$666.42
$750.40
$1,048.66
$1,593.56

$811.75
$891.01
$974.99
$1,273.25

$1,036.34
$1,115.60
$1,199.58
$1,497.84

$1,260.93
$1,340.19
$1,424.17
$1,722.43

$224.59

Toc - Plan #101 Anthem Blue Cross and Blue Shield

Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$305.11
$346.30
$389.93
$544.93
$828.07

$538.52
$579.71
$623.34
$778.34

$771.93
$813.12
$856.75
$1,011.75

$1,005.34
$1,046.53
$1,090.16
$1,245.16

$233.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$610.22
$692.60
$779.86
$1,089.86
$1,656.14

$843.63
$926.01
$1,013.27
$1,323.27

$1,077.04
$1,159.42
$1,246.68
$1,556.68

$1,310.45
$1,392.83
$1,480.09
$1,790.09

$233.41

Toc - Plan #102 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$331.63
$376.40
$423.82
$592.29
$900.04

$585.33
$630.10
$677.52
$845.99

$839.03
$883.80
$931.22
$1,099.69

$1,092.73
$1,137.50
$1,184.92
$1,353.39

$253.70

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$663.26
$752.80
$847.64
$1,184.58
$1,800.08

$916.96
$1,006.50
$1,101.34
$1,438.28

$1,170.66
$1,260.20
$1,355.04
$1,691.98

$1,424.36
$1,513.90
$1,608.74
$1,945.68

$253.70

Toc - Plan #103 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Blue Preferred/Broad 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$395.97
$449.43
$506.05
$707.20
$1,074.66

$698.89
$752.35
$808.97
$1,010.12

$1,001.81
$1,055.27
$1,111.89
$1,313.04

$1,304.73
$1,358.19
$1,414.81
$1,615.96

$302.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$791.94
$898.86
$1,012.10
$1,414.40
$2,149.32

$1,094.86
$1,201.78
$1,315.02
$1,717.32

$1,397.78
$1,504.70
$1,617.94
$2,020.24

$1,700.70
$1,807.62
$1,920.86
$2,323.16

$302.92

Toc - Plan #104 Anthem Blue Cross and Blue Shield

Gold

(HMO) Anthem Gold Blue Preferred/Broad 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$416.39
$472.60
$532.15
$743.67
$1,130.08

$734.93
$791.14
$850.69
$1,062.21

$1,053.47
$1,109.68
$1,169.23
$1,380.75

$1,372.01
$1,428.22
$1,487.77
$1,699.29

$318.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$832.78
$945.20
$1,064.30
$1,487.34
$2,260.16

$1,151.32
$1,263.74
$1,382.84
$1,805.88

$1,469.86
$1,582.28
$1,701.38
$2,124.42

$1,788.40
$1,900.82
$2,019.92
$2,442.96

$318.54

Toc - Plan #105 Anthem Blue Cross and Blue Shield

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$327.56
$371.78
$418.62
$585.02
$889.00

$578.14
$622.36
$669.20
$835.60

$828.72
$872.94
$919.78
$1,086.18

$1,079.30
$1,123.52
$1,170.36
$1,336.76

$250.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$655.12
$743.56
$837.24
$1,170.04
$1,778.00

$905.70
$994.14
$1,087.82
$1,420.62

$1,156.28
$1,244.72
$1,338.40
$1,671.20

$1,406.86
$1,495.30
$1,588.98
$1,921.78

$250.58

Toc - Plan #106 Anthem Blue Cross and Blue Shield

Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$273.55
$310.48
$349.60
$488.56
$742.41

$482.82
$519.75
$558.87
$697.83

$692.09
$729.02
$768.14
$907.10

$901.36
$938.29
$977.41
$1,116.37

$209.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$547.10
$620.96
$699.20
$977.12
$1,484.82

$756.37
$830.23
$908.47
$1,186.39

$965.64
$1,039.50
$1,117.74
$1,395.66

$1,174.91
$1,248.77
$1,327.01
$1,604.93

$209.27

Toc - Plan #107 Anthem Blue Cross and Blue Shield

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$344.49
$391.00
$440.26
$615.26
$934.95

$608.02
$654.53
$703.79
$878.79

$871.55
$918.06
$967.32
$1,142.32

$1,135.08
$1,181.59
$1,230.85
$1,405.85

$263.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$688.98
$782.00
$880.52
$1,230.52
$1,869.90

$952.51
$1,045.53
$1,144.05
$1,494.05

$1,216.04
$1,309.06
$1,407.58
$1,757.58

$1,479.57
$1,572.59
$1,671.11
$2,021.11

$263.53

Toc - Plan #108 Anthem Blue Cross and Blue Shield

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$297.28
$337.41
$379.92
$530.94
$806.82

$524.70
$564.83
$607.34
$758.36

$752.12
$792.25
$834.76
$985.78

$979.54
$1,019.67
$1,062.18
$1,213.20

$227.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.56
$674.82
$759.84
$1,061.88
$1,613.64

$821.98
$902.24
$987.26
$1,289.30

$1,049.40
$1,129.66
$1,214.68
$1,516.72

$1,276.82
$1,357.08
$1,442.10
$1,744.14

$227.42

Network Health

Local: 1-920-720-1400x1400 | Toll Free: 1-855-275-1400 | TTY: 1-800-947-3529

Toc - Plan #109 Network Health

Expanded Bronze

(HMO) Prestige Bronze 20 HDHP + Dental + Vision + Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$289.13
$328.16
$369.50
$516.37
$784.68

$510.31
$549.34
$590.68
$737.55

$731.49
$770.52
$811.86
$958.73

$952.67
$991.70
$1,033.04
$1,179.91

$221.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.26
$656.32
$739.00
$1,032.74
$1,569.36

$799.44
$877.50
$960.18
$1,253.92

$1,020.62
$1,098.68
$1,181.36
$1,475.10

$1,241.80
$1,319.86
$1,402.54
$1,696.28

$221.18

Toc - Plan #110 Network Health

Expanded Bronze

(HMO) Prestige Bronze Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

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

$279.80
$317.58
$357.59
$499.72
$759.38

$493.85
$531.63
$571.64
$713.77

$707.90
$745.68
$785.69
$927.82

$921.95
$959.73
$999.74
$1,141.87

$214.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$559.60
$635.16
$715.18
$999.44
$1,518.76

$773.65
$849.21
$929.23
$1,213.49

$987.70
$1,063.26
$1,143.28
$1,427.54

$1,201.75
$1,277.31
$1,357.33
$1,641.59

$214.05

Toc - Plan #111 Network Health

Silver

(HMO) Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$4,600 $9,200 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

$431.31
$489.53
$551.21
$770.31
$1,170.55

$761.26
$819.48
$881.16
$1,100.26

$1,091.21
$1,149.43
$1,211.11
$1,430.21

$1,421.16
$1,479.38
$1,541.06
$1,760.16

$329.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$862.62
$979.06
$1,102.42
$1,540.62
$2,341.10

$1,192.57
$1,309.01
$1,432.37
$1,870.57

$1,522.52
$1,638.96
$1,762.32
$2,200.52

$1,852.47
$1,968.91
$2,092.27
$2,530.47

$329.95

Toc - Plan #112 Network Health

Gold

(HMO) Prestige Gold Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$1,750 $3,500 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

$396.40
$449.91
$506.59
$707.96
$1,075.81

$699.64
$753.15
$809.83
$1,011.20

$1,002.88
$1,056.39
$1,113.07
$1,314.44

$1,306.12
$1,359.63
$1,416.31
$1,617.68

$303.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$792.80
$899.82
$1,013.18
$1,415.92
$2,151.62

$1,096.04
$1,203.06
$1,316.42
$1,719.16

$1,399.28
$1,506.30
$1,619.66
$2,022.40

$1,702.52
$1,809.54
$1,922.90
$2,325.64

$303.24

Toc - Plan #113 Network Health

Gold

(HMO) Prestige Gold 50 + Dental + Vision + Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$4,300 $8,600 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

$408.61
$463.77
$522.20
$729.77
$1,108.96

$721.20
$776.36
$834.79
$1,042.36

$1,033.79
$1,088.95
$1,147.38
$1,354.95

$1,346.38
$1,401.54
$1,459.97
$1,667.54

$312.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$817.22
$927.54
$1,044.40
$1,459.54
$2,217.92

$1,129.81
$1,240.13
$1,356.99
$1,772.13

$1,442.40
$1,552.72
$1,669.58
$2,084.72

$1,754.99
$1,865.31
$1,982.17
$2,397.31

$312.59

Toc - Plan #114 Network Health

Expanded Bronze

(HMO) Signature Prestige Bronze Copay + Dental + Vision + Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

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

$281.52
$319.53
$359.79
$502.80
$764.05

$496.89
$534.90
$575.16
$718.17

$712.26
$750.27
$790.53
$933.54

$927.63
$965.64
$1,005.90
$1,148.91

$215.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$563.04
$639.06
$719.58
$1,005.60
$1,528.10

$778.41
$854.43
$934.95
$1,220.97

$993.78
$1,069.80
$1,150.32
$1,436.34

$1,209.15
$1,285.17
$1,365.69
$1,651.71

$215.37

Toc - Plan #115 Network Health

Bronze

(HMO) Prestige Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

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

$255.15
$289.60
$326.08
$455.70
$692.48

$450.34
$484.79
$521.27
$650.89

$645.53
$679.98
$716.46
$846.08

$840.72
$875.17
$911.65
$1,041.27

$195.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$510.30
$579.20
$652.16
$911.40
$1,384.96

$705.49
$774.39
$847.35
$1,106.59

$900.68
$969.58
$1,042.54
$1,301.78

$1,095.87
$1,164.77
$1,237.73
$1,496.97

$195.19

Toc - Plan #116 Network Health

Expanded Bronze

(HMO) Prestige Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

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

$273.58
$310.52
$349.64
$488.61
$742.49

$482.87
$519.81
$558.93
$697.90

$692.16
$729.10
$768.22
$907.19

$901.45
$938.39
$977.51
$1,116.48

$209.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$547.16
$621.04
$699.28
$977.22
$1,484.98

$756.45
$830.33
$908.57
$1,186.51

$965.74
$1,039.62
$1,117.86
$1,395.80

$1,175.03
$1,248.91
$1,327.15
$1,605.09

$209.29

Toc - Plan #117 Network Health

Silver

(HMO) Prestige Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

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

$442.64
$502.39
$565.69
$790.55
$1,201.31

$781.26
$841.01
$904.31
$1,129.17

$1,119.88
$1,179.63
$1,242.93
$1,467.79

$1,458.50
$1,518.25
$1,581.55
$1,806.41

$338.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$885.28
$1,004.78
$1,131.38
$1,581.10
$2,402.62

$1,223.90
$1,343.40
$1,470.00
$1,919.72

$1,562.52
$1,682.02
$1,808.62
$2,258.34

$1,901.14
$2,020.64
$2,147.24
$2,596.96

$338.62

Toc - Plan #118 Network Health

Gold

(HMO) Prestige Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

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

$395.91
$449.36
$505.98
$707.10
$1,074.50

$698.78
$752.23
$808.85
$1,009.97

$1,001.65
$1,055.10
$1,111.72
$1,312.84

$1,304.52
$1,357.97
$1,414.59
$1,615.71

$302.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$791.82
$898.72
$1,011.96
$1,414.20
$2,149.00

$1,094.69
$1,201.59
$1,314.83
$1,717.07

$1,397.56
$1,504.46
$1,617.70
$2,019.94

$1,700.43
$1,807.33
$1,920.57
$2,322.81

$302.87

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442

Toc - Plan #119 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$283.96
$322.29
$362.89
$507.14
$770.65

$501.19
$539.52
$580.12
$724.37

$718.42
$756.75
$797.35
$941.60

$935.65
$973.98
$1,014.58
$1,158.83

$217.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$567.92
$644.58
$725.78
$1,014.28
$1,541.30

$785.15
$861.81
$943.01
$1,231.51

$1,002.38
$1,079.04
$1,160.24
$1,448.74

$1,219.61
$1,296.27
$1,377.47
$1,665.97

$217.23

Toc - Plan #120 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Copay Silver $0 Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$403.17
$457.58
$515.23
$720.04
$1,094.17

$711.58
$765.99
$823.64
$1,028.45

$1,019.99
$1,074.40
$1,132.05
$1,336.86

$1,328.40
$1,382.81
$1,440.46
$1,645.27

$308.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$806.34
$915.16
$1,030.46
$1,440.08
$2,188.34

$1,114.75
$1,223.57
$1,338.87
$1,748.49

$1,423.16
$1,531.98
$1,647.28
$2,056.90

$1,731.57
$1,840.39
$1,955.69
$2,365.31

$308.41

Toc - Plan #121 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,000 $16,000 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

$434.51
$493.15
$555.29
$776.01
$1,179.22

$766.90
$825.54
$887.68
$1,108.40

$1,099.29
$1,157.93
$1,220.07
$1,440.79

$1,431.68
$1,490.32
$1,552.46
$1,773.18

$332.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$869.02
$986.30
$1,110.58
$1,552.02
$2,358.44

$1,201.41
$1,318.69
$1,442.97
$1,884.41

$1,533.80
$1,651.08
$1,775.36
$2,216.80

$1,866.19
$1,983.47
$2,107.75
$2,549.19

$332.39

Toc - Plan #122 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC Gold $3000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$374.80
$425.39
$478.98
$669.38
$1,017.18

$661.52
$712.11
$765.70
$956.10

$948.24
$998.83
$1,052.42
$1,242.82

$1,234.96
$1,285.55
$1,339.14
$1,529.54

$286.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$749.60
$850.78
$957.96
$1,338.76
$2,034.36

$1,036.32
$1,137.50
$1,244.68
$1,625.48

$1,323.04
$1,424.22
$1,531.40
$1,912.20

$1,609.76
$1,710.94
$1,818.12
$2,198.92

$286.72

Toc - Plan #123 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC Gold $1800 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$1,800 $3,600 Annual Deductible

$6,600 $13,200 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

$410.52
$465.93
$524.63
$733.18
$1,114.13

$724.56
$779.97
$838.67
$1,047.22

$1,038.60
$1,094.01
$1,152.71
$1,361.26

$1,352.64
$1,408.05
$1,466.75
$1,675.30

$314.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$821.04
$931.86
$1,049.26
$1,466.36
$2,228.26

$1,135.08
$1,245.90
$1,363.30
$1,780.40

$1,449.12
$1,559.94
$1,677.34
$2,094.44

$1,763.16
$1,873.98
$1,991.38
$2,408.48

$314.04

Toc - Plan #124 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $4000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$369.84
$419.76
$472.65
$660.52
$1,003.73

$652.76
$702.68
$755.57
$943.44

$935.68
$985.60
$1,038.49
$1,226.36

$1,218.60
$1,268.52
$1,321.41
$1,509.28

$282.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$739.68
$839.52
$945.30
$1,321.04
$2,007.46

$1,022.60
$1,122.44
$1,228.22
$1,603.96

$1,305.52
$1,405.36
$1,511.14
$1,886.88

$1,588.44
$1,688.28
$1,794.06
$2,169.80

$282.92

Toc - Plan #125 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$316.41
$359.11
$404.35
$565.08
$858.70

$558.45
$601.15
$646.39
$807.12

$800.49
$843.19
$888.43
$1,049.16

$1,042.53
$1,085.23
$1,130.47
$1,291.20

$242.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$632.82
$718.22
$808.70
$1,130.16
$1,717.40

$874.86
$960.26
$1,050.74
$1,372.20

$1,116.90
$1,202.30
$1,292.78
$1,614.24

$1,358.94
$1,444.34
$1,534.82
$1,856.28

$242.04

Toc - Plan #126 Common Ground Healthcare Cooperative

Catastrophic

(EPO) CGHC Catastrophic $9100 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$186.10
$211.21
$237.83
$332.36
$505.05

$328.46
$353.57
$380.19
$474.72

$470.82
$495.93
$522.55
$617.08

$613.18
$638.29
$664.91
$759.44

$142.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$372.20
$422.42
$475.66
$664.72
$1,010.10

$514.56
$564.78
$618.02
$807.08

$656.92
$707.14
$760.38
$949.44

$799.28
$849.50
$902.74
$1,091.80

$142.36

Toc - Plan #127 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Bronze $9100 ($35 PCP Copay) - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$266.02
$301.92
$339.96
$475.09
$721.95

$469.52
$505.42
$543.46
$678.59

$673.02
$708.92
$746.96
$882.09

$876.52
$912.42
$950.46
$1,085.59

$203.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$532.04
$603.84
$679.92
$950.18
$1,443.90

$735.54
$807.34
$883.42
$1,153.68

$939.04
$1,010.84
$1,086.92
$1,357.18

$1,142.54
$1,214.34
$1,290.42
$1,560.68

$203.50

Toc - Plan #128 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Bronze $8150 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$8,150 $16,300 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

$276.09
$313.35
$352.83
$493.07
$749.27

$487.29
$524.55
$564.03
$704.27

$698.49
$735.75
$775.23
$915.47

$909.69
$946.95
$986.43
$1,126.67

$211.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$552.18
$626.70
$705.66
$986.14
$1,498.54

$763.38
$837.90
$916.86
$1,197.34

$974.58
$1,049.10
$1,128.06
$1,408.54

$1,185.78
$1,260.30
$1,339.26
$1,619.74

$211.20

Toc - Plan #129 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$274.64
$311.70
$350.97
$490.48
$745.34

$484.73
$521.79
$561.06
$700.57

$694.82
$731.88
$771.15
$910.66

$904.91
$941.97
$981.24
$1,120.75

$210.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$549.28
$623.40
$701.94
$980.96
$1,490.68

$759.37
$833.49
$912.03
$1,191.05

$969.46
$1,043.58
$1,122.12
$1,401.14

$1,179.55
$1,253.67
$1,332.21
$1,611.23

$210.09

Toc - Plan #130 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC HSA Gold $3000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$3,000 $6,000 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

$436.43
$495.34
$557.75
$779.45
$1,184.45

$770.29
$829.20
$891.61
$1,113.31

$1,104.15
$1,163.06
$1,225.47
$1,447.17

$1,438.01
$1,496.92
$1,559.33
$1,781.03

$333.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$872.86
$990.68
$1,115.50
$1,558.90
$2,368.90

$1,206.72
$1,324.54
$1,449.36
$1,892.76

$1,540.58
$1,658.40
$1,783.22
$2,226.62

$1,874.44
$1,992.26
$2,117.08
$2,560.48

$333.86

Toc - Plan #131 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC HSA Silver $3000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 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

$423.24
$480.36
$540.88
$755.88
$1,148.63

$747.01
$804.13
$864.65
$1,079.65

$1,070.78
$1,127.90
$1,188.42
$1,403.42

$1,394.55
$1,451.67
$1,512.19
$1,727.19

$323.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$846.48
$960.72
$1,081.76
$1,511.76
$2,297.26

$1,170.25
$1,284.49
$1,405.53
$1,835.53

$1,494.02
$1,608.26
$1,729.30
$2,159.30

$1,817.79
$1,932.03
$2,053.07
$2,483.07

$323.77

Toc - Plan #132 Common Ground Healthcare Cooperative

Bronze

(EPO) CGHC Bronze $6000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$272.65
$309.44
$348.43
$486.93
$739.93

$481.22
$518.01
$557.00
$695.50

$689.79
$726.58
$765.57
$904.07

$898.36
$935.15
$974.14
$1,112.64

$208.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$545.30
$618.88
$696.86
$973.86
$1,479.86

$753.87
$827.45
$905.43
$1,182.43

$962.44
$1,036.02
$1,114.00
$1,391.00

$1,171.01
$1,244.59
$1,322.57
$1,599.57

$208.57

Toc - Plan #133 Common Ground Healthcare Cooperative

Bronze

(EPO) Bronze Standard Plan - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$264.09
$299.74
$337.50
$471.65
$716.72

$466.11
$501.76
$539.52
$673.67

$668.13
$703.78
$741.54
$875.69

$870.15
$905.80
$943.56
$1,077.71

$202.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$528.18
$599.48
$675.00
$943.30
$1,433.44

$730.20
$801.50
$877.02
$1,145.32

$932.22
$1,003.52
$1,079.04
$1,347.34

$1,134.24
$1,205.54
$1,281.06
$1,549.36

$202.02

Toc - Plan #134 Common Ground Healthcare Cooperative

Silver

(EPO) Silver Standard Plan - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$319.59
$362.72
$408.42
$570.77
$867.34

$564.07
$607.20
$652.90
$815.25

$808.55
$851.68
$897.38
$1,059.73

$1,053.03
$1,096.16
$1,141.86
$1,304.21

$244.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$639.18
$725.44
$816.84
$1,141.54
$1,734.68

$883.66
$969.92
$1,061.32
$1,386.02

$1,128.14
$1,214.40
$1,305.80
$1,630.50

$1,372.62
$1,458.88
$1,550.28
$1,874.98

$244.48

Toc - Plan #135 Common Ground Healthcare Cooperative

Gold

(EPO) Gold Standard Plan - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$382.09
$433.66
$488.30
$682.40
$1,036.97

$674.38
$725.95
$780.59
$974.69

$966.67
$1,018.24
$1,072.88
$1,266.98

$1,258.96
$1,310.53
$1,365.17
$1,559.27

$292.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$764.18
$867.32
$976.60
$1,364.80
$2,073.94

$1,056.47
$1,159.61
$1,268.89
$1,657.09

$1,348.76
$1,451.90
$1,561.18
$1,949.38

$1,641.05
$1,744.19
$1,853.47
$2,241.67

$292.29

Toc - Plan #136 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5650 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$5,650 $11,300 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

$316.20
$358.87
$404.09
$564.71
$858.13

$558.08
$600.75
$645.97
$806.59

$799.96
$842.63
$887.85
$1,048.47

$1,041.84
$1,084.51
$1,129.73
$1,290.35

$241.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$632.40
$717.74
$808.18
$1,129.42
$1,716.26

$874.28
$959.62
$1,050.06
$1,371.30

$1,116.16
$1,201.50
$1,291.94
$1,613.18

$1,358.04
$1,443.38
$1,533.82
$1,855.06

$241.88

Toc - Plan #137 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC Gold $1800 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$1,800 $3,600 Annual Deductible

$6,600 $13,200 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

$413.44
$469.25
$528.37
$738.39
$1,122.06

$729.72
$785.53
$844.65
$1,054.67

$1,046.00
$1,101.81
$1,160.93
$1,370.95

$1,362.28
$1,418.09
$1,477.21
$1,687.23

$316.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$826.88
$938.50
$1,056.74
$1,476.78
$2,244.12

$1,143.16
$1,254.78
$1,373.02
$1,793.06

$1,459.44
$1,571.06
$1,689.30
$2,109.34

$1,775.72
$1,887.34
$2,005.58
$2,425.62

$316.28

Toc - Plan #138 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC Gold $2000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$384.62
$436.54
$491.54
$686.92
$1,043.84

$678.85
$730.77
$785.77
$981.15

$973.08
$1,025.00
$1,080.00
$1,275.38

$1,267.31
$1,319.23
$1,374.23
$1,569.61

$294.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$769.24
$873.08
$983.08
$1,373.84
$2,087.68

$1,063.47
$1,167.31
$1,277.31
$1,668.07

$1,357.70
$1,461.54
$1,571.54
$1,962.30

$1,651.93
$1,755.77
$1,865.77
$2,256.53

$294.23

Toc - Plan #139 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC Gold $3000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$377.69
$428.67
$482.68
$674.54
$1,025.03

$666.62
$717.60
$771.61
$963.47

$955.55
$1,006.53
$1,060.54
$1,252.40

$1,244.48
$1,295.46
$1,349.47
$1,541.33

$288.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$755.38
$857.34
$965.36
$1,349.08
$2,050.06

$1,044.31
$1,146.27
$1,254.29
$1,638.01

$1,333.24
$1,435.20
$1,543.22
$1,926.94

$1,622.17
$1,724.13
$1,832.15
$2,215.87

$288.93

Toc - Plan #140 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $4000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$372.74
$423.04
$476.34
$665.69
$1,011.58

$657.87
$708.17
$761.47
$950.82

$943.00
$993.30
$1,046.60
$1,235.95

$1,228.13
$1,278.43
$1,331.73
$1,521.08

$285.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$745.48
$846.08
$952.68
$1,331.38
$2,023.16

$1,030.61
$1,131.21
$1,237.81
$1,616.51

$1,315.74
$1,416.34
$1,522.94
$1,901.64

$1,600.87
$1,701.47
$1,808.07
$2,186.77

$285.13

Toc - Plan #141 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5650 (Vision Exam + Allergy Test) - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$5,650 $11,300 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

$319.05
$362.11
$407.73
$569.81
$865.87

$563.12
$606.18
$651.80
$813.88

$807.19
$850.25
$895.87
$1,057.95

$1,051.26
$1,094.32
$1,139.94
$1,302.02

$244.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$638.10
$724.22
$815.46
$1,139.62
$1,731.74

$882.17
$968.29
$1,059.53
$1,383.69

$1,126.24
$1,212.36
$1,303.60
$1,627.76

$1,370.31
$1,456.43
$1,547.67
$1,871.83

$244.07

Toc - Plan #142 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$319.26
$362.35
$408.00
$570.18
$866.44

$563.49
$606.58
$652.23
$814.41

$807.72
$850.81
$896.46
$1,058.64

$1,051.95
$1,095.04
$1,140.69
$1,302.87

$244.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$638.52
$724.70
$816.00
$1,140.36
$1,732.88

$882.75
$968.93
$1,060.23
$1,384.59

$1,126.98
$1,213.16
$1,304.46
$1,628.82

$1,371.21
$1,457.39
$1,548.69
$1,873.05

$244.23

Toc - Plan #143 Common Ground Healthcare Cooperative

Bronze

(EPO) CGHC Bronze $9100 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$266.92
$302.94
$341.11
$476.70
$724.39

$471.11
$507.13
$545.30
$680.89

$675.30
$711.32
$749.49
$885.08

$879.49
$915.51
$953.68
$1,089.27

$204.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$533.84
$605.88
$682.22
$953.40
$1,448.78

$738.03
$810.07
$886.41
$1,157.59

$942.22
$1,014.26
$1,090.60
$1,361.78

$1,146.41
$1,218.45
$1,294.79
$1,565.97

$204.19

Toc - Plan #144 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Bronze $9100 ($35 PCP Copay) - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$268.84
$305.13
$343.57
$480.14
$729.62

$474.50
$510.79
$549.23
$685.80

$680.16
$716.45
$754.89
$891.46

$885.82
$922.11
$960.55
$1,097.12

$205.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$537.68
$610.26
$687.14
$960.28
$1,459.24

$743.34
$815.92
$892.80
$1,165.94

$949.00
$1,021.58
$1,098.46
$1,371.60

$1,154.66
$1,227.24
$1,304.12
$1,577.26

$205.66

Toc - Plan #145 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Bronze $8150 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$8,150 $16,300 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$278.92
$316.56
$356.45
$498.14
$756.96

$492.29
$529.93
$569.82
$711.51

$705.66
$743.30
$783.19
$924.88

$919.03
$956.67
$996.56
$1,138.25

$213.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$557.84
$633.12
$712.90
$996.28
$1,513.92

$771.21
$846.49
$926.27
$1,209.65

$984.58
$1,059.86
$1,139.64
$1,423.02

$1,197.95
$1,273.23
$1,353.01
$1,636.39

$213.37

Toc - Plan #146 Common Ground Healthcare Cooperative

Bronze

(EPO) CGHC Bronze $6000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$275.47
$312.65
$352.04
$491.97
$747.60

$486.20
$523.38
$562.77
$702.70

$696.93
$734.11
$773.50
$913.43

$907.66
$944.84
$984.23
$1,124.16

$210.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$550.94
$625.30
$704.08
$983.94
$1,495.20

$761.67
$836.03
$914.81
$1,194.67

$972.40
$1,046.76
$1,125.54
$1,405.40

$1,183.13
$1,257.49
$1,336.27
$1,616.13

$210.73

Toc - Plan #147 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$277.46
$314.91
$354.58
$495.53
$753.00

$489.71
$527.16
$566.83
$707.78

$701.96
$739.41
$779.08
$920.03

$914.21
$951.66
$991.33
$1,132.28

$212.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$554.92
$629.82
$709.16
$991.06
$1,506.00

$767.17
$842.07
$921.41
$1,203.31

$979.42
$1,054.32
$1,133.66
$1,415.56

$1,191.67
$1,266.57
$1,345.91
$1,627.81

$212.25

Toc - Plan #148 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC HSA Silver $3000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 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

$426.16
$483.69
$544.63
$761.11
$1,156.58

$752.17
$809.70
$870.64
$1,087.12

$1,078.18
$1,135.71
$1,196.65
$1,413.13

$1,404.19
$1,461.72
$1,522.66
$1,739.14

$326.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$852.32
$967.38
$1,089.26
$1,522.22
$2,313.16

$1,178.33
$1,293.39
$1,415.27
$1,848.23

$1,504.34
$1,619.40
$1,741.28
$2,174.24

$1,830.35
$1,945.41
$2,067.29
$2,500.25

$326.01

Toc - Plan #149 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC HSA Gold $3000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$3,000 $6,000 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

$439.37
$498.67
$561.50
$784.70
$1,192.42

$775.48
$834.78
$897.61
$1,120.81

$1,111.59
$1,170.89
$1,233.72
$1,456.92

$1,447.70
$1,507.00
$1,569.83
$1,793.03

$336.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$878.74
$997.34
$1,123.00
$1,569.40
$2,384.84

$1,214.85
$1,333.45
$1,459.11
$1,905.51

$1,550.96
$1,669.56
$1,795.22
$2,241.62

$1,887.07
$2,005.67
$2,131.33
$2,577.73

$336.11

Toc - Plan #150 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$286.80
$325.51
$366.52
$512.21
$778.35

$506.19
$544.90
$585.91
$731.60

$725.58
$764.29
$805.30
$950.99

$944.97
$983.68
$1,024.69
$1,170.38

$219.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$573.60
$651.02
$733.04
$1,024.42
$1,556.70

$792.99
$870.41
$952.43
$1,243.81

$1,012.38
$1,089.80
$1,171.82
$1,463.20

$1,231.77
$1,309.19
$1,391.21
$1,682.59

$219.39

Toc - Plan #151 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Copay Silver $0 Ded - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$406.08
$460.89
$518.95
$725.23
$1,102.06

$716.72
$771.53
$829.59
$1,035.87

$1,027.36
$1,082.17
$1,140.23
$1,346.51

$1,338.00
$1,392.81
$1,450.87
$1,657.15

$310.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$812.16
$921.78
$1,037.90
$1,450.46
$2,204.12

$1,122.80
$1,232.42
$1,348.54
$1,761.10

$1,433.44
$1,543.06
$1,659.18
$2,071.74

$1,744.08
$1,853.70
$1,969.82
$2,382.38

$310.64

Toc - Plan #152 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,000 $16,000 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

$437.44
$496.48
$559.03
$781.24
$1,187.17

$772.07
$831.11
$893.66
$1,115.87

$1,106.70
$1,165.74
$1,228.29
$1,450.50

$1,441.33
$1,500.37
$1,562.92
$1,785.13

$334.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$874.88
$992.96
$1,118.06
$1,562.48
$2,374.34

$1,209.51
$1,327.59
$1,452.69
$1,897.11

$1,544.14
$1,662.22
$1,787.32
$2,231.74

$1,878.77
$1,996.85
$2,121.95
$2,566.37

$334.63

‡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 Calumet County here.

Calumet County is in “Rating Area 11” of Wisconsin.

Currently, there are 152 plans offered in Rating Area 11.

Top

2023 Obamacare Plans for Calumet County, WI

Plan Browser: 152 Plans

Together with CCHP

Local: 1-844-201-4672 | Toll Free: 1-844-201-4672 | TTY: 1-844-531-4856

1. Expanded Bronze Chorus Bronze

2. Silver Chorus Standard Silver

3. Silver Chorus Silver

4. Gold Chorus Gold

5. Expanded Bronze Chorus Bronze HDHP

6. Silver Chorus Silver Select

7. Catastrophic Chorus Catastrophic

8. Expanded Bronze Chorus Bronze Copay

9. Silver Chorus Silver Copay

10. Bronze Chorus Core Bronze

11. Silver Chorus Core Silver

12. Gold Chorus Core Gold

HealthPartners

Local: 1-952-883-5900 | Toll Free: 1-855-813-3887 | TTY: 1-952-883-6060

13. Gold Robin Oak $1,000 w/Copay P-S Gold

14. Expanded Bronze Robin Oak $6,250 Plus Bronze

15. Catastrophic Robin Oak $9,100 Catastrophic

16. Silver Robin Oak $3,800 Plus Silver

17. Expanded Bronze Robin Oak $7,500 HSA Bronze

18. Gold Robin Oak $2,000 w/Copay P-S Gold

19. Silver Robin Oak $5,800 w/Copay P-S Silver

20. Expanded Bronze Robin Oak $7,500 w/Copay P-S Bronze

21. Silver Robin Oak $3,500 HSA Silver

22. Silver Robin Select $3,800 Plus Silver

23. Silver Robin Select $5,800 w/Copay P-S Silver

24. Expanded Bronze Robin Select $6,250 Plus Bronze

25. Expanded Bronze Robin Select $7,500 w/Copay P-S Bronze

26. Silver Robin Select $3,500 HSA Silver

27. Expanded Bronze Robin Select $7,500 HSA Bronze

28. Catastrophic Robin Select $9,100 Catastrophic

Quartz

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310 | TTY: 1-800-877-8973

29. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Dental & Vision

30. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Dental & Vision

31. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Dental & Vision

32. Gold Quartz One with Aurora Health Care Gold I410 Standard with Dental & Vision

33. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Dental & Vision

34. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Dental & Vision

35. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Dental & Vision

36. Silver Quartz One with Aurora Health Care Silver I309 Standard with Dental & Vision

37. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Dental & Vision

38. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Dental & Vision

39. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Dental & Vision

40. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Dental & Vision

41. Expanded Bronze Quartz One with Aurora Health Care Bronze I206 Standard with Dental & Vision

42. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401

43. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance

44. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405

45. Gold Quartz One with Aurora Health Care Gold I410 Standard

46. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301

47. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303

48. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308

49. Silver Quartz One with Aurora Health Care Silver I309 Standard

50. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201

51. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202

52. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204

53. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205

54. Expanded Bronze Quartz One with Aurora Health Care Bronze I206 Standard

55. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I403 HSA

56. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I304 HSA

57. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203

58. Catastrophic QUARTZ ONE WITH AURORA HEALTH CARE CATASTROPHIC I101

59. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307

60. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Vision

61. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Vision

62. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Vision

63. Gold Quartz One with Aurora Health Care Gold I410 Standard with Vision

64. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Vision

65. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Vision

66. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Vision

67. Silver Quartz One with Aurora Health Care Silver I309 Standard with Vision

68. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Vision

69. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Vision

70. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Vision

71. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Vision

72. Expanded Bronze Quartz One with Aurora Health Care Bronze I206 Standard with Vision

73. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I403 HSA with Vision

74. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I304 HSA with Vision

75. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307 with Vision

76. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203 with Vision

Molina Healthcare

Local: 1-888-560-2043 | Toll Free: 1-888-560-2043

77. Gold Confident Care Gold 1

78. Silver Constant Care Silver 1

79. Gold Confident Care Gold 8

80. Silver Constant Care Silver 8

81. Gold Confident Care Gold 1 + Vision

82. Silver Constant Care Silver 1 + Vision

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1813 | Toll Free: 1-855-748-1813

83. Expanded Bronze Anthem Bronze Blue Preferred/Broad 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

84. Expanded Bronze Anthem Bronze Blue Preferred/Broad 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

85. Expanded Bronze Anthem Bronze Blue Preferred/Broad 6550 ($0 Virtual PCP + $0 Select Drugs + Incentives)

86. Bronze Anthem Bronze Blue Preferred/Broad 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

87. Expanded Bronze Anthem Bronze Blue Preferred/Broad 0% for HSA

88. Gold Anthem Gold Blue Preferred/Broad 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

89. Silver Anthem Silver Blue Preferred/Broad 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

90. Silver Anthem Silver Blue Preferred/Broad 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

91. Silver Anthem Silver Blue Preferred/Broad 5300 ($0 Virtual PCP + $0 Select Drugs + Incentives)

92. Expanded Bronze Anthem Bronze Pathway/Lean 0% for HSA

93. Expanded Bronze Anthem Bronze Pathway/Lean 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

94. Expanded Bronze Anthem Bronze Pathway/Lean 6550 ($0 Virtual PCP + $0 Select Drugs + Incentives)

95. Bronze Anthem Bronze Pathway/Lean 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

96. Silver Anthem Silver Pathway/Lean 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

97. Silver Anthem Silver Pathway/Lean 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

98. Silver Anthem Silver Pathway/Lean 5300 ($0 Virtual PCP + $0 Select Drugs + Incentives)

99. Gold Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

100. Expanded Bronze Anthem Bronze Pathway/Lean 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

101. Bronze Anthem Bronze Blue Preferred/Broad 9100/0% Standard

102. Expanded Bronze Anthem Bronze Blue Preferred/Broad 7500/50% Standard

103. Silver Anthem Silver Blue Preferred/Broad 5800/40% Standard

104. Gold Anthem Gold Blue Preferred/Broad 2000/25% Standard

105. Silver Anthem Silver Pathway/Lean 5800/40% Standard

106. Bronze Anthem Bronze Pathway/Lean 9100/0% Standard

107. Gold Anthem Gold Pathway/Lean 2000/25% Standard

108. Expanded Bronze Anthem Bronze Pathway/Lean 7500/50% Standard

Network Health

Local: 1-920-720-1400x1400 | Toll Free: 1-855-275-1400 | TTY: 1-800-947-3529

109. Expanded Bronze Prestige Bronze 20 HDHP + Dental + Vision + Fitness

110. Expanded Bronze Prestige Bronze Essential + Dental + Vision + Fitness + 3 Free PCP Visits

111. Silver Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits

112. Gold Prestige Gold Essential + Dental + Vision + Fitness + 3 Free PCP Visits

113. Gold Prestige Gold 50 + Dental + Vision + Fitness

114. Expanded Bronze Signature Prestige Bronze Copay + Dental + Vision + Fitness

115. Bronze Prestige Bronze

116. Expanded Bronze Prestige Bronze Plus

117. Silver Prestige Silver

118. Gold Prestige Gold

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442

119. Expanded Bronze CGHC Copay Bronze $0 Ded - Envision Network

120. Silver CGHC Copay Silver $0 Ded - Envision Network

121. Gold CGHC Copay Gold $0 Ded - Envision Network

122. Gold CGHC Gold $3000 - Envision Network

123. Gold CGHC Gold $1800 - Envision Network

124. Silver CGHC Silver $4000 - Envision Network

125. Silver CGHC Silver $5000 - Envision Network

126. Catastrophic CGHC Catastrophic $9100 - Envision Network

127. Expanded Bronze CGHC Bronze $9100 ($35 PCP Copay) - Envision Network

128. Expanded Bronze CGHC Bronze $8150 - Envision Network

129. Expanded Bronze CGHC HSA Bronze $7500 - Envision Network

130. Gold CGHC HSA Gold $3000 - Envision Network

131. Silver CGHC HSA Silver $3000 - Envision Network

132. Bronze CGHC Bronze $6000 - Envision Network

133. Bronze Bronze Standard Plan - Envision Network

134. Silver Silver Standard Plan - Envision Network

135. Gold Gold Standard Plan - Envision Network

136. Silver CGHC Silver $5650 - Envision Network

137. Gold CGHC Gold $1800 - Envision Network (Vision Exam + Allergy Test)

138. Gold CGHC Gold $2000 - Envision Network (Vision Exam + Allergy Test)

139. Gold CGHC Gold $3000 - Envision Network (Vision Exam + Allergy Test)

140. Silver CGHC Silver $4000 - Envision Network (Vision Exam + Allergy Test)

141. Silver CGHC Silver $5650 (Vision Exam + Allergy Test) - Envision Network

142. Silver CGHC Silver $5000 - Envision Network (Vision Exam + Allergy Test)

143. Bronze CGHC Bronze $9100 - Envision Network (Vision Exam + Allergy Test)

144. Expanded Bronze CGHC Bronze $9100 ($35 PCP Copay) - Envision Network (Vision Exam + Allergy Test)

145. Expanded Bronze CGHC Bronze $8150 - Envision Network (Vision Exam + Allergy Test)

146. Bronze CGHC Bronze $6000 - Envision Network (Vision Exam + Allergy Test)

147. Expanded Bronze CGHC HSA Bronze $7500 - Envision Network (Vision Exam + Allergy Test)

148. Silver CGHC HSA Silver $3000 - Envision Network (Vision Exam + Allergy Test)

149. Gold CGHC HSA Gold $3000 - Envision Network (Vision Exam + Allergy Test)

150. Expanded Bronze CGHC Copay Bronze $0 Ded - Envision Network (Vision Exam + Allergy Test)

151. Silver CGHC Copay Silver $0 Ded - Envision Network (Vision Exam + Allergy Test)

152. Gold CGHC Copay Gold $0 Ded - Envision Network (Vision Exam + Allergy Test)

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

Obamacare Providers, 152 Plans and 2023 Rates for Calumet County, Wisconsin

You may also be interested in:

Do I Qualify For a Tax Credit to Pay My Premiums?

How do I sign up in Wisconsin?

Using a Broker to Help You Sign Up

Obamacare Rates and Providers for Other Years

How To Sign Up for Obamacare in Wisconsin for 2023

Where's the Wisconsin Health Care Exchange?

Wisconsin Medicaid Expansion: Do I Qualify for Medicaid Under the ACA?

Wisconsin Has Not Expanded Medicaid

Get Help Finding a Health Insurance Plan in Wisconsin

Get Help From Wisconsin's Health Insurance Exchange

Get Help From a Licensed Insurance Broker

More Information

Together with CCHP

(EPO) Chorus Bronze

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:

(EPO) Chorus Standard Silver

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:

(EPO) Chorus Silver

Annual Out of Pocket Expenses:

Individual Family $5,000 $10,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Chorus Gold

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Chorus Bronze HDHP

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:

(EPO) Chorus Silver Select

Annual Out of Pocket Expenses:

Individual Family $3,250 $6,500 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Chorus Catastrophic

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:

(EPO) Chorus Bronze Copay

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Chorus Silver Copay

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Chorus Core Bronze

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:

(EPO) Chorus Core Silver

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:

(EPO) Chorus Core Gold

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:

HealthPartners

(PPO) Robin Oak $1,000 w/Copay P-S Gold

Annual Out of Pocket Expenses:

Individual Family $1,000 $2,000 Annual Deductible $8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(PPO) Robin Oak $6,250 Plus Bronze

Annual Out of Pocket Expenses:

Individual Family $6,250 $12,500 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(PPO) Robin Oak $9,100 Catastrophic

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:

(PPO) Robin Oak $3,800 Plus Silver

Annual Out of Pocket Expenses:

Individual Family $3,800 $7,600 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$4,000 $8,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,000 $10,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$7,000 $14,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$3,250 $6,500 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$1,000 $2,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Individual Family

$6,250 $12,500 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$3,800 $7,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$3,500 $7,000 Annual Deductible

$7,300 $14,600 Maximum Out of Pocket Per Year

Individual Family

$3,800 $7,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$6,250 $12,500 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$3,500 $7,000 Annual Deductible

$7,300 $14,600 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year