Wisconsin Obamacare

2017 Obamacare Rates for Iowa County

Wisconsin 2017 Obamacare Rates for Iowa County

 
Dodgeville, WI

Providers for Zip Code 53533

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Obamacare Providers, Plans and 2017 Rates for Iowa County

The health insurance rates listed below are for calendar year 2017.

2017 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

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

Currently, there are 71 plans offered in Iowa County.

Below, you’ll find a summary of plans and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options. For detailed information on available subsidies to make your coverage affordable, you must complete an application at HealthCare.gov or contact the provider directly.

 

The table below shows premiums for the following scenarios:

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

Each scenario is covered for age

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

 

Note: If you are over 65, you qualify for Medicare. Click here to see listings of 2017 Medicare Advantage plans for Iowa County

 

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

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

‡Source: HealthCare.gov has released sample rates for all counties in those states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Iowa County here.

Group Health Cooperative of South Central Wisconsin

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

TTY: 1-608-828-4815

Plan: (HMO) Platinum Zero Primary Care Visit Copay No Deductible w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Platinum 21
30
40
50
60		 $411.51
$467.06
$525.91
$734.95
$1116.83		 $823.02
$934.12
$1051.82
$1469.90
$2233.66		 $1084.33
$1195.43
$1313.13
$1731.21		 $1345.64
$1456.74
$1574.44
$1992.52		 $1606.95
$1718.05
$1835.75
$2253.83		 $672.82
$728.37
$787.22
$996.26		 $934.13
$989.68
$1048.53
$1257.57		 $1195.44
$1250.99
$1309.84
$1518.88		 $261.31

Unity Health Plans Insurance Corporation

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

TTY: 1-608-643-1421

Plan: (HMO) Prime Gold 30/60 with Dental

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

Deductible: Individual: $1,200 : Family: $2,400
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $364.03
$413.17
$465.23
$650.15
$987.97		 $728.06
$826.34
$930.46
$1300.30
$1975.94		 $959.22
$1057.50
$1161.62
$1531.46		 $1190.38
$1288.66
$1392.78
$1762.62		 $1421.54
$1519.82
$1623.94
$1993.78		 $595.19
$644.33
$696.39
$881.31		 $826.35
$875.49
$927.55
$1112.47		 $1057.51
$1106.65
$1158.71
$1343.63		 $231.16

Plan: (HMO) Prime Silver 30/60 with Dental

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

Deductible: Individual: $5,250 : Family: $10,500
Out of Pocket Maximum per year: Individual: $7,100 : Family: $14,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $306.55
$347.93
$391.77
$547.49
$831.97		 $613.10
$695.86
$783.54
$1094.98
$1663.94		 $807.76
$890.52
$978.20
$1289.64		 $1002.42
$1085.18
$1172.86
$1484.30		 $1197.08
$1279.84
$1367.52
$1678.96		 $501.21
$542.59
$586.43
$742.15		 $695.87
$737.25
$781.09
$936.81		 $890.53
$931.91
$975.75
$1131.47		 $194.66

Plan: (HMO) Prime Silver 25/50 Value with Dental

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

Deductible: Individual: $3,200 : Family: $6,400
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $309.32
$351.07
$395.30
$552.43
$839.47		 $618.64
$702.14
$790.60
$1104.86
$1678.94		 $815.05
$898.55
$987.01
$1301.27		 $1011.46
$1094.96
$1183.42
$1497.68		 $1207.87
$1291.37
$1379.83
$1694.09		 $505.73
$547.48
$591.71
$748.84		 $702.14
$743.89
$788.12
$945.25		 $898.55
$940.30
$984.53
$1141.66		 $196.41

Plan: (HMO) Prime Silver 40/90 Value with Dental

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

Deductible: Individual: $4,350 : Family: $8,700
Out of Pocket Maximum per year: Individual: $7,100 : Family: $14,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $297.06
$337.16
$379.64
$530.54
$806.21		 $594.12
$674.32
$759.28
$1061.08
$1612.42		 $782.75
$862.95
$947.91
$1249.71		 $971.38
$1051.58
$1136.54
$1438.34		 $1160.01
$1240.21
$1325.17
$1626.97		 $485.69
$525.79
$568.27
$719.17		 $674.32
$714.42
$756.90
$907.80		 $862.95
$903.05
$945.53
$1096.43		 $188.63

Plan: (HMO) Prime Silver Maintenance with Dental

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

Deductible: Individual: $1,750 : Family: $3,500
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $318.16
$361.10
$406.60
$568.22
$863.46		 $636.32
$722.20
$813.20
$1136.44
$1726.92		 $838.35
$924.23
$1015.23
$1338.47		 $1040.38
$1126.26
$1217.26
$1540.50		 $1242.41
$1328.29
$1419.29
$1742.53		 $520.19
$563.13
$608.63
$770.25		 $722.22
$765.16
$810.66
$972.28		 $924.25
$967.19
$1012.69
$1174.31		 $202.03

Plan: (HMO) Prime Bronze 55/125 with Dental

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

Deductible: Individual: $6,900 : Family: $13,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $263.77
$299.37
$337.09
$471.08
$715.85		 $527.54
$598.74
$674.18
$942.16
$1431.70		 $695.03
$766.23
$841.67
$1109.65		 $862.52
$933.72
$1009.16
$1277.14		 $1030.01
$1101.21
$1176.65
$1444.63		 $431.26
$466.86
$504.58
$638.57		 $598.75
$634.35
$672.07
$806.06		 $766.24
$801.84
$839.56
$973.55		 $167.49

Plan: (HMO) Prime Gold Wise Savings with Dental

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

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $369.08
$418.90
$471.67
$659.16
$1001.66		 $738.16
$837.80
$943.34
$1318.32
$2003.32		 $972.52
$1072.16
$1177.70
$1552.68		 $1206.88
$1306.52
$1412.06
$1787.04		 $1441.24
$1540.88
$1646.42
$2021.40		 $603.44
$653.26
$706.03
$893.52		 $837.80
$887.62
$940.39
$1127.88		 $1072.16
$1121.98
$1174.75
$1362.24		 $234.36

Plan: (HMO) Prime Gold 30/60

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

Deductible: Individual: $1,200 : Family: $2,400
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $343.53
$389.90
$439.03
$613.54
$932.33		 $687.06
$779.80
$878.06
$1227.08
$1864.66		 $905.20
$997.94
$1096.20
$1445.22		 $1123.34
$1216.08
$1314.34
$1663.36		 $1341.48
$1434.22
$1532.48
$1881.50		 $561.67
$608.04
$657.17
$831.68		 $779.81
$826.18
$875.31
$1049.82		 $997.95
$1044.32
$1093.45
$1267.96		 $218.14

Plan: (HMO) Prime Silver 30/60

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

Deductible: Individual: $5,250 : Family: $10,500
Out of Pocket Maximum per year: Individual: $7,100 : Family: $14,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $289.29
$328.34
$369.70
$516.66
$785.11		 $578.58
$656.68
$739.40
$1033.32
$1570.22		 $762.27
$840.37
$923.09
$1217.01		 $945.96
$1024.06
$1106.78
$1400.70		 $1129.65
$1207.75
$1290.47
$1584.39		 $472.98
$512.03
$553.39
$700.35		 $656.67
$695.72
$737.08
$884.04		 $840.36
$879.41
$920.77
$1067.73		 $183.69

Plan: (HMO) Prime Silver 25/50 Value

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

Deductible: Individual: $3,200 : Family: $6,400
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $291.90
$331.30
$373.04
$521.32
$792.19		 $583.80
$662.60
$746.08
$1042.64
$1584.38		 $769.15
$847.95
$931.43
$1227.99		 $954.50
$1033.30
$1116.78
$1413.34		 $1139.85
$1218.65
$1302.13
$1598.69		 $477.25
$516.65
$558.39
$706.67		 $662.60
$702.00
$743.74
$892.02		 $847.95
$887.35
$929.09
$1077.37		 $185.35

Plan: (HMO) Prime Silver 40/90 Value

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

Deductible: Individual: $4,350 : Family: $8,700
Out of Pocket Maximum per year: Individual: $7,100 : Family: $14,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $280.33
$318.17
$358.26
$500.66
$760.81		 $560.66
$636.34
$716.52
$1001.32
$1521.62		 $738.67
$814.35
$894.53
$1179.33		 $916.68
$992.36
$1072.54
$1357.34		 $1094.69
$1170.37
$1250.55
$1535.35		 $458.34
$496.18
$536.27
$678.67		 $636.35
$674.19
$714.28
$856.68		 $814.36
$852.20
$892.29
$1034.69		 $178.01

Plan: (HMO) Prime Silver Maintenance

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

Deductible: Individual: $1,750 : Family: $3,500
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $300.24
$340.76
$383.70
$536.22
$814.83		 $600.48
$681.52
$767.40
$1072.44
$1629.66		 $791.13
$872.17
$958.05
$1263.09		 $981.78
$1062.82
$1148.70
$1453.74		 $1172.43
$1253.47
$1339.35
$1644.39		 $490.89
$531.41
$574.35
$726.87		 $681.54
$722.06
$765.00
$917.52		 $872.19
$912.71
$955.65
$1108.17		 $190.65

Plan: (HMO) Prime Bronze 55/125

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

Deductible: Individual: $6,900 : Family: $13,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $248.91
$282.51
$318.10
$444.55
$675.53		 $497.82
$565.02
$636.20
$889.10
$1351.06		 $655.88
$723.08
$794.26
$1047.16		 $813.94
$881.14
$952.32
$1205.22		 $972.00
$1039.20
$1110.38
$1363.28		 $406.97
$440.57
$476.16
$602.61		 $565.03
$598.63
$634.22
$760.67		 $723.09
$756.69
$792.28
$918.73		 $158.06

Plan: (HMO) Prime Gold Wise Savings

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

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $348.29
$395.30
$445.11
$622.04
$945.25		 $696.58
$790.60
$890.22
$1244.08
$1890.50		 $917.74
$1011.76
$1111.38
$1465.24		 $1138.90
$1232.92
$1332.54
$1686.40		 $1360.06
$1454.08
$1553.70
$1907.56		 $569.45
$616.46
$666.27
$843.20		 $790.61
$837.62
$887.43
$1064.36		 $1011.77
$1058.78
$1108.59
$1285.52		 $221.16

Plan: (HMO) Prime Gold Standard

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

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $4,750 : Family: $9,500

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $356.63
$404.77
$455.77
$636.93
$967.88		 $713.26
$809.54
$911.54
$1273.86
$1935.76		 $939.72
$1036.00
$1138.00
$1500.32		 $1166.18
$1262.46
$1364.46
$1726.78		 $1392.64
$1488.92
$1590.92
$1953.24		 $583.09
$631.23
$682.23
$863.39		 $809.55
$857.69
$908.69
$1089.85		 $1036.01
$1084.15
$1135.15
$1316.31		 $226.46

Plan: (HMO) Prime Silver Standard

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $299.78
$340.24
$383.11
$535.39
$813.58		 $599.56
$680.48
$766.22
$1070.78
$1627.16		 $789.92
$870.84
$956.58
$1261.14		 $980.28
$1061.20
$1146.94
$1451.50		 $1170.64
$1251.56
$1337.30
$1641.86		 $490.14
$530.60
$573.47
$725.75		 $680.50
$720.96
$763.83
$916.11		 $870.86
$911.32
$954.19
$1106.47		 $190.36

Plan: (HMO) Prime Bronze Standard

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

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $248.45
$281.99
$317.51
$443.72
$674.28		 $496.90
$563.98
$635.02
$887.44
$1348.56		 $654.66
$721.74
$792.78
$1045.20		 $812.42
$879.50
$950.54
$1202.96		 $970.18
$1037.26
$1108.30
$1360.72		 $406.21
$439.75
$475.27
$601.48		 $563.97
$597.51
$633.03
$759.24		 $721.73
$755.27
$790.79
$917.00		 $157.76

Plan: (HMO) Prime Gold Deductible

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

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $5,450 : Family: $10,900

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $329.82
$374.34
$421.50
$589.04
$895.11		 $659.64
$748.68
$843.00
$1178.08
$1790.22		 $869.07
$958.11
$1052.43
$1387.51		 $1078.50
$1167.54
$1261.86
$1596.94		 $1287.93
$1376.97
$1471.29
$1806.37		 $539.25
$583.77
$630.93
$798.47		 $748.68
$793.20
$840.36
$1007.90		 $958.11
$1002.63
$1049.79
$1217.33		 $209.43

Plan: (HMO) Prime Silver Deductible

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

Deductible: Individual: $2,650 : Family: $5,300
Out of Pocket Maximum per year: Individual: $5,400 : Family: $10,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $286.57
$325.26
$366.24
$511.81
$777.75		 $573.14
$650.52
$732.48
$1023.62
$1555.50		 $755.11
$832.49
$914.45
$1205.59		 $937.08
$1014.46
$1096.42
$1387.56		 $1119.05
$1196.43
$1278.39
$1569.53		 $468.54
$507.23
$548.21
$693.78		 $650.51
$689.20
$730.18
$875.75		 $832.48
$871.17
$912.15
$1057.72		 $181.97

Plan: (HMO) Prime Bronze HSA

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $246.15
$279.37
$314.57
$439.61
$668.03		 $492.30
$558.74
$629.14
$879.22
$1336.06		 $648.60
$715.04
$785.44
$1035.52		 $804.90
$871.34
$941.74
$1191.82		 $961.20
$1027.64
$1098.04
$1348.12		 $402.45
$435.67
$470.87
$595.91		 $558.75
$591.97
$627.17
$752.21		 $715.05
$748.27
$783.47
$908.51		 $156.30

Plan: (HMO) Prime Catastrophic

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

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $181.16
$205.61
$231.51
$323.54
$491.65		 $362.32
$411.22
$463.02
$647.08
$983.30		 $477.35
$526.25
$578.05
$762.11		 $592.38
$641.28
$693.08
$877.14		 $707.41
$756.31
$808.11
$992.17		 $296.19
$320.64
$346.54
$438.57		 $411.22
$435.67
$461.57
$553.60		 $526.25
$550.70
$576.60
$668.63

Dean Health Plan

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

TTY: 1-608-827-4086

Plan: (HMO) Dean Catastrophic Safety Net

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

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $127.22
$144.40
$162.59
$227.22
$345.29		 $254.44
$288.80
$325.18
$454.44
$690.58		 $335.23
$369.59
$405.97
$535.23		 $416.02
$450.38
$486.76
$616.02		 $496.81
$531.17
$567.55
$696.81		 $208.01
$225.19
$243.38
$308.01		 $288.80
$305.98
$324.17
$388.80		 $369.59
$386.77
$404.96
$469.59		 $80.79

Plan: (HMO) Dean Silver Copay Plus 2750X

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

Deductible: Individual: $2,750 : Family: $5,500
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $245.15
$278.25
$313.30
$437.84
$665.34		 $490.30
$556.50
$626.60
$875.68
$1330.68		 $645.97
$712.17
$782.27
$1031.35		 $801.64
$867.84
$937.94
$1187.02		 $957.31
$1023.51
$1093.61
$1342.69		 $400.82
$433.92
$468.97
$593.51		 $556.49
$589.59
$624.64
$749.18		 $712.16
$745.26
$780.31
$904.85		 $155.67

Plan: (HMO) Dean Silver Classic 2500X

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

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $243.40
$276.26
$311.07
$434.72
$660.60		 $486.80
$552.52
$622.14
$869.44
$1321.20		 $641.36
$707.08
$776.70
$1024.00		 $795.92
$861.64
$931.26
$1178.56		 $950.48
$1016.20
$1085.82
$1333.12		 $397.96
$430.82
$465.63
$589.28		 $552.52
$585.38
$620.19
$743.84		 $707.08
$739.94
$774.75
$898.40		 $154.56

Group Health Cooperative of South Central Wisconsin

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

TTY: 1-608-828-4815

Plan: (HMO) Gold 1000 Deductible w/ Massage Therapy

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

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $367.62
$417.24
$469.81
$656.56
$997.70		 $735.24
$834.48
$939.62
$1313.12
$1995.40		 $968.68
$1067.92
$1173.06
$1546.56		 $1202.12
$1301.36
$1406.50
$1780.00		 $1435.56
$1534.80
$1639.94
$2013.44		 $601.06
$650.68
$703.25
$890.00		 $834.50
$884.12
$936.69
$1123.44		 $1067.94
$1117.56
$1170.13
$1356.88		 $233.44
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Dean Health Plan

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

TTY: 1-608-827-4086

Plan: (HMO) Dean Silver Classic 3750X

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

Deductible: Individual: $3,750 : Family: $7,500
Out of Pocket Maximum per year: Individual: $6,750 : Family: $13,500

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $233.18
$264.66
$298.00
$416.46
$632.84		 $466.36
$529.32
$596.00
$832.92
$1265.68		 $614.43
$677.39
$744.07
$980.99		 $762.50
$825.46
$892.14
$1129.06		 $910.57
$973.53
$1040.21
$1277.13		 $381.25
$412.73
$446.07
$564.53		 $529.32
$560.80
$594.14
$712.60		 $677.39
$708.87
$742.21
$860.67		 $148.07

Plan: (HMO) Dean Silver Value Copay 5000X

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

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $229.70
$260.71
$293.56
$410.25
$623.41		 $459.40
$521.42
$587.12
$820.50
$1246.82		 $605.26
$667.28
$732.98
$966.36		 $751.12
$813.14
$878.84
$1112.22		 $896.98
$959.00
$1024.70
$1258.08		 $375.56
$406.57
$439.42
$556.11		 $521.42
$552.43
$585.28
$701.97		 $667.28
$698.29
$731.14
$847.83		 $145.86

Plan: (HMO) Dean Gold Value Copay 2650X

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

Deductible: Individual: $2,650 : Family: $5,300
Out of Pocket Maximum per year: Individual: $2,650 : Family: $5,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $266.42
$302.39
$340.49
$475.83
$723.07		 $532.84
$604.78
$680.98
$951.66
$1446.14		 $702.02
$773.96
$850.16
$1120.84		 $871.20
$943.14
$1019.34
$1290.02		 $1040.38
$1112.32
$1188.52
$1459.20		 $435.60
$471.57
$509.67
$645.01		 $604.78
$640.75
$678.85
$814.19		 $773.96
$809.93
$848.03
$983.37		 $169.18

Plan: (HMO) Dean Bronze Value Copay 7150X

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

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $188.31
$213.74
$240.66
$336.33
$511.08		 $376.62
$427.48
$481.32
$672.66
$1022.16		 $496.20
$547.06
$600.90
$792.24		 $615.78
$666.64
$720.48
$911.82		 $735.36
$786.22
$840.06
$1031.40		 $307.89
$333.32
$360.24
$455.91		 $427.47
$452.90
$479.82
$575.49		 $547.05
$572.48
$599.40
$695.07		 $119.58
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Group Health Cooperative of South Central Wisconsin

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

TTY: 1-608-828-4815

Plan: (HMO) Gold 2000 Deductible HSA w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $355.10
$403.04
$453.82
$634.21
$963.74		 $710.20
$806.08
$907.64
$1268.42
$1927.48		 $935.69
$1031.57
$1133.13
$1493.91		 $1161.18
$1257.06
$1358.62
$1719.40		 $1386.67
$1482.55
$1584.11
$1944.89		 $580.59
$628.53
$679.31
$859.70		 $806.08
$854.02
$904.80
$1085.19		 $1031.57
$1079.51
$1130.29
$1310.68		 $225.49
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Dean Health Plan

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

TTY: 1-608-827-4086

Plan: (HMO) Dean Silver HSA-E 3000X

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

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $231.78
$263.07
$296.22
$413.97
$629.06		 $463.56
$526.14
$592.44
$827.94
$1258.12		 $610.74
$673.32
$739.62
$975.12		 $757.92
$820.50
$886.80
$1122.30		 $905.10
$967.68
$1033.98
$1269.48		 $378.96
$410.25
$443.40
$561.15		 $526.14
$557.43
$590.58
$708.33		 $673.32
$704.61
$737.76
$855.51		 $147.18

Plan: (HMO) Dean Gold Copay Plus 1500X

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $267.49
$303.60
$341.85
$477.73
$725.95		 $534.98
$607.20
$683.70
$955.46
$1451.90		 $704.83
$777.05
$853.55
$1125.31		 $874.68
$946.90
$1023.40
$1295.16		 $1044.53
$1116.75
$1193.25
$1465.01		 $437.34
$473.45
$511.70
$647.58		 $607.19
$643.30
$681.55
$817.43		 $777.04
$813.15
$851.40
$987.28		 $169.85

Plan: (HMO) Dean Silver Copay Plus 3500X

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $246.55
$279.83
$315.09
$440.33
$669.13		 $493.10
$559.66
$630.18
$880.66
$1338.26		 $649.66
$716.22
$786.74
$1037.22		 $806.22
$872.78
$943.30
$1193.78		 $962.78
$1029.34
$1099.86
$1350.34		 $403.11
$436.39
$471.65
$596.89		 $559.67
$592.95
$628.21
$753.45		 $716.23
$749.51
$784.77
$910.01		 $156.56

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

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $186.92
$212.15
$238.88
$333.84
$507.30		 $373.84
$424.30
$477.76
$667.68
$1014.60		 $492.53
$542.99
$596.45
$786.37		 $611.22
$661.68
$715.14
$905.06		 $729.91
$780.37
$833.83
$1023.75		 $305.61
$330.84
$357.57
$452.53		 $424.30
$449.53
$476.26
$571.22		 $542.99
$568.22
$594.95
$689.91		 $118.69
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Group Health Cooperative of South Central Wisconsin

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

TTY: 1-608-828-4815

Plan: (HMO) Platinum 500 Ded/1000 MOOP w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Platinum 21
30
40
50
60		 $423.55
$480.73
$541.30
$756.46
$1149.51		 $847.10
$961.46
$1082.60
$1512.92
$2299.02		 $1116.06
$1230.42
$1351.56
$1781.88		 $1385.02
$1499.38
$1620.52
$2050.84		 $1653.98
$1768.34
$1889.48
$2319.80		 $692.51
$749.69
$810.26
$1025.42		 $961.47
$1018.65
$1079.22
$1294.38		 $1230.43
$1287.61
$1348.18
$1563.34		 $268.96

Plan: (HMO) Silver 30 Copay w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $323.69
$367.38
$413.67
$578.10
$878.48		 $647.38
$734.76
$827.34
$1156.20
$1756.96		 $852.92
$940.30
$1032.88
$1361.74		 $1058.46
$1145.84
$1238.42
$1567.28		 $1264.00
$1351.38
$1443.96
$1772.82		 $529.23
$572.92
$619.21
$783.64		 $734.77
$778.46
$824.75
$989.18		 $940.31
$984.00
$1030.29
$1194.72		 $205.54

Plan: (HMO) Silver 2000 Deductible w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $310.70
$352.64
$397.07
$554.91
$843.23		 $621.40
$705.28
$794.14
$1109.82
$1686.46		 $818.70
$902.58
$991.44
$1307.12		 $1016.00
$1099.88
$1188.74
$1504.42		 $1213.30
$1297.18
$1386.04
$1701.72		 $508.00
$549.94
$594.37
$752.21		 $705.30
$747.24
$791.67
$949.51		 $902.60
$944.54
$988.97
$1146.81		 $197.30

Plan: (HMO) Silver 4000 Deductible HSA w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $293.00
$332.55
$374.45
$523.29
$795.19		 $586.00
$665.10
$748.90
$1046.58
$1590.38		 $772.06
$851.16
$934.96
$1232.64		 $958.12
$1037.22
$1121.02
$1418.70		 $1144.18
$1223.28
$1307.08
$1604.76		 $479.06
$518.61
$560.51
$709.35		 $665.12
$704.67
$746.57
$895.41		 $851.18
$890.73
$932.63
$1081.47		 $186.06

Plan: (HMO) Bronze 4000 Deductible w/ Massage Therapy

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

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $279.79
$317.57
$357.58
$499.71
$759.35		 $559.58
$635.14
$715.16
$999.42
$1518.70		 $737.25
$812.81
$892.83
$1177.09		 $914.92
$990.48
$1070.50
$1354.76		 $1092.59
$1168.15
$1248.17
$1532.43		 $457.46
$495.24
$535.25
$677.38		 $635.13
$672.91
$712.92
$855.05		 $812.80
$850.58
$890.59
$1032.72		 $177.67

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

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Platinum 21
30
40
50
60		 $385.06
$437.05
$492.11
$687.72
$1045.06		 $770.12
$874.10
$984.22
$1375.44
$2090.12		 $1014.64
$1118.62
$1228.74
$1619.96		 $1259.16
$1363.14
$1473.26
$1864.48		 $1503.68
$1607.66
$1717.78
$2109.00		 $629.58
$681.57
$736.63
$932.24		 $874.10
$926.09
$981.15
$1176.76		 $1118.62
$1170.61
$1225.67
$1421.28		 $244.52

Plan: (HMO) Select Gold 1000 Deductible w/ Massage Therapy

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

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $334.24
$379.37
$427.16
$596.95
$907.13		 $668.48
$758.74
$854.32
$1193.90
$1814.26		 $880.73
$970.99
$1066.57
$1406.15		 $1092.98
$1183.24
$1278.82
$1618.40		 $1305.23
$1395.49
$1491.07
$1830.65		 $546.49
$591.62
$639.41
$809.20		 $758.74
$803.87
$851.66
$1021.45		 $970.99
$1016.12
$1063.91
$1233.70		 $212.25

Plan: (HMO) Select Gold 2000 Deductible HSA w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $322.85
$366.44
$412.60
$576.61
$876.21		 $645.70
$732.88
$825.20
$1153.22
$1752.42		 $850.71
$937.89
$1030.21
$1358.23		 $1055.72
$1142.90
$1235.22
$1563.24		 $1260.73
$1347.91
$1440.23
$1768.25		 $527.86
$571.45
$617.61
$781.62		 $732.87
$776.46
$822.62
$986.63		 $937.88
$981.47
$1027.63
$1191.64		 $205.01

Plan: (HMO) Select Silver 30 Copay w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $294.30
$334.03
$376.12
$525.62
$798.73		 $588.60
$668.06
$752.24
$1051.24
$1597.46		 $775.49
$854.95
$939.13
$1238.13		 $962.38
$1041.84
$1126.02
$1425.02		 $1149.27
$1228.73
$1312.91
$1611.91		 $481.19
$520.92
$563.01
$712.51		 $668.08
$707.81
$749.90
$899.40		 $854.97
$894.70
$936.79
$1086.29		 $186.89

Plan: (HMO) Select Silver 2000 Deductible w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $281.86
$319.91
$360.22
$503.40
$764.97		 $563.72
$639.82
$720.44
$1006.80
$1529.94		 $742.70
$818.80
$899.42
$1185.78		 $921.68
$997.78
$1078.40
$1364.76		 $1100.66
$1176.76
$1257.38
$1543.74		 $460.84
$498.89
$539.20
$682.38		 $639.82
$677.87
$718.18
$861.36		 $818.80
$856.85
$897.16
$1040.34		 $178.98

Plan: (HMO) Select Bronze 6550 Deductible HSA w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $237.50
$269.56
$303.52
$424.17
$644.56		 $475.00
$539.12
$607.04
$848.34
$1289.12		 $625.81
$689.93
$757.85
$999.15		 $776.62
$840.74
$908.66
$1149.96		 $927.43
$991.55
$1059.47
$1300.77		 $388.31
$420.37
$454.33
$574.98		 $539.12
$571.18
$605.14
$725.79		 $689.93
$721.99
$755.95
$876.60		 $150.81

Plan: (HMO) Select Silver 4000 Deductible HSA w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $266.41
$302.37
$340.47
$475.80
$723.03		 $532.82
$604.74
$680.94
$951.60
$1446.06		 $701.99
$773.91
$850.11
$1120.77		 $871.16
$943.08
$1019.28
$1289.94		 $1040.33
$1112.25
$1188.45
$1459.11		 $435.58
$471.54
$509.64
$644.97		 $604.75
$640.71
$678.81
$814.14		 $773.92
$809.88
$847.98
$983.31		 $169.17

Plan: (HMO) Select Bronze 4000 Deductible w/ Massage Therapy

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

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $254.40
$288.75
$325.12
$454.36
$690.44		 $508.80
$577.50
$650.24
$908.72
$1380.88		 $670.35
$739.05
$811.79
$1070.27		 $831.90
$900.60
$973.34
$1231.82		 $993.45
$1062.15
$1134.89
$1393.37		 $415.95
$450.30
$486.67
$615.91		 $577.50
$611.85
$648.22
$777.46		 $739.05
$773.40
$809.77
$939.01		 $161.55

Plan: (HMO) Silver 3500 Deductible w/ Massage Therapy

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $316.43
$359.15
$404.40
$565.14
$858.79		 $632.86
$718.30
$808.80
$1130.28
$1717.58		 $833.80
$919.24
$1009.74
$1331.22		 $1034.74
$1120.18
$1210.68
$1532.16		 $1235.68
$1321.12
$1411.62
$1733.10		 $517.37
$560.09
$605.34
$766.08		 $718.31
$761.03
$806.28
$967.02		 $919.25
$961.97
$1007.22
$1167.96		 $200.94

Plan: (HMO) Select Silver 3500 Deductible w/ Massage Therapy

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $287.70
$326.54
$367.68
$513.83
$780.82		 $575.40
$653.08
$735.36
$1027.66
$1561.64		 $758.09
$835.77
$918.05
$1210.35		 $940.78
$1018.46
$1100.74
$1393.04		 $1123.47
$1201.15
$1283.43
$1575.73		 $470.39
$509.23
$550.37
$696.52		 $653.08
$691.92
$733.06
$879.21		 $835.77
$874.61
$915.75
$1061.90		 $182.69

Plan: (HMO) Bronze 6550 Deductible HSA w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $262.35
$297.76
$335.28
$468.55
$712.00		 $524.70
$595.52
$670.56
$937.10
$1424.00		 $691.29
$762.11
$837.15
$1103.69		 $857.88
$928.70
$1003.74
$1270.28		 $1024.47
$1095.29
$1170.33
$1436.87		 $428.94
$464.35
$501.87
$635.14		 $595.53
$630.94
$668.46
$801.73		 $762.12
$797.53
$835.05
$968.32		 $166.59

Plan: (HMO) Platinum Zero Primary Care Visit Copay 500 Ded/3000 MOOP w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Platinum 21
30
40
50
60		 $402.69
$457.06
$514.64
$719.21
$1092.90		 $805.38
$914.12
$1029.28
$1438.42
$2185.80		 $1061.09
$1169.83
$1284.99
$1694.13		 $1316.80
$1425.54
$1540.70
$1949.84		 $1572.51
$1681.25
$1796.41
$2205.55		 $658.40
$712.77
$770.35
$974.92		 $914.11
$968.48
$1026.06
$1230.63		 $1169.82
$1224.19
$1281.77
$1486.34		 $255.71

Plan: (HMO) Platinum Zero Primary Care Visit Copay 500 Ded/4500 MOOP w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Platinum 21
30
40
50
60		 $392.36
$445.32
$501.43
$700.74
$1064.85		 $784.72
$890.64
$1002.86
$1401.48
$2129.70		 $1033.87
$1139.79
$1252.01
$1650.63		 $1283.02
$1388.94
$1501.16
$1899.78		 $1532.17
$1638.09
$1750.31
$2148.93		 $641.51
$694.47
$750.58
$949.89		 $890.66
$943.62
$999.73
$1199.04		 $1139.81
$1192.77
$1248.88
$1448.19		 $249.15

Plan: (HMO) Gold Zero Primary Care Visit Copay 1500 Deductible w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $365.04
$414.32
$466.52
$651.96
$990.71		 $730.08
$828.64
$933.04
$1303.92
$1981.42		 $961.88
$1060.44
$1164.84
$1535.72		 $1193.68
$1292.24
$1396.64
$1767.52		 $1425.48
$1524.04
$1628.44
$1999.32		 $596.84
$646.12
$698.32
$883.76		 $828.64
$877.92
$930.12
$1115.56		 $1060.44
$1109.72
$1161.92
$1347.36		 $231.80

Plan: (HMO) Gold Zero Primary Care Visit Copay 2500 Deductible w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $349.66
$396.86
$446.86
$624.49
$948.97		 $699.32
$793.72
$893.72
$1248.98
$1897.94		 $921.36
$1015.76
$1115.76
$1471.02		 $1143.40
$1237.80
$1337.80
$1693.06		 $1365.44
$1459.84
$1559.84
$1915.10		 $571.70
$618.90
$668.90
$846.53		 $793.74
$840.94
$890.94
$1068.57		 $1015.78
$1062.98
$1112.98
$1290.61		 $222.04

Plan: (HMO) Silver Zero Primary Care Visit Copay 3500 Deductible w/ Massage Therapy

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $321.55
$364.96
$410.94
$574.28
$872.67		 $643.10
$729.92
$821.88
$1148.56
$1745.34		 $847.28
$934.10
$1026.06
$1352.74		 $1051.46
$1138.28
$1230.24
$1556.92		 $1255.64
$1342.46
$1434.42
$1761.10		 $525.73
$569.14
$615.12
$778.46		 $729.91
$773.32
$819.30
$982.64		 $934.09
$977.50
$1023.48
$1186.82		 $204.18

Plan: (HMO) Silver Zero Primary Care Visit Copay 4250 Deductible w/ Massage Therapy

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

Deductible: Individual: $4,250 : Family: $8,500
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $317.09
$359.89
$405.23
$566.31
$860.56		 $634.18
$719.78
$810.46
$1132.62
$1721.12		 $835.53
$921.13
$1011.81
$1333.97		 $1036.88
$1122.48
$1213.16
$1535.32		 $1238.23
$1323.83
$1414.51
$1736.67		 $518.44
$561.24
$606.58
$767.66		 $719.79
$762.59
$807.93
$969.01		 $921.14
$963.94
$1009.28
$1170.36		 $201.35

Plan: (HMO) Silver Zero Primary Care Visit Copay 5000 Deductible w/ Massage Therapy

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

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $313.71
$356.06
$400.92
$560.28
$851.40		 $627.42
$712.12
$801.84
$1120.56
$1702.80		 $826.63
$911.33
$1001.05
$1319.77		 $1025.84
$1110.54
$1200.26
$1518.98		 $1225.05
$1309.75
$1399.47
$1718.19		 $512.92
$555.27
$600.13
$759.49		 $712.13
$754.48
$799.34
$958.70		 $911.34
$953.69
$998.55
$1157.91		 $199.21

Plan: (HMO) Select Platinum Zero Primary Care Visit Copay No Deductible w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Platinum 21
30
40
50
60		 $374.15
$424.65
$478.16
$668.22
$1015.42		 $748.30
$849.30
$956.32
$1336.44
$2030.84		 $985.88
$1086.88
$1193.90
$1574.02		 $1223.46
$1324.46
$1431.48
$1811.60		 $1461.04
$1562.04
$1669.06
$2049.18		 $611.73
$662.23
$715.74
$905.80		 $849.31
$899.81
$953.32
$1143.38		 $1086.89
$1137.39
$1190.90
$1380.96		 $237.58

Plan: (HMO) Select Platinum Zero Primary Care Visit Copay 500 Ded/3000 MOOP w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Platinum 21
30
40
50
60		 $366.13
$415.56
$467.91
$653.90
$993.67		 $732.26
$831.12
$935.82
$1307.80
$1987.34		 $964.75
$1063.61
$1168.31
$1540.29		 $1197.24
$1296.10
$1400.80
$1772.78		 $1429.73
$1528.59
$1633.29
$2005.27		 $598.62
$648.05
$700.40
$886.39		 $831.11
$880.54
$932.89
$1118.88		 $1063.60
$1113.03
$1165.38
$1351.37		 $232.49

Plan: (HMO) Select Platinum Zero Primary Care Visit Copay 500 Ded/4500 MOOP w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Platinum 21
30
40
50
60		 $356.73
$404.89
$455.90
$637.12
$968.17		 $713.46
$809.78
$911.80
$1274.24
$1936.34		 $939.99
$1036.31
$1138.33
$1500.77		 $1166.52
$1262.84
$1364.86
$1727.30		 $1393.05
$1489.37
$1591.39
$1953.83		 $583.26
$631.42
$682.43
$863.65		 $809.79
$857.95
$908.96
$1090.18		 $1036.32
$1084.48
$1135.49
$1316.71		 $226.53

Plan: (HMO) Select Gold Zero Primary Care Visit Copay 1500 Deductible w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $331.89
$376.69
$424.15
$592.74
$900.73		 $663.78
$753.38
$848.30
$1185.48
$1801.46		 $874.53
$964.13
$1059.05
$1396.23		 $1085.28
$1174.88
$1269.80
$1606.98		 $1296.03
$1385.63
$1480.55
$1817.73		 $542.64
$587.44
$634.90
$803.49		 $753.39
$798.19
$845.65
$1014.24		 $964.14
$1008.94
$1056.40
$1224.99		 $210.75

Plan: (HMO) Select Gold Zero Primary Care Visit Copay 2500 Deductible w/ Massage Therapy

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

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $317.92
$360.84
$406.30
$567.80
$862.82		 $635.84
$721.68
$812.60
$1135.60
$1725.64		 $837.72
$923.56
$1014.48
$1337.48		 $1039.60
$1125.44
$1216.36
$1539.36		 $1241.48
$1327.32
$1418.24
$1741.24		 $519.80
$562.72
$608.18
$769.68		 $721.68
$764.60
$810.06
$971.56		 $923.56
$966.48
$1011.94
$1173.44		 $201.88

Plan: (HMO) Select Silver Zero Primary Care Visit Copay 3500 Deductible w/ Massage Therapy

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $292.35
$331.81
$373.62
$522.13
$793.42		 $584.70
$663.62
$747.24
$1044.26
$1586.84		 $770.34
$849.26
$932.88
$1229.90		 $955.98
$1034.90
$1118.52
$1415.54		 $1141.62
$1220.54
$1304.16
$1601.18		 $477.99
$517.45
$559.26
$707.77		 $663.63
$703.09
$744.90
$893.41		 $849.27
$888.73
$930.54
$1079.05		 $185.64

Plan: (HMO) Select Silver Zero Primary Care Visit Copay 4250 Deductible w/ Massage Therapy

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

Deductible: Individual: $4,250 : Family: $8,500
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $288.28
$327.20
$368.42
$514.87
$782.39		 $576.56
$654.40
$736.84
$1029.74
$1564.78		 $759.62
$837.46
$919.90
$1212.80		 $942.68
$1020.52
$1102.96
$1395.86		 $1125.74
$1203.58
$1286.02
$1578.92		 $471.34
$510.26
$551.48
$697.93		 $654.40
$693.32
$734.54
$880.99		 $837.46
$876.38
$917.60
$1064.05		 $183.06

Plan: (HMO) Select Silver Zero Primary Care Visit Copay 5000 Deductible w/ Massage Therapy

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

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $285.20
$323.70
$364.48
$509.36
$774.02		 $570.40
$647.40
$728.96
$1018.72
$1548.04		 $751.50
$828.50
$910.06
$1199.82		 $932.60
$1009.60
$1091.16
$1380.92		 $1113.70
$1190.70
$1272.26
$1562.02		 $466.30
$504.80
$545.58
$690.46		 $647.40
$685.90
$726.68
$871.56		 $828.50
$867.00
$907.78
$1052.66		 $181.10

Plan: (HMO) Select Gold Standardized Plan w/ Massage Therapy

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

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $4,750 : Family: $9,500

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $311.61
$353.67
$398.23
$556.53
$845.69		 $623.22
$707.34
$796.46
$1113.06
$1691.38		 $821.09
$905.21
$994.33
$1310.93		 $1018.96
$1103.08
$1192.20
$1508.80		 $1216.83
$1300.95
$1390.07
$1706.67		 $509.48
$551.54
$596.10
$754.40		 $707.35
$749.41
$793.97
$952.27		 $905.22
$947.28
$991.84
$1150.14		 $197.87

Plan: (HMO) Select Silver Standardized Plan w/ Massage Therapy

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $262.93
$298.42
$336.02
$469.58
$713.57		 $525.86
$596.84
$672.04
$939.16
$1427.14		 $692.82
$763.80
$839.00
$1106.12		 $859.78
$930.76
$1005.96
$1273.08		 $1026.74
$1097.72
$1172.92
$1440.04		 $429.89
$465.38
$502.98
$636.54		 $596.85
$632.34
$669.94
$803.50		 $763.81
$799.30
$836.90
$970.46		 $166.96

Plan: (HMO) Select Bronze Standardized Plan w/ Massage Therapy

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

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $242.36
$275.08
$309.73
$432.85
$657.75		 $484.72
$550.16
$619.46
$865.70
$1315.50		 $638.62
$704.06
$773.36
$1019.60		 $792.52
$857.96
$927.26
$1173.50		 $946.42
$1011.86
$1081.16
$1327.40		 $396.26
$428.98
$463.63
$586.75		 $550.16
$582.88
$617.53
$740.65		 $704.06
$736.78
$771.43
$894.55		 $153.90

Plan: (HMO) Catastrophic 7150 Deductible w/ Massage Therapy

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

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $202.06
$229.33
$258.23
$360.87
$548.37		 $404.12
$458.66
$516.46
$721.74
$1096.74		 $532.43
$586.97
$644.77
$850.05		 $660.74
$715.28
$773.08
$978.36		 $789.05
$843.59
$901.39
$1106.67		 $330.37
$357.64
$386.54
$489.18		 $458.68
$485.95
$514.85
$617.49		 $586.99
$614.26
$643.16
$745.80		 $128.31

Plan: (HMO) Select Catastrophic 7150 Deductible w/ Massage Therapy

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

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $183.74
$208.54
$234.82
$328.15
$498.66		 $367.48
$417.08
$469.64
$656.30
$997.32		 $484.16
$533.76
$586.32
$772.98		 $600.84
$650.44
$703.00
$889.66		 $717.52
$767.12
$819.68
$1006.34		 $300.42
$325.22
$351.50
$444.83		 $417.10
$441.90
$468.18
$561.51		 $533.78
$558.58
$584.86
$678.19		 $116.68