Wisconsin

Obamacare 2018 Rates

Obamacare 2018 Rates and Health Insurance Providers for Dane County,Madison,WI


The health insurance rates listed below are for calendar year 2018.

2018 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

(click here for 2017)

This page gives you an overview of the rates for individual and family health insurance plans available from HealthCare.gov, the marketplace for Dane County, Wisconsin.

Obamacare Providers, Plans and 2018 Rates for Dane County

Dane County is in “Rating Area 2” of Wisconsin.

Currently, there are 70 plans offered in Rating Area 2.

Below, you’ll find a summary of plans and rates for each of these providers. This chart is designed to give you a preview of your health insurance options. For detailed information on available subsidies to make your coverage affordable, you must either

  • contact a licensed health insurance agent (by contacting one of the advertisers you see on this website)
  • complete an application at HealthCare.gov, or
  • contact the provider directly.

The table below shows premiums for the following scenarios for:

  • Individual
  • Couple
  • Couple with 1 2 or 3 children
  • Individual with 1 2 or 3 children
  • A child alone

Each scenario is covered for age

  • Age 21, 30, 40, 50
  • Age 60 (Individual and Couple only)

For each plan, there are links that go to the insurance provider's website in a new window. You can find links to:

  • a summary of plan benefits and costs,
  • a plan brochure, and
  • a "Provider Directory" -- where you can find out which doctors and hospitals in the Madison, WI area accept this insurance coverage as within the plan's "network".

2018 Obamacare Rates Providers, Plans for Dane County

Unity Health Plans Insurance Corporation

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

TTY: 1-608-643-1421

Gold

Plan: (HMO) Prime Gold First $500 with Dental

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$447.10
$507.45
$571.39
$798.51
$1,213.42
$894.20
$1,014.90
$1,142.78
$1,597.02
$2,426.84
$1,236.23
$1,356.93
$1,484.81
$1,939.05
$1,578.26
$1,698.96
$1,826.84
$2,281.08
$1,920.29
$2,040.99
$2,168.87
$2,623.11
$789.13
$849.48
$913.42
$1,140.54
$1,131.16
$1,191.51
$1,255.45
$1,482.57
$1,473.19
$1,533.54
$1,597.48
$1,824.60
$342.03

Bronze

Plan: (HMO) Prime Bronze Deductible $6500 with Dental

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$309.13
$350.85
$395.06
$552.09
$838.96
$618.26
$701.70
$790.12
$1,104.18
$1,677.92
$854.74
$938.18
$1,026.60
$1,340.66
$1,091.22
$1,174.66
$1,263.08
$1,577.14
$1,327.70
$1,411.14
$1,499.56
$1,813.62
$545.61
$587.33
$631.54
$788.57
$782.09
$823.81
$868.02
$1,025.05
$1,018.57
$1,060.29
$1,104.50
$1,261.53
$236.48

Gold

Plan: (HMO) Prime Gold Maintenance - PCP Copay $20 with Dental

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $1,700 : Family: $3,400
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$440.52
$499.98
$562.97
$786.75
$1,195.54
$881.04
$999.96
$1,125.94
$1,573.50
$2,391.08
$1,218.03
$1,336.95
$1,462.93
$1,910.49
$1,555.02
$1,673.94
$1,799.92
$2,247.48
$1,892.01
$2,010.93
$2,136.91
$2,584.47
$777.51
$836.97
$899.96
$1,123.74
$1,114.50
$1,173.96
$1,236.95
$1,460.73
$1,451.49
$1,510.95
$1,573.94
$1,797.72
$336.99

Gold

Plan: (HMO) Prime Gold Healthy You - PCP Copay $30

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $2,900 : Family: $5,800
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$395.59
$448.99
$505.56
$706.52
$1,073.62
$791.18
$897.98
$1,011.12
$1,413.04
$2,147.24
$1,093.80
$1,200.60
$1,313.74
$1,715.66
$1,396.42
$1,503.22
$1,616.36
$2,018.28
$1,699.04
$1,805.84
$1,918.98
$2,320.90
$698.21
$751.61
$808.18
$1,009.14
$1,000.83
$1,054.23
$1,110.80
$1,311.76
$1,303.45
$1,356.85
$1,413.42
$1,614.38
$302.62

Group Health Cooperative of South Central Wisconsin

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729

Platinum

Plan: (HMO) Platinum No Ded/3000X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $1,000 : Family: $2,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$465.26
$528.07
$594.61
$830.96
$1,262.72
$930.52
$1,056.14
$1,189.22
$1,661.92
$2,525.44
$1,286.45
$1,412.07
$1,545.15
$2,017.85
$1,642.38
$1,768.00
$1,901.08
$2,373.78
$1,998.31
$2,123.93
$2,257.01
$2,729.71
$821.19
$884.00
$950.54
$1,186.89
$1,177.12
$1,239.93
$1,306.47
$1,542.82
$1,533.05
$1,595.86
$1,662.40
$1,898.75
$355.93

Platinum

Plan: (HMO) Platinum 500 Ded/3000X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $500 : Family: $1,000
Out of Pocket Maximum per year: Individual: $1,000 : Family: $2,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$454.63
$516.01
$581.02
$811.97
$1,233.86
$909.26
$1,032.02
$1,162.04
$1,623.94
$2,467.72
$1,257.05
$1,379.81
$1,509.83
$1,971.73
$1,604.84
$1,727.60
$1,857.62
$2,319.52
$1,952.63
$2,075.39
$2,205.41
$2,667.31
$802.42
$863.80
$928.81
$1,159.76
$1,150.21
$1,211.59
$1,276.60
$1,507.55
$1,498.00
$1,559.38
$1,624.39
$1,855.34
$347.79

Gold

Plan: (HMO) Gold 1500 Ded/5200X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $2,200 : Family: $4,400

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$418.11
$474.55
$534.34
$746.74
$1,134.74
$836.22
$949.10
$1,068.68
$1,493.48
$2,269.48
$1,156.08
$1,268.96
$1,388.54
$1,813.34
$1,475.94
$1,588.82
$1,708.40
$2,133.20
$1,795.80
$1,908.68
$2,028.26
$2,453.06
$737.97
$794.41
$854.20
$1,066.60
$1,057.83
$1,114.27
$1,174.06
$1,386.46
$1,377.69
$1,434.13
$1,493.92
$1,706.32
$319.86

Gold

Plan: (HMO) Gold 2500 Ded/7000X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $3,000 : Family: $6,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$402.35
$456.67
$514.21
$718.60
$1,091.98
$804.70
$913.34
$1,028.42
$1,437.20
$2,183.96
$1,112.50
$1,221.14
$1,336.22
$1,745.00
$1,420.30
$1,528.94
$1,644.02
$2,052.80
$1,728.10
$1,836.74
$1,951.82
$2,360.60
$710.15
$764.47
$822.01
$1,026.40
$1,017.95
$1,072.27
$1,129.81
$1,334.20
$1,325.75
$1,380.07
$1,437.61
$1,642.00
$307.80

Unity Health Plans Insurance Corporation

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

TTY: 1-608-643-1421

Gold

Plan: (HMO) Prime Gold Healthy You - PCP Copay $30 with Dental

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $2,900 : Family: $5,800
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$412.15
$467.78
$526.72
$736.09
$1,118.56
$824.30
$935.56
$1,053.44
$1,472.18
$2,237.12
$1,139.59
$1,250.85
$1,368.73
$1,787.47
$1,454.88
$1,566.14
$1,684.02
$2,102.76
$1,770.17
$1,881.43
$1,999.31
$2,418.05
$727.44
$783.07
$842.01
$1,051.38
$1,042.73
$1,098.36
$1,157.30
$1,366.67
$1,358.02
$1,413.65
$1,472.59
$1,681.96
$315.29

Silver

Plan: (HMO) Prime Silver 5000 Value - PCP Copay $35 with Dental

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$403.25
$457.68
$515.34
$720.19
$1,094.40
$806.50
$915.36
$1,030.68
$1,440.38
$2,188.80
$1,114.98
$1,223.84
$1,339.16
$1,748.86
$1,423.46
$1,532.32
$1,647.64
$2,057.34
$1,731.94
$1,840.80
$1,956.12
$2,365.82
$711.73
$766.16
$823.82
$1,028.67
$1,020.21
$1,074.64
$1,132.30
$1,337.15
$1,328.69
$1,383.12
$1,440.78
$1,645.63
$308.48

Silver

Plan: (HMO) Prime Silver 7100 Value - PCP Copay $75 with Dental

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $7,100 : Family: $14,200
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$395.16
$448.51
$505.01
$705.76
$1,072.46
$790.32
$897.02
$1,010.02
$1,411.52
$2,144.92
$1,092.62
$1,199.32
$1,312.32
$1,713.82
$1,394.92
$1,501.62
$1,614.62
$2,016.12
$1,697.22
$1,803.92
$1,916.92
$2,318.42
$697.46
$750.81
$807.31
$1,008.06
$999.76
$1,053.11
$1,109.61
$1,310.36
$1,302.06
$1,355.41
$1,411.91
$1,612.66
$302.30

Silver

Plan: (HMO) Prime Silver 5000 Value - PCP Copay $35

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$387.05
$439.29
$494.64
$691.26
$1,050.43
$774.10
$878.58
$989.28
$1,382.52
$2,100.86
$1,070.19
$1,174.67
$1,285.37
$1,678.61
$1,366.28
$1,470.76
$1,581.46
$1,974.70
$1,662.37
$1,766.85
$1,877.55
$2,270.79
$683.14
$735.38
$790.73
$987.35
$979.23
$1,031.47
$1,086.82
$1,283.44
$1,275.32
$1,327.56
$1,382.91
$1,579.53
$296.09

Silver

Plan: (HMO) Prime Silver 7100 Value - PCP Copay $75

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $7,100 : Family: $14,200
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$379.29
$430.49
$484.72
$677.40
$1,029.38
$758.58
$860.98
$969.44
$1,354.80
$2,058.76
$1,048.73
$1,151.13
$1,259.59
$1,644.95
$1,338.88
$1,441.28
$1,549.74
$1,935.10
$1,629.03
$1,731.43
$1,839.89
$2,225.25
$669.44
$720.64
$774.87
$967.55
$959.59
$1,010.79
$1,065.02
$1,257.70
$1,249.74
$1,300.94
$1,355.17
$1,547.85
$290.15

Gold

Plan: (HMO) Prime Gold First $500

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$429.14
$487.07
$548.43
$766.43
$1,164.67
$858.28
$974.14
$1,096.86
$1,532.86
$2,329.34
$1,186.57
$1,302.43
$1,425.15
$1,861.15
$1,514.86
$1,630.72
$1,753.44
$2,189.44
$1,843.15
$1,959.01
$2,081.73
$2,517.73
$757.43
$815.36
$876.72
$1,094.72
$1,085.72
$1,143.65
$1,205.01
$1,423.01
$1,414.01
$1,471.94
$1,533.30
$1,751.30
$328.29

Gold

Plan: (HMO) Prime Gold Standard - PCP Copay $20

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $1,400 : Family: $2,800
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$430.54
$488.65
$550.22
$768.93
$1,168.46
$861.08
$977.30
$1,100.44
$1,537.86
$2,336.92
$1,190.44
$1,306.66
$1,429.80
$1,867.22
$1,519.80
$1,636.02
$1,759.16
$2,196.58
$1,849.16
$1,965.38
$2,088.52
$2,525.94
$759.90
$818.01
$879.58
$1,098.29
$1,089.26
$1,147.37
$1,208.94
$1,427.65
$1,418.62
$1,476.73
$1,538.30
$1,757.01
$329.36

Silver

Plan: (HMO) Prime Silver Standard - PCP Copay $30

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$385.83
$437.91
$493.09
$689.09
$1,047.14
$771.66
$875.82
$986.18
$1,378.18
$2,094.28
$1,066.82
$1,170.98
$1,281.34
$1,673.34
$1,361.98
$1,466.14
$1,576.50
$1,968.50
$1,657.14
$1,761.30
$1,871.66
$2,263.66
$680.99
$733.07
$788.25
$984.25
$976.15
$1,028.23
$1,083.41
$1,279.41
$1,271.31
$1,323.39
$1,378.57
$1,574.57
$295.16

Expanded Bronze

Plan: (HMO) Prime Bronze Standard - PCP Copay $35

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$303.27
$344.21
$387.58
$541.64
$823.07
$606.54
$688.42
$775.16
$1,083.28
$1,646.14
$838.54
$920.42
$1,007.16
$1,315.28
$1,070.54
$1,152.42
$1,239.16
$1,547.28
$1,302.54
$1,384.42
$1,471.16
$1,779.28
$535.27
$576.21
$619.58
$773.64
$767.27
$808.21
$851.58
$1,005.64
$999.27
$1,040.21
$1,083.58
$1,237.64
$232.00

Bronze

Plan: (HMO) Prime Bronze Deductible $6500

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$296.71
$336.76
$379.19
$529.91
$805.25
$593.42
$673.52
$758.38
$1,059.82
$1,610.50
$820.40
$900.50
$985.36
$1,286.80
$1,047.38
$1,127.48
$1,212.34
$1,513.78
$1,274.36
$1,354.46
$1,439.32
$1,740.76
$523.69
$563.74
$606.17
$756.89
$750.67
$790.72
$833.15
$983.87
$977.65
$1,017.70
$1,060.13
$1,210.85
$226.98

Gold

Plan: (HMO) Prime Gold Maintenance - PCP Copay $20

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $1,700 : Family: $3,400
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$422.82
$479.89
$540.35
$755.14
$1,147.51
$845.64
$959.78
$1,080.70
$1,510.28
$2,295.02
$1,169.09
$1,283.23
$1,404.15
$1,833.73
$1,492.54
$1,606.68
$1,727.60
$2,157.18
$1,815.99
$1,930.13
$2,051.05
$2,480.63
$746.27
$803.34
$863.80
$1,078.59
$1,069.72
$1,126.79
$1,187.25
$1,402.04
$1,393.17
$1,450.24
$1,510.70
$1,725.49
$323.45

Gold

Plan: (HMO) Prime Gold HSA $1800

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $1,800 : Family: $3,600
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$425.86
$483.34
$544.24
$760.57
$1,155.76
$851.72
$966.68
$1,088.48
$1,521.14
$2,311.52
$1,177.50
$1,292.46
$1,414.26
$1,846.92
$1,503.28
$1,618.24
$1,740.04
$2,172.70
$1,829.06
$1,944.02
$2,065.82
$2,498.48
$751.64
$809.12
$870.02
$1,086.35
$1,077.42
$1,134.90
$1,195.80
$1,412.13
$1,403.20
$1,460.68
$1,521.58
$1,737.91
$325.78

Silver

Plan: (HMO) Prime Silver HSA $3000

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$393.12
$446.18
$502.40
$702.10
$1,066.91
$786.24
$892.36
$1,004.80
$1,404.20
$2,133.82
$1,086.97
$1,193.09
$1,305.53
$1,704.93
$1,387.70
$1,493.82
$1,606.26
$2,005.66
$1,688.43
$1,794.55
$1,906.99
$2,306.39
$693.85
$746.91
$803.13
$1,002.83
$994.58
$1,047.64
$1,103.86
$1,303.56
$1,295.31
$1,348.37
$1,404.59
$1,604.29
$300.73

Bronze

Plan: (HMO) Prime Bronze HSA $6550

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$302.85
$343.73
$387.03
$540.88
$821.91
$605.70
$687.46
$774.06
$1,081.76
$1,643.82
$837.37
$919.13
$1,005.73
$1,313.43
$1,069.04
$1,150.80
$1,237.40
$1,545.10
$1,300.71
$1,382.47
$1,469.07
$1,776.77
$534.52
$575.40
$618.70
$772.55
$766.19
$807.07
$850.37
$1,004.22
$997.86
$1,038.74
$1,082.04
$1,235.89
$231.67

Catastrophic

Plan: (HMO) Prime Catastrophic

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Catastrophic 21
30
40
50
60
$216.61
$245.84
$276.82
$386.85
$587.86
$433.22
$491.68
$553.64
$773.70
$1,175.72
$598.92
$657.38
$719.34
$939.40
$764.62
$823.08
$885.04
$1,105.10
$930.32
$988.78
$1,050.74
$1,270.80
$382.31
$411.54
$442.52
$552.55
$548.01
$577.24
$608.22
$718.25
$713.71
$742.94
$773.92
$883.95

Bronze

Plan: (HMO) Prime Bronze HSA $5000

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$306.43
$347.80
$391.62
$547.28
$831.65
$612.86
$695.60
$783.24
$1,094.56
$1,663.30
$847.28
$930.02
$1,017.66
$1,328.98
$1,081.70
$1,164.44
$1,252.08
$1,563.40
$1,316.12
$1,398.86
$1,486.50
$1,797.82
$540.85
$582.22
$626.04
$781.70
$775.27
$816.64
$860.46
$1,016.12
$1,009.69
$1,051.06
$1,094.88
$1,250.54
$234.42

Expanded Bronze

Plan: (HMO) Prime Bronze Standard HSA $6000

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$309.59
$351.38
$395.65
$552.92
$840.22
$619.18
$702.76
$791.30
$1,105.84
$1,680.44
$856.02
$939.60
$1,028.14
$1,342.68
$1,092.86
$1,176.44
$1,264.98
$1,579.52
$1,329.70
$1,413.28
$1,501.82
$1,816.36
$546.43
$588.22
$632.49
$789.76
$783.27
$825.06
$869.33
$1,026.60
$1,020.11
$1,061.90
$1,106.17
$1,263.44
$236.84

Silver

Plan: (HMO) Prime Silver HSA $5050

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)
Customer Service Phone: 1-800-362-3310

Deductible: Individual: $5,050 : Family: $10,100
Out of Pocket Maximum per year: Individual: $5,050 : Family: $10,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$395.55
$448.94
$505.50
$706.44
$1,073.50
$791.10
$897.88
$1,011.00
$1,412.88
$2,147.00
$1,093.69
$1,200.47
$1,313.59
$1,715.47
$1,396.28
$1,503.06
$1,616.18
$2,018.06
$1,698.87
$1,805.65
$1,918.77
$2,320.65
$698.14
$751.53
$808.09
$1,009.03
$1,000.73
$1,054.12
$1,110.68
$1,311.62
$1,303.32
$1,356.71
$1,413.27
$1,614.21
$302.59
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Dean Health Plan

Local: 1-608-828-1302 | Toll Free: 1-800-279-1302

TTY: 1-608-827-4086

Catastrophic

Plan: (HMO) Dean Catastrophic Safety Net

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Catastrophic 21
30
40
50
60
$186.44
$211.60
$238.26
$332.97
$505.99
$372.88
$423.20
$476.52
$665.94
$1,011.98
$515.50
$565.82
$619.14
$808.56
$658.12
$708.44
$761.76
$951.18
$800.74
$851.06
$904.38
$1,093.80
$329.06
$354.22
$380.88
$475.59
$471.68
$496.84
$523.50
$618.21
$614.30
$639.46
$666.12
$760.83
$142.62

Group Health Cooperative of South Central Wisconsin

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729

Gold

Plan: (HMO) Select Gold Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $1,400 : Family: $2,800
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$346.11
$392.83
$442.32
$618.15
$939.33
$692.22
$785.66
$884.64
$1,236.30
$1,878.66
$956.99
$1,050.43
$1,149.41
$1,501.07
$1,221.76
$1,315.20
$1,414.18
$1,765.84
$1,486.53
$1,579.97
$1,678.95
$2,030.61
$610.88
$657.60
$707.09
$882.92
$875.65
$922.37
$971.86
$1,147.69
$1,140.42
$1,187.14
$1,236.63
$1,412.46
$264.77
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Dean Health Plan

Local: 1-608-828-1302 | Toll Free: 1-800-279-1302

TTY: 1-608-827-4086

Silver

Plan: (HMO) Dean Silver Copay Plus 3250X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $3,250 : Family: $6,500
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$366.42
$415.88
$468.28
$654.42
$994.45
$732.84
$831.76
$936.56
$1,308.84
$1,988.90
$1,013.15
$1,112.07
$1,216.87
$1,589.15
$1,293.46
$1,392.38
$1,497.18
$1,869.46
$1,573.77
$1,672.69
$1,777.49
$2,149.77
$646.73
$696.19
$748.59
$934.73
$927.04
$976.50
$1,028.90
$1,215.04
$1,207.35
$1,256.81
$1,309.21
$1,495.35
$280.31

Silver

Plan: (HMO) Dean Silver Classic 4750X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $4,750 : Family: $9,500
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$367.32
$416.91
$469.44
$656.04
$996.92
$734.64
$833.82
$938.88
$1,312.08
$1,993.84
$1,015.64
$1,114.82
$1,219.88
$1,593.08
$1,296.64
$1,395.82
$1,500.88
$1,874.08
$1,577.64
$1,676.82
$1,781.88
$2,155.08
$648.32
$697.91
$750.44
$937.04
$929.32
$978.91
$1,031.44
$1,218.04
$1,210.32
$1,259.91
$1,312.44
$1,499.04
$281.00

Silver

Plan: (HMO) Dean Silver Value Copay 5000X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$383.43
$435.20
$490.03
$684.81
$1,040.64
$766.86
$870.40
$980.06
$1,369.62
$2,081.28
$1,060.19
$1,163.73
$1,273.39
$1,662.95
$1,353.52
$1,457.06
$1,566.72
$1,956.28
$1,646.85
$1,750.39
$1,860.05
$2,249.61
$676.76
$728.53
$783.36
$978.14
$970.09
$1,021.86
$1,076.69
$1,271.47
$1,263.42
$1,315.19
$1,370.02
$1,564.80
$293.33

Gold

Plan: (HMO) Dean Gold Value Copay 3500X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$323.83
$367.54
$413.85
$578.35
$878.86
$647.66
$735.08
$827.70
$1,156.70
$1,757.72
$895.39
$982.81
$1,075.43
$1,404.43
$1,143.12
$1,230.54
$1,323.16
$1,652.16
$1,390.85
$1,478.27
$1,570.89
$1,899.89
$571.56
$615.27
$661.58
$826.08
$819.29
$863.00
$909.31
$1,073.81
$1,067.02
$1,110.73
$1,157.04
$1,321.54
$247.73

Bronze

Plan: (HMO) Dean Bronze Value Copay 7350X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$270.61
$307.14
$345.84
$483.31
$734.44
$541.22
$614.28
$691.68
$966.62
$1,468.88
$748.24
$821.30
$898.70
$1,173.64
$955.26
$1,028.32
$1,105.72
$1,380.66
$1,162.28
$1,235.34
$1,312.74
$1,587.68
$477.63
$514.16
$552.86
$690.33
$684.65
$721.18
$759.88
$897.35
$891.67
$928.20
$966.90
$1,104.37
$207.02

Silver

Plan: (HMO) Dean Silver HSA-E 3500X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$386.82
$439.04
$494.35
$690.86
$1,049.82
$773.64
$878.08
$988.70
$1,381.72
$2,099.64
$1,069.56
$1,174.00
$1,284.62
$1,677.64
$1,365.48
$1,469.92
$1,580.54
$1,973.56
$1,661.40
$1,765.84
$1,876.46
$2,269.48
$682.74
$734.96
$790.27
$986.78
$978.66
$1,030.88
$1,086.19
$1,282.70
$1,274.58
$1,326.80
$1,382.11
$1,578.62
$295.92

Gold

Plan: (HMO) Dean Gold Copay Plus 1500X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $3,000 : Family: $6,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$332.41
$377.29
$424.82
$593.69
$902.17
$664.82
$754.58
$849.64
$1,187.38
$1,804.34
$919.12
$1,008.88
$1,103.94
$1,441.68
$1,173.42
$1,263.18
$1,358.24
$1,695.98
$1,427.72
$1,517.48
$1,612.54
$1,950.28
$586.71
$631.59
$679.12
$847.99
$841.01
$885.89
$933.42
$1,102.29
$1,095.31
$1,140.19
$1,187.72
$1,356.59
$254.30

Bronze

Plan: (HMO) Dean Bronze HSA-E 6550X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$258.77
$293.70
$330.70
$462.16
$702.29
$517.54
$587.40
$661.40
$924.32
$1,404.58
$715.50
$785.36
$859.36
$1,122.28
$913.46
$983.32
$1,057.32
$1,320.24
$1,111.42
$1,181.28
$1,255.28
$1,518.20
$456.73
$491.66
$528.66
$660.12
$654.69
$689.62
$726.62
$858.08
$852.65
$887.58
$924.58
$1,056.04
$197.96

Silver

Plan: (EPO) Dean Focus Network Silver Value Copay 5000X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$352.63
$400.23
$450.66
$629.79
$957.03
$705.26
$800.46
$901.32
$1,259.58
$1,914.06
$975.02
$1,070.22
$1,171.08
$1,529.34
$1,244.78
$1,339.98
$1,440.84
$1,799.10
$1,514.54
$1,609.74
$1,710.60
$2,068.86
$622.39
$669.99
$720.42
$899.55
$892.15
$939.75
$990.18
$1,169.31
$1,161.91
$1,209.51
$1,259.94
$1,439.07
$269.76

Bronze

Plan: (EPO) Dean Focus Network Bronze Value Copay 7350X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$247.20
$280.57
$315.92
$441.50
$670.91
$494.40
$561.14
$631.84
$883.00
$1,341.82
$683.51
$750.25
$820.95
$1,072.11
$872.62
$939.36
$1,010.06
$1,261.22
$1,061.73
$1,128.47
$1,199.17
$1,450.33
$436.31
$469.68
$505.03
$630.61
$625.42
$658.79
$694.14
$819.72
$814.53
$847.90
$883.25
$1,008.83
$189.11

Silver

Plan: (EPO) Dean Focus Network Silver HSA-E 3500X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$333.95
$379.03
$426.79
$596.43
$906.34
$667.90
$758.06
$853.58
$1,192.86
$1,812.68
$923.37
$1,013.53
$1,109.05
$1,448.33
$1,178.84
$1,269.00
$1,364.52
$1,703.80
$1,434.31
$1,524.47
$1,619.99
$1,959.27
$589.42
$634.50
$682.26
$851.90
$844.89
$889.97
$937.73
$1,107.37
$1,100.36
$1,145.44
$1,193.20
$1,362.84
$255.47

Bronze

Plan: (EPO) Dean Focus Network Bronze HSA-E 6550X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$236.48
$268.41
$302.23
$422.36
$641.82
$472.96
$536.82
$604.46
$844.72
$1,283.64
$653.87
$717.73
$785.37
$1,025.63
$834.78
$898.64
$966.28
$1,206.54
$1,015.69
$1,079.55
$1,147.19
$1,387.45
$417.39
$449.32
$483.14
$603.27
$598.30
$630.23
$664.05
$784.18
$779.21
$811.14
$844.96
$965.09
$180.91

Gold

Plan: (EPO) Dean Focus Network Gold Value Copay 3500X

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Dean Health Plan)
Customer Service Phone: 1-800-279-1302

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$295.34
$335.21
$377.44
$527.48
$801.55
$590.68
$670.42
$754.88
$1,054.96
$1,603.10
$816.61
$896.35
$980.81
$1,280.89
$1,042.54
$1,122.28
$1,206.74
$1,506.82
$1,268.47
$1,348.21
$1,432.67
$1,732.75
$521.27
$561.14
$603.37
$753.41
$747.20
$787.07
$829.30
$979.34
$973.13
$1,013.00
$1,055.23
$1,205.27
$225.93
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Group Health Cooperative of South Central Wisconsin

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729

Platinum

Plan: (HMO) Platinum 500 Ded/1000 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $500 : Family: $1,000
Out of Pocket Maximum per year: Individual: $1,000 : Family: $2,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$468.19
$531.40
$598.35
$836.19
$1,270.66
$936.38
$1,062.80
$1,196.70
$1,672.38
$2,541.32
$1,294.55
$1,420.97
$1,554.87
$2,030.55
$1,652.72
$1,779.14
$1,913.04
$2,388.72
$2,010.89
$2,137.31
$2,271.21
$2,746.89
$826.36
$889.57
$956.52
$1,194.36
$1,184.53
$1,247.74
$1,314.69
$1,552.53
$1,542.70
$1,605.91
$1,672.86
$1,910.70
$358.17

Gold

Plan: (HMO) Gold 1000 Ded/4000 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$402.82
$457.20
$514.80
$719.43
$1,093.23
$805.64
$914.40
$1,029.60
$1,438.86
$2,186.46
$1,113.80
$1,222.56
$1,337.76
$1,747.02
$1,421.96
$1,530.72
$1,645.92
$2,055.18
$1,730.12
$1,838.88
$1,954.08
$2,363.34
$710.98
$765.36
$822.96
$1,027.59
$1,019.14
$1,073.52
$1,131.12
$1,335.75
$1,327.30
$1,381.68
$1,439.28
$1,643.91
$308.16

Gold

Plan: (HMO) Gold 2000 Ded/2000 MOOP HSA

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $2,000 : Family: $4,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$398.39
$452.17
$509.14
$711.51
$1,081.21
$796.78
$904.34
$1,018.28
$1,423.02
$2,162.42
$1,101.55
$1,209.11
$1,323.05
$1,727.79
$1,406.32
$1,513.88
$1,627.82
$2,032.56
$1,711.09
$1,818.65
$1,932.59
$2,337.33
$703.16
$756.94
$813.91
$1,016.28
$1,007.93
$1,061.71
$1,118.68
$1,321.05
$1,312.70
$1,366.48
$1,423.45
$1,625.82
$304.77

Silver

Plan: (HMO) Silver 2000 Ded/6000 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$439.22
$498.52
$561.32
$784.45
$1,192.04
$878.44
$997.04
$1,122.64
$1,568.90
$2,384.08
$1,214.45
$1,333.05
$1,458.65
$1,904.91
$1,550.46
$1,669.06
$1,794.66
$2,240.92
$1,886.47
$2,005.07
$2,130.67
$2,576.93
$775.23
$834.53
$897.33
$1,120.46
$1,111.24
$1,170.54
$1,233.34
$1,456.47
$1,447.25
$1,506.55
$1,569.35
$1,792.48
$336.01

Expanded Bronze

Plan: (HMO) Bronze 4000 Ded/7350 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$315.29
$357.85
$402.94
$563.10
$855.68
$630.58
$715.70
$805.88
$1,126.20
$1,711.36
$871.78
$956.90
$1,047.08
$1,367.40
$1,112.98
$1,198.10
$1,288.28
$1,608.60
$1,354.18
$1,439.30
$1,529.48
$1,849.80
$556.49
$599.05
$644.14
$804.30
$797.69
$840.25
$885.34
$1,045.50
$1,038.89
$1,081.45
$1,126.54
$1,286.70
$241.20

Platinum

Plan: (HMO) Select Platinum 500 Ded/1000 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $500 : Family: $1,000
Out of Pocket Maximum per year: Individual: $1,000 : Family: $2,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$425.66
$483.12
$543.99
$760.23
$1,155.24
$851.32
$966.24
$1,087.98
$1,520.46
$2,310.48
$1,176.95
$1,291.87
$1,413.61
$1,846.09
$1,502.58
$1,617.50
$1,739.24
$2,171.72
$1,828.21
$1,943.13
$2,064.87
$2,497.35
$751.29
$808.75
$869.62
$1,085.86
$1,076.92
$1,134.38
$1,195.25
$1,411.49
$1,402.55
$1,460.01
$1,520.88
$1,737.12
$325.63

Gold

Plan: (HMO) Select Gold 1000 Ded/4000 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$366.22
$415.66
$468.03
$654.06
$993.91
$732.44
$831.32
$936.06
$1,308.12
$1,987.82
$1,012.60
$1,111.48
$1,216.22
$1,588.28
$1,292.76
$1,391.64
$1,496.38
$1,868.44
$1,572.92
$1,671.80
$1,776.54
$2,148.60
$646.38
$695.82
$748.19
$934.22
$926.54
$975.98
$1,028.35
$1,214.38
$1,206.70
$1,256.14
$1,308.51
$1,494.54
$280.16

Gold

Plan: (HMO) Select Gold 2000 Ded/2000 MOOP HSA

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $2,000 : Family: $4,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$362.21
$411.11
$462.90
$646.91
$983.03
$724.42
$822.22
$925.80
$1,293.82
$1,966.06
$1,001.51
$1,099.31
$1,202.89
$1,570.91
$1,278.60
$1,376.40
$1,479.98
$1,848.00
$1,555.69
$1,653.49
$1,757.07
$2,125.09
$639.30
$688.20
$739.99
$924.00
$916.39
$965.29
$1,017.08
$1,201.09
$1,193.48
$1,242.38
$1,294.17
$1,478.18
$277.09

Silver

Plan: (HMO) Select Silver 2000 Ded/6000 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$399.31
$453.22
$510.32
$713.16
$1,083.72
$798.62
$906.44
$1,020.64
$1,426.32
$2,167.44
$1,104.09
$1,211.91
$1,326.11
$1,731.79
$1,409.56
$1,517.38
$1,631.58
$2,037.26
$1,715.03
$1,822.85
$1,937.05
$2,342.73
$704.78
$758.69
$815.79
$1,018.63
$1,010.25
$1,064.16
$1,121.26
$1,324.10
$1,315.72
$1,369.63
$1,426.73
$1,629.57
$305.47

Expanded Bronze

Plan: (HMO) Select Bronze 4000 Ded/7350 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$286.67
$325.36
$366.36
$511.98
$778.00
$573.34
$650.72
$732.72
$1,023.96
$1,556.00
$792.64
$870.02
$952.02
$1,243.26
$1,011.94
$1,089.32
$1,171.32
$1,462.56
$1,231.24
$1,308.62
$1,390.62
$1,681.86
$505.97
$544.66
$585.66
$731.28
$725.27
$763.96
$804.96
$950.58
$944.57
$983.26
$1,024.26
$1,169.88
$219.30

Bronze

Plan: (HMO) Bronze 6550 Ded/6550 MOOP HSA

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$301.27
$341.94
$385.02
$538.06
$817.63
$602.54
$683.88
$770.04
$1,076.12
$1,635.26
$833.01
$914.35
$1,000.51
$1,306.59
$1,063.48
$1,144.82
$1,230.98
$1,537.06
$1,293.95
$1,375.29
$1,461.45
$1,767.53
$531.74
$572.41
$615.49
$768.53
$762.21
$802.88
$845.96
$999.00
$992.68
$1,033.35
$1,076.43
$1,229.47
$230.47

Bronze

Plan: (HMO) Select Bronze 6550 Ded/6550 MOOP HSA

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$273.91
$310.89
$350.06
$489.21
$743.39
$547.82
$621.78
$700.12
$978.42
$1,486.78
$757.36
$831.32
$909.66
$1,187.96
$966.90
$1,040.86
$1,119.20
$1,397.50
$1,176.44
$1,250.40
$1,328.74
$1,607.04
$483.45
$520.43
$559.60
$698.75
$692.99
$729.97
$769.14
$908.29
$902.53
$939.51
$978.68
$1,117.83
$209.54

Gold

Plan: (HMO) Gold 2500 Ded/6500 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$368.88
$418.67
$471.42
$658.81
$1,001.12
$737.76
$837.34
$942.84
$1,317.62
$2,002.24
$1,019.95
$1,119.53
$1,225.03
$1,599.81
$1,302.14
$1,401.72
$1,507.22
$1,882.00
$1,584.33
$1,683.91
$1,789.41
$2,164.19
$651.07
$700.86
$753.61
$941.00
$933.26
$983.05
$1,035.80
$1,223.19
$1,215.45
$1,265.24
$1,317.99
$1,505.38
$282.19

Gold

Plan: (HMO) Select Gold 2500 Ded/6500 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$335.36
$380.63
$428.59
$598.95
$910.16
$670.72
$761.26
$857.18
$1,197.90
$1,820.32
$927.27
$1,017.81
$1,113.73
$1,454.45
$1,183.82
$1,274.36
$1,370.28
$1,711.00
$1,440.37
$1,530.91
$1,626.83
$1,967.55
$591.91
$637.18
$685.14
$855.50
$848.46
$893.73
$941.69
$1,112.05
$1,105.01
$1,150.28
$1,198.24
$1,368.60
$256.55

Silver

Plan: (HMO) Silver 4000 Ded/7350X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$441.53
$501.14
$564.28
$788.57
$1,198.31
$883.06
$1,002.28
$1,128.56
$1,577.14
$2,396.62
$1,220.83
$1,340.05
$1,466.33
$1,914.91
$1,558.60
$1,677.82
$1,804.10
$2,252.68
$1,896.37
$2,015.59
$2,141.87
$2,590.45
$779.30
$838.91
$902.05
$1,126.34
$1,117.07
$1,176.68
$1,239.82
$1,464.11
$1,454.84
$1,514.45
$1,577.59
$1,801.88
$337.77

Platinum

Plan: (HMO) Select Platinum No Ded/3000X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $1,000 : Family: $2,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$423.00
$480.11
$540.60
$755.48
$1,148.02
$846.00
$960.22
$1,081.20
$1,510.96
$2,296.04
$1,169.60
$1,283.82
$1,404.80
$1,834.56
$1,493.20
$1,607.42
$1,728.40
$2,158.16
$1,816.80
$1,931.02
$2,052.00
$2,481.76
$746.60
$803.71
$864.20
$1,079.08
$1,070.20
$1,127.31
$1,187.80
$1,402.68
$1,393.80
$1,450.91
$1,511.40
$1,726.28
$323.60

Platinum

Plan: (HMO) Select Platinum 500 Ded/3000X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $500 : Family: $1,000
Out of Pocket Maximum per year: Individual: $1,000 : Family: $2,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$413.33
$469.13
$528.24
$738.21
$1,121.78
$826.66
$938.26
$1,056.48
$1,476.42
$2,243.56
$1,142.86
$1,254.46
$1,372.68
$1,792.62
$1,459.06
$1,570.66
$1,688.88
$2,108.82
$1,775.26
$1,886.86
$2,005.08
$2,425.02
$729.53
$785.33
$844.44
$1,054.41
$1,045.73
$1,101.53
$1,160.64
$1,370.61
$1,361.93
$1,417.73
$1,476.84
$1,686.81
$316.20

Gold

Plan: (HMO) Select Gold 1500 Ded/5200X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $2,200 : Family: $4,400

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$380.13
$431.44
$485.80
$678.90
$1,031.65
$760.26
$862.88
$971.60
$1,357.80
$2,063.30
$1,051.06
$1,153.68
$1,262.40
$1,648.60
$1,341.86
$1,444.48
$1,553.20
$1,939.40
$1,632.66
$1,735.28
$1,844.00
$2,230.20
$670.93
$722.24
$776.60
$969.70
$961.73
$1,013.04
$1,067.40
$1,260.50
$1,252.53
$1,303.84
$1,358.20
$1,551.30
$290.80

Gold

Plan: (HMO) Select Gold 2500 Ded/7000X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $3,000 : Family: $6,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$365.83
$415.22
$467.53
$653.37
$992.86
$731.66
$830.44
$935.06
$1,306.74
$1,985.72
$1,011.52
$1,110.30
$1,214.92
$1,586.60
$1,291.38
$1,390.16
$1,494.78
$1,866.46
$1,571.24
$1,670.02
$1,774.64
$2,146.32
$645.69
$695.08
$747.39
$933.23
$925.55
$974.94
$1,027.25
$1,213.09
$1,205.41
$1,254.80
$1,307.11
$1,492.95
$279.86

Silver

Plan: (HMO) Select Silver 4000 Ded/7350X MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$401.43
$455.62
$513.03
$716.95
$1,089.47
$802.86
$911.24
$1,026.06
$1,433.90
$2,178.94
$1,109.95
$1,218.33
$1,333.15
$1,740.99
$1,417.04
$1,525.42
$1,640.24
$2,048.08
$1,724.13
$1,832.51
$1,947.33
$2,355.17
$708.52
$762.71
$820.12
$1,024.04
$1,015.61
$1,069.80
$1,127.21
$1,331.13
$1,322.70
$1,376.89
$1,434.30
$1,638.22
$307.09

Silver

Plan: (HMO) Select Silver Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$367.76
$417.41
$469.99
$656.81
$998.09
$735.52
$834.82
$939.98
$1,313.62
$1,996.18
$1,016.86
$1,116.16
$1,221.32
$1,594.96
$1,298.20
$1,397.50
$1,502.66
$1,876.30
$1,579.54
$1,678.84
$1,784.00
$2,157.64
$649.10
$698.75
$751.33
$938.15
$930.44
$980.09
$1,032.67
$1,219.49
$1,211.78
$1,261.43
$1,314.01
$1,500.83
$281.34

Expanded Bronze

Plan: (HMO) Select Bronze Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$279.27
$316.97
$356.90
$498.77
$757.93
$558.54
$633.94
$713.80
$997.54
$1,515.86
$772.18
$847.58
$927.44
$1,211.18
$985.82
$1,061.22
$1,141.08
$1,424.82
$1,199.46
$1,274.86
$1,354.72
$1,638.46
$492.91
$530.61
$570.54
$712.41
$706.55
$744.25
$784.18
$926.05
$920.19
$957.89
$997.82
$1,139.69
$213.64

Catastrophic

Plan: (HMO) Catastrophic 7350 Ded/7350 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Catastrophic 21
30
40
50
60
$232.38
$263.76
$296.99
$415.03
$630.68
$464.76
$527.52
$593.98
$830.06
$1,261.36
$642.54
$705.30
$771.76
$1,007.84
$820.32
$883.08
$949.54
$1,185.62
$998.10
$1,060.86
$1,127.32
$1,363.40
$410.16
$441.54
$474.77
$592.81
$587.94
$619.32
$652.55
$770.59
$765.72
$797.10
$830.33
$948.37
$177.78

Catastrophic

Plan: (HMO) Select Catastrophic 7350 Ded/7350 MOOP

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Catastrophic 21
30
40
50
60
$211.27
$239.79
$270.01
$377.33
$573.39
$422.54
$479.58
$540.02
$754.66
$1,146.78
$584.16
$641.20
$701.64
$916.28
$745.78
$802.82
$863.26
$1,077.90
$907.40
$964.44
$1,024.88
$1,239.52
$372.89
$401.41
$431.63
$538.95
$534.51
$563.03
$593.25
$700.57
$696.13
$724.65
$754.87
$862.19
$161.62

Expanded Bronze

Plan: (HMO) Select Bronze Simple Choice Plan HSA

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$281.58
$319.59
$359.86
$502.90
$764.20
$563.16
$639.18
$719.72
$1,005.80
$1,528.40
$778.57
$854.59
$935.13
$1,221.21
$993.98
$1,070.00
$1,150.54
$1,436.62
$1,209.39
$1,285.41
$1,365.95
$1,652.03
$496.99
$535.00
$575.27
$718.31
$712.40
$750.41
$790.68
$933.72
$927.81
$965.82
$1,006.09
$1,149.13
$215.41

Gold

Plan: (HMO) Gold Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $1,400 : Family: $2,800
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$380.70
$432.10
$486.54
$679.93
$1,033.22
$761.40
$864.20
$973.08
$1,359.86
$2,066.44
$1,052.64
$1,155.44
$1,264.32
$1,651.10
$1,343.88
$1,446.68
$1,555.56
$1,942.34
$1,635.12
$1,737.92
$1,846.80
$2,233.58
$671.94
$723.34
$777.78
$971.17
$963.18
$1,014.58
$1,069.02
$1,262.41
$1,254.42
$1,305.82
$1,360.26
$1,553.65
$291.24

Silver

Plan: (HMO) Silver Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$404.47
$459.08
$516.91
$722.38
$1,097.73
$808.94
$918.16
$1,033.82
$1,444.76
$2,195.46
$1,118.36
$1,227.58
$1,343.24
$1,754.18
$1,427.78
$1,537.00
$1,652.66
$2,063.60
$1,737.20
$1,846.42
$1,962.08
$2,373.02
$713.89
$768.50
$826.33
$1,031.80
$1,023.31
$1,077.92
$1,135.75
$1,341.22
$1,332.73
$1,387.34
$1,445.17
$1,650.64
$309.42

Expanded Bronze

Plan: (HMO) Bronze Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$307.16
$348.63
$392.55
$548.58
$833.62
$614.32
$697.26
$785.10
$1,097.16
$1,667.24
$849.30
$932.24
$1,020.08
$1,332.14
$1,084.28
$1,167.22
$1,255.06
$1,567.12
$1,319.26
$1,402.20
$1,490.04
$1,802.10
$542.14
$583.61
$627.53
$783.56
$777.12
$818.59
$862.51
$1,018.54
$1,012.10
$1,053.57
$1,097.49
$1,253.52
$234.98

Expanded Bronze

Plan: (HMO) Bronze Simple Choice Plan HSA

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)
Customer Service Phone: 1-855-344-2729

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$309.70
$351.51
$395.80
$553.12
$840.52
$619.40
$703.02
$791.60
$1,106.24
$1,681.04
$856.32
$939.94
$1,028.52
$1,343.16
$1,093.24
$1,176.86
$1,265.44
$1,580.08
$1,330.16
$1,413.78
$1,502.36
$1,817.00
$546.62
$588.43
$632.72
$790.04
$783.54
$825.35
$869.64
$1,026.96
$1,020.46
$1,062.27
$1,106.56
$1,263.88
$236.92

‡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 Dane County here.

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