Green County, Wisconsin Obamacare 2024 Rates

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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 Green County, WI.

The health insurance rates listed below are for calendar year 2024.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 76 Plans and 2024 Rates for Green County, Wisconsin

Below, you’ll find a summary of the 76 plans for Green 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 | 2023 | 2024 |



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Quartz

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

Toc - Plan #1 Quartz
Gold

(HMO) QUARTZ ONE GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$475.18
$539.32
$607.27
$848.66
$1,289.61
$838.69
$902.83
$970.78
$1,212.17
$1,202.20
$1,266.34
$1,334.29
$1,575.68
$1,565.71
$1,629.85
$1,697.80
$1,939.19
$363.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$950.36
$1,078.64
$1,214.54
$1,697.32
$2,579.22
$1,313.87
$1,442.15
$1,578.05
$2,060.83
$1,677.38
$1,805.66
$1,941.56
$2,424.34
$2,040.89
$2,169.17
$2,305.07
$2,787.85
$363.51
Toc - Plan #2 Quartz
Gold

(HMO) QUARTZ ONE GOLD I410 STANDARD W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$478.88
$543.52
$612.00
$855.26
$1,299.66
$845.22
$909.86
$978.34
$1,221.60
$1,211.56
$1,276.20
$1,344.68
$1,587.94
$1,577.90
$1,642.54
$1,711.02
$1,954.28
$366.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$957.76
$1,087.04
$1,224.00
$1,710.52
$2,599.32
$1,324.10
$1,453.38
$1,590.34
$2,076.86
$1,690.44
$1,819.72
$1,956.68
$2,443.20
$2,056.78
$2,186.06
$2,323.02
$2,809.54
$366.34
Toc - Plan #3 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$506.21
$574.54
$646.93
$904.08
$1,373.84
$893.46
$961.79
$1,034.18
$1,291.33
$1,280.71
$1,349.04
$1,421.43
$1,678.58
$1,667.96
$1,736.29
$1,808.68
$2,065.83
$387.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,012.42
$1,149.08
$1,293.86
$1,808.16
$2,747.68
$1,399.67
$1,536.33
$1,681.11
$2,195.41
$1,786.92
$1,923.58
$2,068.36
$2,582.66
$2,174.17
$2,310.83
$2,455.61
$2,969.91
$387.25
Toc - Plan #4 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.64
$427.48
$481.34
$672.67
$1,022.18
$664.76
$715.60
$769.46
$960.79
$952.88
$1,003.72
$1,057.58
$1,248.91
$1,241.00
$1,291.84
$1,345.70
$1,537.03
$288.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.28
$854.96
$962.68
$1,345.34
$2,044.36
$1,041.40
$1,143.08
$1,250.80
$1,633.46
$1,329.52
$1,431.20
$1,538.92
$1,921.58
$1,617.64
$1,719.32
$1,827.04
$2,209.70
$288.12
Toc - Plan #5 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.57
$416.05
$468.46
$654.68
$994.84
$646.99
$696.47
$748.88
$935.10
$927.41
$976.89
$1,029.30
$1,215.52
$1,207.83
$1,257.31
$1,309.72
$1,495.94
$280.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.14
$832.10
$936.92
$1,309.36
$1,989.68
$1,013.56
$1,112.52
$1,217.34
$1,589.78
$1,293.98
$1,392.94
$1,497.76
$1,870.20
$1,574.40
$1,673.36
$1,778.18
$2,150.62
$280.42
Toc - Plan #6 Quartz
Silver

(HMO) QUARTZ ONE SILVER I320 VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$518.25
$588.21
$662.32
$925.59
$1,406.52
$914.71
$984.67
$1,058.78
$1,322.05
$1,311.17
$1,381.13
$1,455.24
$1,718.51
$1,707.63
$1,777.59
$1,851.70
$2,114.97
$396.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,036.50
$1,176.42
$1,324.64
$1,851.18
$2,813.04
$1,432.96
$1,572.88
$1,721.10
$2,247.64
$1,829.42
$1,969.34
$2,117.56
$2,644.10
$2,225.88
$2,365.80
$2,514.02
$3,040.56
$396.46
Toc - Plan #7 Quartz
Gold

(HMO) QUARTZ ONE GOLD I420 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.40
$494.17
$556.43
$777.61
$1,181.66
$768.48
$827.25
$889.51
$1,110.69
$1,101.56
$1,160.33
$1,222.59
$1,443.77
$1,434.64
$1,493.41
$1,555.67
$1,776.85
$333.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$870.80
$988.34
$1,112.86
$1,555.22
$2,363.32
$1,203.88
$1,321.42
$1,445.94
$1,888.30
$1,536.96
$1,654.50
$1,779.02
$2,221.38
$1,870.04
$1,987.58
$2,112.10
$2,554.46
$333.08
Toc - Plan #8 Quartz
Gold

(HMO) QUARTZ ONE GOLD I402 MAINTENANCE VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$452.53
$513.61
$578.32
$808.20
$1,228.14
$798.71
$859.79
$924.50
$1,154.38
$1,144.89
$1,205.97
$1,270.68
$1,500.56
$1,491.07
$1,552.15
$1,616.86
$1,846.74
$346.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$905.06
$1,027.22
$1,156.64
$1,616.40
$2,456.28
$1,251.24
$1,373.40
$1,502.82
$1,962.58
$1,597.42
$1,719.58
$1,849.00
$2,308.76
$1,943.60
$2,065.76
$2,195.18
$2,654.94
$346.18
Toc - Plan #9 Quartz
Gold

(HMO) QUARTZ ONE GOLD I410 STANDARD

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$456.05
$517.61
$582.82
$814.50
$1,237.71
$804.92
$866.48
$931.69
$1,163.37
$1,153.79
$1,215.35
$1,280.56
$1,512.24
$1,502.66
$1,564.22
$1,629.43
$1,861.11
$348.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$912.10
$1,035.22
$1,165.64
$1,629.00
$2,475.42
$1,260.97
$1,384.09
$1,514.51
$1,977.87
$1,609.84
$1,732.96
$1,863.38
$2,326.74
$1,958.71
$2,081.83
$2,212.25
$2,675.61
$348.87
Toc - Plan #10 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$482.08
$547.15
$616.09
$860.98
$1,308.35
$850.87
$915.94
$984.88
$1,229.77
$1,219.66
$1,284.73
$1,353.67
$1,598.56
$1,588.45
$1,653.52
$1,722.46
$1,967.35
$368.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$964.16
$1,094.30
$1,232.18
$1,721.96
$2,616.70
$1,332.95
$1,463.09
$1,600.97
$2,090.75
$1,701.74
$1,831.88
$1,969.76
$2,459.54
$2,070.53
$2,200.67
$2,338.55
$2,828.33
$368.79
Toc - Plan #11 Quartz
Silver

(HMO) QUARTZ ONE SILVER I309 STANDARD

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$469.22
$532.56
$599.66
$838.02
$1,273.45
$828.17
$891.51
$958.61
$1,196.97
$1,187.12
$1,250.46
$1,317.56
$1,555.92
$1,546.07
$1,609.41
$1,676.51
$1,914.87
$358.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$938.44
$1,065.12
$1,199.32
$1,676.04
$2,546.90
$1,297.39
$1,424.07
$1,558.27
$2,034.99
$1,656.34
$1,783.02
$1,917.22
$2,393.94
$2,015.29
$2,141.97
$2,276.17
$2,752.89
$358.95
Toc - Plan #12 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.69
$407.10
$458.39
$640.60
$973.46
$633.08
$681.49
$732.78
$914.99
$907.47
$955.88
$1,007.17
$1,189.38
$1,181.86
$1,230.27
$1,281.56
$1,463.77
$274.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.38
$814.20
$916.78
$1,281.20
$1,946.92
$991.77
$1,088.59
$1,191.17
$1,555.59
$1,266.16
$1,362.98
$1,465.56
$1,829.98
$1,540.55
$1,637.37
$1,739.95
$2,104.37
$274.39
Toc - Plan #13 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$349.09
$396.21
$446.13
$623.47
$947.42
$616.14
$663.26
$713.18
$890.52
$883.19
$930.31
$980.23
$1,157.57
$1,150.24
$1,197.36
$1,247.28
$1,424.62
$267.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.18
$792.42
$892.26
$1,246.94
$1,894.84
$965.23
$1,059.47
$1,159.31
$1,513.99
$1,232.28
$1,326.52
$1,426.36
$1,781.04
$1,499.33
$1,593.57
$1,693.41
$2,048.09
$267.05
Toc - Plan #14 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I206 STANDARD

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.18
$378.15
$425.79
$595.04
$904.23
$588.06
$633.03
$680.67
$849.92
$842.94
$887.91
$935.55
$1,104.80
$1,097.82
$1,142.79
$1,190.43
$1,359.68
$254.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.36
$756.30
$851.58
$1,190.08
$1,808.46
$921.24
$1,011.18
$1,106.46
$1,444.96
$1,176.12
$1,266.06
$1,361.34
$1,699.84
$1,431.00
$1,520.94
$1,616.22
$1,954.72
$254.88
Toc - Plan #15 Quartz
Silver

(HMO) QUARTZ ONE SILVER I320 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$493.55
$560.17
$630.75
$881.47
$1,339.48
$871.11
$937.73
$1,008.31
$1,259.03
$1,248.67
$1,315.29
$1,385.87
$1,636.59
$1,626.23
$1,692.85
$1,763.43
$2,014.15
$377.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$987.10
$1,120.34
$1,261.50
$1,762.94
$2,678.96
$1,364.66
$1,497.90
$1,639.06
$2,140.50
$1,742.22
$1,875.46
$2,016.62
$2,518.06
$2,119.78
$2,253.02
$2,394.18
$2,895.62
$377.56
Toc - Plan #16 Quartz
Gold

(HMO) QUARTZ ONE GOLD I401 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$428.81
$486.70
$548.02
$765.85
$1,163.78
$756.85
$814.74
$876.06
$1,093.89
$1,084.89
$1,142.78
$1,204.10
$1,421.93
$1,412.93
$1,470.82
$1,532.14
$1,749.97
$328.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$857.62
$973.40
$1,096.04
$1,531.70
$2,327.56
$1,185.66
$1,301.44
$1,424.08
$1,859.74
$1,513.70
$1,629.48
$1,752.12
$2,187.78
$1,841.74
$1,957.52
$2,080.16
$2,515.82
$328.04
Toc - Plan #17 Quartz
Silver

(HMO) QUARTZ ONE SILVER I303 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$458.61
$520.52
$586.10
$819.07
$1,244.66
$809.45
$871.36
$936.94
$1,169.91
$1,160.29
$1,222.20
$1,287.78
$1,520.75
$1,511.13
$1,573.04
$1,638.62
$1,871.59
$350.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.22
$1,041.04
$1,172.20
$1,638.14
$2,489.32
$1,268.06
$1,391.88
$1,523.04
$1,988.98
$1,618.90
$1,742.72
$1,873.88
$2,339.82
$1,969.74
$2,093.56
$2,224.72
$2,690.66
$350.84
Toc - Plan #18 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I201 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$9,400 $18,800 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$313.96
$356.34
$401.23
$560.72
$852.07
$554.14
$596.52
$641.41
$800.90
$794.32
$836.70
$881.59
$1,041.08
$1,034.50
$1,076.88
$1,121.77
$1,281.26
$240.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627.92
$712.68
$802.46
$1,121.44
$1,704.14
$868.10
$952.86
$1,042.64
$1,361.62
$1,108.28
$1,193.04
$1,282.82
$1,601.80
$1,348.46
$1,433.22
$1,523.00
$1,841.98
$240.18
Toc - Plan #19 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I203 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.23
$387.29
$436.09
$609.43
$926.09
$602.27
$648.33
$697.13
$870.47
$863.31
$909.37
$958.17
$1,131.51
$1,124.35
$1,170.41
$1,219.21
$1,392.55
$261.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.46
$774.58
$872.18
$1,218.86
$1,852.18
$943.50
$1,035.62
$1,133.22
$1,479.90
$1,204.54
$1,296.66
$1,394.26
$1,740.94
$1,465.58
$1,557.70
$1,655.30
$2,001.98
$261.04
Toc - Plan #20 Quartz
Catastrophic

(HMO) QUARTZ ONE CATASTROPHIC I101

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$247.75
$281.19
$316.62
$442.47
$672.38
$437.28
$470.72
$506.15
$632.00
$626.81
$660.25
$695.68
$821.53
$816.34
$849.78
$885.21
$1,011.06
$189.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$495.50
$562.38
$633.24
$884.94
$1,344.76
$685.03
$751.91
$822.77
$1,074.47
$874.56
$941.44
$1,012.30
$1,264.00
$1,064.09
$1,130.97
$1,201.83
$1,453.53
$189.53
Toc - Plan #21 Quartz
Silver

(HMO) QUARTZ ONE SILVER I304 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$486.41
$552.07
$621.63
$868.72
$1,320.10
$858.51
$924.17
$993.73
$1,240.82
$1,230.61
$1,296.27
$1,365.83
$1,612.92
$1,602.71
$1,668.37
$1,737.93
$1,985.02
$372.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$972.82
$1,104.14
$1,243.26
$1,737.44
$2,640.20
$1,344.92
$1,476.24
$1,615.36
$2,109.54
$1,717.02
$1,848.34
$1,987.46
$2,481.64
$2,089.12
$2,220.44
$2,359.56
$2,853.74
$372.10
Toc - Plan #22 Quartz
Gold

(HMO) QUARTZ ONE GOLD I403 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$446.25
$506.49
$570.31
$797.00
$1,211.12
$787.63
$847.87
$911.69
$1,138.38
$1,129.01
$1,189.25
$1,253.07
$1,479.76
$1,470.39
$1,530.63
$1,594.45
$1,821.14
$341.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$892.50
$1,012.98
$1,140.62
$1,594.00
$2,422.24
$1,233.88
$1,354.36
$1,482.00
$1,935.38
$1,575.26
$1,695.74
$1,823.38
$2,276.76
$1,916.64
$2,037.12
$2,164.76
$2,618.14
$341.38

ADVERTISEMENT

Dean Health Plan

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

Toc - Plan #23 Dean Health Plan
Gold

(HMO) Dean Gold Copay Plus 1500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,700 $11,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$447.60
$508.03
$572.03
$799.41
$1,214.79
$790.01
$850.44
$914.44
$1,141.82
$1,132.42
$1,192.85
$1,256.85
$1,484.23
$1,474.83
$1,535.26
$1,599.26
$1,826.64
$342.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$895.20
$1,016.06
$1,144.06
$1,598.82
$2,429.58
$1,237.61
$1,358.47
$1,486.47
$1,941.23
$1,580.02
$1,700.88
$1,828.88
$2,283.64
$1,922.43
$2,043.29
$2,171.29
$2,626.05
$342.41
Toc - Plan #24 Dean Health Plan
Silver

(HMO) Dean Silver Copay Plus 4800X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.22
$480.35
$540.87
$755.86
$1,148.61
$746.98
$804.11
$864.63
$1,079.62
$1,070.74
$1,127.87
$1,188.39
$1,403.38
$1,394.50
$1,451.63
$1,512.15
$1,727.14
$323.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$846.44
$960.70
$1,081.74
$1,511.72
$2,297.22
$1,170.20
$1,284.46
$1,405.50
$1,835.48
$1,493.96
$1,608.22
$1,729.26
$2,159.24
$1,817.72
$1,931.98
$2,053.02
$2,483.00
$323.76
Toc - Plan #25 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Copay Plus 9400X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,400 $18,800 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$280.40
$318.25
$358.35
$500.79
$761.00
$494.90
$532.75
$572.85
$715.29
$709.40
$747.25
$787.35
$929.79
$923.90
$961.75
$1,001.85
$1,144.29
$214.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$560.80
$636.50
$716.70
$1,001.58
$1,522.00
$775.30
$851.00
$931.20
$1,216.08
$989.80
$1,065.50
$1,145.70
$1,430.58
$1,204.30
$1,280.00
$1,360.20
$1,645.08
$214.50
Toc - Plan #26 Dean Health Plan
Silver

(HMO) Dean Silver HSA-E HDHP 3550X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,550 $7,100 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$424.55
$481.87
$542.58
$758.25
$1,152.23
$749.33
$806.65
$867.36
$1,083.03
$1,074.11
$1,131.43
$1,192.14
$1,407.81
$1,398.89
$1,456.21
$1,516.92
$1,732.59
$324.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.10
$963.74
$1,085.16
$1,516.50
$2,304.46
$1,173.88
$1,288.52
$1,409.94
$1,841.28
$1,498.66
$1,613.30
$1,734.72
$2,166.06
$1,823.44
$1,938.08
$2,059.50
$2,490.84
$324.78
Toc - Plan #27 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze HSA-E HDHP 7450X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$295.50
$335.39
$377.65
$527.76
$801.98
$521.56
$561.45
$603.71
$753.82
$747.62
$787.51
$829.77
$979.88
$973.68
$1,013.57
$1,055.83
$1,205.94
$226.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$591.00
$670.78
$755.30
$1,055.52
$1,603.96
$817.06
$896.84
$981.36
$1,281.58
$1,043.12
$1,122.90
$1,207.42
$1,507.64
$1,269.18
$1,348.96
$1,433.48
$1,733.70
$226.06
Toc - Plan #28 Dean Health Plan
Catastrophic

(HMO) Dean Catastrophic Safety Net

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$202.67
$230.04
$259.02
$361.98
$550.06
$357.72
$385.09
$414.07
$517.03
$512.77
$540.14
$569.12
$672.08
$667.82
$695.19
$724.17
$827.13
$155.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$405.34
$460.08
$518.04
$723.96
$1,100.12
$560.39
$615.13
$673.09
$879.01
$715.44
$770.18
$828.14
$1,034.06
$870.49
$925.23
$983.19
$1,189.11
$155.05
Toc - Plan #29 Dean Health Plan
Gold

(HMO) Dean Gold HSA HDHP 2000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,500 $9,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$399.41
$453.33
$510.45
$713.35
$1,084.00
$704.96
$758.88
$816.00
$1,018.90
$1,010.51
$1,064.43
$1,121.55
$1,324.45
$1,316.06
$1,369.98
$1,427.10
$1,630.00
$305.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798.82
$906.66
$1,020.90
$1,426.70
$2,168.00
$1,104.37
$1,212.21
$1,326.45
$1,732.25
$1,409.92
$1,517.76
$1,632.00
$2,037.80
$1,715.47
$1,823.31
$1,937.55
$2,343.35
$305.55
Toc - Plan #30 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Copay PCP 8000X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$274.53
$311.59
$350.85
$490.31
$745.08
$484.55
$521.61
$560.87
$700.33
$694.57
$731.63
$770.89
$910.35
$904.59
$941.65
$980.91
$1,120.37
$210.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$549.06
$623.18
$701.70
$980.62
$1,490.16
$759.08
$833.20
$911.72
$1,190.64
$969.10
$1,043.22
$1,121.74
$1,400.66
$1,179.12
$1,253.24
$1,331.76
$1,610.68
$210.02
Toc - Plan #31 Dean Health Plan
Silver

(HMO) Dean Silver Copay PCP 4500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$401.90
$456.16
$513.63
$717.80
$1,090.76
$709.36
$763.62
$821.09
$1,025.26
$1,016.82
$1,071.08
$1,128.55
$1,332.72
$1,324.28
$1,378.54
$1,436.01
$1,640.18
$307.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.80
$912.32
$1,027.26
$1,435.60
$2,181.52
$1,111.26
$1,219.78
$1,334.72
$1,743.06
$1,418.72
$1,527.24
$1,642.18
$2,050.52
$1,726.18
$1,834.70
$1,949.64
$2,357.98
$307.46
Toc - Plan #32 Dean Health Plan
Gold

(HMO) Dean Gold Copay PCP 3000X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$4,900 $9,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.64
$458.13
$515.85
$720.89
$1,095.47
$712.42
$766.91
$824.63
$1,029.67
$1,021.20
$1,075.69
$1,133.41
$1,338.45
$1,329.98
$1,384.47
$1,442.19
$1,647.23
$308.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$807.28
$916.26
$1,031.70
$1,441.78
$2,190.94
$1,116.06
$1,225.04
$1,340.48
$1,750.56
$1,424.84
$1,533.82
$1,649.26
$2,059.34
$1,733.62
$1,842.60
$1,958.04
$2,368.12
$308.78
Toc - Plan #33 Dean Health Plan
Gold

(HMO) Dean Gold Standard 1500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415.22
$471.27
$530.65
$741.58
$1,126.90
$732.86
$788.91
$848.29
$1,059.22
$1,050.50
$1,106.55
$1,165.93
$1,376.86
$1,368.14
$1,424.19
$1,483.57
$1,694.50
$317.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$830.44
$942.54
$1,061.30
$1,483.16
$2,253.80
$1,148.08
$1,260.18
$1,378.94
$1,800.80
$1,465.72
$1,577.82
$1,696.58
$2,118.44
$1,783.36
$1,895.46
$2,014.22
$2,436.08
$317.64
Toc - Plan #34 Dean Health Plan
Silver

(HMO) Dean Silver Standard 5900X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.23
$459.94
$517.89
$723.75
$1,099.81
$715.23
$769.94
$827.89
$1,033.75
$1,025.23
$1,079.94
$1,137.89
$1,343.75
$1,335.23
$1,389.94
$1,447.89
$1,653.75
$310.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.46
$919.88
$1,035.78
$1,447.50
$2,199.62
$1,120.46
$1,229.88
$1,345.78
$1,757.50
$1,430.46
$1,539.88
$1,655.78
$2,067.50
$1,740.46
$1,849.88
$1,965.78
$2,377.50
$310.00
Toc - Plan #35 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Standard 7500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$284.48
$322.89
$363.57
$508.09
$772.09
$502.11
$540.52
$581.20
$725.72
$719.74
$758.15
$798.83
$943.35
$937.37
$975.78
$1,016.46
$1,160.98
$217.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$568.96
$645.78
$727.14
$1,016.18
$1,544.18
$786.59
$863.41
$944.77
$1,233.81
$1,004.22
$1,081.04
$1,162.40
$1,451.44
$1,221.85
$1,298.67
$1,380.03
$1,669.07
$217.63
Toc - Plan #36 Dean Health Plan
Bronze

(HMO) Dean Bronze Standard 9100X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$252.42
$286.50
$322.59
$450.82
$685.06
$445.52
$479.60
$515.69
$643.92
$638.62
$672.70
$708.79
$837.02
$831.72
$865.80
$901.89
$1,030.12
$193.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$504.84
$573.00
$645.18
$901.64
$1,370.12
$697.94
$766.10
$838.28
$1,094.74
$891.04
$959.20
$1,031.38
$1,287.84
$1,084.14
$1,152.30
$1,224.48
$1,480.94
$193.10
Toc - Plan #37 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver HSA-E HDHP 3550X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,550 $7,100 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.27
$442.95
$498.76
$697.02
$1,059.19
$688.82
$741.50
$797.31
$995.57
$987.37
$1,040.05
$1,095.86
$1,294.12
$1,285.92
$1,338.60
$1,394.41
$1,592.67
$298.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.54
$885.90
$997.52
$1,394.04
$2,118.38
$1,079.09
$1,184.45
$1,296.07
$1,692.59
$1,377.64
$1,483.00
$1,594.62
$1,991.14
$1,676.19
$1,781.55
$1,893.17
$2,289.69
$298.55
Toc - Plan #38 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze HSA-E HDHP 7450X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$271.63
$308.30
$347.14
$485.13
$737.21
$479.43
$516.10
$554.94
$692.93
$687.23
$723.90
$762.74
$900.73
$895.03
$931.70
$970.54
$1,108.53
$207.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$543.26
$616.60
$694.28
$970.26
$1,474.42
$751.06
$824.40
$902.08
$1,178.06
$958.86
$1,032.20
$1,109.88
$1,385.86
$1,166.66
$1,240.00
$1,317.68
$1,593.66
$207.80
Toc - Plan #39 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Copay Plus 9400X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,400 $18,800 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$257.76
$292.56
$329.41
$460.36
$699.55
$454.94
$489.74
$526.59
$657.54
$652.12
$686.92
$723.77
$854.72
$849.30
$884.10
$920.95
$1,051.90
$197.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$515.52
$585.12
$658.82
$920.72
$1,399.10
$712.70
$782.30
$856.00
$1,117.90
$909.88
$979.48
$1,053.18
$1,315.08
$1,107.06
$1,176.66
$1,250.36
$1,512.26
$197.18
Toc - Plan #40 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Copay Plus 1500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,700 $11,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.46
$467.00
$525.84
$734.86
$1,116.69
$726.22
$781.76
$840.60
$1,049.62
$1,040.98
$1,096.52
$1,155.36
$1,364.38
$1,355.74
$1,411.28
$1,470.12
$1,679.14
$314.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.92
$934.00
$1,051.68
$1,469.72
$2,233.38
$1,137.68
$1,248.76
$1,366.44
$1,784.48
$1,452.44
$1,563.52
$1,681.20
$2,099.24
$1,767.20
$1,878.28
$1,995.96
$2,414.00
$314.76
Toc - Plan #41 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Copay Plus 4800X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389.04
$441.56
$497.19
$694.82
$1,055.85
$686.65
$739.17
$794.80
$992.43
$984.26
$1,036.78
$1,092.41
$1,290.04
$1,281.87
$1,334.39
$1,390.02
$1,587.65
$297.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.08
$883.12
$994.38
$1,389.64
$2,111.70
$1,075.69
$1,180.73
$1,291.99
$1,687.25
$1,373.30
$1,478.34
$1,589.60
$1,984.86
$1,670.91
$1,775.95
$1,887.21
$2,282.47
$297.61
Toc - Plan #42 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold HSA HDHP 2000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,500 $9,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.16
$416.72
$469.23
$655.74
$996.46
$648.03
$697.59
$750.10
$936.61
$928.90
$978.46
$1,030.97
$1,217.48
$1,209.77
$1,259.33
$1,311.84
$1,498.35
$280.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.32
$833.44
$938.46
$1,311.48
$1,992.92
$1,015.19
$1,114.31
$1,219.33
$1,592.35
$1,296.06
$1,395.18
$1,500.20
$1,873.22
$1,576.93
$1,676.05
$1,781.07
$2,154.09
$280.87
Toc - Plan #43 Dean Health Plan
Catastrophic

(EPO) Dean Focus Network Catastrophic Safety Net

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$186.30
$211.45
$238.09
$332.73
$505.62
$328.82
$353.97
$380.61
$475.25
$471.34
$496.49
$523.13
$617.77
$613.86
$639.01
$665.65
$760.29
$142.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$372.60
$422.90
$476.18
$665.46
$1,011.24
$515.12
$565.42
$618.70
$807.98
$657.64
$707.94
$761.22
$950.50
$800.16
$850.46
$903.74
$1,093.02
$142.52
Toc - Plan #44 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Copay PCP 8000X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$252.37
$286.44
$322.52
$450.73
$684.92
$445.43
$479.50
$515.58
$643.79
$638.49
$672.56
$708.64
$836.85
$831.55
$865.62
$901.70
$1,029.91
$193.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$504.74
$572.88
$645.04
$901.46
$1,369.84
$697.80
$765.94
$838.10
$1,094.52
$890.86
$959.00
$1,031.16
$1,287.58
$1,083.92
$1,152.06
$1,224.22
$1,480.64
$193.06
Toc - Plan #45 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Copay PCP 4500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.45
$419.32
$472.15
$659.83
$1,002.68
$652.08
$701.95
$754.78
$942.46
$934.71
$984.58
$1,037.41
$1,225.09
$1,217.34
$1,267.21
$1,320.04
$1,507.72
$282.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.90
$838.64
$944.30
$1,319.66
$2,005.36
$1,021.53
$1,121.27
$1,226.93
$1,602.29
$1,304.16
$1,403.90
$1,509.56
$1,884.92
$1,586.79
$1,686.53
$1,792.19
$2,167.55
$282.63
Toc - Plan #46 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Copay PCP 3000X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$4,900 $9,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$371.03
$421.12
$474.18
$662.67
$1,006.99
$654.87
$704.96
$758.02
$946.51
$938.71
$988.80
$1,041.86
$1,230.35
$1,222.55
$1,272.64
$1,325.70
$1,514.19
$283.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.06
$842.24
$948.36
$1,325.34
$2,013.98
$1,025.90
$1,126.08
$1,232.20
$1,609.18
$1,309.74
$1,409.92
$1,516.04
$1,893.02
$1,593.58
$1,693.76
$1,799.88
$2,176.86
$283.84
Toc - Plan #47 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Standard 1500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.69
$433.22
$487.80
$681.70
$1,035.91
$673.68
$725.21
$779.79
$973.69
$965.67
$1,017.20
$1,071.78
$1,265.68
$1,257.66
$1,309.19
$1,363.77
$1,557.67
$291.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.38
$866.44
$975.60
$1,363.40
$2,071.82
$1,055.37
$1,158.43
$1,267.59
$1,655.39
$1,347.36
$1,450.42
$1,559.58
$1,947.38
$1,639.35
$1,742.41
$1,851.57
$2,239.37
$291.99
Toc - Plan #48 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Standard 5900X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.51
$422.79
$476.06
$665.30
$1,010.98
$657.48
$707.76
$761.03
$950.27
$942.45
$992.73
$1,046.00
$1,235.24
$1,227.42
$1,277.70
$1,330.97
$1,520.21
$284.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$745.02
$845.58
$952.12
$1,330.60
$2,021.96
$1,029.99
$1,130.55
$1,237.09
$1,615.57
$1,314.96
$1,415.52
$1,522.06
$1,900.54
$1,599.93
$1,700.49
$1,807.03
$2,185.51
$284.97
Toc - Plan #49 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Standard 7500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$261.51
$296.81
$334.21
$467.06
$709.74
$461.57
$496.87
$534.27
$667.12
$661.63
$696.93
$734.33
$867.18
$861.69
$896.99
$934.39
$1,067.24
$200.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$523.02
$593.62
$668.42
$934.12
$1,419.48
$723.08
$793.68
$868.48
$1,134.18
$923.14
$993.74
$1,068.54
$1,334.24
$1,123.20
$1,193.80
$1,268.60
$1,534.30
$200.06
Toc - Plan #50 Dean Health Plan
Bronze

(EPO) Dean Focus Network Bronze Standard 9100X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$232.04
$263.37
$296.55
$414.42
$629.76
$409.55
$440.88
$474.06
$591.93
$587.06
$618.39
$651.57
$769.44
$764.57
$795.90
$829.08
$946.95
$177.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$464.08
$526.74
$593.10
$828.84
$1,259.52
$641.59
$704.25
$770.61
$1,006.35
$819.10
$881.76
$948.12
$1,183.86
$996.61
$1,059.27
$1,125.63
$1,361.37
$177.51

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

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

Toc - Plan #51 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$314.58
$357.05
$402.03
$561.84
$853.77
$555.23
$597.70
$642.68
$802.49
$795.88
$838.35
$883.33
$1,043.14
$1,036.53
$1,079.00
$1,123.98
$1,283.79
$240.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$629.16
$714.10
$804.06
$1,123.68
$1,707.54
$869.81
$954.75
$1,044.71
$1,364.33
$1,110.46
$1,195.40
$1,285.36
$1,604.98
$1,351.11
$1,436.05
$1,526.01
$1,845.63
$240.65
Toc - Plan #52 Anthem Blue Cross and Blue Shield
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,700 $15,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.36
$422.63
$475.88
$665.03
$1,010.59
$657.22
$707.49
$760.74
$949.89
$942.08
$992.35
$1,045.60
$1,234.75
$1,226.94
$1,277.21
$1,330.46
$1,519.61
$284.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.72
$845.26
$951.76
$1,330.06
$2,021.18
$1,029.58
$1,130.12
$1,236.62
$1,614.92
$1,314.44
$1,414.98
$1,521.48
$1,899.78
$1,599.30
$1,699.84
$1,806.34
$2,184.64
$284.86
Toc - Plan #53 Anthem Blue Cross and Blue Shield
Bronze

(POS) Anthem Bronze Blue Preferred/Broad 9450 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$285.06
$323.54
$364.31
$509.12
$773.65
$503.13
$541.61
$582.38
$727.19
$721.20
$759.68
$800.45
$945.26
$939.27
$977.75
$1,018.52
$1,163.33
$218.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$570.12
$647.08
$728.62
$1,018.24
$1,547.30
$788.19
$865.15
$946.69
$1,236.31
$1,006.26
$1,083.22
$1,164.76
$1,454.38
$1,224.33
$1,301.29
$1,382.83
$1,672.45
$218.07
Toc - Plan #54 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$299.03
$339.40
$382.16
$534.07
$811.57
$527.79
$568.16
$610.92
$762.83
$756.55
$796.92
$839.68
$991.59
$985.31
$1,025.68
$1,068.44
$1,220.35
$228.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.06
$678.80
$764.32
$1,068.14
$1,623.14
$826.82
$907.56
$993.08
$1,296.90
$1,055.58
$1,136.32
$1,221.84
$1,525.66
$1,284.34
$1,365.08
$1,450.60
$1,754.42
$228.76
Toc - Plan #55 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Blue Preferred/Broad 5000 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$300.17
$340.69
$383.62
$536.10
$814.66
$529.80
$570.32
$613.25
$765.73
$759.43
$799.95
$842.88
$995.36
$989.06
$1,029.58
$1,072.51
$1,224.99
$229.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$600.34
$681.38
$767.24
$1,072.20
$1,629.32
$829.97
$911.01
$996.87
$1,301.83
$1,059.60
$1,140.64
$1,226.50
$1,531.46
$1,289.23
$1,370.27
$1,456.13
$1,761.09
$229.63
Toc - Plan #56 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 5300 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.61
$412.70
$464.69
$649.41
$986.84
$641.77
$690.86
$742.85
$927.57
$919.93
$969.02
$1,021.01
$1,205.73
$1,198.09
$1,247.18
$1,299.17
$1,483.89
$278.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.22
$825.40
$929.38
$1,298.82
$1,973.68
$1,005.38
$1,103.56
$1,207.54
$1,576.98
$1,283.54
$1,381.72
$1,485.70
$1,855.14
$1,561.70
$1,659.88
$1,763.86
$2,133.30
$278.16
Toc - Plan #57 Anthem Blue Cross and Blue Shield
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,800 $13,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.18
$451.93
$508.87
$711.15
$1,080.66
$702.79
$756.54
$813.48
$1,015.76
$1,007.40
$1,061.15
$1,118.09
$1,320.37
$1,312.01
$1,365.76
$1,422.70
$1,624.98
$304.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.36
$903.86
$1,017.74
$1,422.30
$2,161.32
$1,100.97
$1,208.47
$1,322.35
$1,726.91
$1,405.58
$1,513.08
$1,626.96
$2,031.52
$1,710.19
$1,817.69
$1,931.57
$2,336.13
$304.61
Toc - Plan #58 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$299.29
$339.69
$382.49
$534.53
$812.27
$528.25
$568.65
$611.45
$763.49
$757.21
$797.61
$840.41
$992.45
$986.17
$1,026.57
$1,069.37
$1,221.41
$228.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.58
$679.38
$764.98
$1,069.06
$1,624.54
$827.54
$908.34
$993.94
$1,298.02
$1,056.50
$1,137.30
$1,222.90
$1,526.98
$1,285.46
$1,366.26
$1,451.86
$1,755.94
$228.96
Toc - Plan #59 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 5900/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.32
$412.37
$464.32
$648.89
$986.05
$641.26
$690.31
$742.26
$926.83
$919.20
$968.25
$1,020.20
$1,204.77
$1,197.14
$1,246.19
$1,298.14
$1,482.71
$277.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$726.64
$824.74
$928.64
$1,297.78
$1,972.10
$1,004.58
$1,102.68
$1,206.58
$1,575.72
$1,282.52
$1,380.62
$1,484.52
$1,853.66
$1,560.46
$1,658.56
$1,762.46
$2,131.60
$277.94
Toc - Plan #60 Anthem Blue Cross and Blue Shield
Gold

(POS) Anthem Gold Blue Preferred/Broad 1500/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.66
$460.42
$518.43
$724.51
$1,100.96
$715.99
$770.75
$828.76
$1,034.84
$1,026.32
$1,081.08
$1,139.09
$1,345.17
$1,336.65
$1,391.41
$1,449.42
$1,655.50
$310.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.32
$920.84
$1,036.86
$1,449.02
$2,201.92
$1,121.65
$1,231.17
$1,347.19
$1,759.35
$1,431.98
$1,541.50
$1,657.52
$2,069.68
$1,742.31
$1,851.83
$1,967.85
$2,380.01
$310.33
Toc - Plan #61 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.15
$422.39
$475.61
$664.66
$1,010.02
$656.84
$707.08
$760.30
$949.35
$941.53
$991.77
$1,044.99
$1,234.04
$1,226.22
$1,276.46
$1,329.68
$1,518.73
$284.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.30
$844.78
$951.22
$1,329.32
$2,020.04
$1,028.99
$1,129.47
$1,235.91
$1,614.01
$1,313.68
$1,414.16
$1,520.60
$1,898.70
$1,598.37
$1,698.85
$1,805.29
$2,183.39
$284.69

ADVERTISEMENT

Group Health Cooperative-SCW

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729 | TTY: 1-608-828-4815

Toc - Plan #62 Group Health Cooperative-SCW
Gold

(HMO) Gold 2800 Ded/2800 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.97
$473.26
$532.88
$744.70
$1,131.64
$735.95
$792.24
$851.86
$1,063.68
$1,054.93
$1,111.22
$1,170.84
$1,382.66
$1,373.91
$1,430.20
$1,489.82
$1,701.64
$318.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$833.94
$946.52
$1,065.76
$1,489.40
$2,263.28
$1,152.92
$1,265.50
$1,384.74
$1,808.38
$1,471.90
$1,584.48
$1,703.72
$2,127.36
$1,790.88
$1,903.46
$2,022.70
$2,446.34
$318.98
Toc - Plan #63 Group Health Cooperative-SCW
Silver

(HMO) Silver 5700 Ded/5700 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$5,700 $11,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414.43
$470.37
$529.63
$740.16
$1,124.74
$731.47
$787.41
$846.67
$1,057.20
$1,048.51
$1,104.45
$1,163.71
$1,374.24
$1,365.55
$1,421.49
$1,480.75
$1,691.28
$317.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$828.86
$940.74
$1,059.26
$1,480.32
$2,249.48
$1,145.90
$1,257.78
$1,376.30
$1,797.36
$1,462.94
$1,574.82
$1,693.34
$2,114.40
$1,779.98
$1,891.86
$2,010.38
$2,431.44
$317.04
Toc - Plan #64 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 4000 Ded/9450 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.80
$387.95
$436.82
$610.46
$927.64
$603.28
$649.43
$698.30
$871.94
$864.76
$910.91
$959.78
$1,133.42
$1,126.24
$1,172.39
$1,221.26
$1,394.90
$261.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.60
$775.90
$873.64
$1,220.92
$1,855.28
$945.08
$1,037.38
$1,135.12
$1,482.40
$1,206.56
$1,298.86
$1,396.60
$1,743.88
$1,468.04
$1,560.34
$1,658.08
$2,005.36
$261.48
Toc - Plan #65 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 7900 Ded/7900 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$334.00
$379.09
$426.85
$596.52
$906.46
$589.51
$634.60
$682.36
$852.03
$845.02
$890.11
$937.87
$1,107.54
$1,100.53
$1,145.62
$1,193.38
$1,363.05
$255.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$668.00
$758.18
$853.70
$1,193.04
$1,812.92
$923.51
$1,013.69
$1,109.21
$1,448.55
$1,179.02
$1,269.20
$1,364.72
$1,704.06
$1,434.53
$1,524.71
$1,620.23
$1,959.57
$255.51
Toc - Plan #66 Group Health Cooperative-SCW
Gold

(HMO) Gold 2500 Ded/6500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.51
$480.68
$541.24
$756.38
$1,149.39
$747.49
$804.66
$865.22
$1,080.36
$1,071.47
$1,128.64
$1,189.20
$1,404.34
$1,395.45
$1,452.62
$1,513.18
$1,728.32
$323.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$847.02
$961.36
$1,082.48
$1,512.76
$2,298.78
$1,171.00
$1,285.34
$1,406.46
$1,836.74
$1,494.98
$1,609.32
$1,730.44
$2,160.72
$1,818.96
$1,933.30
$2,054.42
$2,484.70
$323.98
Toc - Plan #67 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 7000 Ded/8500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.63
$403.64
$454.50
$635.16
$965.18
$627.69
$675.70
$726.56
$907.22
$899.75
$947.76
$998.62
$1,179.28
$1,171.81
$1,219.82
$1,270.68
$1,451.34
$272.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.26
$807.28
$909.00
$1,270.32
$1,930.36
$983.32
$1,079.34
$1,181.06
$1,542.38
$1,255.38
$1,351.40
$1,453.12
$1,814.44
$1,527.44
$1,623.46
$1,725.18
$2,086.50
$272.06
Toc - Plan #68 Group Health Cooperative-SCW
Silver

(HMO) Silver 4900 Ded/7900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,900 $9,800 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$493.15
$559.72
$630.24
$880.76
$1,338.40
$870.41
$936.98
$1,007.50
$1,258.02
$1,247.67
$1,314.24
$1,384.76
$1,635.28
$1,624.93
$1,691.50
$1,762.02
$2,012.54
$377.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$986.30
$1,119.44
$1,260.48
$1,761.52
$2,676.80
$1,363.56
$1,496.70
$1,637.74
$2,138.78
$1,740.82
$1,873.96
$2,015.00
$2,516.04
$2,118.08
$2,251.22
$2,392.26
$2,893.30
$377.26
Toc - Plan #69 Group Health Cooperative-SCW
Gold

(HMO) Gold 1000 Ded/6000 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$430.59
$488.72
$550.30
$769.04
$1,168.62
$760.00
$818.13
$879.71
$1,098.45
$1,089.41
$1,147.54
$1,209.12
$1,427.86
$1,418.82
$1,476.95
$1,538.53
$1,757.27
$329.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$861.18
$977.44
$1,100.60
$1,538.08
$2,337.24
$1,190.59
$1,306.85
$1,430.01
$1,867.49
$1,520.00
$1,636.26
$1,759.42
$2,196.90
$1,849.41
$1,965.67
$2,088.83
$2,526.31
$329.41
Toc - Plan #70 Group Health Cooperative-SCW
Catastrophic

(HMO) Catastrophic 9450 Ded/9450 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$274.13
$311.14
$350.34
$489.60
$743.99
$483.84
$520.85
$560.05
$699.31
$693.55
$730.56
$769.76
$909.02
$903.26
$940.27
$979.47
$1,118.73
$209.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$548.26
$622.28
$700.68
$979.20
$1,487.98
$757.97
$831.99
$910.39
$1,188.91
$967.68
$1,041.70
$1,120.10
$1,398.62
$1,177.39
$1,251.41
$1,329.81
$1,608.33
$209.71
Toc - Plan #71 Group Health Cooperative-SCW
Gold

(HMO) Gold 2500 Ded/5000 MOOP Primary Care Preferred with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$440.83
$500.34
$563.38
$787.32
$1,196.40
$778.07
$837.58
$900.62
$1,124.56
$1,115.31
$1,174.82
$1,237.86
$1,461.80
$1,452.55
$1,512.06
$1,575.10
$1,799.04
$337.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$881.66
$1,000.68
$1,126.76
$1,574.64
$2,392.80
$1,218.90
$1,337.92
$1,464.00
$1,911.88
$1,556.14
$1,675.16
$1,801.24
$2,249.12
$1,893.38
$2,012.40
$2,138.48
$2,586.36
$337.24
Toc - Plan #72 Group Health Cooperative-SCW
Silver

(HMO) Silver 9400 Ded/9400 MOOP Primary Care Preferred with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$9,400 $18,800 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$509.77
$578.59
$651.48
$910.44
$1,383.51
$899.74
$968.56
$1,041.45
$1,300.41
$1,289.71
$1,358.53
$1,431.42
$1,690.38
$1,679.68
$1,748.50
$1,821.39
$2,080.35
$389.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,019.54
$1,157.18
$1,302.96
$1,820.88
$2,767.02
$1,409.51
$1,547.15
$1,692.93
$2,210.85
$1,799.48
$1,937.12
$2,082.90
$2,600.82
$2,189.45
$2,327.09
$2,472.87
$2,990.79
$389.97
Toc - Plan #73 Group Health Cooperative-SCW
Gold

(HMO) Gold 1500 Ded/8700 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.93
$474.35
$534.12
$746.43
$1,134.26
$737.65
$794.07
$853.84
$1,066.15
$1,057.37
$1,113.79
$1,173.56
$1,385.87
$1,377.09
$1,433.51
$1,493.28
$1,705.59
$319.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.86
$948.70
$1,068.24
$1,492.86
$2,268.52
$1,155.58
$1,268.42
$1,387.96
$1,812.58
$1,475.30
$1,588.14
$1,707.68
$2,132.30
$1,795.02
$1,907.86
$2,027.40
$2,452.02
$319.72
Toc - Plan #74 Group Health Cooperative-SCW
Silver

(HMO) Silver 5900 Ded/9100 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$473.79
$537.75
$605.50
$846.18
$1,285.85
$836.24
$900.20
$967.95
$1,208.63
$1,198.69
$1,262.65
$1,330.40
$1,571.08
$1,561.14
$1,625.10
$1,692.85
$1,933.53
$362.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$947.58
$1,075.50
$1,211.00
$1,692.36
$2,571.70
$1,310.03
$1,437.95
$1,573.45
$2,054.81
$1,672.48
$1,800.40
$1,935.90
$2,417.26
$2,034.93
$2,162.85
$2,298.35
$2,779.71
$362.45
Toc - Plan #75 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 7500 Ded/9400 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351.90
$399.40
$449.72
$628.48
$955.04
$621.10
$668.60
$718.92
$897.68
$890.30
$937.80
$988.12
$1,166.88
$1,159.50
$1,207.00
$1,257.32
$1,436.08
$269.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$703.80
$798.80
$899.44
$1,256.96
$1,910.08
$973.00
$1,068.00
$1,168.64
$1,526.16
$1,242.20
$1,337.20
$1,437.84
$1,795.36
$1,511.40
$1,606.40
$1,707.04
$2,064.56
$269.20
Toc - Plan #76 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze No Medical Ded/9450 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.37
$433.99
$488.67
$682.91
$1,037.75
$674.89
$726.51
$781.19
$975.43
$967.41
$1,019.03
$1,073.71
$1,267.95
$1,259.93
$1,311.55
$1,366.23
$1,560.47
$292.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.74
$867.98
$977.34
$1,365.82
$2,075.50
$1,057.26
$1,160.50
$1,269.86
$1,658.34
$1,349.78
$1,453.02
$1,562.38
$1,950.86
$1,642.30
$1,745.54
$1,854.90
$2,243.38
$292.52

‡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 Green County here.

Green County is in “Rating Area 14” of Wisconsin.

Currently, there are 76 plans offered in Rating Area 14.

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2024 Obamacare Plans for Green County, WI

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