Obamacare 2022 Rates and Health Insurance Providers for Fond Du Lac County , Wisconsin

Obamacare > Rates > Wisconsin > Fond Du Lac County

Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 |

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 Fond Du Lac County, WI.

The health insurance rates listed below are for calendar year 2022.

For detailed information on available 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

The table below shows premiums for the following profiles at various ages:

  • Individuals
  • Couples
  • Couples with 1, 2, or 3 children
  • Individuals with 1, 2, or 3 children
  • A child alone

Each plan links to the insurance provider's website. You can find the following:

  • Summary of plan benefits and costs
  • Plan brochure
  • Provider Directory where you can find out which doctors and hospitals in the Fond Du Lac, WI area accept this insurance coverage as within the plan's network.

Obamacare Providers, Plans and 2022 Rates for Fond Du Lac County, Wisconsin

Below, you’ll find a summary of the 69 plans for Fond Du Lac County, Wisconsin and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.

Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016| 2017 | 2018 | 2019 2020 2021 2022

You may also be interested in:

How To Sign Up for Obamacare in Wisconsin

For 2022 health plans, Wisconsin open enrollment has ended. However, you may still be able to purchase health insurance for this year if you qualify for a special enrollment period. For example, if you’ve recently lost your job or income due to the COVID-19 crisis or for any other reason, you might qualify for a 60-day special enrollment period that will allow you to sign up for a new health insurance plan. (See What Happens If I Missed the Enrollment Deadline for 2022?)

To get covered, you can go directly to the online health insurance marketplace for Wisconsin. If you need personalized help, you can reach out to an enrollment assistant. Most enrollment helpers are working remotely during the COVID crisis.

Where's the Wisconsin Health Care Exchange?

You can find the health insurance exchange for Wisconsin at Healthcare.gov. This is where you can learn about the various health insurance options available to you under the Affordable Care Act. If you see a plan you like, you'll be guided through the enrollment process online.

more...  

Wisconsin Medicaid Expansion: Do I Qualify for Medicaid Under the ACA?

The Affordable Care Act (Obamacare) expanded Medicaid eligibility to include more people who couldn’t otherwise obtain health insurance. As written, the ACA would extend Medicaid to all adults with incomes at or below 138% of the federal poverty level. (For a single person in Wisconsin in 2021, that’s $17,609. For a family of four, it’s $36,156.)

However, the U.S. Supreme Court later ruled that it was up to individual states to decide whether to expand Medicaid. As of October 2021, 12 states have not expanded their programs.

Wisconsin Has Not Expanded Medicaid

Wisconsin has repeatedly rejected federal funding to expand Medicaid under the Affordable Care Act, but the state is unique in that its Medicaid program -- called BadgerCare -- covers all state residents with incomes up to the federal poverty level. That makes Wisconsin the only non-Medicaid-expansion state without a coverage gap -- that is, a failure to provide coverage or subsidies for many adults with incomes under the poverty level.

If you're a low-income Wisconsin resident, you'll most likely qualify for BadgerCare or be eligible for subsidies to help you purchase health insurance at Healthcare.gov.

more...  

Get Help Finding a Health Insurance Plan in Wisconsin

Get Help From Wisconsin's Health Insurance Exchange

The following links and telephone numbers take you to the official help resources for Healthcare.gov, the health insurance marketplace for Wisconsin.

Help by phone: 800-318-2596 (TTY: 855-889-4325)

In-person help: Go to Find Local Help, where you can enter your city and state or zip code to find an application assister, insurance agent, or health insurance broker in your area.

Get Help From a Licensed Insurance Broker

To directly connect with a Wisconsin insurance broker who can help you evaluate insurance plans and choose a plan that's appropriate for your situation, call 800-943-6832. (We receive advertising income from the licensed brokers who offer their services through this telephone number.)

More Information

For more detailed information, see How Do I Sign Up for Obamacare in Wisconsin?

  • Fond Du Lac County, WI Obamacare Rates
  • General Info
  • Rates

ADVERTISEMENT

Quartz

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

Toc - Plan #1 Quartz
Silver

(HMO) Quartz One Silver I302 with Dental

Annual Out of Pocket Expenses
Individual Family
$5,000 $10,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435,50
$494,29
$556,56
$777,80
$1 181,93
$768,65
$827,44
$889,71
$1 110,95
$1 101,80
$1 160,59
$1 222,86
$1 444,10
$1 434,95
$1 493,74
$1 556,01
$1 777,25
$333,15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871,00
$988,58
$1 113,12
$1 555,60
$2 363,86
$1 204,15
$1 321,73
$1 446,27
$1 888,75
$1 537,30
$1 654,88
$1 779,42
$2 221,90
$1 870,45
$1 988,03
$2 112,57
$2 555,05
$333,15
Toc - Plan #2 Quartz
Silver

(HMO) Quartz One Silver I303 with Dental

Annual Out of Pocket Expenses
Individual Family
$8,500 $17,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419,34
$475,95
$535,91
$748,94
$1 138,08
$740,13
$796,74
$856,70
$1 069,73
$1 060,92
$1 117,53
$1 177,49
$1 390,52
$1 381,71
$1 438,32
$1 498,28
$1 711,31
$320,79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$838,68
$951,90
$1 071,82
$1 497,88
$2 276,16
$1 159,47
$1 272,69
$1 392,61
$1 818,67
$1 480,26
$1 593,48
$1 713,40
$2 139,46
$1 801,05
$1 914,27
$2 034,19
$2 460,25
$320,79
Toc - Plan #3 Quartz
Gold

(HMO) Quartz One Gold I402 Maintenance with Dental

Annual Out of Pocket Expenses
Individual Family
$1,500 $3,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385,03
$437,00
$492,06
$687,65
$1 044,96
$679,57
$731,54
$786,60
$982,19
$974,11
$1 026,08
$1 081,14
$1 276,73
$1 268,65
$1 320,62
$1 375,68
$1 571,27
$294,54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770,06
$874,00
$984,12
$1 375,30
$2 089,92
$1 064,60
$1 168,54
$1 278,66
$1 669,84
$1 359,14
$1 463,08
$1 573,20
$1 964,38
$1 653,68
$1 757,62
$1 867,74
$2 258,92
$294,54
Toc - Plan #4 Quartz
Gold

(HMO) Quartz One Gold I401 with Dental

Annual Out of Pocket Expenses
Individual Family
$2,000 $4,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389,47
$442,04
$497,73
$695,58
$1 057,00
$687,41
$739,98
$795,67
$993,52
$985,35
$1 037,92
$1 093,61
$1 291,46
$1 283,29
$1 335,86
$1 391,55
$1 589,40
$297,94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778,94
$884,08
$995,46
$1 391,16
$2 114,00
$1 076,88
$1 182,02
$1 293,40
$1 689,10
$1 374,82
$1 479,96
$1 591,34
$1 987,04
$1 672,76
$1 777,90
$1 889,28
$2 284,98
$297,94
Toc - Plan #5 Quartz
Silver

(HMO) Quartz One Silver I301 with Dental

Annual Out of Pocket Expenses
Individual Family
$4,400 $8,800 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434,70
$493,38
$555,54
$776,37
$1 179,77
$767,24
$825,92
$888,08
$1 108,91
$1 099,78
$1 158,46
$1 220,62
$1 441,45
$1 432,32
$1 491,00
$1 553,16
$1 773,99
$332,54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869,40
$986,76
$1 111,08
$1 552,74
$2 359,54
$1 201,94
$1 319,30
$1 443,62
$1 885,28
$1 534,48
$1 651,84
$1 776,16
$2 217,82
$1 867,02
$1 984,38
$2 108,70
$2 550,36
$332,54
Toc - Plan #6 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I202 with Dental

Annual Out of Pocket Expenses
Individual Family
$8,200 $16,400 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$300,39
$340,94
$383,90
$536,49
$815,26
$530,19
$570,74
$613,70
$766,29
$759,99
$800,54
$843,50
$996,09
$989,79
$1 030,34
$1 073,30
$1 225,89
$229,80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$600,78
$681,88
$767,80
$1 072,98
$1 630,52
$830,58
$911,68
$997,60
$1 302,78
$1 060,38
$1 141,48
$1 227,40
$1 532,58
$1 290,18
$1 371,28
$1 457,20
$1 762,38
$229,80
Toc - Plan #7 Quartz
Gold

(HMO) Quartz One Gold I405 with Dental

Annual Out of Pocket Expenses
Individual Family
$2,000 $4,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385,55
$437,60
$492,73
$688,59
$1 046,38
$680,49
$732,54
$787,67
$983,53
$975,43
$1 027,48
$1 082,61
$1 278,47
$1 270,37
$1 322,42
$1 377,55
$1 573,41
$294,94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771,10
$875,20
$985,46
$1 377,18
$2 092,76
$1 066,04
$1 170,14
$1 280,40
$1 672,12
$1 360,98
$1 465,08
$1 575,34
$1 967,06
$1 655,92
$1 760,02
$1 870,28
$2 262,00
$294,94
Toc - Plan #8 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I201 with Dental

Annual Out of Pocket Expenses
Individual Family
$8,000 $16,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$301,47
$342,16
$385,27
$538,41
$818,17
$532,09
$572,78
$615,89
$769,03
$762,71
$803,40
$846,51
$999,65
$993,33
$1 034,02
$1 077,13
$1 230,27
$230,62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$602,94
$684,32
$770,54
$1 076,82
$1 636,34
$833,56
$914,94
$1 001,16
$1 307,44
$1 064,18
$1 145,56
$1 231,78
$1 538,06
$1 294,80
$1 376,18
$1 462,40
$1 768,68
$230,62
Toc - Plan #9 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I204 with Dental

Annual Out of Pocket Expenses
Individual Family
$2,450 $4,900 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$313,85
$356,22
$401,10
$560,53
$851,78
$553,94
$596,31
$641,19
$800,62
$794,03
$836,40
$881,28
$1 040,71
$1 034,12
$1 076,49
$1 121,37
$1 280,80
$240,09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627,70
$712,44
$802,20
$1 121,06
$1 703,56
$867,79
$952,53
$1 042,29
$1 361,15
$1 107,88
$1 192,62
$1 282,38
$1 601,24
$1 347,97
$1 432,71
$1 522,47
$1 841,33
$240,09
Toc - Plan #10 Quartz
Silver

(HMO) Quartz One Silver I302

Annual Out of Pocket Expenses
Individual Family
$5,000 $10,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418,48
$474,97
$534,81
$747,40
$1 135,74
$738,61
$795,10
$854,94
$1 067,53
$1 058,74
$1 115,23
$1 175,07
$1 387,66
$1 378,87
$1 435,36
$1 495,20
$1 707,79
$320,13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836,96
$949,94
$1 069,62
$1 494,80
$2 271,48
$1 157,09
$1 270,07
$1 389,75
$1 814,93
$1 477,22
$1 590,20
$1 709,88
$2 135,06
$1 797,35
$1 910,33
$2 030,01
$2 455,19
$320,13
Toc - Plan #11 Quartz
Silver

(HMO) Quartz One Silver I303

Annual Out of Pocket Expenses
Individual Family
$8,500 $17,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$402,95
$457,35
$514,97
$719,67
$1 093,60
$711,21
$765,61
$823,23
$1 027,93
$1 019,47
$1 073,87
$1 131,49
$1 336,19
$1 327,73
$1 382,13
$1 439,75
$1 644,45
$308,26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805,90
$914,70
$1 029,94
$1 439,34
$2 187,20
$1 114,16
$1 222,96
$1 338,20
$1 747,60
$1 422,42
$1 531,22
$1 646,46
$2 055,86
$1 730,68
$1 839,48
$1 954,72
$2 364,12
$308,26
Toc - Plan #12 Quartz
Gold

(HMO) Quartz One Gold I402 Maintenance

Annual Out of Pocket Expenses
Individual Family
$1,500 $3,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369,98
$419,92
$472,83
$660,78
$1 004,12
$653,01
$702,95
$755,86
$943,81
$936,04
$985,98
$1 038,89
$1 226,84
$1 219,07
$1 269,01
$1 321,92
$1 509,87
$283,03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$739,96
$839,84
$945,66
$1 321,56
$2 008,24
$1 022,99
$1 122,87
$1 228,69
$1 604,59
$1 306,02
$1 405,90
$1 511,72
$1 887,62
$1 589,05
$1 688,93
$1 794,75
$2 170,65
$283,03
Toc - Plan #13 Quartz
Gold

(HMO) Quartz One Gold I401

Annual Out of Pocket Expenses
Individual Family
$2,000 $4,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$374,24
$424,76
$478,28
$668,39
$1 015,68
$660,53
$711,05
$764,57
$954,68
$946,82
$997,34
$1 050,86
$1 240,97
$1 233,11
$1 283,63
$1 337,15
$1 527,26
$286,29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$748,48
$849,52
$956,56
$1 336,78
$2 031,36
$1 034,77
$1 135,81
$1 242,85
$1 623,07
$1 321,06
$1 422,10
$1 529,14
$1 909,36
$1 607,35
$1 708,39
$1 815,43
$2 195,65
$286,29
Toc - Plan #14 Quartz
Silver

(HMO) Quartz One Silver I301

Annual Out of Pocket Expenses
Individual Family
$4,400 $8,800 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417,71
$474,10
$533,83
$746,03
$1 133,66
$737,26
$793,65
$853,38
$1 065,58
$1 056,81
$1 113,20
$1 172,93
$1 385,13
$1 376,36
$1 432,75
$1 492,48
$1 704,68
$319,55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835,42
$948,20
$1 067,66
$1 492,06
$2 267,32
$1 154,97
$1 267,75
$1 387,21
$1 811,61
$1 474,52
$1 587,30
$1 706,76
$2 131,16
$1 794,07
$1 906,85
$2 026,31
$2 450,71
$319,55
Toc - Plan #15 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I202

Annual Out of Pocket Expenses
Individual Family
$8,200 $16,400 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288,65
$327,62
$368,89
$515,53
$783,39
$509,47
$548,44
$589,71
$736,35
$730,29
$769,26
$810,53
$957,17
$951,11
$990,08
$1 031,35
$1 177,99
$220,82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$577,30
$655,24
$737,78
$1 031,06
$1 566,78
$798,12
$876,06
$958,60
$1 251,88
$1 018,94
$1 096,88
$1 179,42
$1 472,70
$1 239,76
$1 317,70
$1 400,24
$1 693,52
$220,82
Toc - Plan #16 Quartz
Gold

(HMO) Quartz One Gold I405

Annual Out of Pocket Expenses
Individual Family
$2,000 $4,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370,48
$420,49
$473,47
$661,68
$1 005,48
$653,90
$703,91
$756,89
$945,10
$937,32
$987,33
$1 040,31
$1 228,52
$1 220,74
$1 270,75
$1 323,73
$1 511,94
$283,42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740,96
$840,98
$946,94
$1 323,36
$2 010,96
$1 024,38
$1 124,40
$1 230,36
$1 606,78
$1 307,80
$1 407,82
$1 513,78
$1 890,20
$1 591,22
$1 691,24
$1 797,20
$2 173,62
$283,42
Toc - Plan #17 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I201

Annual Out of Pocket Expenses
Individual Family
$8,000 $16,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$289,68
$328,79
$370,21
$517,37
$786,19
$511,28
$550,39
$591,81
$738,97
$732,88
$771,99
$813,41
$960,57
$954,48
$993,59
$1 035,01
$1 182,17
$221,60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$579,36
$657,58
$740,42
$1 034,74
$1 572,38
$800,96
$879,18
$962,02
$1 256,34
$1 022,56
$1 100,78
$1 183,62
$1 477,94
$1 244,16
$1 322,38
$1 405,22
$1 699,54
$221,60
Toc - Plan #18 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I204

Annual Out of Pocket Expenses
Individual Family
$2,450 $4,900 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$301,59
$342,29
$385,42
$538,62
$818,49
$532,30
$573,00
$616,13
$769,33
$763,01
$803,71
$846,84
$1 000,04
$993,72
$1 034,42
$1 077,55
$1 230,75
$230,71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$603,18
$684,58
$770,84
$1 077,24
$1 636,98
$833,89
$915,29
$1 001,55
$1 307,95
$1 064,60
$1 146,00
$1 232,26
$1 538,66
$1 295,31
$1 376,71
$1 462,97
$1 769,37
$230,71
Toc - Plan #19 Quartz
Gold

(HMO) Quartz One Gold I404 HSA

Annual Out of Pocket Expenses
Individual Family
$2,000 $4,000 Annual Deductible
$6,650 $13,300 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390,06
$442,71
$498,49
$696,63
$1 058,60
$688,45
$741,10
$796,88
$995,02
$986,84
$1 039,49
$1 095,27
$1 293,41
$1 285,23
$1 337,88
$1 393,66
$1 591,80
$298,39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780,12
$885,42
$996,98
$1 393,26
$2 117,20
$1 078,51
$1 183,81
$1 295,37
$1 691,65
$1 376,90
$1 482,20
$1 593,76
$1 990,04
$1 675,29
$1 780,59
$1 892,15
$2 288,43
$298,39
Toc - Plan #20 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I203 HSA

Annual Out of Pocket Expenses
Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$296,71
$336,76
$379,19
$529,91
$805,25
$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
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$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
$226,98
Toc - Plan #21 Quartz
Catastrophic

(HMO) Quartz One Catastrophic I101

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$216,08
$245,24
$276,14
$385,90
$586,42
$381,37
$410,53
$441,43
$551,19
$546,66
$575,82
$606,72
$716,48
$711,95
$741,11
$772,01
$881,77
$165,29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$432,16
$490,48
$552,28
$771,80
$1 172,84
$597,45
$655,77
$717,57
$937,09
$762,74
$821,06
$882,86
$1 102,38
$928,03
$986,35
$1 048,15
$1 267,67
$165,29
Toc - Plan #22 Quartz
Silver

(HMO) Quartz One Silver I304 HSA

Annual Out of Pocket Expenses
Individual Family
$5,250 $10,500 Annual Deductible
$5,250 $10,500 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$431,66
$489,92
$551,65
$770,93
$1 171,50
$761,87
$820,13
$881,86
$1 101,14
$1 092,08
$1 150,34
$1 212,07
$1 431,35
$1 422,29
$1 480,55
$1 542,28
$1 761,56
$330,21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$863,32
$979,84
$1 103,30
$1 541,86
$2 343,00
$1 193,53
$1 310,05
$1 433,51
$1 872,07
$1 523,74
$1 640,26
$1 763,72
$2 202,28
$1 853,95
$1 970,47
$2 093,93
$2 532,49
$330,21
Toc - Plan #23 Quartz
Gold

(HMO) Quartz One Gold I403 HSA

Annual Out of Pocket Expenses
Individual Family
$3,000 $6,000 Annual Deductible
$3,000 $6,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395,80
$449,22
$505,82
$706,88
$1 074,18
$698,58
$752,00
$808,60
$1 009,66
$1 001,36
$1 054,78
$1 111,38
$1 312,44
$1 304,14
$1 357,56
$1 414,16
$1 615,22
$302,78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791,60
$898,44
$1 011,64
$1 413,76
$2 148,36
$1 094,38
$1 201,22
$1 314,42
$1 716,54
$1 397,16
$1 504,00
$1 617,20
$2 019,32
$1 699,94
$1 806,78
$1 919,98
$2 322,10
$302,78

ADVERTISEMENT

Dean Health Plan

Local: 1-800-279-1302 | Toll Free: 1-800-279-1302 | TTY: 1-800-279-1302

Toc - Plan #24 Dean Health Plan
Gold

(HMO) Dean Gold Copay Plus 1500X

Annual Out of Pocket Expenses
Individual Family
$1,500 $3,000 Annual Deductible
$5,100 $10,200 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$362,57
$411,52
$463,37
$647,55
$984,02
$639,94
$688,89
$740,74
$924,92
$917,31
$966,26
$1 018,11
$1 202,29
$1 194,68
$1 243,63
$1 295,48
$1 479,66
$277,37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$725,14
$823,04
$926,74
$1 295,10
$1 968,04
$1 002,51
$1 100,41
$1 204,11
$1 572,47
$1 279,88
$1 377,78
$1 481,48
$1 849,84
$1 557,25
$1 655,15
$1 758,85
$2 127,21
$277,37
Toc - Plan #25 Dean Health Plan
Silver

(HMO) Dean Silver Copay Plus 4800X

Annual Out of Pocket Expenses
Individual Family
$4,800 $9,600 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367,99
$417,67
$470,30
$657,24
$998,73
$649,50
$699,18
$751,81
$938,75
$931,01
$980,69
$1 033,32
$1 220,26
$1 212,52
$1 262,20
$1 314,83
$1 501,77
$281,51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735,98
$835,34
$940,60
$1 314,48
$1 997,46
$1 017,49
$1 116,85
$1 222,11
$1 595,99
$1 299,00
$1 398,36
$1 503,62
$1 877,50
$1 580,51
$1 679,87
$1 785,13
$2 159,01
$281,51
Toc - Plan #26 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Copay Plus 8500X

Annual Out of Pocket Expenses
Individual Family
$8,500 $17,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$244,11
$277,07
$311,97
$435,98
$662,52
$430,86
$463,82
$498,72
$622,73
$617,61
$650,57
$685,47
$809,48
$804,36
$837,32
$872,22
$996,23
$186,75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$488,22
$554,14
$623,94
$871,96
$1 325,04
$674,97
$740,89
$810,69
$1 058,71
$861,72
$927,64
$997,44
$1 245,46
$1 048,47
$1 114,39
$1 184,19
$1 432,21
$186,75
Toc - Plan #27 Dean Health Plan
Silver

(HMO) Dean Silver Classic 5000X

Annual Out of Pocket Expenses
Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360,58
$409,26
$460,82
$644,00
$978,62
$636,43
$685,11
$736,67
$919,85
$912,28
$960,96
$1 012,52
$1 195,70
$1 188,13
$1 236,81
$1 288,37
$1 471,55
$275,85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721,16
$818,52
$921,64
$1 288,00
$1 957,24
$997,01
$1 094,37
$1 197,49
$1 563,85
$1 272,86
$1 370,22
$1 473,34
$1 839,70
$1 548,71
$1 646,07
$1 749,19
$2 115,55
$275,85
Toc - Plan #28 Dean Health Plan
Gold

(HMO) Dean Gold Value Copay 3700X

Annual Out of Pocket Expenses
Individual Family
$3,700 $7,400 Annual Deductible
$3,700 $7,400 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351,47
$398,92
$449,18
$627,73
$953,90
$620,35
$667,80
$718,06
$896,61
$889,23
$936,68
$986,94
$1 165,49
$1 158,11
$1 205,56
$1 255,82
$1 434,37
$268,88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702,94
$797,84
$898,36
$1 255,46
$1 907,80
$971,82
$1 066,72
$1 167,24
$1 524,34
$1 240,70
$1 335,60
$1 436,12
$1 793,22
$1 509,58
$1 604,48
$1 705,00
$2 062,10
$268,88
Toc - Plan #29 Dean Health Plan
Silver

(HMO) Dean Silver Value Copay 5000X

Annual Out of Pocket Expenses
Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367,09
$416,65
$469,14
$655,62
$996,28
$647,91
$697,47
$749,96
$936,44
$928,73
$978,29
$1 030,78
$1 217,26
$1 209,55
$1 259,11
$1 311,60
$1 498,08
$280,82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734,18
$833,30
$938,28
$1 311,24
$1 992,56
$1 015,00
$1 114,12
$1 219,10
$1 592,06
$1 295,82
$1 394,94
$1 499,92
$1 872,88
$1 576,64
$1 675,76
$1 780,74
$2 153,70
$280,82
Toc - Plan #30 Dean Health Plan
Bronze

(HMO) Dean Bronze Value Copay 8500X

Annual Out of Pocket Expenses
Individual Family
$8,500 $17,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$237,89
$270,01
$304,03
$424,88
$645,65
$419,88
$452,00
$486,02
$606,87
$601,87
$633,99
$668,01
$788,86
$783,86
$815,98
$850,00
$970,85
$181,99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$475,78
$540,02
$608,06
$849,76
$1 291,30
$657,77
$722,01
$790,05
$1 031,75
$839,76
$904,00
$972,04
$1 213,74
$1 021,75
$1 085,99
$1 154,03
$1 395,73
$181,99
Toc - Plan #31 Dean Health Plan
Silver

(HMO) Dean Silver HSA-E 4500X

Annual Out of Pocket Expenses
Individual Family
$4,500 $9,000 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$352,41
$399,99
$450,38
$629,41
$956,45
$622,01
$669,59
$719,98
$899,01
$891,61
$939,19
$989,58
$1 168,61
$1 161,21
$1 208,79
$1 259,18
$1 438,21
$269,60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704,82
$799,98
$900,76
$1 258,82
$1 912,90
$974,42
$1 069,58
$1 170,36
$1 528,42
$1 244,02
$1 339,18
$1 439,96
$1 798,02
$1 513,62
$1 608,78
$1 709,56
$2 067,62
$269,60
Toc - Plan #32 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze HSA-E 6850X

Annual Out of Pocket Expenses
Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$252,32
$286,38
$322,46
$450,64
$684,79
$445,34
$479,40
$515,48
$643,66
$638,36
$672,42
$708,50
$836,68
$831,38
$865,44
$901,52
$1 029,70
$193,02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$504,64
$572,76
$644,92
$901,28
$1 369,58
$697,66
$765,78
$837,94
$1 094,30
$890,68
$958,80
$1 030,96
$1 287,32
$1 083,70
$1 151,82
$1 223,98
$1 480,34
$193,02
Toc - Plan #33 Dean Health Plan
Catastrophic

(HMO) Dean Catastrophic Safety Net

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$198,02
$224,76
$253,07
$353,67
$537,43
$349,51
$376,25
$404,56
$505,16
$501,00
$527,74
$556,05
$656,65
$652,49
$679,23
$707,54
$808,14
$151,49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$396,04
$449,52
$506,14
$707,34
$1 074,86
$547,53
$601,01
$657,63
$858,83
$699,02
$752,50
$809,12
$1 010,32
$850,51
$903,99
$960,61
$1 161,81
$151,49

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #34 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Annual Out of Pocket Expenses
Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395,71
$449,13
$505,72
$706,74
$1 073,96
$698,43
$751,85
$808,44
$1 009,46
$1 001,15
$1 054,57
$1 111,16
$1 312,18
$1 303,87
$1 357,29
$1 413,88
$1 614,90
$302,72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791,42
$898,26
$1 011,44
$1 413,48
$2 147,92
$1 094,14
$1 200,98
$1 314,16
$1 716,20
$1 396,86
$1 503,70
$1 616,88
$2 018,92
$1 699,58
$1 806,42
$1 919,60
$2 321,64
$302,72
Toc - Plan #35 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$348,80
$395,88
$445,76
$622,95
$946,63
$615,63
$662,71
$712,59
$889,78
$882,46
$929,54
$979,42
$1 156,61
$1 149,29
$1 196,37
$1 246,25
$1 423,44
$266,83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$697,60
$791,76
$891,52
$1 245,90
$1 893,26
$964,43
$1 058,59
$1 158,35
$1 512,73
$1 231,26
$1 325,42
$1 425,18
$1 779,56
$1 498,09
$1 592,25
$1 692,01
$2 046,39
$266,83
Toc - Plan #36 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

Annual Out of Pocket Expenses
Individual Family
$6,100 $12,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$276,46
$313,78
$353,31
$493,75
$750,30
$487,95
$525,27
$564,80
$705,24
$699,44
$736,76
$776,29
$916,73
$910,93
$948,25
$987,78
$1 128,22
$211,49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$552,92
$627,56
$706,62
$987,50
$1 500,60
$764,41
$839,05
$918,11
$1 198,99
$975,90
$1 050,54
$1 129,60
$1 410,48
$1 187,39
$1 262,03
$1 341,09
$1 621,97
$211,49
Toc - Plan #37 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$345,11
$391,70
$441,05
$616,37
$936,63
$609,12
$655,71
$705,06
$880,38
$873,13
$919,72
$969,07
$1 144,39
$1 137,14
$1 183,73
$1 233,08
$1 408,40
$264,01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$690,22
$783,40
$882,10
$1 232,74
$1 873,26
$954,23
$1 047,41
$1 146,11
$1 496,75
$1 218,24
$1 311,42
$1 410,12
$1 760,76
$1 482,25
$1 575,43
$1 674,13
$2 024,77
$264,01
Toc - Plan #38 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$289,59
$328,68
$370,09
$517,20
$785,94
$511,12
$550,21
$591,62
$738,73
$732,65
$771,74
$813,15
$960,26
$954,18
$993,27
$1 034,68
$1 181,79
$221,53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$579,18
$657,36
$740,18
$1 034,40
$1 571,88
$800,71
$878,89
$961,71
$1 255,93
$1 022,24
$1 100,42
$1 183,24
$1 477,46
$1 243,77
$1 321,95
$1 404,77
$1 698,99
$221,53
Toc - Plan #39 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 5

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$281,56
$319,57
$359,83
$502,87
$764,16
$496,95
$534,96
$575,22
$718,26
$712,34
$750,35
$790,61
$933,65
$927,73
$965,74
$1 006,00
$1 149,04
$215,39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$563,12
$639,14
$719,66
$1 005,74
$1 528,32
$778,51
$854,53
$935,05
$1 221,13
$993,90
$1 069,92
$1 150,44
$1 436,52
$1 209,29
$1 285,31
$1 365,83
$1 651,91
$215,39
Toc - Plan #40 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Annual Out of Pocket Expenses
Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398,84
$452,68
$509,72
$712,33
$1 082,45
$703,95
$757,79
$814,83
$1 017,44
$1 009,06
$1 062,90
$1 119,94
$1 322,55
$1 314,17
$1 368,01
$1 425,05
$1 627,66
$305,11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$797,68
$905,36
$1 019,44
$1 424,66
$2 164,90
$1 102,79
$1 210,47
$1 324,55
$1 729,77
$1 407,90
$1 515,58
$1 629,66
$2 034,88
$1 713,01
$1 820,69
$1 934,77
$2 339,99
$305,11
Toc - Plan #41 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351,93
$399,44
$449,76
$628,54
$955,13
$621,15
$668,66
$718,98
$897,76
$890,37
$937,88
$988,20
$1 166,98
$1 159,59
$1 207,10
$1 257,42
$1 436,20
$269,22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$703,86
$798,88
$899,52
$1 257,08
$1 910,26
$973,08
$1 068,10
$1 168,74
$1 526,30
$1 242,30
$1 337,32
$1 437,96
$1 795,52
$1 511,52
$1 606,54
$1 707,18
$2 064,74
$269,22
Toc - Plan #42 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1 + Vision

Annual Out of Pocket Expenses
Individual Family
$6,100 $12,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$279,59
$317,33
$357,31
$499,34
$758,80
$493,47
$531,21
$571,19
$713,22
$707,35
$745,09
$785,07
$927,10
$921,23
$958,97
$998,95
$1 140,98
$213,88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$559,18
$634,66
$714,62
$998,68
$1 517,60
$773,06
$848,54
$928,50
$1 212,56
$986,94
$1 062,42
$1 142,38
$1 426,44
$1 200,82
$1 276,30
$1 356,26
$1 640,32
$213,88
Toc - Plan #43 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Annual Out of Pocket Expenses
Individual Family
$5,200 $10,400 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$348,42
$395,46
$445,28
$622,28
$945,61
$614,96
$662,00
$711,82
$888,82
$881,50
$928,54
$978,36
$1 155,36
$1 148,04
$1 195,08
$1 244,90
$1 421,90
$266,54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696,84
$790,92
$890,56
$1 244,56
$1 891,22
$963,38
$1 057,46
$1 157,10
$1 511,10
$1 229,92
$1 324,00
$1 423,64
$1 777,64
$1 496,46
$1 590,54
$1 690,18
$2 044,18
$266,54
Toc - Plan #44 Molina Healthcare
Bronze

(HMO) Core Care Bronze 2

Annual Out of Pocket Expenses
Individual Family
$8,000 $16,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$274,01
$311,01
$350,19
$489,39
$743,67
$483,63
$520,63
$559,81
$699,01
$693,25
$730,25
$769,43
$908,63
$902,87
$939,87
$979,05
$1 118,25
$209,62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$548,02
$622,02
$700,38
$978,78
$1 487,34
$757,64
$831,64
$910,00
$1 188,40
$967,26
$1 041,26
$1 119,62
$1 398,02
$1 176,88
$1 250,88
$1 329,24
$1 607,64
$209,62

ADVERTISEMENT

Arise Health Plan

Local: 1-920-490-6900 | Toll Free: 1-800-332-6249 | TTY: 1-888-332-0144

Toc - Plan #45 Arise Health Plan
Bronze

(HMO) WPS HMO Bronze $8,550 | Select Network

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$299,32
$339,73
$382,53
$534,59
$812,35
$528,30
$568,71
$611,51
$763,57
$757,28
$797,69
$840,49
$992,55
$986,26
$1 026,67
$1 069,47
$1 221,53
$228,98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598,64
$679,46
$765,06
$1 069,18
$1 624,70
$827,62
$908,44
$994,04
$1 298,16
$1 056,60
$1 137,42
$1 223,02
$1 527,14
$1 285,58
$1 366,40
$1 452,00
$1 756,12
$228,98
Toc - Plan #46 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO Bronze $6,500 with 3 Free PCP Visits | Select Network

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310,79
$352,75
$397,19
$555,07
$843,48
$548,54
$590,50
$634,94
$792,82
$786,29
$828,25
$872,69
$1 030,57
$1 024,04
$1 066,00
$1 110,44
$1 268,32
$237,75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621,58
$705,50
$794,38
$1 110,14
$1 686,96
$859,33
$943,25
$1 032,13
$1 347,89
$1 097,08
$1 181,00
$1 269,88
$1 585,64
$1 334,83
$1 418,75
$1 507,63
$1 823,39
$237,75
Toc - Plan #47 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO Bronze $7,200 | Select Network

Annual Out of Pocket Expenses
Individual Family
$7,200 $14,400 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304,51
$345,62
$389,16
$543,85
$826,44
$537,46
$578,57
$622,11
$776,80
$770,41
$811,52
$855,06
$1 009,75
$1 003,36
$1 044,47
$1 088,01
$1 242,70
$232,95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$609,02
$691,24
$778,32
$1 087,70
$1 652,88
$841,97
$924,19
$1 011,27
$1 320,65
$1 074,92
$1 157,14
$1 244,22
$1 553,60
$1 307,87
$1 390,09
$1 477,17
$1 786,55
$232,95
Toc - Plan #48 Arise Health Plan
Silver

(HMO) WPS HMO Silver $7,500 | Select Network

Annual Out of Pocket Expenses
Individual Family
$7,500 $15,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$402,38
$456,70
$514,24
$718,65
$1 092,06
$710,20
$764,52
$822,06
$1 026,47
$1 018,02
$1 072,34
$1 129,88
$1 334,29
$1 325,84
$1 380,16
$1 437,70
$1 642,11
$307,82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$804,76
$913,40
$1 028,48
$1 437,30
$2 184,12
$1 112,58
$1 221,22
$1 336,30
$1 745,12
$1 420,40
$1 529,04
$1 644,12
$2 052,94
$1 728,22
$1 836,86
$1 951,94
$2 360,76
$307,82
Toc - Plan #49 Arise Health Plan
Silver

(HMO) WPS HMO Silver $4,500 | Select Network

Annual Out of Pocket Expenses
Individual Family
$4,500 $9,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403,34
$457,79
$515,47
$720,37
$1 094,66
$711,90
$766,35
$824,03
$1 028,93
$1 020,46
$1 074,91
$1 132,59
$1 337,49
$1 329,02
$1 383,47
$1 441,15
$1 646,05
$308,56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806,68
$915,58
$1 030,94
$1 440,74
$2 189,32
$1 115,24
$1 224,14
$1 339,50
$1 749,30
$1 423,80
$1 532,70
$1 648,06
$2 057,86
$1 732,36
$1 841,26
$1 956,62
$2 366,42
$308,56
Toc - Plan #50 Arise Health Plan
Silver

(HMO) WPS HMO Silver $5,000 with 3 Free PCP Visits | Select Network

Annual Out of Pocket Expenses
Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419,56
$476,20
$536,20
$749,33
$1 138,69
$740,52
$797,16
$857,16
$1 070,29
$1 061,48
$1 118,12
$1 178,12
$1 391,25
$1 382,44
$1 439,08
$1 499,08
$1 712,21
$320,96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839,12
$952,40
$1 072,40
$1 498,66
$2 277,38
$1 160,08
$1 273,36
$1 393,36
$1 819,62
$1 481,04
$1 594,32
$1 714,32
$2 140,58
$1 802,00
$1 915,28
$2 035,28
$2 461,54
$320,96
Toc - Plan #51 Arise Health Plan
Gold

(HMO) WPS HMO Gold $2,500 | Select Network

Annual Out of Pocket Expenses
Individual Family
$2,500 $5,000 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$555,76
$630,79
$710,26
$992,59
$1 508,33
$980,92
$1 055,95
$1 135,42
$1 417,75
$1 406,08
$1 481,11
$1 560,58
$1 842,91
$1 831,24
$1 906,27
$1 985,74
$2 268,07
$425,16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 111,52
$1 261,58
$1 420,52
$1 985,18
$3 016,66
$1 536,68
$1 686,74
$1 845,68
$2 410,34
$1 961,84
$2 111,90
$2 270,84
$2 835,50
$2 387,00
$2 537,06
$2 696,00
$3 260,66
$425,16
Toc - Plan #52 Arise Health Plan
Catastrophic

(HMO) WPS HMO Catastrophic $8,550 with 3 Free PCP Visits | Select Network

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$260,22
$295,35
$332,56
$464,75
$706,24
$459,29
$494,42
$531,63
$663,82
$658,36
$693,49
$730,70
$862,89
$857,43
$892,56
$929,77
$1 061,96
$199,07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$520,44
$590,70
$665,12
$929,50
$1 412,48
$719,51
$789,77
$864,19
$1 128,57
$918,58
$988,84
$1 063,26
$1 327,64
$1 117,65
$1 187,91
$1 262,33
$1 526,71
$199,07
Toc - Plan #53 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO HDHP Bronze $7,000 | Select Network

Annual Out of Pocket Expenses
Individual Family
$7,000 $14,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$311,17
$353,18
$397,68
$555,75
$844,52
$549,22
$591,23
$635,73
$793,80
$787,27
$829,28
$873,78
$1 031,85
$1 025,32
$1 067,33
$1 111,83
$1 269,90
$238,05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$622,34
$706,36
$795,36
$1 111,50
$1 689,04
$860,39
$944,41
$1 033,41
$1 349,55
$1 098,44
$1 182,46
$1 271,46
$1 587,60
$1 336,49
$1 420,51
$1 509,51
$1 825,65
$238,05
Toc - Plan #54 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO HDHP Bronze $6,830 | Select Network

Annual Out of Pocket Expenses
Individual Family
$6,830 $13,660 Annual Deductible
$6,830 $13,660 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317,52
$360,39
$405,79
$567,09
$861,75
$560,42
$603,29
$648,69
$809,99
$803,32
$846,19
$891,59
$1 052,89
$1 046,22
$1 089,09
$1 134,49
$1 295,79
$242,90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$635,04
$720,78
$811,58
$1 134,18
$1 723,50
$877,94
$963,68
$1 054,48
$1 377,08
$1 120,84
$1 206,58
$1 297,38
$1 619,98
$1 363,74
$1 449,48
$1 540,28
$1 862,88
$242,90
Toc - Plan #55 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO HDHP Bronze $6,000 | Select Network

Annual Out of Pocket Expenses
Individual Family
$6,000 $12,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$311,82
$353,92
$398,51
$556,91
$846,28
$550,36
$592,46
$637,05
$795,45
$788,90
$831,00
$875,59
$1 033,99
$1 027,44
$1 069,54
$1 114,13
$1 272,53
$238,54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$623,64
$707,84
$797,02
$1 113,82
$1 692,56
$862,18
$946,38
$1 035,56
$1 352,36
$1 100,72
$1 184,92
$1 274,10
$1 590,90
$1 339,26
$1 423,46
$1 512,64
$1 829,44
$238,54
Toc - Plan #56 Arise Health Plan
Silver

(HMO) WPS HMO HDHP Silver $2,800 | Select Network

Annual Out of Pocket Expenses
Individual Family
$2,800 $5,600 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413,53
$469,36
$528,49
$738,56
$1 122,32
$729,88
$785,71
$844,84
$1 054,91
$1 046,23
$1 102,06
$1 161,19
$1 371,26
$1 362,58
$1 418,41
$1 477,54
$1 687,61
$316,35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$827,06
$938,72
$1 056,98
$1 477,12
$2 244,64
$1 143,41
$1 255,07
$1 373,33
$1 793,47
$1 459,76
$1 571,42
$1 689,68
$2 109,82
$1 776,11
$1 887,77
$2 006,03
$2 426,17
$316,35
Toc - Plan #57 Arise Health Plan
Silver

(HMO) WPS HMO HDHP Silver $4,500 | Select Network

Annual Out of Pocket Expenses
Individual Family
$4,500 $9,000 Annual Deductible
$4,500 $9,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412,57
$468,27
$527,26
$736,85
$1 119,71
$728,19
$783,89
$842,88
$1 052,47
$1 043,81
$1 099,51
$1 158,50
$1 368,09
$1 359,43
$1 415,13
$1 474,12
$1 683,71
$315,62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$825,14
$936,54
$1 054,52
$1 473,70
$2 239,42
$1 140,76
$1 252,16
$1 370,14
$1 789,32
$1 456,38
$1 567,78
$1 685,76
$2 104,94
$1 772,00
$1 883,40
$2 001,38
$2 420,56
$315,62
Toc - Plan #58 Arise Health Plan
Silver

(HMO) WPS HMO HDHP Silver $5,500 | Select Network

Annual Out of Pocket Expenses
Individual Family
$5,500 $11,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391,74
$444,62
$500,64
$699,65
$1 063,18
$691,42
$744,30
$800,32
$999,33
$991,10
$1 043,98
$1 100,00
$1 299,01
$1 290,78
$1 343,66
$1 399,68
$1 598,69
$299,68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783,48
$889,24
$1 001,28
$1 399,30
$2 126,36
$1 083,16
$1 188,92
$1 300,96
$1 698,98
$1 382,84
$1 488,60
$1 600,64
$1 998,66
$1 682,52
$1 788,28
$1 900,32
$2 298,34
$299,68
Toc - Plan #59 Arise Health Plan
Bronze

(POS) WPS POS Bronze $8,550 | Select Network

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$320,15
$363,37
$409,15
$571,79
$868,89
$565,06
$608,28
$654,06
$816,70
$809,97
$853,19
$898,97
$1 061,61
$1 054,88
$1 098,10
$1 143,88
$1 306,52
$244,91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640,30
$726,74
$818,30
$1 143,58
$1 737,78
$885,21
$971,65
$1 063,21
$1 388,49
$1 130,12
$1 216,56
$1 308,12
$1 633,40
$1 375,03
$1 461,47
$1 553,03
$1 878,31
$244,91
Toc - Plan #60 Arise Health Plan
Expanded Bronze

(POS) WPS POS HDHP Bronze $6,000 | Select Network

Annual Out of Pocket Expenses
Individual Family
$6,000 $12,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333,48
$378,50
$426,19
$595,60
$905,06
$588,59
$633,61
$681,30
$850,71
$843,70
$888,72
$936,41
$1 105,82
$1 098,81
$1 143,83
$1 191,52
$1 360,93
$255,11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666,96
$757,00
$852,38
$1 191,20
$1 810,12
$922,07
$1 012,11
$1 107,49
$1 446,31
$1 177,18
$1 267,22
$1 362,60
$1 701,42
$1 432,29
$1 522,33
$1 617,71
$1 956,53
$255,11

ADVERTISEMENT

Common Ground Healthcare Cooperative

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

Toc - Plan #61 Common Ground Healthcare Cooperative
Gold

(EPO) Envision - Gold 1800/80

Annual Out of Pocket Expenses
Individual Family
$1,800 $3,600 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405,48
$460,21
$518,20
$724,18
$1 100,46
$715,67
$770,40
$828,39
$1 034,37
$1 025,86
$1 080,59
$1 138,58
$1 344,56
$1 336,05
$1 390,78
$1 448,77
$1 654,75
$310,19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810,96
$920,42
$1 036,40
$1 448,36
$2 200,92
$1 121,15
$1 230,61
$1 346,59
$1 758,55
$1 431,34
$1 540,80
$1 656,78
$2 068,74
$1 741,53
$1 850,99
$1 966,97
$2 378,93
$310,19
Toc - Plan #62 Common Ground Healthcare Cooperative
Gold

(EPO) Envision - Gold 2000/80

Annual Out of Pocket Expenses
Individual Family
$2,000 $4,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381,23
$432,69
$487,20
$680,86
$1 034,64
$672,87
$724,33
$778,84
$972,50
$964,51
$1 015,97
$1 070,48
$1 264,14
$1 256,15
$1 307,61
$1 362,12
$1 555,78
$291,64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762,46
$865,38
$974,40
$1 361,72
$2 069,28
$1 054,10
$1 157,02
$1 266,04
$1 653,36
$1 345,74
$1 448,66
$1 557,68
$1 945,00
$1 637,38
$1 740,30
$1 849,32
$2 236,64
$291,64
Toc - Plan #63 Common Ground Healthcare Cooperative
Silver

(EPO) Envision - Silver 4000/75

Annual Out of Pocket Expenses
Individual Family
$4,000 $8,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372,86
$423,18
$476,50
$665,90
$1 011,91
$658,09
$708,41
$761,73
$951,13
$943,32
$993,64
$1 046,96
$1 236,36
$1 228,55
$1 278,87
$1 332,19
$1 521,59
$285,23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$745,72
$846,36
$953,00
$1 331,80
$2 023,82
$1 030,95
$1 131,59
$1 238,23
$1 617,03
$1 316,18
$1 416,82
$1 523,46
$1 902,26
$1 601,41
$1 702,05
$1 808,69
$2 187,49
$285,23
Toc - Plan #64 Common Ground Healthcare Cooperative
Silver

(EPO) Envision - Silver 3000/75/Copay40

Annual Out of Pocket Expenses
Individual Family
$3,000 $6,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389,94
$442,57
$498,33
$696,41
$1 058,26
$688,23
$740,86
$796,62
$994,70
$986,52
$1 039,15
$1 094,91
$1 292,99
$1 284,81
$1 337,44
$1 393,20
$1 591,28
$298,29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$779,88
$885,14
$996,66
$1 392,82
$2 116,52
$1 078,17
$1 183,43
$1 294,95
$1 691,11
$1 376,46
$1 481,72
$1 593,24
$1 989,40
$1 674,75
$1 780,01
$1 891,53
$2 287,69
$298,29
Toc - Plan #65 Common Ground Healthcare Cooperative
Catastrophic

(EPO) Envision - Catastrophic 8550/100

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$184,53
$209,43
$235,81
$329,55
$500,78
$325,69
$350,59
$376,97
$470,71
$466,85
$491,75
$518,13
$611,87
$608,01
$632,91
$659,29
$753,03
$141,16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$369,06
$418,86
$471,62
$659,10
$1 001,56
$510,22
$560,02
$612,78
$800,26
$651,38
$701,18
$753,94
$941,42
$792,54
$842,34
$895,10
$1 082,58
$141,16
Toc - Plan #66 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) Envision - Bronze 8550/100

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$259,60
$294,64
$331,76
$463,64
$704,54
$458,19
$493,23
$530,35
$662,23
$656,78
$691,82
$728,94
$860,82
$855,37
$890,41
$927,53
$1 059,41
$198,59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$519,20
$589,28
$663,52
$927,28
$1 409,08
$717,79
$787,87
$862,11
$1 125,87
$916,38
$986,46
$1 060,70
$1 324,46
$1 114,97
$1 185,05
$1 259,29
$1 523,05
$198,59
Toc - Plan #67 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) Envision - Bronze 8150/ 100

Annual Out of Pocket Expenses
Individual Family
$8,150 $16,300 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$276,53
$313,85
$353,39
$493,87
$750,48
$488,07
$525,39
$564,93
$705,41
$699,61
$736,93
$776,47
$916,95
$911,15
$948,47
$988,01
$1 128,49
$211,54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$553,06
$627,70
$706,78
$987,74
$1 500,96
$764,60
$839,24
$918,32
$1 199,28
$976,14
$1 050,78
$1 129,86
$1 410,82
$1 187,68
$1 262,32
$1 341,40
$1 622,36
$211,54
Toc - Plan #68 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) Envision - HSA Bronze 7000/100

Annual Out of Pocket Expenses
Individual Family
$7,000 $14,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$274,29
$311,31
$350,53
$489,87
$744,40
$484,12
$521,14
$560,36
$699,70
$693,95
$730,97
$770,19
$909,53
$903,78
$940,80
$980,02
$1 119,36
$209,83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$548,58
$622,62
$701,06
$979,74
$1 488,80
$758,41
$832,45
$910,89
$1 189,57
$968,24
$1 042,28
$1 120,72
$1 399,40
$1 178,07
$1 252,11
$1 330,55
$1 609,23
$209,83
Toc - Plan #69 Common Ground Healthcare Cooperative
Silver

(EPO) Envision - Silver 7000/75

Annual Out of Pocket Expenses
Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310,01
$351,85
$396,18
$553,65
$841,33
$547,16
$589,00
$633,33
$790,80
$784,31
$826,15
$870,48
$1 027,95
$1 021,46
$1 063,30
$1 107,63
$1 265,10
$237,15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620,02
$703,70
$792,36
$1 107,30
$1 682,66
$857,17
$940,85
$1 029,51
$1 344,45
$1 094,32
$1 178,00
$1 266,66
$1 581,60
$1 331,47
$1 415,15
$1 503,81
$1 818,75
$237,15

‡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 Fond Du Lac County here.

Fond Du Lac County is in “Rating Area 11” of Wisconsin.

Currently, there are 69 plans offered in Rating Area 11.

Top

2022 Obamacare Rates for Fond Du Lac County

ADVERTISEMENT