Kewaunee 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 Kewaunee 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, 114 Plans and 2024 Rates for Kewaunee County, Wisconsin

Below, you’ll find a summary of the 114 plans for Kewaunee 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

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Chorus Community Health Plans

Local: 1-844-201-4672 | Toll Free: 1-844-201-4672 | TTY: 1-844-531-4856

Toc - Plan #1 Chorus Community Health Plans
Silver

(EPO) Chorus Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.20
$462.16
$520.39
$727.24
$1,105.11
$718.70
$773.66
$831.89
$1,038.74
$1,030.20
$1,085.16
$1,143.39
$1,350.24
$1,341.70
$1,396.66
$1,454.89
$1,661.74
$311.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.40
$924.32
$1,040.78
$1,454.48
$2,210.22
$1,125.90
$1,235.82
$1,352.28
$1,765.98
$1,437.40
$1,547.32
$1,663.78
$2,077.48
$1,748.90
$1,858.82
$1,975.28
$2,388.98
$311.50
Toc - Plan #2 Chorus Community Health Plans
Silver

(EPO) Chorus Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$376.66
$427.50
$481.36
$672.70
$1,022.23
$664.80
$715.64
$769.50
$960.84
$952.94
$1,003.78
$1,057.64
$1,248.98
$1,241.08
$1,291.92
$1,345.78
$1,537.12
$288.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.32
$855.00
$962.72
$1,345.40
$2,044.46
$1,041.46
$1,143.14
$1,250.86
$1,633.54
$1,329.60
$1,431.28
$1,539.00
$1,921.68
$1,617.74
$1,719.42
$1,827.14
$2,209.82
$288.14
Toc - Plan #3 Chorus Community Health Plans
Gold

(EPO) Chorus Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.40
$500.98
$564.10
$788.33
$1,197.94
$779.07
$838.65
$901.77
$1,126.00
$1,116.74
$1,176.32
$1,239.44
$1,463.67
$1,454.41
$1,513.99
$1,577.11
$1,801.34
$337.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.80
$1,001.96
$1,128.20
$1,576.66
$2,395.88
$1,220.47
$1,339.63
$1,465.87
$1,914.33
$1,558.14
$1,677.30
$1,803.54
$2,252.00
$1,895.81
$2,014.97
$2,141.21
$2,589.67
$337.67
Toc - Plan #4 Chorus Community Health Plans
Expanded Bronze

(EPO) Chorus Bronze HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.83
$386.83
$435.57
$608.70
$924.98
$601.56
$647.56
$696.30
$869.43
$862.29
$908.29
$957.03
$1,130.16
$1,123.02
$1,169.02
$1,217.76
$1,390.89
$260.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$681.66
$773.66
$871.14
$1,217.40
$1,849.96
$942.39
$1,034.39
$1,131.87
$1,478.13
$1,203.12
$1,295.12
$1,392.60
$1,738.86
$1,463.85
$1,555.85
$1,653.33
$1,999.59
$260.73
Toc - Plan #5 Chorus Community Health Plans
Silver

(EPO) Chorus Silver Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393.76
$446.91
$503.22
$703.24
$1,068.64
$694.98
$748.13
$804.44
$1,004.46
$996.20
$1,049.35
$1,105.66
$1,305.68
$1,297.42
$1,350.57
$1,406.88
$1,606.90
$301.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.52
$893.82
$1,006.44
$1,406.48
$2,137.28
$1,088.74
$1,195.04
$1,307.66
$1,707.70
$1,389.96
$1,496.26
$1,608.88
$2,008.92
$1,691.18
$1,797.48
$1,910.10
$2,310.14
$301.22
Toc - Plan #6 Chorus Community Health Plans
Catastrophic

(EPO) Chorus Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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
$261.83
$297.17
$334.61
$467.62
$710.59
$462.12
$497.46
$534.90
$667.91
$662.41
$697.75
$735.19
$868.20
$862.70
$898.04
$935.48
$1,068.49
$200.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$523.66
$594.34
$669.22
$935.24
$1,421.18
$723.95
$794.63
$869.51
$1,135.53
$924.24
$994.92
$1,069.80
$1,335.82
$1,124.53
$1,195.21
$1,270.09
$1,536.11
$200.29
Toc - Plan #7 Chorus Community Health Plans
Expanded Bronze

(EPO) Chorus Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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
$353.45
$401.16
$451.70
$631.24
$959.24
$623.83
$671.54
$722.08
$901.62
$894.21
$941.92
$992.46
$1,172.00
$1,164.59
$1,212.30
$1,262.84
$1,442.38
$270.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.90
$802.32
$903.40
$1,262.48
$1,918.48
$977.28
$1,072.70
$1,173.78
$1,532.86
$1,247.66
$1,343.08
$1,444.16
$1,803.24
$1,518.04
$1,613.46
$1,714.54
$2,073.62
$270.38
Toc - Plan #8 Chorus Community Health Plans
Silver

(EPO) Chorus Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$443.03
$502.83
$566.18
$791.24
$1,202.36
$781.94
$841.74
$905.09
$1,130.15
$1,120.85
$1,180.65
$1,244.00
$1,469.06
$1,459.76
$1,519.56
$1,582.91
$1,807.97
$338.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.06
$1,005.66
$1,132.36
$1,582.48
$2,404.72
$1,224.97
$1,344.57
$1,471.27
$1,921.39
$1,563.88
$1,683.48
$1,810.18
$2,260.30
$1,902.79
$2,022.39
$2,149.09
$2,599.21
$338.91
Toc - Plan #9 Chorus Community Health Plans
Bronze

(EPO) Chorus Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$293.59
$333.22
$375.20
$524.34
$796.79
$518.18
$557.81
$599.79
$748.93
$742.77
$782.40
$824.38
$973.52
$967.36
$1,006.99
$1,048.97
$1,198.11
$224.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$587.18
$666.44
$750.40
$1,048.68
$1,593.58
$811.77
$891.03
$974.99
$1,273.27
$1,036.36
$1,115.62
$1,199.58
$1,497.86
$1,260.95
$1,340.21
$1,424.17
$1,722.45
$224.59
Toc - Plan #10 Chorus Community Health Plans
Silver

(EPO) Chorus Core Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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
$367.70
$417.33
$469.91
$656.70
$997.92
$648.98
$698.61
$751.19
$937.98
$930.26
$979.89
$1,032.47
$1,219.26
$1,211.54
$1,261.17
$1,313.75
$1,500.54
$281.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.40
$834.66
$939.82
$1,313.40
$1,995.84
$1,016.68
$1,115.94
$1,221.10
$1,594.68
$1,297.96
$1,397.22
$1,502.38
$1,875.96
$1,579.24
$1,678.50
$1,783.66
$2,157.24
$281.28
Toc - Plan #11 Chorus Community Health Plans
Gold

(EPO) Chorus Core Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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
$431.63
$489.89
$551.61
$770.88
$1,171.42
$761.82
$820.08
$881.80
$1,101.07
$1,092.01
$1,150.27
$1,211.99
$1,431.26
$1,422.20
$1,480.46
$1,542.18
$1,761.45
$330.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$863.26
$979.78
$1,103.22
$1,541.76
$2,342.84
$1,193.45
$1,309.97
$1,433.41
$1,871.95
$1,523.64
$1,640.16
$1,763.60
$2,202.14
$1,853.83
$1,970.35
$2,093.79
$2,532.33
$330.19
Toc - Plan #12 Chorus Community Health Plans
Expanded Bronze

(EPO) Chorus Core Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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
$305.40
$346.62
$390.29
$545.43
$828.83
$539.03
$580.25
$623.92
$779.06
$772.66
$813.88
$857.55
$1,012.69
$1,006.29
$1,047.51
$1,091.18
$1,246.32
$233.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610.80
$693.24
$780.58
$1,090.86
$1,657.66
$844.43
$926.87
$1,014.21
$1,324.49
$1,078.06
$1,160.50
$1,247.84
$1,558.12
$1,311.69
$1,394.13
$1,481.47
$1,791.75
$233.63

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HealthPartners

Local: 1-952-883-5900 | Toll Free: 1-855-813-3887 | TTY: 1-952-883-6060

Toc - Plan #13 HealthPartners
Gold

(PPO) Robin Oak $1,000 w/Copay P-S Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,000 $16,000 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
$497.10
$564.21
$635.29
$887.82
$1,349.13
$877.38
$944.49
$1,015.57
$1,268.10
$1,257.66
$1,324.77
$1,395.85
$1,648.38
$1,637.94
$1,705.05
$1,776.13
$2,028.66
$380.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$994.20
$1,128.42
$1,270.58
$1,775.64
$2,698.26
$1,374.48
$1,508.70
$1,650.86
$2,155.92
$1,754.76
$1,888.98
$2,031.14
$2,536.20
$2,135.04
$2,269.26
$2,411.42
$2,916.48
$380.28
Toc - Plan #14 HealthPartners
Gold

(PPO) Robin Oak $1,500 w/Copay P-S Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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
$480.50
$545.37
$614.08
$858.17
$1,304.08
$848.08
$912.95
$981.66
$1,225.75
$1,215.66
$1,280.53
$1,349.24
$1,593.33
$1,583.24
$1,648.11
$1,716.82
$1,960.91
$367.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$961.00
$1,090.74
$1,228.16
$1,716.34
$2,608.16
$1,328.58
$1,458.32
$1,595.74
$2,083.92
$1,696.16
$1,825.90
$1,963.32
$2,451.50
$2,063.74
$2,193.48
$2,330.90
$2,819.08
$367.58
Toc - Plan #15 HealthPartners
Silver

(PPO) Robin Select $3,600 Plus Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386.77
$438.98
$494.29
$690.77
$1,049.69
$682.65
$734.86
$790.17
$986.65
$978.53
$1,030.74
$1,086.05
$1,282.53
$1,274.41
$1,326.62
$1,381.93
$1,578.41
$295.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$773.54
$877.96
$988.58
$1,381.54
$2,099.38
$1,069.42
$1,173.84
$1,284.46
$1,677.42
$1,365.30
$1,469.72
$1,580.34
$1,973.30
$1,661.18
$1,765.60
$1,876.22
$2,269.18
$295.88
Toc - Plan #16 HealthPartners
Silver

(PPO) Robin Select $5,900 w/Copay P-S Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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
$386.40
$438.56
$493.82
$690.11
$1,048.69
$682.00
$734.16
$789.42
$985.71
$977.60
$1,029.76
$1,085.02
$1,281.31
$1,273.20
$1,325.36
$1,380.62
$1,576.91
$295.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$772.80
$877.12
$987.64
$1,380.22
$2,097.38
$1,068.40
$1,172.72
$1,283.24
$1,675.82
$1,364.00
$1,468.32
$1,578.84
$1,971.42
$1,659.60
$1,763.92
$1,874.44
$2,267.02
$295.60
Toc - Plan #17 HealthPartners
Expanded Bronze

(PPO) Robin Select $6,350 Plus Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 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
$297.55
$337.72
$380.27
$531.42
$807.55
$525.18
$565.35
$607.90
$759.05
$752.81
$792.98
$835.53
$986.68
$980.44
$1,020.61
$1,063.16
$1,214.31
$227.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.10
$675.44
$760.54
$1,062.84
$1,615.10
$822.73
$903.07
$988.17
$1,290.47
$1,050.36
$1,130.70
$1,215.80
$1,518.10
$1,277.99
$1,358.33
$1,443.43
$1,745.73
$227.63
Toc - Plan #18 HealthPartners
Expanded Bronze

(PPO) Robin Select $7,500 w/Copay P-S Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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
$300.05
$340.56
$383.46
$535.89
$814.34
$529.59
$570.10
$613.00
$765.43
$759.13
$799.64
$842.54
$994.97
$988.67
$1,029.18
$1,072.08
$1,224.51
$229.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$600.10
$681.12
$766.92
$1,071.78
$1,628.68
$829.64
$910.66
$996.46
$1,301.32
$1,059.18
$1,140.20
$1,226.00
$1,530.86
$1,288.72
$1,369.74
$1,455.54
$1,760.40
$229.54
Toc - Plan #19 HealthPartners
Silver

(PPO) Robin Select $3,800 HSA Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 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
$376.56
$427.40
$481.24
$672.54
$1,021.98
$664.63
$715.47
$769.31
$960.61
$952.70
$1,003.54
$1,057.38
$1,248.68
$1,240.77
$1,291.61
$1,345.45
$1,536.75
$288.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.12
$854.80
$962.48
$1,345.08
$2,043.96
$1,041.19
$1,142.87
$1,250.55
$1,633.15
$1,329.26
$1,430.94
$1,538.62
$1,921.22
$1,617.33
$1,719.01
$1,826.69
$2,209.29
$288.07
Toc - Plan #20 HealthPartners
Expanded Bronze

(PPO) Robin Select $8,000 HSA Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,000 $16,000 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
$284.47
$322.87
$363.55
$508.06
$772.05
$502.09
$540.49
$581.17
$725.68
$719.71
$758.11
$798.79
$943.30
$937.33
$975.73
$1,016.41
$1,160.92
$217.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$568.94
$645.74
$727.10
$1,016.12
$1,544.10
$786.56
$863.36
$944.72
$1,233.74
$1,004.18
$1,080.98
$1,162.34
$1,451.36
$1,221.80
$1,298.60
$1,379.96
$1,668.98
$217.62
Toc - Plan #21 HealthPartners
Catastrophic

(PPO) Robin Select $9,450 Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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
$225.34
$255.76
$287.98
$402.46
$611.57
$397.73
$428.15
$460.37
$574.85
$570.12
$600.54
$632.76
$747.24
$742.51
$772.93
$805.15
$919.63
$172.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$450.68
$511.52
$575.96
$804.92
$1,223.14
$623.07
$683.91
$748.35
$977.31
$795.46
$856.30
$920.74
$1,149.70
$967.85
$1,028.69
$1,093.13
$1,322.09
$172.39

ADVERTISEMENT

Quartz

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

Toc - Plan #22 Quartz
Gold

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$507.99
$576.56
$649.20
$907.26
$1,378.67
$896.60
$965.17
$1,037.81
$1,295.87
$1,285.21
$1,353.78
$1,426.42
$1,684.48
$1,673.82
$1,742.39
$1,815.03
$2,073.09
$388.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,015.98
$1,153.12
$1,298.40
$1,814.52
$2,757.34
$1,404.59
$1,541.73
$1,687.01
$2,203.13
$1,793.20
$1,930.34
$2,075.62
$2,591.74
$2,181.81
$2,318.95
$2,464.23
$2,980.35
$388.61
Toc - Plan #23 Quartz
Gold

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$511.95
$581.05
$654.26
$914.33
$1,389.41
$903.58
$972.68
$1,045.89
$1,305.96
$1,295.21
$1,364.31
$1,437.52
$1,697.59
$1,686.84
$1,755.94
$1,829.15
$2,089.22
$391.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,023.90
$1,162.10
$1,308.52
$1,828.66
$2,778.82
$1,415.53
$1,553.73
$1,700.15
$2,220.29
$1,807.16
$1,945.36
$2,091.78
$2,611.92
$2,198.79
$2,336.99
$2,483.41
$3,003.55
$391.63
Toc - Plan #24 Quartz
Silver

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$541.17
$614.22
$691.60
$966.51
$1,468.71
$955.16
$1,028.21
$1,105.59
$1,380.50
$1,369.15
$1,442.20
$1,519.58
$1,794.49
$1,783.14
$1,856.19
$1,933.57
$2,208.48
$413.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,082.34
$1,228.44
$1,383.20
$1,933.02
$2,937.42
$1,496.33
$1,642.43
$1,797.19
$2,347.01
$1,910.32
$2,056.42
$2,211.18
$2,761.00
$2,324.31
$2,470.41
$2,625.17
$3,174.99
$413.99
Toc - Plan #25 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$402.65
$457.00
$514.58
$719.12
$1,092.77
$710.67
$765.02
$822.60
$1,027.14
$1,018.69
$1,073.04
$1,130.62
$1,335.16
$1,326.71
$1,381.06
$1,438.64
$1,643.18
$308.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.30
$914.00
$1,029.16
$1,438.24
$2,185.54
$1,113.32
$1,222.02
$1,337.18
$1,746.26
$1,421.34
$1,530.04
$1,645.20
$2,054.28
$1,729.36
$1,838.06
$1,953.22
$2,362.30
$308.02
Toc - Plan #26 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$391.88
$444.78
$500.81
$699.89
$1,063.55
$691.66
$744.56
$800.59
$999.67
$991.44
$1,044.34
$1,100.37
$1,299.45
$1,291.22
$1,344.12
$1,400.15
$1,599.23
$299.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.76
$889.56
$1,001.62
$1,399.78
$2,127.10
$1,083.54
$1,189.34
$1,301.40
$1,699.56
$1,383.32
$1,489.12
$1,601.18
$1,999.34
$1,683.10
$1,788.90
$1,900.96
$2,299.12
$299.78
Toc - Plan #27 Quartz
Silver

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$554.04
$628.83
$708.06
$989.51
$1,503.65
$977.88
$1,052.67
$1,131.90
$1,413.35
$1,401.72
$1,476.51
$1,555.74
$1,837.19
$1,825.56
$1,900.35
$1,979.58
$2,261.03
$423.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,108.08
$1,257.66
$1,416.12
$1,979.02
$3,007.30
$1,531.92
$1,681.50
$1,839.96
$2,402.86
$1,955.76
$2,105.34
$2,263.80
$2,826.70
$2,379.60
$2,529.18
$2,687.64
$3,250.54
$423.84
Toc - Plan #28 Quartz
Gold

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$465.47
$528.30
$594.86
$831.31
$1,263.26
$821.55
$884.38
$950.94
$1,187.39
$1,177.63
$1,240.46
$1,307.02
$1,543.47
$1,533.71
$1,596.54
$1,663.10
$1,899.55
$356.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$930.94
$1,056.60
$1,189.72
$1,662.62
$2,526.52
$1,287.02
$1,412.68
$1,545.80
$2,018.70
$1,643.10
$1,768.76
$1,901.88
$2,374.78
$1,999.18
$2,124.84
$2,257.96
$2,730.86
$356.08
Toc - Plan #29 Quartz
Gold

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$483.78
$549.08
$618.26
$864.01
$1,312.95
$853.86
$919.16
$988.34
$1,234.09
$1,223.94
$1,289.24
$1,358.42
$1,604.17
$1,594.02
$1,659.32
$1,728.50
$1,974.25
$370.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$967.56
$1,098.16
$1,236.52
$1,728.02
$2,625.90
$1,337.64
$1,468.24
$1,606.60
$2,098.10
$1,707.72
$1,838.32
$1,976.68
$2,468.18
$2,077.80
$2,208.40
$2,346.76
$2,838.26
$370.08
Toc - Plan #30 Quartz
Gold

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$487.54
$553.36
$623.07
$870.74
$1,323.18
$860.51
$926.33
$996.04
$1,243.71
$1,233.48
$1,299.30
$1,369.01
$1,616.68
$1,606.45
$1,672.27
$1,741.98
$1,989.65
$372.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$975.08
$1,106.72
$1,246.14
$1,741.48
$2,646.36
$1,348.05
$1,479.69
$1,619.11
$2,114.45
$1,721.02
$1,852.66
$1,992.08
$2,487.42
$2,093.99
$2,225.63
$2,365.05
$2,860.39
$372.97
Toc - Plan #31 Quartz
Silver

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$515.37
$584.94
$658.64
$920.44
$1,398.70
$909.62
$979.19
$1,052.89
$1,314.69
$1,303.87
$1,373.44
$1,447.14
$1,708.94
$1,698.12
$1,767.69
$1,841.39
$2,103.19
$394.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,030.74
$1,169.88
$1,317.28
$1,840.88
$2,797.40
$1,424.99
$1,564.13
$1,711.53
$2,235.13
$1,819.24
$1,958.38
$2,105.78
$2,629.38
$2,213.49
$2,352.63
$2,500.03
$3,023.63
$394.25
Toc - Plan #32 Quartz
Silver

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$501.62
$569.34
$641.07
$895.89
$1,361.39
$885.36
$953.08
$1,024.81
$1,279.63
$1,269.10
$1,336.82
$1,408.55
$1,663.37
$1,652.84
$1,720.56
$1,792.29
$2,047.11
$383.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,003.24
$1,138.68
$1,282.14
$1,791.78
$2,722.78
$1,386.98
$1,522.42
$1,665.88
$2,175.52
$1,770.72
$1,906.16
$2,049.62
$2,559.26
$2,154.46
$2,289.90
$2,433.36
$2,943.00
$383.74
Toc - Plan #33 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$383.45
$435.22
$490.05
$684.84
$1,040.68
$676.79
$728.56
$783.39
$978.18
$970.13
$1,021.90
$1,076.73
$1,271.52
$1,263.47
$1,315.24
$1,370.07
$1,564.86
$293.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.90
$870.44
$980.10
$1,369.68
$2,081.36
$1,060.24
$1,163.78
$1,273.44
$1,663.02
$1,353.58
$1,457.12
$1,566.78
$1,956.36
$1,646.92
$1,750.46
$1,860.12
$2,249.70
$293.34
Toc - Plan #34 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$373.20
$423.58
$476.94
$666.52
$1,012.85
$658.69
$709.07
$762.43
$952.01
$944.18
$994.56
$1,047.92
$1,237.50
$1,229.67
$1,280.05
$1,333.41
$1,522.99
$285.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.40
$847.16
$953.88
$1,333.04
$2,025.70
$1,031.89
$1,132.65
$1,239.37
$1,618.53
$1,317.38
$1,418.14
$1,524.86
$1,904.02
$1,602.87
$1,703.63
$1,810.35
$2,189.51
$285.49
Toc - Plan #35 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$356.18
$404.26
$455.20
$636.14
$966.67
$628.66
$676.74
$727.68
$908.62
$901.14
$949.22
$1,000.16
$1,181.10
$1,173.62
$1,221.70
$1,272.64
$1,453.58
$272.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.36
$808.52
$910.40
$1,272.28
$1,933.34
$984.84
$1,081.00
$1,182.88
$1,544.76
$1,257.32
$1,353.48
$1,455.36
$1,817.24
$1,529.80
$1,625.96
$1,727.84
$2,089.72
$272.48
Toc - Plan #36 Quartz
Silver

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$527.63
$598.86
$674.31
$942.34
$1,431.98
$931.26
$1,002.49
$1,077.94
$1,345.97
$1,334.89
$1,406.12
$1,481.57
$1,749.60
$1,738.52
$1,809.75
$1,885.20
$2,153.23
$403.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,055.26
$1,197.72
$1,348.62
$1,884.68
$2,863.96
$1,458.89
$1,601.35
$1,752.25
$2,288.31
$1,862.52
$2,004.98
$2,155.88
$2,691.94
$2,266.15
$2,408.61
$2,559.51
$3,095.57
$403.63
Toc - Plan #37 Quartz
Gold

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$458.42
$520.31
$585.86
$818.74
$1,244.15
$809.11
$871.00
$936.55
$1,169.43
$1,159.80
$1,221.69
$1,287.24
$1,520.12
$1,510.49
$1,572.38
$1,637.93
$1,870.81
$350.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$916.84
$1,040.62
$1,171.72
$1,637.48
$2,488.30
$1,267.53
$1,391.31
$1,522.41
$1,988.17
$1,618.22
$1,742.00
$1,873.10
$2,338.86
$1,968.91
$2,092.69
$2,223.79
$2,689.55
$350.69
Toc - Plan #38 Quartz
Silver

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$490.28
$556.47
$626.58
$875.64
$1,330.62
$865.34
$931.53
$1,001.64
$1,250.70
$1,240.40
$1,306.59
$1,376.70
$1,625.76
$1,615.46
$1,681.65
$1,751.76
$2,000.82
$375.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$980.56
$1,112.94
$1,253.16
$1,751.28
$2,661.24
$1,355.62
$1,488.00
$1,628.22
$2,126.34
$1,730.68
$1,863.06
$2,003.28
$2,501.40
$2,105.74
$2,238.12
$2,378.34
$2,876.46
$375.06
Toc - Plan #39 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$335.64
$380.95
$428.94
$599.44
$910.91
$592.40
$637.71
$685.70
$856.20
$849.16
$894.47
$942.46
$1,112.96
$1,105.92
$1,151.23
$1,199.22
$1,369.72
$256.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$671.28
$761.90
$857.88
$1,198.88
$1,821.82
$928.04
$1,018.66
$1,114.64
$1,455.64
$1,184.80
$1,275.42
$1,371.40
$1,712.40
$1,441.56
$1,532.18
$1,628.16
$1,969.16
$256.76
Toc - Plan #40 Quartz
Gold

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$477.07
$541.47
$609.69
$852.04
$1,294.76
$842.02
$906.42
$974.64
$1,216.99
$1,206.97
$1,271.37
$1,339.59
$1,581.94
$1,571.92
$1,636.32
$1,704.54
$1,946.89
$364.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$954.14
$1,082.94
$1,219.38
$1,704.08
$2,589.52
$1,319.09
$1,447.89
$1,584.33
$2,069.03
$1,684.04
$1,812.84
$1,949.28
$2,433.98
$2,048.99
$2,177.79
$2,314.23
$2,798.93
$364.95
Toc - Plan #41 Quartz
Silver

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$520.00
$590.19
$664.55
$928.71
$1,411.27
$917.80
$987.99
$1,062.35
$1,326.51
$1,315.60
$1,385.79
$1,460.15
$1,724.31
$1,713.40
$1,783.59
$1,857.95
$2,122.11
$397.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,040.00
$1,180.38
$1,329.10
$1,857.42
$2,822.54
$1,437.80
$1,578.18
$1,726.90
$2,255.22
$1,835.60
$1,975.98
$2,124.70
$2,653.02
$2,233.40
$2,373.78
$2,522.50
$3,050.82
$397.80
Toc - Plan #42 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$364.80
$414.04
$466.20
$651.52
$990.04
$643.87
$693.11
$745.27
$930.59
$922.94
$972.18
$1,024.34
$1,209.66
$1,202.01
$1,251.25
$1,303.41
$1,488.73
$279.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.60
$828.08
$932.40
$1,303.04
$1,980.08
$1,008.67
$1,107.15
$1,211.47
$1,582.11
$1,287.74
$1,386.22
$1,490.54
$1,861.18
$1,566.81
$1,665.29
$1,769.61
$2,140.25
$279.07
Toc - Plan #43 Quartz
Catastrophic

(HMO) QUARTZ ONE WITH ADVOCATE HEALTH CARE 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
$264.86
$300.61
$338.48
$473.03
$718.82
$467.47
$503.22
$541.09
$675.64
$670.08
$705.83
$743.70
$878.25
$872.69
$908.44
$946.31
$1,080.86
$202.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$529.72
$601.22
$676.96
$946.06
$1,437.64
$732.33
$803.83
$879.57
$1,148.67
$934.94
$1,006.44
$1,082.18
$1,351.28
$1,137.55
$1,209.05
$1,284.79
$1,553.89
$202.61

ADVERTISEMENT

Dean Health Plan

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

Toc - Plan #44 Dean Health Plan
Gold

(HMO) Prevea360 Gold Copay Plus 1500X (Free Virtual Care)

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
$499.14
$566.53
$637.91
$891.47
$1,354.68
$880.99
$948.38
$1,019.76
$1,273.32
$1,262.84
$1,330.23
$1,401.61
$1,655.17
$1,644.69
$1,712.08
$1,783.46
$2,037.02
$381.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$998.28
$1,133.06
$1,275.82
$1,782.94
$2,709.36
$1,380.13
$1,514.91
$1,657.67
$2,164.79
$1,761.98
$1,896.76
$2,039.52
$2,546.64
$2,143.83
$2,278.61
$2,421.37
$2,928.49
$381.85
Toc - Plan #45 Dean Health Plan
Silver

(HMO) Prevea360 Silver Copay Plus 4800X (Free Virtual Care)

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
$471.96
$535.67
$603.16
$842.91
$1,280.89
$833.01
$896.72
$964.21
$1,203.96
$1,194.06
$1,257.77
$1,325.26
$1,565.01
$1,555.11
$1,618.82
$1,686.31
$1,926.06
$361.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$943.92
$1,071.34
$1,206.32
$1,685.82
$2,561.78
$1,304.97
$1,432.39
$1,567.37
$2,046.87
$1,666.02
$1,793.44
$1,928.42
$2,407.92
$2,027.07
$2,154.49
$2,289.47
$2,768.97
$361.05
Toc - Plan #46 Dean Health Plan
Expanded Bronze

(HMO) Prevea360 Bronze Copay Plus 9400X (Free Virtual Care)

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
$312.69
$354.90
$399.61
$558.46
$848.63
$551.89
$594.10
$638.81
$797.66
$791.09
$833.30
$878.01
$1,036.86
$1,030.29
$1,072.50
$1,117.21
$1,276.06
$239.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625.38
$709.80
$799.22
$1,116.92
$1,697.26
$864.58
$949.00
$1,038.42
$1,356.12
$1,103.78
$1,188.20
$1,277.62
$1,595.32
$1,342.98
$1,427.40
$1,516.82
$1,834.52
$239.20
Toc - Plan #47 Dean Health Plan
Silver

(HMO) Prevea360 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
$473.44
$537.36
$605.06
$845.57
$1,284.92
$835.62
$899.54
$967.24
$1,207.75
$1,197.80
$1,261.72
$1,329.42
$1,569.93
$1,559.98
$1,623.90
$1,691.60
$1,932.11
$362.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$946.88
$1,074.72
$1,210.12
$1,691.14
$2,569.84
$1,309.06
$1,436.90
$1,572.30
$2,053.32
$1,671.24
$1,799.08
$1,934.48
$2,415.50
$2,033.42
$2,161.26
$2,296.66
$2,777.68
$362.18
Toc - Plan #48 Dean Health Plan
Expanded Bronze

(HMO) Prevea360 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
$329.53
$374.01
$421.14
$588.54
$894.34
$581.62
$626.10
$673.23
$840.63
$833.71
$878.19
$925.32
$1,092.72
$1,085.80
$1,130.28
$1,177.41
$1,344.81
$252.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$659.06
$748.02
$842.28
$1,177.08
$1,788.68
$911.15
$1,000.11
$1,094.37
$1,429.17
$1,163.24
$1,252.20
$1,346.46
$1,681.26
$1,415.33
$1,504.29
$1,598.55
$1,933.35
$252.09
Toc - Plan #49 Dean Health Plan
Catastrophic

(HMO) Prevea360 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
$226.02
$256.53
$288.85
$403.66
$613.41
$398.92
$429.43
$461.75
$576.56
$571.82
$602.33
$634.65
$749.46
$744.72
$775.23
$807.55
$922.36
$172.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$452.04
$513.06
$577.70
$807.32
$1,226.82
$624.94
$685.96
$750.60
$980.22
$797.84
$858.86
$923.50
$1,153.12
$970.74
$1,031.76
$1,096.40
$1,326.02
$172.90
Toc - Plan #50 Dean Health Plan
Gold

(HMO) Prevea360 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
$445.41
$505.54
$569.23
$795.50
$1,208.84
$786.15
$846.28
$909.97
$1,136.24
$1,126.89
$1,187.02
$1,250.71
$1,476.98
$1,467.63
$1,527.76
$1,591.45
$1,817.72
$340.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$890.82
$1,011.08
$1,138.46
$1,591.00
$2,417.68
$1,231.56
$1,351.82
$1,479.20
$1,931.74
$1,572.30
$1,692.56
$1,819.94
$2,272.48
$1,913.04
$2,033.30
$2,160.68
$2,613.22
$340.74
Toc - Plan #51 Dean Health Plan
Expanded Bronze

(HMO) Prevea360 Bronze Copay PCP 8000X (Free Virtual Care)

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
$306.15
$347.48
$391.26
$546.78
$830.89
$540.35
$581.68
$625.46
$780.98
$774.55
$815.88
$859.66
$1,015.18
$1,008.75
$1,050.08
$1,093.86
$1,249.38
$234.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.30
$694.96
$782.52
$1,093.56
$1,661.78
$846.50
$929.16
$1,016.72
$1,327.76
$1,080.70
$1,163.36
$1,250.92
$1,561.96
$1,314.90
$1,397.56
$1,485.12
$1,796.16
$234.20
Toc - Plan #52 Dean Health Plan
Silver

(HMO) Prevea360 Silver Copay PCP 4500X (Free Virtual Care)

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
$448.19
$508.70
$572.79
$800.47
$1,216.39
$791.06
$851.57
$915.66
$1,143.34
$1,133.93
$1,194.44
$1,258.53
$1,486.21
$1,476.80
$1,537.31
$1,601.40
$1,829.08
$342.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.38
$1,017.40
$1,145.58
$1,600.94
$2,432.78
$1,239.25
$1,360.27
$1,488.45
$1,943.81
$1,582.12
$1,703.14
$1,831.32
$2,286.68
$1,924.99
$2,046.01
$2,174.19
$2,629.55
$342.87
Toc - Plan #53 Dean Health Plan
Gold

(HMO) Prevea360 Gold Copay PCP 3000X (Free Virtual Care)

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
$450.12
$510.88
$575.25
$803.91
$1,221.62
$794.46
$855.22
$919.59
$1,148.25
$1,138.80
$1,199.56
$1,263.93
$1,492.59
$1,483.14
$1,543.90
$1,608.27
$1,836.93
$344.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$900.24
$1,021.76
$1,150.50
$1,607.82
$2,443.24
$1,244.58
$1,366.10
$1,494.84
$1,952.16
$1,588.92
$1,710.44
$1,839.18
$2,296.50
$1,933.26
$2,054.78
$2,183.52
$2,640.84
$344.34
Toc - Plan #54 Dean Health Plan
Gold

(HMO) Prevea360 Gold Standard 1500X (Free Virtual Care)

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
$463.04
$525.55
$591.77
$826.99
$1,256.70
$817.27
$879.78
$946.00
$1,181.22
$1,171.50
$1,234.01
$1,300.23
$1,535.45
$1,525.73
$1,588.24
$1,654.46
$1,889.68
$354.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$926.08
$1,051.10
$1,183.54
$1,653.98
$2,513.40
$1,280.31
$1,405.33
$1,537.77
$2,008.21
$1,634.54
$1,759.56
$1,892.00
$2,362.44
$1,988.77
$2,113.79
$2,246.23
$2,716.67
$354.23
Toc - Plan #55 Dean Health Plan
Silver

(HMO) Prevea360 Silver Standard 5900X (Free Virtual Care)

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
$451.90
$512.91
$577.53
$807.10
$1,226.47
$797.61
$858.62
$923.24
$1,152.81
$1,143.32
$1,204.33
$1,268.95
$1,498.52
$1,489.03
$1,550.04
$1,614.66
$1,844.23
$345.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$903.80
$1,025.82
$1,155.06
$1,614.20
$2,452.94
$1,249.51
$1,371.53
$1,500.77
$1,959.91
$1,595.22
$1,717.24
$1,846.48
$2,305.62
$1,940.93
$2,062.95
$2,192.19
$2,651.33
$345.71
Toc - Plan #56 Dean Health Plan
Expanded Bronze

(HMO) Prevea360 Bronze Standard 7500X (Free Virtual Care)

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
$317.24
$360.07
$405.44
$566.60
$861.00
$559.93
$602.76
$648.13
$809.29
$802.62
$845.45
$890.82
$1,051.98
$1,045.31
$1,088.14
$1,133.51
$1,294.67
$242.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.48
$720.14
$810.88
$1,133.20
$1,722.00
$877.17
$962.83
$1,053.57
$1,375.89
$1,119.86
$1,205.52
$1,296.26
$1,618.58
$1,362.55
$1,448.21
$1,538.95
$1,861.27
$242.69
Toc - Plan #57 Dean Health Plan
Bronze

(HMO) Prevea360 Bronze Standard 9100X (Free Virtual Care)

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
$281.50
$319.50
$359.75
$502.75
$763.98
$496.84
$534.84
$575.09
$718.09
$712.18
$750.18
$790.43
$933.43
$927.52
$965.52
$1,005.77
$1,148.77
$215.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$563.00
$639.00
$719.50
$1,005.50
$1,527.96
$778.34
$854.34
$934.84
$1,220.84
$993.68
$1,069.68
$1,150.18
$1,436.18
$1,209.02
$1,285.02
$1,365.52
$1,651.52
$215.34

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #58 Molina Healthcare
Gold

(HMO) Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 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
$453.15
$514.32
$579.12
$809.32
$1,229.85
$799.81
$860.98
$925.78
$1,155.98
$1,146.47
$1,207.64
$1,272.44
$1,502.64
$1,493.13
$1,554.30
$1,619.10
$1,849.30
$346.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$906.30
$1,028.64
$1,158.24
$1,618.64
$2,459.70
$1,252.96
$1,375.30
$1,504.90
$1,965.30
$1,599.62
$1,721.96
$1,851.56
$2,311.96
$1,946.28
$2,068.62
$2,198.22
$2,658.62
$346.66
Toc - Plan #59 Molina Healthcare
Silver

(HMO) Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 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
$384.72
$436.66
$491.67
$687.11
$1,044.13
$679.03
$730.97
$785.98
$981.42
$973.34
$1,025.28
$1,080.29
$1,275.73
$1,267.65
$1,319.59
$1,374.60
$1,570.04
$294.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$769.44
$873.32
$983.34
$1,374.22
$2,088.26
$1,063.75
$1,167.63
$1,277.65
$1,668.53
$1,358.06
$1,461.94
$1,571.96
$1,962.84
$1,652.37
$1,756.25
$1,866.27
$2,257.15
$294.31
Toc - Plan #60 Molina Healthcare
Gold

(HMO) Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

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
$467.76
$530.90
$597.79
$835.41
$1,269.49
$825.59
$888.73
$955.62
$1,193.24
$1,183.42
$1,246.56
$1,313.45
$1,551.07
$1,541.25
$1,604.39
$1,671.28
$1,908.90
$357.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$935.52
$1,061.80
$1,195.58
$1,670.82
$2,538.98
$1,293.35
$1,419.63
$1,553.41
$2,028.65
$1,651.18
$1,777.46
$1,911.24
$2,386.48
$2,009.01
$2,135.29
$2,269.07
$2,744.31
$357.83
Toc - Plan #61 Molina Healthcare
Silver

(HMO) Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

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
$375.68
$426.39
$480.11
$670.96
$1,019.59
$663.07
$713.78
$767.50
$958.35
$950.46
$1,001.17
$1,054.89
$1,245.74
$1,237.85
$1,288.56
$1,342.28
$1,533.13
$287.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$751.36
$852.78
$960.22
$1,341.92
$2,039.18
$1,038.75
$1,140.17
$1,247.61
$1,629.31
$1,326.14
$1,427.56
$1,535.00
$1,916.70
$1,613.53
$1,714.95
$1,822.39
$2,204.09
$287.39
Toc - Plan #62 Molina Healthcare
Silver

(HMO) Silver 12 with First 4 Primary Care Visits Free

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$378.76
$429.89
$484.05
$676.46
$1,027.95
$668.51
$719.64
$773.80
$966.21
$958.26
$1,009.39
$1,063.55
$1,255.96
$1,248.01
$1,299.14
$1,353.30
$1,545.71
$289.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.52
$859.78
$968.10
$1,352.92
$2,055.90
$1,047.27
$1,149.53
$1,257.85
$1,642.67
$1,337.02
$1,439.28
$1,547.60
$1,932.42
$1,626.77
$1,729.03
$1,837.35
$2,222.17
$289.75
Toc - Plan #63 Molina Healthcare
Gold

(HMO) Gold 1 with Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 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
$455.74
$517.27
$582.44
$813.96
$1,236.89
$804.38
$865.91
$931.08
$1,162.60
$1,153.02
$1,214.55
$1,279.72
$1,511.24
$1,501.66
$1,563.19
$1,628.36
$1,859.88
$348.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$911.48
$1,034.54
$1,164.88
$1,627.92
$2,473.78
$1,260.12
$1,383.18
$1,513.52
$1,976.56
$1,608.76
$1,731.82
$1,862.16
$2,325.20
$1,957.40
$2,080.46
$2,210.80
$2,673.84
$348.64
Toc - Plan #64 Molina Healthcare
Silver

(HMO) Silver 1 with Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 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
$387.07
$439.32
$494.67
$691.30
$1,050.50
$683.18
$735.43
$790.78
$987.41
$979.29
$1,031.54
$1,086.89
$1,283.52
$1,275.40
$1,327.65
$1,383.00
$1,579.63
$296.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774.14
$878.64
$989.34
$1,382.60
$2,101.00
$1,070.25
$1,174.75
$1,285.45
$1,678.71
$1,366.36
$1,470.86
$1,581.56
$1,974.82
$1,662.47
$1,766.97
$1,877.67
$2,270.93
$296.11

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

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

Toc - Plan #65 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Priority/Lean 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
$313.94
$356.32
$401.22
$560.70
$852.03
$554.10
$596.48
$641.38
$800.86
$794.26
$836.64
$881.54
$1,041.02
$1,034.42
$1,076.80
$1,121.70
$1,281.18
$240.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627.88
$712.64
$802.44
$1,121.40
$1,704.06
$868.04
$952.80
$1,042.60
$1,361.56
$1,108.20
$1,192.96
$1,282.76
$1,601.72
$1,348.36
$1,433.12
$1,522.92
$1,841.88
$240.16
Toc - Plan #66 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Priority/Lean 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
$390.72
$443.47
$499.34
$697.83
$1,060.41
$689.62
$742.37
$798.24
$996.73
$988.52
$1,041.27
$1,097.14
$1,295.63
$1,287.42
$1,340.17
$1,396.04
$1,594.53
$298.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.44
$886.94
$998.68
$1,395.66
$2,120.82
$1,080.34
$1,185.84
$1,297.58
$1,694.56
$1,379.24
$1,484.74
$1,596.48
$1,993.46
$1,678.14
$1,783.64
$1,895.38
$2,292.36
$298.90
Toc - Plan #67 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Blue Priority/Lean 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
$299.27
$339.67
$382.47
$534.50
$812.22
$528.21
$568.61
$611.41
$763.44
$757.15
$797.55
$840.35
$992.38
$986.09
$1,026.49
$1,069.29
$1,221.32
$228.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.54
$679.34
$764.94
$1,069.00
$1,624.44
$827.48
$908.28
$993.88
$1,297.94
$1,056.42
$1,137.22
$1,222.82
$1,526.88
$1,285.36
$1,366.16
$1,451.76
$1,755.82
$228.94
Toc - Plan #68 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Priority/Lean 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
$418.06
$474.50
$534.28
$746.66
$1,134.61
$737.88
$794.32
$854.10
$1,066.48
$1,057.70
$1,114.14
$1,173.92
$1,386.30
$1,377.52
$1,433.96
$1,493.74
$1,706.12
$319.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.12
$949.00
$1,068.56
$1,493.32
$2,269.22
$1,155.94
$1,268.82
$1,388.38
$1,813.14
$1,475.76
$1,588.64
$1,708.20
$2,132.96
$1,795.58
$1,908.46
$2,028.02
$2,452.78
$319.82
Toc - Plan #69 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Priority/Lean 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
$320.14
$363.36
$409.14
$571.77
$868.86
$565.05
$608.27
$654.05
$816.68
$809.96
$853.18
$898.96
$1,061.59
$1,054.87
$1,098.09
$1,143.87
$1,306.50
$244.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.28
$726.72
$818.28
$1,143.54
$1,737.72
$885.19
$971.63
$1,063.19
$1,388.45
$1,130.10
$1,216.54
$1,308.10
$1,633.36
$1,375.01
$1,461.45
$1,553.01
$1,878.27
$244.91
Toc - Plan #70 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Priority/Lean 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
$381.75
$433.29
$487.88
$681.81
$1,036.07
$673.79
$725.33
$779.92
$973.85
$965.83
$1,017.37
$1,071.96
$1,265.89
$1,257.87
$1,309.41
$1,364.00
$1,557.93
$292.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.50
$866.58
$975.76
$1,363.62
$2,072.14
$1,055.54
$1,158.62
$1,267.80
$1,655.66
$1,347.58
$1,450.66
$1,559.84
$1,947.70
$1,639.62
$1,742.70
$1,851.88
$2,239.74
$292.04
Toc - Plan #71 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Priority/Lean 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
$314.22
$356.64
$401.57
$561.20
$852.79
$554.60
$597.02
$641.95
$801.58
$794.98
$837.40
$882.33
$1,041.96
$1,035.36
$1,077.78
$1,122.71
$1,282.34
$240.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$628.44
$713.28
$803.14
$1,122.40
$1,705.58
$868.82
$953.66
$1,043.52
$1,362.78
$1,109.20
$1,194.04
$1,283.90
$1,603.16
$1,349.58
$1,434.42
$1,524.28
$1,843.54
$240.38
Toc - Plan #72 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Priority/Lean 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
$315.15
$357.70
$402.76
$562.86
$855.32
$556.24
$598.79
$643.85
$803.95
$797.33
$839.88
$884.94
$1,045.04
$1,038.42
$1,080.97
$1,126.03
$1,286.13
$241.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.30
$715.40
$805.52
$1,125.72
$1,710.64
$871.39
$956.49
$1,046.61
$1,366.81
$1,112.48
$1,197.58
$1,287.70
$1,607.90
$1,353.57
$1,438.67
$1,528.79
$1,848.99
$241.09
Toc - Plan #73 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Priority/Lean 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
$390.92
$443.69
$499.60
$698.18
$1,060.96
$689.97
$742.74
$798.65
$997.23
$989.02
$1,041.79
$1,097.70
$1,296.28
$1,288.07
$1,340.84
$1,396.75
$1,595.33
$299.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.84
$887.38
$999.20
$1,396.36
$2,121.92
$1,080.89
$1,186.43
$1,298.25
$1,695.41
$1,379.94
$1,485.48
$1,597.30
$1,994.46
$1,678.99
$1,784.53
$1,896.35
$2,293.51
$299.05
Toc - Plan #74 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Priority/Lean 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
$425.88
$483.37
$544.27
$760.62
$1,155.84
$751.68
$809.17
$870.07
$1,086.42
$1,077.48
$1,134.97
$1,195.87
$1,412.22
$1,403.28
$1,460.77
$1,521.67
$1,738.02
$325.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$851.76
$966.74
$1,088.54
$1,521.24
$2,311.68
$1,177.56
$1,292.54
$1,414.34
$1,847.04
$1,503.36
$1,618.34
$1,740.14
$2,172.84
$1,829.16
$1,944.14
$2,065.94
$2,498.64
$325.80
Toc - Plan #75 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Priority/Lean 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
$381.44
$432.93
$487.48
$681.25
$1,035.23
$673.24
$724.73
$779.28
$973.05
$965.04
$1,016.53
$1,071.08
$1,264.85
$1,256.84
$1,308.33
$1,362.88
$1,556.65
$291.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.88
$865.86
$974.96
$1,362.50
$2,070.46
$1,054.68
$1,157.66
$1,266.76
$1,654.30
$1,346.48
$1,449.46
$1,558.56
$1,946.10
$1,638.28
$1,741.26
$1,850.36
$2,237.90
$291.80
Toc - Plan #76 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
$371.09
$421.19
$474.25
$662.77
$1,007.14
$654.97
$705.07
$758.13
$946.65
$938.85
$988.95
$1,042.01
$1,230.53
$1,222.73
$1,272.83
$1,325.89
$1,514.41
$283.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.18
$842.38
$948.50
$1,325.54
$2,014.28
$1,026.06
$1,126.26
$1,232.38
$1,609.42
$1,309.94
$1,410.14
$1,516.26
$1,893.30
$1,593.82
$1,694.02
$1,800.14
$2,177.18
$283.88
Toc - Plan #77 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
$439.24
$498.54
$561.35
$784.48
$1,192.10
$775.26
$834.56
$897.37
$1,120.50
$1,111.28
$1,170.58
$1,233.39
$1,456.52
$1,447.30
$1,506.60
$1,569.41
$1,792.54
$336.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$878.48
$997.08
$1,122.70
$1,568.96
$2,384.20
$1,214.50
$1,333.10
$1,458.72
$1,904.98
$1,550.52
$1,669.12
$1,794.74
$2,241.00
$1,886.54
$2,005.14
$2,130.76
$2,577.02
$336.02
Toc - Plan #78 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
$336.27
$381.67
$429.75
$600.58
$912.64
$593.52
$638.92
$687.00
$857.83
$850.77
$896.17
$944.25
$1,115.08
$1,108.02
$1,153.42
$1,201.50
$1,372.33
$257.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.54
$763.34
$859.50
$1,201.16
$1,825.28
$929.79
$1,020.59
$1,116.75
$1,458.41
$1,187.04
$1,277.84
$1,374.00
$1,715.66
$1,444.29
$1,535.09
$1,631.25
$1,972.91
$257.25
Toc - Plan #79 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
$352.75
$400.37
$450.81
$630.01
$957.36
$622.60
$670.22
$720.66
$899.86
$892.45
$940.07
$990.51
$1,169.71
$1,162.30
$1,209.92
$1,260.36
$1,439.56
$269.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$705.50
$800.74
$901.62
$1,260.02
$1,914.72
$975.35
$1,070.59
$1,171.47
$1,529.87
$1,245.20
$1,340.44
$1,441.32
$1,799.72
$1,515.05
$1,610.29
$1,711.17
$2,069.57
$269.85
Toc - Plan #80 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
$354.10
$401.90
$452.54
$632.42
$961.03
$624.99
$672.79
$723.43
$903.31
$895.88
$943.68
$994.32
$1,174.20
$1,166.77
$1,214.57
$1,265.21
$1,445.09
$270.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.20
$803.80
$905.08
$1,264.84
$1,922.06
$979.09
$1,074.69
$1,175.97
$1,535.73
$1,249.98
$1,345.58
$1,446.86
$1,806.62
$1,520.87
$1,616.47
$1,717.75
$2,077.51
$270.89
Toc - Plan #81 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
$428.93
$486.84
$548.17
$766.07
$1,164.12
$757.06
$814.97
$876.30
$1,094.20
$1,085.19
$1,143.10
$1,204.43
$1,422.33
$1,413.32
$1,471.23
$1,532.56
$1,750.46
$328.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$857.86
$973.68
$1,096.34
$1,532.14
$2,328.24
$1,185.99
$1,301.81
$1,424.47
$1,860.27
$1,514.12
$1,629.94
$1,752.60
$2,188.40
$1,842.25
$1,958.07
$2,080.73
$2,516.53
$328.13
Toc - Plan #82 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
$469.70
$533.11
$600.28
$838.88
$1,274.77
$829.02
$892.43
$959.60
$1,198.20
$1,188.34
$1,251.75
$1,318.92
$1,557.52
$1,547.66
$1,611.07
$1,678.24
$1,916.84
$359.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$939.40
$1,066.22
$1,200.56
$1,677.76
$2,549.54
$1,298.72
$1,425.54
$1,559.88
$2,037.08
$1,658.04
$1,784.86
$1,919.20
$2,396.40
$2,017.36
$2,144.18
$2,278.52
$2,755.72
$359.32
Toc - Plan #83 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
$353.06
$400.72
$451.21
$630.57
$958.20
$623.15
$670.81
$721.30
$900.66
$893.24
$940.90
$991.39
$1,170.75
$1,163.33
$1,210.99
$1,261.48
$1,440.84
$270.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.12
$801.44
$902.42
$1,261.14
$1,916.40
$976.21
$1,071.53
$1,172.51
$1,531.23
$1,246.30
$1,341.62
$1,442.60
$1,801.32
$1,516.39
$1,611.71
$1,712.69
$2,071.41
$270.09
Toc - Plan #84 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
$428.58
$486.44
$547.73
$765.44
$1,163.17
$756.44
$814.30
$875.59
$1,093.30
$1,084.30
$1,142.16
$1,203.45
$1,421.16
$1,412.16
$1,470.02
$1,531.31
$1,749.02
$327.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$857.16
$972.88
$1,095.46
$1,530.88
$2,326.34
$1,185.02
$1,300.74
$1,423.32
$1,858.74
$1,512.88
$1,628.60
$1,751.18
$2,186.60
$1,840.74
$1,956.46
$2,079.04
$2,514.46
$327.86
Toc - Plan #85 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
$478.53
$543.13
$611.56
$854.65
$1,298.73
$844.61
$909.21
$977.64
$1,220.73
$1,210.69
$1,275.29
$1,343.72
$1,586.81
$1,576.77
$1,641.37
$1,709.80
$1,952.89
$366.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$957.06
$1,086.26
$1,223.12
$1,709.30
$2,597.46
$1,323.14
$1,452.34
$1,589.20
$2,075.38
$1,689.22
$1,818.42
$1,955.28
$2,441.46
$2,055.30
$2,184.50
$2,321.36
$2,807.54
$366.08
Toc - Plan #86 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
$439.00
$498.27
$561.04
$784.05
$1,191.45
$774.84
$834.11
$896.88
$1,119.89
$1,110.68
$1,169.95
$1,232.72
$1,455.73
$1,446.52
$1,505.79
$1,568.56
$1,791.57
$335.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$878.00
$996.54
$1,122.08
$1,568.10
$2,382.90
$1,213.84
$1,332.38
$1,457.92
$1,903.94
$1,549.68
$1,668.22
$1,793.76
$2,239.78
$1,885.52
$2,004.06
$2,129.60
$2,575.62
$335.84

ADVERTISEMENT

Common Ground Healthcare Cooperative

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

Toc - Plan #87 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$316.55
$359.28
$404.54
$565.35
$859.10
$558.71
$601.44
$646.70
$807.51
$800.87
$843.60
$888.86
$1,049.67
$1,043.03
$1,085.76
$1,131.02
$1,291.83
$242.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$633.10
$718.56
$809.08
$1,130.70
$1,718.20
$875.26
$960.72
$1,051.24
$1,372.86
$1,117.42
$1,202.88
$1,293.40
$1,615.02
$1,359.58
$1,445.04
$1,535.56
$1,857.18
$242.16
Toc - Plan #88 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$494.46
$561.20
$631.91
$883.09
$1,341.94
$872.71
$939.45
$1,010.16
$1,261.34
$1,250.96
$1,317.70
$1,388.41
$1,639.59
$1,629.21
$1,695.95
$1,766.66
$2,017.84
$378.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$988.92
$1,122.40
$1,263.82
$1,766.18
$2,683.88
$1,367.17
$1,500.65
$1,642.07
$2,144.43
$1,745.42
$1,878.90
$2,020.32
$2,522.68
$2,123.67
$2,257.15
$2,398.57
$2,900.93
$378.25
Toc - Plan #89 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $3000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,300 $18,600 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
$430.67
$488.80
$550.39
$769.16
$1,168.82
$760.13
$818.26
$879.85
$1,098.62
$1,089.59
$1,147.72
$1,209.31
$1,428.08
$1,419.05
$1,477.18
$1,538.77
$1,757.54
$329.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$861.34
$977.60
$1,100.78
$1,538.32
$2,337.64
$1,190.80
$1,307.06
$1,430.24
$1,867.78
$1,520.26
$1,636.52
$1,759.70
$2,197.24
$1,849.72
$1,965.98
$2,089.16
$2,526.70
$329.46
Toc - Plan #90 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $1800 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$6,600 $13,200 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
$466.64
$529.63
$596.36
$833.40
$1,266.44
$823.61
$886.60
$953.33
$1,190.37
$1,180.58
$1,243.57
$1,310.30
$1,547.34
$1,537.55
$1,600.54
$1,667.27
$1,904.31
$356.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$933.28
$1,059.26
$1,192.72
$1,666.80
$2,532.88
$1,290.25
$1,416.23
$1,549.69
$2,023.77
$1,647.22
$1,773.20
$1,906.66
$2,380.74
$2,004.19
$2,130.17
$2,263.63
$2,737.71
$356.97
Toc - Plan #91 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $4000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$424.90
$482.25
$543.01
$758.86
$1,153.16
$749.94
$807.29
$868.05
$1,083.90
$1,074.98
$1,132.33
$1,193.09
$1,408.94
$1,400.02
$1,457.37
$1,518.13
$1,733.98
$325.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.80
$964.50
$1,086.02
$1,517.72
$2,306.32
$1,174.84
$1,289.54
$1,411.06
$1,842.76
$1,499.88
$1,614.58
$1,736.10
$2,167.80
$1,824.92
$1,939.62
$2,061.14
$2,492.84
$325.04
Toc - Plan #92 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$360.12
$408.73
$460.22
$643.16
$977.34
$635.61
$684.22
$735.71
$918.65
$911.10
$959.71
$1,011.20
$1,194.14
$1,186.59
$1,235.20
$1,286.69
$1,469.63
$275.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.24
$817.46
$920.44
$1,286.32
$1,954.68
$995.73
$1,092.95
$1,195.93
$1,561.81
$1,271.22
$1,368.44
$1,471.42
$1,837.30
$1,546.71
$1,643.93
$1,746.91
$2,112.79
$275.49
Toc - Plan #93 Common Ground Healthcare Cooperative
Catastrophic

(EPO) CGHC Catastrophic $9450 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$203.62
$231.10
$260.22
$363.65
$552.61
$359.38
$386.86
$415.98
$519.41
$515.14
$542.62
$571.74
$675.17
$670.90
$698.38
$727.50
$830.93
$155.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$407.24
$462.20
$520.44
$727.30
$1,105.22
$563.00
$617.96
$676.20
$883.06
$718.76
$773.72
$831.96
$1,038.82
$874.52
$929.48
$987.72
$1,194.58
$155.76
Toc - Plan #94 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $9450 ($35 PCP Copay) - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$302.50
$343.33
$386.59
$540.26
$820.97
$533.91
$574.74
$618.00
$771.67
$765.32
$806.15
$849.41
$1,003.08
$996.73
$1,037.56
$1,080.82
$1,234.49
$231.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$605.00
$686.66
$773.18
$1,080.52
$1,641.94
$836.41
$918.07
$1,004.59
$1,311.93
$1,067.82
$1,149.48
$1,236.00
$1,543.34
$1,299.23
$1,380.89
$1,467.41
$1,774.75
$231.41
Toc - Plan #95 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.29
$357.84
$402.93
$563.09
$855.67
$556.48
$599.03
$644.12
$804.28
$797.67
$840.22
$885.31
$1,045.47
$1,038.86
$1,081.41
$1,126.50
$1,286.66
$241.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.58
$715.68
$805.86
$1,126.18
$1,711.34
$871.77
$956.87
$1,047.05
$1,367.37
$1,112.96
$1,198.06
$1,288.24
$1,608.56
$1,354.15
$1,439.25
$1,529.43
$1,849.75
$241.19
Toc - Plan #96 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $3200 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$3,200 $6,400 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
$492.21
$558.65
$629.03
$879.07
$1,335.83
$868.74
$935.18
$1,005.56
$1,255.60
$1,245.27
$1,311.71
$1,382.09
$1,632.13
$1,621.80
$1,688.24
$1,758.62
$2,008.66
$376.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$984.42
$1,117.30
$1,258.06
$1,758.14
$2,671.66
$1,360.95
$1,493.83
$1,634.59
$2,134.67
$1,737.48
$1,870.36
$2,011.12
$2,511.20
$2,114.01
$2,246.89
$2,387.65
$2,887.73
$376.53
Toc - Plan #97 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3200 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$8,000 $16,000 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
$447.18
$507.54
$571.49
$798.65
$1,213.63
$789.27
$849.63
$913.58
$1,140.74
$1,131.36
$1,191.72
$1,255.67
$1,482.83
$1,473.45
$1,533.81
$1,597.76
$1,824.92
$342.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$894.36
$1,015.08
$1,142.98
$1,597.30
$2,427.26
$1,236.45
$1,357.17
$1,485.07
$1,939.39
$1,578.54
$1,699.26
$1,827.16
$2,281.48
$1,920.63
$2,041.35
$2,169.25
$2,623.57
$342.09
Toc - Plan #98 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $6000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$310.56
$352.47
$396.88
$554.63
$842.82
$548.13
$590.04
$634.45
$792.20
$785.70
$827.61
$872.02
$1,029.77
$1,023.27
$1,065.18
$1,109.59
$1,267.34
$237.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.12
$704.94
$793.76
$1,109.26
$1,685.64
$858.69
$942.51
$1,031.33
$1,346.83
$1,096.26
$1,180.08
$1,268.90
$1,584.40
$1,333.83
$1,417.65
$1,506.47
$1,821.97
$237.57
Toc - Plan #99 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze Standard $7500 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$306.26
$347.60
$391.39
$546.97
$831.17
$540.54
$581.88
$625.67
$781.25
$774.82
$816.16
$859.95
$1,015.53
$1,009.10
$1,050.44
$1,094.23
$1,249.81
$234.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.52
$695.20
$782.78
$1,093.94
$1,662.34
$846.80
$929.48
$1,017.06
$1,328.22
$1,081.08
$1,163.76
$1,251.34
$1,562.50
$1,315.36
$1,398.04
$1,485.62
$1,796.78
$234.28
Toc - Plan #100 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver Standard $5900 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$377.36
$428.29
$482.25
$673.94
$1,024.12
$666.03
$716.96
$770.92
$962.61
$954.70
$1,005.63
$1,059.59
$1,251.28
$1,243.37
$1,294.30
$1,348.26
$1,539.95
$288.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$754.72
$856.58
$964.50
$1,347.88
$2,048.24
$1,043.39
$1,145.25
$1,253.17
$1,636.55
$1,332.06
$1,433.92
$1,541.84
$1,925.22
$1,620.73
$1,722.59
$1,830.51
$2,213.89
$288.67
Toc - Plan #101 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold Standard $1500 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$442.91
$502.70
$566.03
$791.03
$1,202.04
$781.73
$841.52
$904.85
$1,129.85
$1,120.55
$1,180.34
$1,243.67
$1,468.67
$1,459.37
$1,519.16
$1,582.49
$1,807.49
$338.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$885.82
$1,005.40
$1,132.06
$1,582.06
$2,404.08
$1,224.64
$1,344.22
$1,470.88
$1,920.88
$1,563.46
$1,683.04
$1,809.70
$2,259.70
$1,902.28
$2,021.86
$2,148.52
$2,598.52
$338.82
Toc - Plan #102 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5650 Ded / $6000 Rx Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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
$360.00
$408.59
$460.07
$642.94
$977.02
$635.39
$683.98
$735.46
$918.33
$910.78
$959.37
$1,010.85
$1,193.72
$1,186.17
$1,234.76
$1,286.24
$1,469.11
$275.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.00
$817.18
$920.14
$1,285.88
$1,954.04
$995.39
$1,092.57
$1,195.53
$1,561.27
$1,270.78
$1,367.96
$1,470.92
$1,836.66
$1,546.17
$1,643.35
$1,746.31
$2,112.05
$275.39
Toc - Plan #103 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $1800 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$6,600 $13,200 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
$469.63
$533.01
$600.17
$838.73
$1,274.54
$828.89
$892.27
$959.43
$1,197.99
$1,188.15
$1,251.53
$1,318.69
$1,557.25
$1,547.41
$1,610.79
$1,677.95
$1,916.51
$359.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$939.26
$1,066.02
$1,200.34
$1,677.46
$2,549.08
$1,298.52
$1,425.28
$1,559.60
$2,036.72
$1,657.78
$1,784.54
$1,918.86
$2,395.98
$2,017.04
$2,143.80
$2,278.12
$2,755.24
$359.26
Toc - Plan #104 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $3000 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,300 $18,600 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
$433.63
$492.16
$554.16
$774.44
$1,176.84
$765.35
$823.88
$885.88
$1,106.16
$1,097.07
$1,155.60
$1,217.60
$1,437.88
$1,428.79
$1,487.32
$1,549.32
$1,769.60
$331.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.26
$984.32
$1,108.32
$1,548.88
$2,353.68
$1,198.98
$1,316.04
$1,440.04
$1,880.60
$1,530.70
$1,647.76
$1,771.76
$2,212.32
$1,862.42
$1,979.48
$2,103.48
$2,544.04
$331.72
Toc - Plan #105 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $4000 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$427.86
$485.61
$546.79
$764.14
$1,161.18
$755.16
$812.91
$874.09
$1,091.44
$1,082.46
$1,140.21
$1,201.39
$1,418.74
$1,409.76
$1,467.51
$1,528.69
$1,746.04
$327.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$855.72
$971.22
$1,093.58
$1,528.28
$2,322.36
$1,183.02
$1,298.52
$1,420.88
$1,855.58
$1,510.32
$1,625.82
$1,748.18
$2,182.88
$1,837.62
$1,953.12
$2,075.48
$2,510.18
$327.30
Toc - Plan #106 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5650 Ded / $6000 Rx Ded - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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
$362.92
$411.90
$463.79
$648.15
$984.93
$640.54
$689.52
$741.41
$925.77
$918.16
$967.14
$1,019.03
$1,203.39
$1,195.78
$1,244.76
$1,296.65
$1,481.01
$277.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$725.84
$823.80
$927.58
$1,296.30
$1,969.86
$1,003.46
$1,101.42
$1,205.20
$1,573.92
$1,281.08
$1,379.04
$1,482.82
$1,851.54
$1,558.70
$1,656.66
$1,760.44
$2,129.16
$277.62
Toc - Plan #107 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$363.05
$412.05
$463.96
$648.38
$985.28
$640.77
$689.77
$741.68
$926.10
$918.49
$967.49
$1,019.40
$1,203.82
$1,196.21
$1,245.21
$1,297.12
$1,481.54
$277.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$726.10
$824.10
$927.92
$1,296.76
$1,970.56
$1,003.82
$1,101.82
$1,205.64
$1,574.48
$1,281.54
$1,379.54
$1,483.36
$1,852.20
$1,559.26
$1,657.26
$1,761.08
$2,129.92
$277.72
Toc - Plan #108 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $9450 ($35 PCP Copay) - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$305.39
$346.61
$390.27
$545.41
$828.80
$539.01
$580.23
$623.89
$779.03
$772.63
$813.85
$857.51
$1,012.65
$1,006.25
$1,047.47
$1,091.13
$1,246.27
$233.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610.78
$693.22
$780.54
$1,090.82
$1,657.60
$844.40
$926.84
$1,014.16
$1,324.44
$1,078.02
$1,160.46
$1,247.78
$1,558.06
$1,311.64
$1,394.08
$1,481.40
$1,791.68
$233.62
Toc - Plan #109 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $6000 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$313.45
$355.75
$400.58
$559.80
$850.67
$553.23
$595.53
$640.36
$799.58
$793.01
$835.31
$880.14
$1,039.36
$1,032.79
$1,075.09
$1,119.92
$1,279.14
$239.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$626.90
$711.50
$801.16
$1,119.60
$1,701.34
$866.68
$951.28
$1,040.94
$1,359.38
$1,106.46
$1,191.06
$1,280.72
$1,599.16
$1,346.24
$1,430.84
$1,520.50
$1,838.94
$239.78
Toc - Plan #110 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$318.18
$361.13
$406.63
$568.26
$863.52
$561.58
$604.53
$650.03
$811.66
$804.98
$847.93
$893.43
$1,055.06
$1,048.38
$1,091.33
$1,136.83
$1,298.46
$243.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636.36
$722.26
$813.26
$1,136.52
$1,727.04
$879.76
$965.66
$1,056.66
$1,379.92
$1,123.16
$1,209.06
$1,300.06
$1,623.32
$1,366.56
$1,452.46
$1,543.46
$1,866.72
$243.40
Toc - Plan #111 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3200 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$8,000 $16,000 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
$450.15
$510.91
$575.28
$803.95
$1,221.68
$794.51
$855.27
$919.64
$1,148.31
$1,138.87
$1,199.63
$1,264.00
$1,492.67
$1,483.23
$1,543.99
$1,608.36
$1,837.03
$344.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$900.30
$1,021.82
$1,150.56
$1,607.90
$2,443.36
$1,244.66
$1,366.18
$1,494.92
$1,952.26
$1,589.02
$1,710.54
$1,839.28
$2,296.62
$1,933.38
$2,054.90
$2,183.64
$2,640.98
$344.36
Toc - Plan #112 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $3200 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$3,200 $6,400 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
$495.19
$562.03
$632.84
$884.40
$1,343.93
$874.01
$940.85
$1,011.66
$1,263.22
$1,252.83
$1,319.67
$1,390.48
$1,642.04
$1,631.65
$1,698.49
$1,769.30
$2,020.86
$378.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$990.38
$1,124.06
$1,265.68
$1,768.80
$2,687.86
$1,369.20
$1,502.88
$1,644.50
$2,147.62
$1,748.02
$1,881.70
$2,023.32
$2,526.44
$2,126.84
$2,260.52
$2,402.14
$2,905.26
$378.82
Toc - Plan #113 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$319.45
$362.56
$408.24
$570.52
$866.96
$563.82
$606.93
$652.61
$814.89
$808.19
$851.30
$896.98
$1,059.26
$1,052.56
$1,095.67
$1,141.35
$1,303.63
$244.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$638.90
$725.12
$816.48
$1,141.04
$1,733.92
$883.27
$969.49
$1,060.85
$1,385.41
$1,127.64
$1,213.86
$1,305.22
$1,629.78
$1,372.01
$1,458.23
$1,549.59
$1,874.15
$244.37
Toc - Plan #114 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$497.45
$564.60
$635.73
$888.44
$1,350.07
$878.00
$945.15
$1,016.28
$1,268.99
$1,258.55
$1,325.70
$1,396.83
$1,649.54
$1,639.10
$1,706.25
$1,777.38
$2,030.09
$380.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$994.90
$1,129.20
$1,271.46
$1,776.88
$2,700.14
$1,375.45
$1,509.75
$1,652.01
$2,157.43
$1,756.00
$1,890.30
$2,032.56
$2,537.98
$2,136.55
$2,270.85
$2,413.11
$2,918.53
$380.55

‡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 Kewaunee County here.

Kewaunee County is in “Rating Area 16” of Wisconsin.

Currently, there are 114 plans offered in Rating Area 16.

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