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You are viewing information for Clark County, WI

Obamacare 2023 Rates for Clark County

Obamacare > Rates > Wisconsin > Clark 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 Clark 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, 52 Plans and 2023 Rates for Clark County, Wisconsin

Below, you’ll find a summary of the 52 plans for Clark County, Wisconsin and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Security Health Plan

Local: 1-715-221-9258x19258 | Toll Free: 1-844-293-9624 | TTY: 1-877-727-2232
Toc - Plan #1 Security Health Plan
Gold

(EPO) SimplyOne $3,500 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.17
$470.07
$529.29
$739.68
$1,124.02 		$731.00
$786.90
$846.12
$1,056.51 		$1,047.83
$1,103.73
$1,162.95
$1,373.34 		$1,364.66
$1,420.56
$1,479.78
$1,690.17 		$316.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.34
$940.14
$1,058.58
$1,479.36
$2,248.04 		$1,145.17
$1,256.97
$1,375.41
$1,796.19 		$1,462.00
$1,573.80
$1,692.24
$2,113.02 		$1,778.83
$1,890.63
$2,009.07
$2,429.85 		$316.83
Toc - Plan #2 Security Health Plan
Silver

(EPO) SimplyOne $4,100 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$503.02
$570.91
$642.84
$898.37
$1,365.16 		$887.82
$955.71
$1,027.64
$1,283.17 		$1,272.62
$1,340.51
$1,412.44
$1,667.97 		$1,657.42
$1,725.31
$1,797.24
$2,052.77 		$384.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,006.04
$1,141.82
$1,285.68
$1,796.74
$2,730.32 		$1,390.84
$1,526.62
$1,670.48
$2,181.54 		$1,775.64
$1,911.42
$2,055.28
$2,566.34 		$2,160.44
$2,296.22
$2,440.08
$2,951.14 		$384.80
Toc - Plan #3 Security Health Plan
Expanded Bronze

(EPO) SimplyOne $6,200 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$342.88
$389.16
$438.19
$612.37
$930.55 		$605.18
$651.46
$700.49
$874.67 		$867.48
$913.76
$962.79
$1,136.97 		$1,129.78
$1,176.06
$1,225.09
$1,399.27 		$262.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.76
$778.32
$876.38
$1,224.74
$1,861.10 		$948.06
$1,040.62
$1,138.68
$1,487.04 		$1,210.36
$1,302.92
$1,400.98
$1,749.34 		$1,472.66
$1,565.22
$1,663.28
$2,011.64 		$262.30
Toc - Plan #4 Security Health Plan
Bronze

(EPO) SimplyOne $9,100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$295.36
$335.22
$377.45
$527.49
$801.57 		$521.30
$561.16
$603.39
$753.43 		$747.24
$787.10
$829.33
$979.37 		$973.18
$1,013.04
$1,055.27
$1,205.31 		$225.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$590.72
$670.44
$754.90
$1,054.98
$1,603.14 		$816.66
$896.38
$980.84
$1,280.92 		$1,042.60
$1,122.32
$1,206.78
$1,506.86 		$1,268.54
$1,348.26
$1,432.72
$1,732.80 		$225.94
Toc - Plan #5 Security Health Plan
Catastrophic

(EPO) SimplyOne Protection

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$202.06
$229.32
$258.22
$360.86
$548.35 		$356.63
$383.89
$412.79
$515.43 		$511.20
$538.46
$567.36
$670.00 		$665.77
$693.03
$721.93
$824.57 		$154.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$404.12
$458.64
$516.44
$721.72
$1,096.70 		$558.69
$613.21
$671.01
$876.29 		$713.26
$767.78
$825.58
$1,030.86 		$867.83
$922.35
$980.15
$1,185.43 		$154.57
Toc - Plan #6 Security Health Plan
Gold

(EPO) SimplyOne $2,000 - 25%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$439.74
$499.09
$561.97
$785.35
$1,193.42 		$776.13
$835.48
$898.36
$1,121.74 		$1,112.52
$1,171.87
$1,234.75
$1,458.13 		$1,448.91
$1,508.26
$1,571.14
$1,794.52 		$336.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.48
$998.18
$1,123.94
$1,570.70
$2,386.84 		$1,215.87
$1,334.57
$1,460.33
$1,907.09 		$1,552.26
$1,670.96
$1,796.72
$2,243.48 		$1,888.65
$2,007.35
$2,133.11
$2,579.87 		$336.39
Toc - Plan #7 Security Health Plan
Silver

(EPO) SimplyOne $5,800 - 40%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$435.95
$494.79
$557.13
$778.59
$1,183.14 		$769.44
$828.28
$890.62
$1,112.08 		$1,102.93
$1,161.77
$1,224.11
$1,445.57 		$1,436.42
$1,495.26
$1,557.60
$1,779.06 		$333.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.90
$989.58
$1,114.26
$1,557.18
$2,366.28 		$1,205.39
$1,323.07
$1,447.75
$1,890.67 		$1,538.88
$1,656.56
$1,781.24
$2,224.16 		$1,872.37
$1,990.05
$2,114.73
$2,557.65 		$333.49
Toc - Plan #8 Security Health Plan
Expanded Bronze

(EPO) SimplyOne $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$301.86
$342.60
$385.76
$539.10
$819.21 		$532.77
$573.51
$616.67
$770.01 		$763.68
$804.42
$847.58
$1,000.92 		$994.59
$1,035.33
$1,078.49
$1,231.83 		$230.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.72
$685.20
$771.52
$1,078.20
$1,638.42 		$834.63
$916.11
$1,002.43
$1,309.11 		$1,065.54
$1,147.02
$1,233.34
$1,540.02 		$1,296.45
$1,377.93
$1,464.25
$1,770.93 		$230.91
Toc - Plan #9 Security Health Plan
Gold

(HMO) Premier $2,000 - 25%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$546.49
$620.26
$698.41
$976.02
$1,483.16 		$964.55
$1,038.32
$1,116.47
$1,394.08 		$1,382.61
$1,456.38
$1,534.53
$1,812.14 		$1,800.67
$1,874.44
$1,952.59
$2,230.20 		$418.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,092.98
$1,240.52
$1,396.82
$1,952.04
$2,966.32 		$1,511.04
$1,658.58
$1,814.88
$2,370.10 		$1,929.10
$2,076.64
$2,232.94
$2,788.16 		$2,347.16
$2,494.70
$2,651.00
$3,206.22 		$418.06
Toc - Plan #10 Security Health Plan
Gold

(HMO) Premier $3,500 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$514.72
$584.19
$657.79
$919.27
$1,396.91 		$908.47
$977.94
$1,051.54
$1,313.02 		$1,302.22
$1,371.69
$1,445.29
$1,706.77 		$1,695.97
$1,765.44
$1,839.04
$2,100.52 		$393.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,029.44
$1,168.38
$1,315.58
$1,838.54
$2,793.82 		$1,423.19
$1,562.13
$1,709.33
$2,232.29 		$1,816.94
$1,955.88
$2,103.08
$2,626.04 		$2,210.69
$2,349.63
$2,496.83
$3,019.79 		$393.75
Toc - Plan #11 Security Health Plan
Silver

(HMO) Premier $5,800 - 40%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$541.79
$614.92
$692.39
$967.61
$1,470.38 		$956.25
$1,029.38
$1,106.85
$1,382.07 		$1,370.71
$1,443.84
$1,521.31
$1,796.53 		$1,785.17
$1,858.30
$1,935.77
$2,210.99 		$414.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,083.58
$1,229.84
$1,384.78
$1,935.22
$2,940.76 		$1,498.04
$1,644.30
$1,799.24
$2,349.68 		$1,912.50
$2,058.76
$2,213.70
$2,764.14 		$2,326.96
$2,473.22
$2,628.16
$3,178.60 		$414.46
Toc - Plan #12 Security Health Plan
Silver

(HMO) Premier $4,100 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$625.14
$709.52
$798.91
$1,116.48
$1,696.59 		$1,103.36
$1,187.74
$1,277.13
$1,594.70 		$1,581.58
$1,665.96
$1,755.35
$2,072.92 		$2,059.80
$2,144.18
$2,233.57
$2,551.14 		$478.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,250.28
$1,419.04
$1,597.82
$2,232.96
$3,393.18 		$1,728.50
$1,897.26
$2,076.04
$2,711.18 		$2,206.72
$2,375.48
$2,554.26
$3,189.40 		$2,684.94
$2,853.70
$3,032.48
$3,667.62 		$478.22
Toc - Plan #13 Security Health Plan
Expanded Bronze

(HMO) Premier $6,200 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$426.12
$483.64
$544.57
$761.04
$1,156.47 		$752.10
$809.62
$870.55
$1,087.02 		$1,078.08
$1,135.60
$1,196.53
$1,413.00 		$1,404.06
$1,461.58
$1,522.51
$1,738.98 		$325.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.24
$967.28
$1,089.14
$1,522.08
$2,312.94 		$1,178.22
$1,293.26
$1,415.12
$1,848.06 		$1,504.20
$1,619.24
$1,741.10
$2,174.04 		$1,830.18
$1,945.22
$2,067.08
$2,500.02 		$325.98
Toc - Plan #14 Security Health Plan
Expanded Bronze

(HMO) Premier $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$375.14
$425.77
$479.42
$669.98
$1,018.10 		$662.11
$712.74
$766.39
$956.95 		$949.08
$999.71
$1,053.36
$1,243.92 		$1,236.05
$1,286.68
$1,340.33
$1,530.89 		$286.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.28
$851.54
$958.84
$1,339.96
$2,036.20 		$1,037.25
$1,138.51
$1,245.81
$1,626.93 		$1,324.22
$1,425.48
$1,532.78
$1,913.90 		$1,611.19
$1,712.45
$1,819.75
$2,200.87 		$286.97
Toc - Plan #15 Security Health Plan
Bronze

(HMO) Premier $9,100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$367.06
$416.60
$469.09
$655.55
$996.18 		$647.85
$697.39
$749.88
$936.34 		$928.64
$978.18
$1,030.67
$1,217.13 		$1,209.43
$1,258.97
$1,311.46
$1,497.92 		$280.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.12
$833.20
$938.18
$1,311.10
$1,992.36 		$1,014.91
$1,113.99
$1,218.97
$1,591.89 		$1,295.70
$1,394.78
$1,499.76
$1,872.68 		$1,576.49
$1,675.57
$1,780.55
$2,153.47 		$280.79
Toc - Plan #16 Security Health Plan
Catastrophic

(HMO) Premier Protection

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$251.11
$285.00
$320.91
$448.46
$681.48 		$443.20
$477.09
$513.00
$640.55 		$635.29
$669.18
$705.09
$832.64 		$827.38
$861.27
$897.18
$1,024.73 		$192.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$502.22
$570.00
$641.82
$896.92
$1,362.96 		$694.31
$762.09
$833.91
$1,089.01 		$886.40
$954.18
$1,026.00
$1,281.10 		$1,078.49
$1,146.27
$1,218.09
$1,473.19 		$192.09

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-947-3529
Toc - Plan #17 Medica
Gold

(EPO) Medica Individual Choice Gold Copay ($0 Virtual Care with Designated Providers + $0 Preferred Generic Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$522.16
$592.65
$667.31
$932.57
$1,417.13 		$921.61
$992.10
$1,066.76
$1,332.02 		$1,321.06
$1,391.55
$1,466.21
$1,731.47 		$1,720.51
$1,791.00
$1,865.66
$2,130.92 		$399.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,044.32
$1,185.30
$1,334.62
$1,865.14
$2,834.26 		$1,443.77
$1,584.75
$1,734.07
$2,264.59 		$1,843.22
$1,984.20
$2,133.52
$2,664.04 		$2,242.67
$2,383.65
$2,532.97
$3,063.49 		$399.45
Toc - Plan #18 Medica
Expanded Bronze

(EPO) Medica Individual Choice Bronze Copay ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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 		$399.07
$452.93
$509.99
$712.71
$1,083.04 		$704.35
$758.21
$815.27
$1,017.99 		$1,009.63
$1,063.49
$1,120.55
$1,323.27 		$1,314.91
$1,368.77
$1,425.83
$1,628.55 		$305.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.14
$905.86
$1,019.98
$1,425.42
$2,166.08 		$1,103.42
$1,211.14
$1,325.26
$1,730.70 		$1,408.70
$1,516.42
$1,630.54
$2,035.98 		$1,713.98
$1,821.70
$1,935.82
$2,341.26 		$305.28
Toc - Plan #19 Medica
Expanded Bronze

(EPO) Medica Individual Choice Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$454.55
$515.91
$580.91
$811.81
$1,233.63 		$802.28
$863.64
$928.64
$1,159.54 		$1,150.01
$1,211.37
$1,276.37
$1,507.27 		$1,497.74
$1,559.10
$1,624.10
$1,855.00 		$347.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.10
$1,031.82
$1,161.82
$1,623.62
$2,467.26 		$1,256.83
$1,379.55
$1,509.55
$1,971.35 		$1,604.56
$1,727.28
$1,857.28
$2,319.08 		$1,952.29
$2,075.01
$2,205.01
$2,666.81 		$347.73
Toc - Plan #20 Medica
Catastrophic

(EPO) Medica Individual Choice Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$254.92
$289.32
$325.78
$455.27
$691.83 		$449.93
$484.33
$520.79
$650.28 		$644.94
$679.34
$715.80
$845.29 		$839.95
$874.35
$910.81
$1,040.30 		$195.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$509.84
$578.64
$651.56
$910.54
$1,383.66 		$704.85
$773.65
$846.57
$1,105.55 		$899.86
$968.66
$1,041.58
$1,300.56 		$1,094.87
$1,163.67
$1,236.59
$1,495.57 		$195.01
Toc - Plan #21 Medica
Silver

(EPO) Medica Individual Choice Silver Share ($0 Virtual Care with Designated Providers + $5 Preferred Generic Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$521.95
$592.41
$667.04
$932.19
$1,416.55 		$921.24
$991.70
$1,066.33
$1,331.48 		$1,320.53
$1,390.99
$1,465.62
$1,730.77 		$1,719.82
$1,790.28
$1,864.91
$2,130.06 		$399.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,043.90
$1,184.82
$1,334.08
$1,864.38
$2,833.10 		$1,443.19
$1,584.11
$1,733.37
$2,263.67 		$1,842.48
$1,983.40
$2,132.66
$2,662.96 		$2,241.77
$2,382.69
$2,531.95
$3,062.25 		$399.29
Toc - Plan #22 Medica
Expanded Bronze

(EPO) Medica Individual Choice Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.28
$464.53
$523.05
$730.96
$1,110.77 		$722.37
$777.62
$836.14
$1,044.05 		$1,035.46
$1,090.71
$1,149.23
$1,357.14 		$1,348.55
$1,403.80
$1,462.32
$1,670.23 		$313.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.56
$929.06
$1,046.10
$1,461.92
$2,221.54 		$1,131.65
$1,242.15
$1,359.19
$1,775.01 		$1,444.74
$1,555.24
$1,672.28
$2,088.10 		$1,757.83
$1,868.33
$1,985.37
$2,401.19 		$313.09
Toc - Plan #23 Medica
Gold

(EPO) Medica Individual Choice Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$521.37
$591.74
$666.30
$931.15
$1,414.97 		$920.21
$990.58
$1,065.14
$1,329.99 		$1,319.05
$1,389.42
$1,463.98
$1,728.83 		$1,717.89
$1,788.26
$1,862.82
$2,127.67 		$398.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,042.74
$1,183.48
$1,332.60
$1,862.30
$2,829.94 		$1,441.58
$1,582.32
$1,731.44
$2,261.14 		$1,840.42
$1,981.16
$2,130.28
$2,659.98 		$2,239.26
$2,380.00
$2,529.12
$3,058.82 		$398.84
Toc - Plan #24 Medica
Silver

(EPO) Medica Individual Choice Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$503.10
$571.01
$642.95
$898.53
$1,365.40 		$887.97
$955.88
$1,027.82
$1,283.40 		$1,272.84
$1,340.75
$1,412.69
$1,668.27 		$1,657.71
$1,725.62
$1,797.56
$2,053.14 		$384.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,006.20
$1,142.02
$1,285.90
$1,797.06
$2,730.80 		$1,391.07
$1,526.89
$1,670.77
$2,181.93 		$1,775.94
$1,911.76
$2,055.64
$2,566.80 		$2,160.81
$2,296.63
$2,440.51
$2,951.67 		$384.87
Toc - Plan #25 Medica
Bronze

(EPO) Medica Individual Choice Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$389.43
$441.99
$497.68
$695.50
$1,056.88 		$687.34
$739.90
$795.59
$993.41 		$985.25
$1,037.81
$1,093.50
$1,291.32 		$1,283.16
$1,335.72
$1,391.41
$1,589.23 		$297.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.86
$883.98
$995.36
$1,391.00
$2,113.76 		$1,076.77
$1,181.89
$1,293.27
$1,688.91 		$1,374.68
$1,479.80
$1,591.18
$1,986.82 		$1,672.59
$1,777.71
$1,889.09
$2,284.73 		$297.91

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

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

Toc - Plan #26 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 		$442.29
$502.00
$565.25
$789.93
$1,200.38 		$780.64
$840.35
$903.60
$1,128.28 		$1,118.99
$1,178.70
$1,241.95
$1,466.63 		$1,457.34
$1,517.05
$1,580.30
$1,804.98 		$338.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.58
$1,004.00
$1,130.50
$1,579.86
$2,400.76 		$1,222.93
$1,342.35
$1,468.85
$1,918.21 		$1,561.28
$1,680.70
$1,807.20
$2,256.56 		$1,899.63
$2,019.05
$2,145.55
$2,594.91 		$338.35
Toc - Plan #27 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 		$428.84
$486.73
$548.06
$765.91
$1,163.87 		$756.90
$814.79
$876.12
$1,093.97 		$1,084.96
$1,142.85
$1,204.18
$1,422.03 		$1,413.02
$1,470.91
$1,532.24
$1,750.09 		$328.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.68
$973.46
$1,096.12
$1,531.82
$2,327.74 		$1,185.74
$1,301.52
$1,424.18
$1,859.88 		$1,513.80
$1,629.58
$1,752.24
$2,187.94 		$1,841.86
$1,957.64
$2,080.30
$2,516.00 		$328.06
Toc - Plan #28 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 		$421.16
$478.02
$538.24
$752.19
$1,143.03 		$743.35
$800.21
$860.43
$1,074.38 		$1,065.54
$1,122.40
$1,182.62
$1,396.57 		$1,387.73
$1,444.59
$1,504.81
$1,718.76 		$322.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.32
$956.04
$1,076.48
$1,504.38
$2,286.06 		$1,164.51
$1,278.23
$1,398.67
$1,826.57 		$1,486.70
$1,600.42
$1,720.86
$2,148.76 		$1,808.89
$1,922.61
$2,043.05
$2,470.95 		$322.19
Toc - Plan #29 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 		$399.20
$453.09
$510.18
$712.97
$1,083.43 		$704.59
$758.48
$815.57
$1,018.36 		$1,009.98
$1,063.87
$1,120.96
$1,323.75 		$1,315.37
$1,369.26
$1,426.35
$1,629.14 		$305.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.40
$906.18
$1,020.36
$1,425.94
$2,166.86 		$1,103.79
$1,211.57
$1,325.75
$1,731.33 		$1,409.18
$1,516.96
$1,631.14
$2,036.72 		$1,714.57
$1,822.35
$1,936.53
$2,342.11 		$305.39
Toc - Plan #30 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 		$420.29
$477.03
$537.13
$750.64
$1,140.67 		$741.81
$798.55
$858.65
$1,072.16 		$1,063.33
$1,120.07
$1,180.17
$1,393.68 		$1,384.85
$1,441.59
$1,501.69
$1,715.20 		$321.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.58
$954.06
$1,074.26
$1,501.28
$2,281.34 		$1,162.10
$1,275.58
$1,395.78
$1,822.80 		$1,483.62
$1,597.10
$1,717.30
$2,144.32 		$1,805.14
$1,918.62
$2,038.82
$2,465.84 		$321.52
Toc - Plan #31 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 		$545.19
$618.79
$696.75
$973.71
$1,479.65 		$962.26
$1,035.86
$1,113.82
$1,390.78 		$1,379.33
$1,452.93
$1,530.89
$1,807.85 		$1,796.40
$1,870.00
$1,947.96
$2,224.92 		$417.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,090.38
$1,237.58
$1,393.50
$1,947.42
$2,959.30 		$1,507.45
$1,654.65
$1,810.57
$2,364.49 		$1,924.52
$2,071.72
$2,227.64
$2,781.56 		$2,341.59
$2,488.79
$2,644.71
$3,198.63 		$417.07
Toc - Plan #32 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 		$526.37
$597.43
$672.70
$940.10
$1,428.57 		$929.04
$1,000.10
$1,075.37
$1,342.77 		$1,331.71
$1,402.77
$1,478.04
$1,745.44 		$1,734.38
$1,805.44
$1,880.71
$2,148.11 		$402.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,052.74
$1,194.86
$1,345.40
$1,880.20
$2,857.14 		$1,455.41
$1,597.53
$1,748.07
$2,282.87 		$1,858.08
$2,000.20
$2,150.74
$2,685.54 		$2,260.75
$2,402.87
$2,553.41
$3,088.21 		$402.67
Toc - Plan #33 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 		$532.70
$604.61
$680.79
$951.40
$1,445.75 		$940.22
$1,012.13
$1,088.31
$1,358.92 		$1,347.74
$1,419.65
$1,495.83
$1,766.44 		$1,755.26
$1,827.17
$1,903.35
$2,173.96 		$407.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,065.40
$1,209.22
$1,361.58
$1,902.80
$2,891.50 		$1,472.92
$1,616.74
$1,769.10
$2,310.32 		$1,880.44
$2,024.26
$2,176.62
$2,717.84 		$2,287.96
$2,431.78
$2,584.14
$3,125.36 		$407.52
Toc - Plan #34 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 		$523.27
$593.91
$668.74
$934.56
$1,420.15 		$923.57
$994.21
$1,069.04
$1,334.86 		$1,323.87
$1,394.51
$1,469.34
$1,735.16 		$1,724.17
$1,794.81
$1,869.64
$2,135.46 		$400.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,046.54
$1,187.82
$1,337.48
$1,869.12
$2,840.30 		$1,446.84
$1,588.12
$1,737.78
$2,269.42 		$1,847.14
$1,988.42
$2,138.08
$2,669.72 		$2,247.44
$2,388.72
$2,538.38
$3,070.02 		$400.30
Toc - Plan #35 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 		$399.77
$453.74
$510.91
$713.99
$1,084.98 		$705.59
$759.56
$816.73
$1,019.81 		$1,011.41
$1,065.38
$1,122.55
$1,325.63 		$1,317.23
$1,371.20
$1,428.37
$1,631.45 		$305.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.54
$907.48
$1,021.82
$1,427.98
$2,169.96 		$1,105.36
$1,213.30
$1,327.64
$1,733.80 		$1,411.18
$1,519.12
$1,633.46
$2,039.62 		$1,717.00
$1,824.94
$1,939.28
$2,345.44 		$305.82
Toc - Plan #36 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 		$434.52
$493.18
$555.32
$776.05
$1,179.29 		$766.93
$825.59
$887.73
$1,108.46 		$1,099.34
$1,158.00
$1,220.14
$1,440.87 		$1,431.75
$1,490.41
$1,552.55
$1,773.28 		$332.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869.04
$986.36
$1,110.64
$1,552.10
$2,358.58 		$1,201.45
$1,318.77
$1,443.05
$1,884.51 		$1,533.86
$1,651.18
$1,775.46
$2,216.92 		$1,866.27
$1,983.59
$2,107.87
$2,549.33 		$332.41
Toc - Plan #37 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 		$518.82
$588.86
$663.05
$926.61
$1,408.08 		$915.72
$985.76
$1,059.95
$1,323.51 		$1,312.62
$1,382.66
$1,456.85
$1,720.41 		$1,709.52
$1,779.56
$1,853.75
$2,117.31 		$396.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,037.64
$1,177.72
$1,326.10
$1,853.22
$2,816.16 		$1,434.54
$1,574.62
$1,723.00
$2,250.12 		$1,831.44
$1,971.52
$2,119.90
$2,647.02 		$2,228.34
$2,368.42
$2,516.80
$3,043.92 		$396.90
Toc - Plan #38 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 		$545.58
$619.23
$697.25
$974.41
$1,480.70 		$962.95
$1,036.60
$1,114.62
$1,391.78 		$1,380.32
$1,453.97
$1,531.99
$1,809.15 		$1,797.69
$1,871.34
$1,949.36
$2,226.52 		$417.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,091.16
$1,238.46
$1,394.50
$1,948.82
$2,961.40 		$1,508.53
$1,655.83
$1,811.87
$2,366.19 		$1,925.90
$2,073.20
$2,229.24
$2,783.56 		$2,343.27
$2,490.57
$2,646.61
$3,200.93 		$417.37

ADVERTISEMENT

Aspirus Health Plan

Local: 1-866-631-4611 | Toll Free: 1-866-631-4611 | TTY: 1-866-631-8597
Toc - Plan #39 Aspirus Health Plan
Silver

(HMO) HMO Silver 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$546.05
$619.76
$697.85
$975.24
$1,481.97 		$963.78
$1,037.49
$1,115.58
$1,392.97 		$1,381.51
$1,455.22
$1,533.31
$1,810.70 		$1,799.24
$1,872.95
$1,951.04
$2,228.43 		$417.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,092.10
$1,239.52
$1,395.70
$1,950.48
$2,963.94 		$1,509.83
$1,657.25
$1,813.43
$2,368.21 		$1,927.56
$2,074.98
$2,231.16
$2,785.94 		$2,345.29
$2,492.71
$2,648.89
$3,203.67 		$417.73
Toc - Plan #40 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$6,950 $13,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.41
$457.87
$515.56
$720.50
$1,094.86 		$712.02
$766.48
$824.17
$1,029.11 		$1,020.63
$1,075.09
$1,132.78
$1,337.72 		$1,329.24
$1,383.70
$1,441.39
$1,646.33 		$308.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.82
$915.74
$1,031.12
$1,441.00
$2,189.72 		$1,115.43
$1,224.35
$1,339.73
$1,749.61 		$1,424.04
$1,532.96
$1,648.34
$2,058.22 		$1,732.65
$1,841.57
$1,956.95
$2,366.83 		$308.61
Toc - Plan #41 Aspirus Health Plan
Bronze

(HMO) HMO Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$370.96
$421.04
$474.08
$662.53
$1,006.78 		$654.74
$704.82
$757.86
$946.31 		$938.52
$988.60
$1,041.64
$1,230.09 		$1,222.30
$1,272.38
$1,325.42
$1,513.87 		$283.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.92
$842.08
$948.16
$1,325.06
$2,013.56 		$1,025.70
$1,125.86
$1,231.94
$1,608.84 		$1,309.48
$1,409.64
$1,515.72
$1,892.62 		$1,593.26
$1,693.42
$1,799.50
$2,176.40 		$283.78
Toc - Plan #42 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze 6500 with 3 Free PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.14
$453.03
$510.11
$712.87
$1,083.28 		$704.49
$758.38
$815.46
$1,018.22 		$1,009.84
$1,063.73
$1,120.81
$1,323.57 		$1,315.19
$1,369.08
$1,426.16
$1,628.92 		$305.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.28
$906.06
$1,020.22
$1,425.74
$2,166.56 		$1,103.63
$1,211.41
$1,325.57
$1,731.09 		$1,408.98
$1,516.76
$1,630.92
$2,036.44 		$1,714.33
$1,822.11
$1,936.27
$2,341.79 		$305.35
Toc - Plan #43 Aspirus Health Plan
Gold

(HMO) HMO Gold 2800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$501.99
$569.76
$641.54
$896.55
$1,362.40 		$886.01
$953.78
$1,025.56
$1,280.57 		$1,270.03
$1,337.80
$1,409.58
$1,664.59 		$1,654.05
$1,721.82
$1,793.60
$2,048.61 		$384.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,003.98
$1,139.52
$1,283.08
$1,793.10
$2,724.80 		$1,388.00
$1,523.54
$1,667.10
$2,177.12 		$1,772.02
$1,907.56
$2,051.12
$2,561.14 		$2,156.04
$2,291.58
$2,435.14
$2,945.16 		$384.02
Toc - Plan #44 Aspirus Health Plan
Catastrophic

(HMO) HMO Catastrophic 9100 with 3 Free PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$270.01
$306.46
$345.08
$482.24
$732.82 		$476.57
$513.02
$551.64
$688.80 		$683.13
$719.58
$758.20
$895.36 		$889.69
$926.14
$964.76
$1,101.92 		$206.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.02
$612.92
$690.16
$964.48
$1,465.64 		$746.58
$819.48
$896.72
$1,171.04 		$953.14
$1,026.04
$1,103.28
$1,377.60 		$1,159.70
$1,232.60
$1,309.84
$1,584.16 		$206.56
Toc - Plan #45 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 6900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.81
$456.06
$513.52
$717.64
$1,090.52 		$709.20
$763.45
$820.91
$1,025.03 		$1,016.59
$1,070.84
$1,128.30
$1,332.42 		$1,323.98
$1,378.23
$1,435.69
$1,639.81 		$307.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.62
$912.12
$1,027.04
$1,435.28
$2,181.04 		$1,111.01
$1,219.51
$1,334.43
$1,742.67 		$1,418.40
$1,526.90
$1,641.82
$2,050.06 		$1,725.79
$1,834.29
$1,949.21
$2,357.45 		$307.39
Toc - Plan #46 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$395.32
$448.68
$505.21
$706.04
$1,072.89 		$697.74
$751.10
$807.63
$1,008.46 		$1,000.16
$1,053.52
$1,110.05
$1,310.88 		$1,302.58
$1,355.94
$1,412.47
$1,613.30 		$302.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.64
$897.36
$1,010.42
$1,412.08
$2,145.78 		$1,093.06
$1,199.78
$1,312.84
$1,714.50 		$1,395.48
$1,502.20
$1,615.26
$2,016.92 		$1,697.90
$1,804.62
$1,917.68
$2,319.34 		$302.42
Toc - Plan #47 Aspirus Health Plan
Silver

(HMO) HMO Silver 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$544.67
$618.20
$696.08
$972.77
$1,478.22 		$961.34
$1,034.87
$1,112.75
$1,389.44 		$1,378.01
$1,451.54
$1,529.42
$1,806.11 		$1,794.68
$1,868.21
$1,946.09
$2,222.78 		$416.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,089.34
$1,236.40
$1,392.16
$1,945.54
$2,956.44 		$1,506.01
$1,653.07
$1,808.83
$2,362.21 		$1,922.68
$2,069.74
$2,225.50
$2,778.88 		$2,339.35
$2,486.41
$2,642.17
$3,195.55 		$416.67
Toc - Plan #48 Aspirus Health Plan
Silver

(HMO) HMO HDHP Silver 5400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$553.93
$628.72
$707.93
$989.33
$1,503.38 		$977.69
$1,052.48
$1,131.69
$1,413.09 		$1,401.45
$1,476.24
$1,555.45
$1,836.85 		$1,825.21
$1,900.00
$1,979.21
$2,260.61 		$423.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,107.86
$1,257.44
$1,415.86
$1,978.66
$3,006.76 		$1,531.62
$1,681.20
$1,839.62
$2,402.42 		$1,955.38
$2,104.96
$2,263.38
$2,826.18 		$2,379.14
$2,528.72
$2,687.14
$3,249.94 		$423.76
Toc - Plan #49 Aspirus Health Plan
Gold

(HMO) HMO Gold 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$501.40
$569.09
$640.79
$895.50
$1,360.80 		$884.97
$952.66
$1,024.36
$1,279.07 		$1,268.54
$1,336.23
$1,407.93
$1,662.64 		$1,652.11
$1,719.80
$1,791.50
$2,046.21 		$383.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,002.80
$1,138.18
$1,281.58
$1,791.00
$2,721.60 		$1,386.37
$1,521.75
$1,665.15
$2,174.57 		$1,769.94
$1,905.32
$2,048.72
$2,558.14 		$2,153.51
$2,288.89
$2,432.29
$2,941.71 		$383.57
Toc - Plan #50 Aspirus Health Plan
Silver

(POS) POS Silver 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$623.57
$707.75
$796.92
$1,113.70
$1,692.37 		$1,100.60
$1,184.78
$1,273.95
$1,590.73 		$1,577.63
$1,661.81
$1,750.98
$2,067.76 		$2,054.66
$2,138.84
$2,228.01
$2,544.79 		$477.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,247.14
$1,415.50
$1,593.84
$2,227.40
$3,384.74 		$1,724.17
$1,892.53
$2,070.87
$2,704.43 		$2,201.20
$2,369.56
$2,547.90
$3,181.46 		$2,678.23
$2,846.59
$3,024.93
$3,658.49 		$477.03
Toc - Plan #51 Aspirus Health Plan
Expanded Bronze

(POS) POS HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$6,950 $13,900 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 		$443.99
$503.93
$567.42
$792.97
$1,204.99 		$783.64
$843.58
$907.07
$1,132.62 		$1,123.29
$1,183.23
$1,246.72
$1,472.27 		$1,462.94
$1,522.88
$1,586.37
$1,811.92 		$339.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.98
$1,007.86
$1,134.84
$1,585.94
$2,409.98 		$1,227.63
$1,347.51
$1,474.49
$1,925.59 		$1,567.28
$1,687.16
$1,814.14
$2,265.24 		$1,906.93
$2,026.81
$2,153.79
$2,604.89 		$339.65
Toc - Plan #52 Aspirus Health Plan
Expanded Bronze

(POS) POS Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$570.94
$648.02
$729.66
$1,019.70
$1,549.53 		$1,007.71
$1,084.79
$1,166.43
$1,456.47 		$1,444.48
$1,521.56
$1,603.20
$1,893.24 		$1,881.25
$1,958.33
$2,039.97
$2,330.01 		$436.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,141.88
$1,296.04
$1,459.32
$2,039.40
$3,099.06 		$1,578.65
$1,732.81
$1,896.09
$2,476.17 		$2,015.42
$2,169.58
$2,332.86
$2,912.94 		$2,452.19
$2,606.35
$2,769.63
$3,349.71 		$436.77

‡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 Clark County here.

Clark County is in “Rating Area 8” of Wisconsin.

Currently, there are 52 plans offered in Rating Area 8.

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2023 Obamacare Plans for Clark County, WI

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