Obamacare 2023 Rates for Ozaukee County

Obamacare > Rates > Wisconsin > Ozaukee County

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 Ozaukee County, WI.

The health insurance rates listed below are for calendar year 2023.

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, 139 Plans and 2023 Rates for Ozaukee County, Wisconsin

Below, you’ll find a summary of the 139 plans for Ozaukee County, Wisconsin and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Together with CCHP

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

Toc - Plan #1 Together with CCHP

Expanded Bronze

(EPO) Chorus 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

$9,100 $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

$325.57
$369.51
$416.06
$581.44
$883.56

$574.62
$618.56
$665.11
$830.49

$823.67
$867.61
$914.16
$1,079.54

$1,072.72
$1,116.66
$1,163.21
$1,328.59

$249.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$651.14
$739.02
$832.12
$1,162.88
$1,767.12

$900.19
$988.07
$1,081.17
$1,411.93

$1,149.24
$1,237.12
$1,330.22
$1,660.98

$1,398.29
$1,486.17
$1,579.27
$1,910.03

$249.05

Toc - Plan #2 Together with CCHP

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

$425.57
$483.01
$543.87
$760.06
$1,154.98

$751.13
$808.57
$869.43
$1,085.62

$1,076.69
$1,134.13
$1,194.99
$1,411.18

$1,402.25
$1,459.69
$1,520.55
$1,736.74

$325.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$851.14
$966.02
$1,087.74
$1,520.12
$2,309.96

$1,176.70
$1,291.58
$1,413.30
$1,845.68

$1,502.26
$1,617.14
$1,738.86
$2,171.24

$1,827.82
$1,942.70
$2,064.42
$2,496.80

$325.56

Toc - Plan #3 Together with CCHP

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

$8,700 $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

$388.12
$440.51
$496.01
$693.17
$1,053.34

$685.03
$737.42
$792.92
$990.08

$981.94
$1,034.33
$1,089.83
$1,286.99

$1,278.85
$1,331.24
$1,386.74
$1,583.90

$296.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$776.24
$881.02
$992.02
$1,386.34
$2,106.68

$1,073.15
$1,177.93
$1,288.93
$1,683.25

$1,370.06
$1,474.84
$1,585.84
$1,980.16

$1,666.97
$1,771.75
$1,882.75
$2,277.07

$296.91

Toc - Plan #4 Together with CCHP

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

$459.62
$521.65
$587.38
$820.86
$1,247.38

$811.22
$873.25
$938.98
$1,172.46

$1,162.82
$1,224.85
$1,290.58
$1,524.06

$1,514.42
$1,576.45
$1,642.18
$1,875.66

$351.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$919.24
$1,043.30
$1,174.76
$1,641.72
$2,494.76

$1,270.84
$1,394.90
$1,526.36
$1,993.32

$1,622.44
$1,746.50
$1,877.96
$2,344.92

$1,974.04
$2,098.10
$2,229.56
$2,696.52

$351.60

Toc - Plan #5 Together with CCHP

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

$7,000 $14,000 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

$358.33
$406.70
$457.94
$639.97
$972.49

$632.45
$680.82
$732.06
$914.09

$906.57
$954.94
$1,006.18
$1,188.21

$1,180.69
$1,229.06
$1,280.30
$1,462.33

$274.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$716.66
$813.40
$915.88
$1,279.94
$1,944.98

$990.78
$1,087.52
$1,190.00
$1,554.06

$1,264.90
$1,361.64
$1,464.12
$1,828.18

$1,539.02
$1,635.76
$1,738.24
$2,102.30

$274.12

Toc - Plan #6 Together with CCHP

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

$411.95
$467.56
$526.47
$735.73
$1,118.02

$727.09
$782.70
$841.61
$1,050.87

$1,042.23
$1,097.84
$1,156.75
$1,366.01

$1,357.37
$1,412.98
$1,471.89
$1,681.15

$315.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$823.90
$935.12
$1,052.94
$1,471.46
$2,236.04

$1,139.04
$1,250.26
$1,368.08
$1,786.60

$1,454.18
$1,565.40
$1,683.22
$2,101.74

$1,769.32
$1,880.54
$1,998.36
$2,416.88

$315.14

Toc - Plan #7 Together with CCHP

Catastrophic

(EPO) Chorus Catastrophic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family

$9,100 $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

$270.67
$307.20
$345.90
$483.40
$734.57

$477.72
$514.25
$552.95
$690.45

$684.77
$721.30
$760.00
$897.50

$891.82
$928.35
$967.05
$1,104.55

$207.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$541.34
$614.40
$691.80
$966.80
$1,469.14

$748.39
$821.45
$898.85
$1,173.85

$955.44
$1,028.50
$1,105.90
$1,380.90

$1,162.49
$1,235.55
$1,312.95
$1,587.95

$207.05

Toc - Plan #8 Together with CCHP

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

$9,100 $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

$362.59
$411.53
$463.38
$647.57
$984.04

$639.96
$688.90
$740.75
$924.94

$917.33
$966.27
$1,018.12
$1,202.31

$1,194.70
$1,243.64
$1,295.49
$1,479.68

$277.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$725.18
$823.06
$926.76
$1,295.14
$1,968.08

$1,002.55
$1,100.43
$1,204.13
$1,572.51

$1,279.92
$1,377.80
$1,481.50
$1,849.88

$1,557.29
$1,655.17
$1,758.87
$2,127.25

$277.37

Toc - Plan #9 Together with CCHP

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

$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

$459.62
$521.65
$587.38
$820.86
$1,247.38

$811.22
$873.25
$938.98
$1,172.46

$1,162.82
$1,224.85
$1,290.58
$1,524.06

$1,514.42
$1,576.45
$1,642.18
$1,875.66

$351.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$919.24
$1,043.30
$1,174.76
$1,641.72
$2,494.76

$1,270.84
$1,394.90
$1,526.36
$1,993.32

$1,622.44
$1,746.50
$1,877.96
$2,344.92

$1,974.04
$2,098.10
$2,229.56
$2,696.52

$351.60

Toc - Plan #10 Together with CCHP

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

$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

$305.56
$346.80
$390.50
$545.72
$829.27

$539.31
$580.55
$624.25
$779.47

$773.06
$814.30
$858.00
$1,013.22

$1,006.81
$1,048.05
$1,091.75
$1,246.97

$233.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$611.12
$693.60
$781.00
$1,091.44
$1,658.54

$844.87
$927.35
$1,014.75
$1,325.19

$1,078.62
$1,161.10
$1,248.50
$1,558.94

$1,312.37
$1,394.85
$1,482.25
$1,792.69

$233.75

Toc - Plan #11 Together with CCHP

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

$5,800 $11,600 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

$386.42
$438.58
$493.83
$690.13
$1,048.72

$682.02
$734.18
$789.43
$985.73

$977.62
$1,029.78
$1,085.03
$1,281.33

$1,273.22
$1,325.38
$1,380.63
$1,576.93

$295.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$772.84
$877.16
$987.66
$1,380.26
$2,097.44

$1,068.44
$1,172.76
$1,283.26
$1,675.86

$1,364.04
$1,468.36
$1,578.86
$1,971.46

$1,659.64
$1,763.96
$1,874.46
$2,267.06

$295.60

Toc - Plan #12 Together with CCHP

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

$2,000 $4,000 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

$441.32
$500.89
$563.99
$788.18
$1,197.71

$778.92
$838.49
$901.59
$1,125.78

$1,116.52
$1,176.09
$1,239.19
$1,463.38

$1,454.12
$1,513.69
$1,576.79
$1,800.98

$337.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$882.64
$1,001.78
$1,127.98
$1,576.36
$2,395.42

$1,220.24
$1,339.38
$1,465.58
$1,913.96

$1,557.84
$1,676.98
$1,803.18
$2,251.56

$1,895.44
$2,014.58
$2,140.78
$2,589.16

$337.60

Quartz

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

Toc - Plan #13 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

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

$407.67
$462.70
$520.99
$728.08
$1,106.39

$719.53
$774.56
$832.85
$1,039.94

$1,031.39
$1,086.42
$1,144.71
$1,351.80

$1,343.25
$1,398.28
$1,456.57
$1,663.66

$311.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$815.34
$925.40
$1,041.98
$1,456.16
$2,212.78

$1,127.20
$1,237.26
$1,353.84
$1,768.02

$1,439.06
$1,549.12
$1,665.70
$2,079.88

$1,750.92
$1,860.98
$1,977.56
$2,391.74

$311.86

Toc - Plan #14 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Dental & Vision

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

$8,000 $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

$403.84
$458.36
$516.10
$721.25
$1,096.02

$712.78
$767.30
$825.04
$1,030.19

$1,021.72
$1,076.24
$1,133.98
$1,339.13

$1,330.66
$1,385.18
$1,442.92
$1,648.07

$308.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$807.68
$916.72
$1,032.20
$1,442.50
$2,192.04

$1,116.62
$1,225.66
$1,341.14
$1,751.44

$1,425.56
$1,534.60
$1,650.08
$2,060.38

$1,734.50
$1,843.54
$1,959.02
$2,369.32

$308.94

Toc - Plan #15 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$407.20
$462.17
$520.39
$727.25
$1,105.13

$718.70
$773.67
$831.89
$1,038.75

$1,030.20
$1,085.17
$1,143.39
$1,350.25

$1,341.70
$1,396.67
$1,454.89
$1,661.75

$311.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$814.40
$924.34
$1,040.78
$1,454.50
$2,210.26

$1,125.90
$1,235.84
$1,352.28
$1,766.00

$1,437.40
$1,547.34
$1,663.78
$2,077.50

$1,748.90
$1,858.84
$1,975.28
$2,389.00

$311.50

Toc - Plan #16 Quartz

Gold

(HMO) Quartz One with Aurora Health Care Gold I410 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$417.63
$474.00
$533.72
$745.87
$1,133.43

$737.11
$793.48
$853.20
$1,065.35

$1,056.59
$1,112.96
$1,172.68
$1,384.83

$1,376.07
$1,432.44
$1,492.16
$1,704.31

$319.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$835.26
$948.00
$1,067.44
$1,491.74
$2,266.86

$1,154.74
$1,267.48
$1,386.92
$1,811.22

$1,474.22
$1,586.96
$1,706.40
$2,130.70

$1,793.70
$1,906.44
$2,025.88
$2,450.18

$319.48

Toc - Plan #17 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$419.61
$476.26
$536.26
$749.42
$1,138.82

$740.61
$797.26
$857.26
$1,070.42

$1,061.61
$1,118.26
$1,178.26
$1,391.42

$1,382.61
$1,439.26
$1,499.26
$1,712.42

$321.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$839.22
$952.52
$1,072.52
$1,498.84
$2,277.64

$1,160.22
$1,273.52
$1,393.52
$1,819.84

$1,481.22
$1,594.52
$1,714.52
$2,140.84

$1,802.22
$1,915.52
$2,035.52
$2,461.84

$321.00

Toc - Plan #18 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$416.06
$472.22
$531.72
$743.08
$1,129.18

$734.34
$790.50
$850.00
$1,061.36

$1,052.62
$1,108.78
$1,168.28
$1,379.64

$1,370.90
$1,427.06
$1,486.56
$1,697.92

$318.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$832.12
$944.44
$1,063.44
$1,486.16
$2,258.36

$1,150.40
$1,262.72
$1,381.72
$1,804.44

$1,468.68
$1,581.00
$1,700.00
$2,122.72

$1,786.96
$1,899.28
$2,018.28
$2,441.00

$318.28

Toc - Plan #19 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,000 $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

$436.53
$495.45
$557.87
$779.63
$1,184.72

$770.47
$829.39
$891.81
$1,113.57

$1,104.41
$1,163.33
$1,225.75
$1,447.51

$1,438.35
$1,497.27
$1,559.69
$1,781.45

$333.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$873.06
$990.90
$1,115.74
$1,559.26
$2,369.44

$1,207.00
$1,324.84
$1,449.68
$1,893.20

$1,540.94
$1,658.78
$1,783.62
$2,227.14

$1,874.88
$1,992.72
$2,117.56
$2,561.08

$333.94

Toc - Plan #20 Quartz

Silver

(HMO) Quartz One with Aurora Health Care Silver I309 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 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

$457.19
$518.91
$584.29
$816.54
$1,240.81

$806.94
$868.66
$934.04
$1,166.29

$1,156.69
$1,218.41
$1,283.79
$1,516.04

$1,506.44
$1,568.16
$1,633.54
$1,865.79

$349.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$914.38
$1,037.82
$1,168.58
$1,633.08
$2,481.62

$1,264.13
$1,387.57
$1,518.33
$1,982.83

$1,613.88
$1,737.32
$1,868.08
$2,332.58

$1,963.63
$2,087.07
$2,217.83
$2,682.33

$349.75

Toc - Plan #21 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

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

$309.45
$351.22
$395.47
$552.67
$839.83

$546.17
$587.94
$632.19
$789.39

$782.89
$824.66
$868.91
$1,026.11

$1,019.61
$1,061.38
$1,105.63
$1,262.83

$236.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$618.90
$702.44
$790.94
$1,105.34
$1,679.66

$855.62
$939.16
$1,027.66
$1,342.06

$1,092.34
$1,175.88
$1,264.38
$1,578.78

$1,329.06
$1,412.60
$1,501.10
$1,815.50

$236.72

Toc - Plan #22 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$312.51
$354.69
$399.38
$558.13
$848.14

$551.58
$593.76
$638.45
$797.20

$790.65
$832.83
$877.52
$1,036.27

$1,029.72
$1,071.90
$1,116.59
$1,275.34

$239.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$625.02
$709.38
$798.76
$1,116.26
$1,696.28

$864.09
$948.45
$1,037.83
$1,355.33

$1,103.16
$1,187.52
$1,276.90
$1,594.40

$1,342.23
$1,426.59
$1,515.97
$1,833.47

$239.07

Toc - Plan #23 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Dental & Vision

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

$327.58
$371.79
$418.64
$585.04
$889.03

$578.17
$622.38
$669.23
$835.63

$828.76
$872.97
$919.82
$1,086.22

$1,079.35
$1,123.56
$1,170.41
$1,336.81

$250.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$655.16
$743.58
$837.28
$1,170.08
$1,778.06

$905.75
$994.17
$1,087.87
$1,420.67

$1,156.34
$1,244.76
$1,338.46
$1,671.26

$1,406.93
$1,495.35
$1,589.05
$1,921.85

$250.59

Toc - Plan #24 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$324.23
$367.99
$414.36
$579.06
$879.94

$572.26
$616.02
$662.39
$827.09

$820.29
$864.05
$910.42
$1,075.12

$1,068.32
$1,112.08
$1,158.45
$1,323.15

$248.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$648.46
$735.98
$828.72
$1,158.12
$1,759.88

$896.49
$984.01
$1,076.75
$1,406.15

$1,144.52
$1,232.04
$1,324.78
$1,654.18

$1,392.55
$1,480.07
$1,572.81
$1,902.21

$248.03

Toc - Plan #25 Quartz

Expanded Bronze

(HMO) Quartz One with Aurora Health Care Bronze I206 Standard with Dental & Vision

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

$9,000 $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

$337.58
$383.14
$431.42
$602.90
$916.17

$595.82
$641.38
$689.66
$861.14

$854.06
$899.62
$947.90
$1,119.38

$1,112.30
$1,157.86
$1,206.14
$1,377.62

$258.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$675.16
$766.28
$862.84
$1,205.80
$1,832.34

$933.40
$1,024.52
$1,121.08
$1,464.04

$1,191.64
$1,282.76
$1,379.32
$1,722.28

$1,449.88
$1,541.00
$1,637.56
$1,980.52

$258.24

Toc - Plan #26 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

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

$389.59
$442.18
$497.89
$695.80
$1,057.34

$687.62
$740.21
$795.92
$993.83

$985.65
$1,038.24
$1,093.95
$1,291.86

$1,283.68
$1,336.27
$1,391.98
$1,589.89

$298.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$779.18
$884.36
$995.78
$1,391.60
$2,114.68

$1,077.21
$1,182.39
$1,293.81
$1,689.63

$1,375.24
$1,480.42
$1,591.84
$1,987.66

$1,673.27
$1,778.45
$1,889.87
$2,285.69

$298.03

Toc - Plan #27 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance

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

$8,000 $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

$385.94
$438.03
$493.22
$689.28
$1,047.42

$681.18
$733.27
$788.46
$984.52

$976.42
$1,028.51
$1,083.70
$1,279.76

$1,271.66
$1,323.75
$1,378.94
$1,575.00

$295.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$771.88
$876.06
$986.44
$1,378.56
$2,094.84

$1,067.12
$1,171.30
$1,281.68
$1,673.80

$1,362.36
$1,466.54
$1,576.92
$1,969.04

$1,657.60
$1,761.78
$1,872.16
$2,264.28

$295.24

Toc - Plan #28 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$389.15
$441.68
$497.32
$695.01
$1,056.13

$686.84
$739.37
$795.01
$992.70

$984.53
$1,037.06
$1,092.70
$1,290.39

$1,282.22
$1,334.75
$1,390.39
$1,588.08

$297.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$778.30
$883.36
$994.64
$1,390.02
$2,112.26

$1,075.99
$1,181.05
$1,292.33
$1,687.71

$1,373.68
$1,478.74
$1,590.02
$1,985.40

$1,671.37
$1,776.43
$1,887.71
$2,283.09

$297.69

Toc - Plan #29 Quartz

Gold

(HMO) Quartz One with Aurora 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

$2,000 $4,000 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

$399.11
$452.99
$510.06
$712.80
$1,083.18

$704.43
$758.31
$815.38
$1,018.12

$1,009.75
$1,063.63
$1,120.70
$1,323.44

$1,315.07
$1,368.95
$1,426.02
$1,628.76

$305.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$798.22
$905.98
$1,020.12
$1,425.60
$2,166.36

$1,103.54
$1,211.30
$1,325.44
$1,730.92

$1,408.86
$1,516.62
$1,630.76
$2,036.24

$1,714.18
$1,821.94
$1,936.08
$2,341.56

$305.32

Toc - Plan #30 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$401.01
$455.14
$512.48
$716.19
$1,088.33

$707.78
$761.91
$819.25
$1,022.96

$1,014.55
$1,068.68
$1,126.02
$1,329.73

$1,321.32
$1,375.45
$1,432.79
$1,636.50

$306.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$802.02
$910.28
$1,024.96
$1,432.38
$2,176.66

$1,108.79
$1,217.05
$1,331.73
$1,739.15

$1,415.56
$1,523.82
$1,638.50
$2,045.92

$1,722.33
$1,830.59
$1,945.27
$2,352.69

$306.77

Toc - Plan #31 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$397.62
$451.29
$508.15
$710.13
$1,079.12

$701.79
$755.46
$812.32
$1,014.30

$1,005.96
$1,059.63
$1,116.49
$1,318.47

$1,310.13
$1,363.80
$1,420.66
$1,622.64

$304.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$795.24
$902.58
$1,016.30
$1,420.26
$2,158.24

$1,099.41
$1,206.75
$1,320.47
$1,724.43

$1,403.58
$1,510.92
$1,624.64
$2,028.60

$1,707.75
$1,815.09
$1,928.81
$2,332.77

$304.17

Toc - Plan #32 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,000 $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

$417.17
$473.48
$533.14
$745.06
$1,132.19

$736.30
$792.61
$852.27
$1,064.19

$1,055.43
$1,111.74
$1,171.40
$1,383.32

$1,374.56
$1,430.87
$1,490.53
$1,702.45

$319.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$834.34
$946.96
$1,066.28
$1,490.12
$2,264.38

$1,153.47
$1,266.09
$1,385.41
$1,809.25

$1,472.60
$1,585.22
$1,704.54
$2,128.38

$1,791.73
$1,904.35
$2,023.67
$2,447.51

$319.13

Toc - Plan #33 Quartz

Silver

(HMO) Quartz One with Aurora 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

$5,800 $11,600 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

$436.92
$495.90
$558.38
$780.34
$1,185.80

$771.16
$830.14
$892.62
$1,114.58

$1,105.40
$1,164.38
$1,226.86
$1,448.82

$1,439.64
$1,498.62
$1,561.10
$1,783.06

$334.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$873.84
$991.80
$1,116.76
$1,560.68
$2,371.60

$1,208.08
$1,326.04
$1,451.00
$1,894.92

$1,542.32
$1,660.28
$1,785.24
$2,229.16

$1,876.56
$1,994.52
$2,119.48
$2,563.40

$334.24

Toc - Plan #34 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

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

$295.73
$335.65
$377.93
$528.16
$802.59

$521.96
$561.88
$604.16
$754.39

$748.19
$788.11
$830.39
$980.62

$974.42
$1,014.34
$1,056.62
$1,206.85

$226.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$591.46
$671.30
$755.86
$1,056.32
$1,605.18

$817.69
$897.53
$982.09
$1,282.55

$1,043.92
$1,123.76
$1,208.32
$1,508.78

$1,270.15
$1,349.99
$1,434.55
$1,735.01

$226.23

Toc - Plan #35 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$298.66
$338.97
$381.67
$533.39
$810.54

$527.13
$567.44
$610.14
$761.86

$755.60
$795.91
$838.61
$990.33

$984.07
$1,024.38
$1,067.08
$1,218.80

$228.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$597.32
$677.94
$763.34
$1,066.78
$1,621.08

$825.79
$906.41
$991.81
$1,295.25

$1,054.26
$1,134.88
$1,220.28
$1,523.72

$1,282.73
$1,363.35
$1,448.75
$1,752.19

$228.47

Toc - Plan #36 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204

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

$313.05
$355.31
$400.08
$559.10
$849.61

$552.53
$594.79
$639.56
$798.58

$792.01
$834.27
$879.04
$1,038.06

$1,031.49
$1,073.75
$1,118.52
$1,277.54

$239.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$626.10
$710.62
$800.16
$1,118.20
$1,699.22

$865.58
$950.10
$1,039.64
$1,357.68

$1,105.06
$1,189.58
$1,279.12
$1,597.16

$1,344.54
$1,429.06
$1,518.60
$1,836.64

$239.48

Toc - Plan #37 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$309.85
$351.68
$395.99
$553.39
$840.93

$546.88
$588.71
$633.02
$790.42

$783.91
$825.74
$870.05
$1,027.45

$1,020.94
$1,062.77
$1,107.08
$1,264.48

$237.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$619.70
$703.36
$791.98
$1,106.78
$1,681.86

$856.73
$940.39
$1,029.01
$1,343.81

$1,093.76
$1,177.42
$1,266.04
$1,580.84

$1,330.79
$1,414.45
$1,503.07
$1,817.87

$237.03

Toc - Plan #38 Quartz

Expanded Bronze

(HMO) Quartz One with Aurora 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

$9,000 $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

$322.61
$366.16
$412.29
$576.17
$875.55

$569.40
$612.95
$659.08
$822.96

$816.19
$859.74
$905.87
$1,069.75

$1,062.98
$1,106.53
$1,152.66
$1,316.54

$246.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$645.22
$732.32
$824.58
$1,152.34
$1,751.10

$892.01
$979.11
$1,071.37
$1,399.13

$1,138.80
$1,225.90
$1,318.16
$1,645.92

$1,385.59
$1,472.69
$1,564.95
$1,892.71

$246.79

Toc - Plan #39 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA 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

$413.47
$469.28
$528.41
$738.44
$1,122.14

$729.77
$785.58
$844.71
$1,054.74

$1,046.07
$1,101.88
$1,161.01
$1,371.04

$1,362.37
$1,418.18
$1,477.31
$1,687.34

$316.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$826.94
$938.56
$1,056.82
$1,476.88
$2,244.28

$1,143.24
$1,254.86
$1,373.12
$1,793.18

$1,459.54
$1,571.16
$1,689.42
$2,109.48

$1,775.84
$1,887.46
$2,005.72
$2,425.78

$316.30

Toc - Plan #40 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA 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

$5,000 $10,000 Annual Deductible

$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$439.29
$498.59
$561.40
$784.56
$1,192.21

$775.34
$834.64
$897.45
$1,120.61

$1,111.39
$1,170.69
$1,233.50
$1,456.66

$1,447.44
$1,506.74
$1,569.55
$1,792.71

$336.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$878.58
$997.18
$1,122.80
$1,569.12
$2,384.42

$1,214.63
$1,333.23
$1,458.85
$1,905.17

$1,550.68
$1,669.28
$1,794.90
$2,241.22

$1,886.73
$2,005.33
$2,130.95
$2,577.27

$336.05

Toc - Plan #41 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$310.78
$352.73
$397.17
$555.04
$843.44

$548.52
$590.47
$634.91
$792.78

$786.26
$828.21
$872.65
$1,030.52

$1,024.00
$1,065.95
$1,110.39
$1,268.26

$237.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$621.56
$705.46
$794.34
$1,110.08
$1,686.88

$859.30
$943.20
$1,032.08
$1,347.82

$1,097.04
$1,180.94
$1,269.82
$1,585.56

$1,334.78
$1,418.68
$1,507.56
$1,823.30

$237.74

Toc - Plan #42 Quartz

Catastrophic

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE CATASTROPHIC I101

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$9,100 $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

$229.10
$260.02
$292.79
$409.17
$621.77

$404.36
$435.28
$468.05
$584.43

$579.62
$610.54
$643.31
$759.69

$754.88
$785.80
$818.57
$934.95

$175.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$458.20
$520.04
$585.58
$818.34
$1,243.54

$633.46
$695.30
$760.84
$993.60

$808.72
$870.56
$936.10
$1,168.86

$983.98
$1,045.82
$1,111.36
$1,344.12

$175.26

Toc - Plan #43 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307

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

$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$441.20
$500.76
$563.85
$787.98
$1,197.41

$778.72
$838.28
$901.37
$1,125.50

$1,116.24
$1,175.80
$1,238.89
$1,463.02

$1,453.76
$1,513.32
$1,576.41
$1,800.54

$337.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$882.40
$1,001.52
$1,127.70
$1,575.96
$2,394.82

$1,219.92
$1,339.04
$1,465.22
$1,913.48

$1,557.44
$1,676.56
$1,802.74
$2,251.00

$1,894.96
$2,014.08
$2,140.26
$2,588.52

$337.52

Toc - Plan #44 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

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

$394.12
$447.32
$503.68
$703.88
$1,069.62

$695.62
$748.82
$805.18
$1,005.38

$997.12
$1,050.32
$1,106.68
$1,306.88

$1,298.62
$1,351.82
$1,408.18
$1,608.38

$301.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$788.24
$894.64
$1,007.36
$1,407.76
$2,139.24

$1,089.74
$1,196.14
$1,308.86
$1,709.26

$1,391.24
$1,497.64
$1,610.36
$2,010.76

$1,692.74
$1,799.14
$1,911.86
$2,312.26

$301.50

Toc - Plan #45 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Vision

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

$8,000 $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

$390.42
$443.12
$498.95
$697.28
$1,059.59

$689.09
$741.79
$797.62
$995.95

$987.76
$1,040.46
$1,096.29
$1,294.62

$1,286.43
$1,339.13
$1,394.96
$1,593.29

$298.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$780.84
$886.24
$997.90
$1,394.56
$2,119.18

$1,079.51
$1,184.91
$1,296.57
$1,693.23

$1,378.18
$1,483.58
$1,595.24
$1,991.90

$1,676.85
$1,782.25
$1,893.91
$2,290.57

$298.67

Toc - Plan #46 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$393.67
$446.81
$503.10
$703.08
$1,068.40

$694.82
$747.96
$804.25
$1,004.23

$995.97
$1,049.11
$1,105.40
$1,305.38

$1,297.12
$1,350.26
$1,406.55
$1,606.53

$301.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$787.34
$893.62
$1,006.20
$1,406.16
$2,136.80

$1,088.49
$1,194.77
$1,307.35
$1,707.31

$1,389.64
$1,495.92
$1,608.50
$2,008.46

$1,690.79
$1,797.07
$1,909.65
$2,309.61

$301.15

Toc - Plan #47 Quartz

Gold

(HMO) Quartz One with Aurora Health Care Gold I410 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$403.75
$458.25
$515.98
$721.08
$1,095.76

$712.61
$767.11
$824.84
$1,029.94

$1,021.47
$1,075.97
$1,133.70
$1,338.80

$1,330.33
$1,384.83
$1,442.56
$1,647.66

$308.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$807.50
$916.50
$1,031.96
$1,442.16
$2,191.52

$1,116.36
$1,225.36
$1,340.82
$1,751.02

$1,425.22
$1,534.22
$1,649.68
$2,059.88

$1,734.08
$1,843.08
$1,958.54
$2,368.74

$308.86

Toc - Plan #48 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$405.67
$460.43
$518.44
$724.51
$1,100.97

$716.00
$770.76
$828.77
$1,034.84

$1,026.33
$1,081.09
$1,139.10
$1,345.17

$1,336.66
$1,391.42
$1,449.43
$1,655.50

$310.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$811.34
$920.86
$1,036.88
$1,449.02
$2,201.94

$1,121.67
$1,231.19
$1,347.21
$1,759.35

$1,432.00
$1,541.52
$1,657.54
$2,069.68

$1,742.33
$1,851.85
$1,967.87
$2,380.01

$310.33

Toc - Plan #49 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$402.23
$456.53
$514.05
$718.38
$1,091.65

$709.94
$764.24
$821.76
$1,026.09

$1,017.65
$1,071.95
$1,129.47
$1,333.80

$1,325.36
$1,379.66
$1,437.18
$1,641.51

$307.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$804.46
$913.06
$1,028.10
$1,436.76
$2,183.30

$1,112.17
$1,220.77
$1,335.81
$1,744.47

$1,419.88
$1,528.48
$1,643.52
$2,052.18

$1,727.59
$1,836.19
$1,951.23
$2,359.89

$307.71

Toc - Plan #50 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,000 $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

$422.02
$478.98
$539.33
$753.72
$1,145.34

$744.86
$801.82
$862.17
$1,076.56

$1,067.70
$1,124.66
$1,185.01
$1,399.40

$1,390.54
$1,447.50
$1,507.85
$1,722.24

$322.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$844.04
$957.96
$1,078.66
$1,507.44
$2,290.68

$1,166.88
$1,280.80
$1,401.50
$1,830.28

$1,489.72
$1,603.64
$1,724.34
$2,153.12

$1,812.56
$1,926.48
$2,047.18
$2,475.96

$322.84

Toc - Plan #51 Quartz

Silver

(HMO) Quartz One with Aurora Health Care Silver I309 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 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

$442.00
$501.66
$564.87
$789.40
$1,199.57

$780.13
$839.79
$903.00
$1,127.53

$1,118.26
$1,177.92
$1,241.13
$1,465.66

$1,456.39
$1,516.05
$1,579.26
$1,803.79

$338.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$884.00
$1,003.32
$1,129.74
$1,578.80
$2,399.14

$1,222.13
$1,341.45
$1,467.87
$1,916.93

$1,560.26
$1,679.58
$1,806.00
$2,255.06

$1,898.39
$2,017.71
$2,144.13
$2,593.19

$338.13

Toc - Plan #52 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

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

$299.16
$339.55
$382.32
$534.30
$811.92

$528.02
$568.41
$611.18
$763.16

$756.88
$797.27
$840.04
$992.02

$985.74
$1,026.13
$1,068.90
$1,220.88

$228.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$598.32
$679.10
$764.64
$1,068.60
$1,623.84

$827.18
$907.96
$993.50
$1,297.46

$1,056.04
$1,136.82
$1,222.36
$1,526.32

$1,284.90
$1,365.68
$1,451.22
$1,755.18

$228.86

Toc - Plan #53 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$302.12
$342.91
$386.11
$539.58
$819.95

$533.24
$574.03
$617.23
$770.70

$764.36
$805.15
$848.35
$1,001.82

$995.48
$1,036.27
$1,079.47
$1,232.94

$231.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$604.24
$685.82
$772.22
$1,079.16
$1,639.90

$835.36
$916.94
$1,003.34
$1,310.28

$1,066.48
$1,148.06
$1,234.46
$1,541.40

$1,297.60
$1,379.18
$1,465.58
$1,772.52

$231.12

Toc - Plan #54 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Vision

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

$316.69
$359.44
$404.72
$565.60
$859.48

$558.95
$601.70
$646.98
$807.86

$801.21
$843.96
$889.24
$1,050.12

$1,043.47
$1,086.22
$1,131.50
$1,292.38

$242.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$633.38
$718.88
$809.44
$1,131.20
$1,718.96

$875.64
$961.14
$1,051.70
$1,373.46

$1,117.90
$1,203.40
$1,293.96
$1,615.72

$1,360.16
$1,445.66
$1,536.22
$1,857.98

$242.26

Toc - Plan #55 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$313.45
$355.76
$400.59
$559.82
$850.70

$553.24
$595.55
$640.38
$799.61

$793.03
$835.34
$880.17
$1,039.40

$1,032.82
$1,075.13
$1,119.96
$1,279.19

$239.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$626.90
$711.52
$801.18
$1,119.64
$1,701.40

$866.69
$951.31
$1,040.97
$1,359.43

$1,106.48
$1,191.10
$1,280.76
$1,599.22

$1,346.27
$1,430.89
$1,520.55
$1,839.01

$239.79

Toc - Plan #56 Quartz

Expanded Bronze

(HMO) Quartz One with Aurora Health Care Bronze I206 Standard with Vision

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

$9,000 $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

$326.36
$370.41
$417.08
$582.86
$885.72

$576.02
$620.07
$666.74
$832.52

$825.68
$869.73
$916.40
$1,082.18

$1,075.34
$1,119.39
$1,166.06
$1,331.84

$249.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$652.72
$740.82
$834.16
$1,165.72
$1,771.44

$902.38
$990.48
$1,083.82
$1,415.38

$1,152.04
$1,240.14
$1,333.48
$1,665.04

$1,401.70
$1,489.80
$1,583.14
$1,914.70

$249.66

Toc - Plan #57 Quartz

Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I403 HSA with Vision

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

$418.27
$474.73
$534.54
$747.02
$1,135.17

$738.24
$794.70
$854.51
$1,066.99

$1,058.21
$1,114.67
$1,174.48
$1,386.96

$1,378.18
$1,434.64
$1,494.45
$1,706.93

$319.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$836.54
$949.46
$1,069.08
$1,494.04
$2,270.34

$1,156.51
$1,269.43
$1,389.05
$1,814.01

$1,476.48
$1,589.40
$1,709.02
$2,133.98

$1,796.45
$1,909.37
$2,028.99
$2,453.95

$319.97

Toc - Plan #58 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I304 HSA with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$444.39
$504.38
$567.92
$793.67
$1,206.06

$784.34
$844.33
$907.87
$1,133.62

$1,124.29
$1,184.28
$1,247.82
$1,473.57

$1,464.24
$1,524.23
$1,587.77
$1,813.52

$339.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$888.78
$1,008.76
$1,135.84
$1,587.34
$2,412.12

$1,228.73
$1,348.71
$1,475.79
$1,927.29

$1,568.68
$1,688.66
$1,815.74
$2,267.24

$1,908.63
$2,028.61
$2,155.69
$2,607.19

$339.95

Toc - Plan #59 Quartz

Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307 with Vision

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

$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$446.33
$506.58
$570.40
$797.13
$1,211.32

$787.77
$848.02
$911.84
$1,138.57

$1,129.21
$1,189.46
$1,253.28
$1,480.01

$1,470.65
$1,530.90
$1,594.72
$1,821.45

$341.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$892.66
$1,013.16
$1,140.80
$1,594.26
$2,422.64

$1,234.10
$1,354.60
$1,482.24
$1,935.70

$1,575.54
$1,696.04
$1,823.68
$2,277.14

$1,916.98
$2,037.48
$2,165.12
$2,618.58

$341.44

Toc - Plan #60 Quartz

Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203 with Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$314.39
$356.83
$401.78
$561.49
$853.24

$554.89
$597.33
$642.28
$801.99

$795.39
$837.83
$882.78
$1,042.49

$1,035.89
$1,078.33
$1,123.28
$1,282.99

$240.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$628.78
$713.66
$803.56
$1,122.98
$1,706.48

$869.28
$954.16
$1,044.06
$1,363.48

$1,109.78
$1,194.66
$1,284.56
$1,603.98

$1,350.28
$1,435.16
$1,525.06
$1,844.48

$240.50

Molina Healthcare

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

Toc - Plan #61 Molina Healthcare

Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 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

$533.62
$605.66
$681.96
$953.04
$1,448.24

$941.84
$1,013.88
$1,090.18
$1,361.26

$1,350.06
$1,422.10
$1,498.40
$1,769.48

$1,758.28
$1,830.32
$1,906.62
$2,177.70

$408.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,067.24
$1,211.32
$1,363.92
$1,906.08
$2,896.48

$1,475.46
$1,619.54
$1,772.14
$2,314.30

$1,883.68
$2,027.76
$2,180.36
$2,722.52

$2,291.90
$2,435.98
$2,588.58
$3,130.74

$408.22

Toc - Plan #62 Molina Healthcare

Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$2,500 $5,000 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

$447.94
$508.41
$572.47
$800.02
$1,215.71

$790.61
$851.08
$915.14
$1,142.69

$1,133.28
$1,193.75
$1,257.81
$1,485.36

$1,475.95
$1,536.42
$1,600.48
$1,828.03

$342.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$895.88
$1,016.82
$1,144.94
$1,600.04
$2,431.42

$1,238.55
$1,359.49
$1,487.61
$1,942.71

$1,581.22
$1,702.16
$1,830.28
$2,285.38

$1,923.89
$2,044.83
$2,172.95
$2,628.05

$342.67

Toc - Plan #63 Molina Healthcare

Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$545.11
$618.70
$696.65
$973.57
$1,479.43

$962.12
$1,035.71
$1,113.66
$1,390.58

$1,379.13
$1,452.72
$1,530.67
$1,807.59

$1,796.14
$1,869.73
$1,947.68
$2,224.60

$417.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,090.22
$1,237.40
$1,393.30
$1,947.14
$2,958.86

$1,507.23
$1,654.41
$1,810.31
$2,364.15

$1,924.24
$2,071.42
$2,227.32
$2,781.16

$2,341.25
$2,488.43
$2,644.33
$3,198.17

$417.01

Toc - Plan #64 Molina Healthcare

Silver

(HMO) Constant Care Silver 8

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 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

$460.67
$522.86
$588.74
$822.76
$1,250.26

$813.08
$875.27
$941.15
$1,175.17

$1,165.49
$1,227.68
$1,293.56
$1,527.58

$1,517.90
$1,580.09
$1,645.97
$1,879.99

$352.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$921.34
$1,045.72
$1,177.48
$1,645.52
$2,500.52

$1,273.75
$1,398.13
$1,529.89
$1,997.93

$1,626.16
$1,750.54
$1,882.30
$2,350.34

$1,978.57
$2,102.95
$2,234.71
$2,702.75

$352.41

Toc - Plan #65 Molina Healthcare

Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 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

$538.66
$611.38
$688.41
$962.04
$1,461.92

$950.73
$1,023.45
$1,100.48
$1,374.11

$1,362.80
$1,435.52
$1,512.55
$1,786.18

$1,774.87
$1,847.59
$1,924.62
$2,198.25

$412.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,077.32
$1,222.76
$1,376.82
$1,924.08
$2,923.84

$1,489.39
$1,634.83
$1,788.89
$2,336.15

$1,901.46
$2,046.90
$2,200.96
$2,748.22

$2,313.53
$2,458.97
$2,613.03
$3,160.29

$412.07

Toc - Plan #66 Molina Healthcare

Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family

$2,500 $5,000 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

$460.17
$522.29
$588.09
$821.86
$1,248.90

$812.20
$874.32
$940.12
$1,173.89

$1,164.23
$1,226.35
$1,292.15
$1,525.92

$1,516.26
$1,578.38
$1,644.18
$1,877.95

$352.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$920.34
$1,044.58
$1,176.18
$1,643.72
$2,497.80

$1,272.37
$1,396.61
$1,528.21
$1,995.75

$1,624.40
$1,748.64
$1,880.24
$2,347.78

$1,976.43
$2,100.67
$2,232.27
$2,699.81

$352.03

Anthem Blue Cross and Blue Shield

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

Toc - Plan #67 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) 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

$9,100 $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

$388.80
$441.29
$496.89
$694.40
$1,055.20

$686.23
$738.72
$794.32
$991.83

$983.66
$1,036.15
$1,091.75
$1,289.26

$1,281.09
$1,333.58
$1,389.18
$1,586.69

$297.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$777.60
$882.58
$993.78
$1,388.80
$2,110.40

$1,075.03
$1,180.01
$1,291.21
$1,686.23

$1,372.46
$1,477.44
$1,588.64
$1,983.66

$1,669.89
$1,774.87
$1,886.07
$2,281.09

$297.43

Toc - Plan #68 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 5000 ($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

$5,000 $10,000 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

$376.98
$427.87
$481.78
$673.29
$1,023.12

$665.37
$716.26
$770.17
$961.68

$953.76
$1,004.65
$1,058.56
$1,250.07

$1,242.15
$1,293.04
$1,346.95
$1,538.46

$288.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$753.96
$855.74
$963.56
$1,346.58
$2,046.24

$1,042.35
$1,144.13
$1,251.95
$1,634.97

$1,330.74
$1,432.52
$1,540.34
$1,923.36

$1,619.13
$1,720.91
$1,828.73
$2,211.75

$288.39

Toc - Plan #69 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 6550 ($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

$6,550 $13,100 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

$370.22
$420.20
$473.14
$661.21
$1,004.78

$653.44
$703.42
$756.36
$944.43

$936.66
$986.64
$1,039.58
$1,227.65

$1,219.88
$1,269.86
$1,322.80
$1,510.87

$283.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$740.44
$840.40
$946.28
$1,322.42
$2,009.56

$1,023.66
$1,123.62
$1,229.50
$1,605.64

$1,306.88
$1,406.84
$1,512.72
$1,888.86

$1,590.10
$1,690.06
$1,795.94
$2,172.08

$283.22

Toc - Plan #70 Anthem Blue Cross and Blue Shield

Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100 ($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

$9,100 $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

$350.92
$398.29
$448.48
$626.74
$952.40

$619.37
$666.74
$716.93
$895.19

$887.82
$935.19
$985.38
$1,163.64

$1,156.27
$1,203.64
$1,253.83
$1,432.09

$268.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$701.84
$796.58
$896.96
$1,253.48
$1,904.80

$970.29
$1,065.03
$1,165.41
$1,521.93

$1,238.74
$1,333.48
$1,433.86
$1,790.38

$1,507.19
$1,601.93
$1,702.31
$2,058.83

$268.45

Toc - Plan #71 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) 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

$7,450 $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

$369.45
$419.33
$472.16
$659.84
$1,002.69

$652.08
$701.96
$754.79
$942.47

$934.71
$984.59
$1,037.42
$1,225.10

$1,217.34
$1,267.22
$1,320.05
$1,507.73

$282.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$738.90
$838.66
$944.32
$1,319.68
$2,005.38

$1,021.53
$1,121.29
$1,226.95
$1,602.31

$1,304.16
$1,403.92
$1,509.58
$1,884.94

$1,586.79
$1,686.55
$1,792.21
$2,167.57

$282.63

Toc - Plan #72 Anthem Blue Cross and Blue Shield

Gold

(HMO) 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

$6,900 $13,800 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

$479.25
$543.95
$612.48
$855.94
$1,300.68

$845.88
$910.58
$979.11
$1,222.57

$1,212.51
$1,277.21
$1,345.74
$1,589.20

$1,579.14
$1,643.84
$1,712.37
$1,955.83

$366.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$958.50
$1,087.90
$1,224.96
$1,711.88
$2,601.36

$1,325.13
$1,454.53
$1,591.59
$2,078.51

$1,691.76
$1,821.16
$1,958.22
$2,445.14

$2,058.39
$2,187.79
$2,324.85
$2,811.77

$366.63

Toc - Plan #73 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Blue Preferred/Broad 4000 ($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

$4,000 $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

$462.71
$525.18
$591.34
$826.40
$1,255.79

$816.68
$879.15
$945.31
$1,180.37

$1,170.65
$1,233.12
$1,299.28
$1,534.34

$1,524.62
$1,587.09
$1,653.25
$1,888.31

$353.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$925.42
$1,050.36
$1,182.68
$1,652.80
$2,511.58

$1,279.39
$1,404.33
$1,536.65
$2,006.77

$1,633.36
$1,758.30
$1,890.62
$2,360.74

$1,987.33
$2,112.27
$2,244.59
$2,714.71

$353.97

Toc - Plan #74 Anthem Blue Cross and Blue Shield

Silver

(HMO) 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

$7,250 $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

$468.27
$531.49
$598.45
$836.33
$1,270.88

$826.50
$889.72
$956.68
$1,194.56

$1,184.73
$1,247.95
$1,314.91
$1,552.79

$1,542.96
$1,606.18
$1,673.14
$1,911.02

$358.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$936.54
$1,062.98
$1,196.90
$1,672.66
$2,541.76

$1,294.77
$1,421.21
$1,555.13
$2,030.89

$1,653.00
$1,779.44
$1,913.36
$2,389.12

$2,011.23
$2,137.67
$2,271.59
$2,747.35

$358.23

Toc - Plan #75 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Blue Preferred/Broad 5300 ($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

$5,300 $10,600 Annual Deductible

$8,250 $16,500 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

$459.98
$522.08
$587.85
$821.52
$1,248.39

$811.86
$873.96
$939.73
$1,173.40

$1,163.74
$1,225.84
$1,291.61
$1,525.28

$1,515.62
$1,577.72
$1,643.49
$1,877.16

$351.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$919.96
$1,044.16
$1,175.70
$1,643.04
$2,496.78

$1,271.84
$1,396.04
$1,527.58
$1,994.92

$1,623.72
$1,747.92
$1,879.46
$2,346.80

$1,975.60
$2,099.80
$2,231.34
$2,698.68

$351.88

Toc - Plan #76 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Pathway/Lean 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$7,450 $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

$293.01
$332.57
$374.47
$523.32
$795.23

$517.16
$556.72
$598.62
$747.47

$741.31
$780.87
$822.77
$971.62

$965.46
$1,005.02
$1,046.92
$1,195.77

$224.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$586.02
$665.14
$748.94
$1,046.64
$1,590.46

$810.17
$889.29
$973.09
$1,270.79

$1,034.32
$1,113.44
$1,197.24
$1,494.94

$1,258.47
$1,337.59
$1,421.39
$1,719.09

$224.15

Toc - Plan #77 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Pathway/Lean 5000 ($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

$5,000 $10,000 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

$298.92
$339.27
$382.02
$533.87
$811.27

$527.59
$567.94
$610.69
$762.54

$756.26
$796.61
$839.36
$991.21

$984.93
$1,025.28
$1,068.03
$1,219.88

$228.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$597.84
$678.54
$764.04
$1,067.74
$1,622.54

$826.51
$907.21
$992.71
$1,296.41

$1,055.18
$1,135.88
$1,221.38
$1,525.08

$1,283.85
$1,364.55
$1,450.05
$1,753.75

$228.67

Toc - Plan #78 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Pathway/Lean 6550 ($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

$6,550 $13,100 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

$293.62
$333.26
$375.25
$524.41
$796.88

$518.24
$557.88
$599.87
$749.03

$742.86
$782.50
$824.49
$973.65

$967.48
$1,007.12
$1,049.11
$1,198.27

$224.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$587.24
$666.52
$750.50
$1,048.82
$1,593.76

$811.86
$891.14
$975.12
$1,273.44

$1,036.48
$1,115.76
$1,199.74
$1,498.06

$1,261.10
$1,340.38
$1,424.36
$1,722.68

$224.62

Toc - Plan #79 Anthem Blue Cross and Blue Shield

Bronze

(HMO) Anthem Bronze Pathway/Lean 9100 ($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

$9,100 $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

$278.31
$315.88
$355.68
$497.06
$755.33

$491.22
$528.79
$568.59
$709.97

$704.13
$741.70
$781.50
$922.88

$917.04
$954.61
$994.41
$1,135.79

$212.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$556.62
$631.76
$711.36
$994.12
$1,510.66

$769.53
$844.67
$924.27
$1,207.03

$982.44
$1,057.58
$1,137.18
$1,419.94

$1,195.35
$1,270.49
$1,350.09
$1,632.85

$212.91

Toc - Plan #80 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Pathway/Lean 4000 ($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

$4,000 $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

$338.64
$384.36
$432.78
$604.81
$919.07

$597.70
$643.42
$691.84
$863.87

$856.76
$902.48
$950.90
$1,122.93

$1,115.82
$1,161.54
$1,209.96
$1,381.99

$259.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$677.28
$768.72
$865.56
$1,209.62
$1,838.14

$936.34
$1,027.78
$1,124.62
$1,468.68

$1,195.40
$1,286.84
$1,383.68
$1,727.74

$1,454.46
$1,545.90
$1,642.74
$1,986.80

$259.06

Toc - Plan #81 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Pathway/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

$7,250 $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

$342.70
$388.96
$437.97
$612.06
$930.09

$604.87
$651.13
$700.14
$874.23

$867.04
$913.30
$962.31
$1,136.40

$1,129.21
$1,175.47
$1,224.48
$1,398.57

$262.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$685.40
$777.92
$875.94
$1,224.12
$1,860.18

$947.57
$1,040.09
$1,138.11
$1,486.29

$1,209.74
$1,302.26
$1,400.28
$1,748.46

$1,471.91
$1,564.43
$1,662.45
$2,010.63

$262.17

Toc - Plan #82 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Pathway/Lean 5300 ($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

$5,300 $10,600 Annual Deductible

$8,250 $16,500 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

$336.64
$382.09
$430.23
$601.24
$913.64

$594.17
$639.62
$687.76
$858.77

$851.70
$897.15
$945.29
$1,116.30

$1,109.23
$1,154.68
$1,202.82
$1,373.83

$257.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$673.28
$764.18
$860.46
$1,202.48
$1,827.28

$930.81
$1,021.71
$1,117.99
$1,460.01

$1,188.34
$1,279.24
$1,375.52
$1,717.54

$1,445.87
$1,536.77
$1,633.05
$1,975.07

$257.53

Toc - Plan #83 Anthem Blue Cross and Blue Shield

Gold

(HMO) Anthem Gold Pathway/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

$6,900 $13,800 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

$350.73
$398.08
$448.23
$626.40
$951.88

$619.04
$666.39
$716.54
$894.71

$887.35
$934.70
$984.85
$1,163.02

$1,155.66
$1,203.01
$1,253.16
$1,431.33

$268.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$701.46
$796.16
$896.46
$1,252.80
$1,903.76

$969.77
$1,064.47
$1,164.77
$1,521.11

$1,238.08
$1,332.78
$1,433.08
$1,789.42

$1,506.39
$1,601.09
$1,701.39
$2,057.73

$268.31

Toc - Plan #84 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Pathway/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

$9,100 $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

$299.15
$339.54
$382.31
$534.28
$811.89

$528.00
$568.39
$611.16
$763.13

$756.85
$797.24
$840.01
$991.98

$985.70
$1,026.09
$1,068.86
$1,220.83

$228.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$598.30
$679.08
$764.62
$1,068.56
$1,623.78

$827.15
$907.93
$993.47
$1,297.41

$1,056.00
$1,136.78
$1,222.32
$1,526.26

$1,284.85
$1,365.63
$1,451.17
$1,755.11

$228.85

Toc - Plan #85 Anthem Blue Cross and Blue Shield

Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$351.42
$398.86
$449.11
$627.64
$953.75

$620.26
$667.70
$717.95
$896.48

$889.10
$936.54
$986.79
$1,165.32

$1,157.94
$1,205.38
$1,255.63
$1,434.16

$268.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$702.84
$797.72
$898.22
$1,255.28
$1,907.50

$971.68
$1,066.56
$1,167.06
$1,524.12

$1,240.52
$1,335.40
$1,435.90
$1,792.96

$1,509.36
$1,604.24
$1,704.74
$2,061.80

$268.84

Toc - Plan #86 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) 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

$9,000 $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

$381.96
$433.52
$488.14
$682.18
$1,036.64

$674.16
$725.72
$780.34
$974.38

$966.36
$1,017.92
$1,072.54
$1,266.58

$1,258.56
$1,310.12
$1,364.74
$1,558.78

$292.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$763.92
$867.04
$976.28
$1,364.36
$2,073.28

$1,056.12
$1,159.24
$1,268.48
$1,656.56

$1,348.32
$1,451.44
$1,560.68
$1,948.76

$1,640.52
$1,743.64
$1,852.88
$2,240.96

$292.20

Toc - Plan #87 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Blue Preferred/Broad 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 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

$456.07
$517.64
$582.86
$814.54
$1,237.77

$804.96
$866.53
$931.75
$1,163.43

$1,153.85
$1,215.42
$1,280.64
$1,512.32

$1,502.74
$1,564.31
$1,629.53
$1,861.21

$348.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$912.14
$1,035.28
$1,165.72
$1,629.08
$2,475.54

$1,261.03
$1,384.17
$1,514.61
$1,977.97

$1,609.92
$1,733.06
$1,863.50
$2,326.86

$1,958.81
$2,081.95
$2,212.39
$2,675.75

$348.89

Toc - Plan #88 Anthem Blue Cross and Blue Shield

Gold

(HMO) Anthem Gold Blue Preferred/Broad 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$479.59
$544.33
$612.92
$856.55
$1,301.61

$846.48
$911.22
$979.81
$1,223.44

$1,213.37
$1,278.11
$1,346.70
$1,590.33

$1,580.26
$1,645.00
$1,713.59
$1,957.22

$366.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$959.18
$1,088.66
$1,225.84
$1,713.10
$2,603.22

$1,326.07
$1,455.55
$1,592.73
$2,079.99

$1,692.96
$1,822.44
$1,959.62
$2,446.88

$2,059.85
$2,189.33
$2,326.51
$2,813.77

$366.89

Toc - Plan #89 Anthem Blue Cross and Blue Shield

Bronze

(HMO) Anthem Bronze Pathway/Lean 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

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

$278.73
$316.36
$356.22
$497.81
$756.47

$491.96
$529.59
$569.45
$711.04

$705.19
$742.82
$782.68
$924.27

$918.42
$956.05
$995.91
$1,137.50

$213.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$557.46
$632.72
$712.44
$995.62
$1,512.94

$770.69
$845.95
$925.67
$1,208.85

$983.92
$1,059.18
$1,138.90
$1,422.08

$1,197.15
$1,272.41
$1,352.13
$1,635.31

$213.23

Toc - Plan #90 Anthem Blue Cross and Blue Shield

Gold

(HMO) Anthem Gold Pathway/Lean 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$350.99
$398.37
$448.57
$626.87
$952.59

$619.50
$666.88
$717.08
$895.38

$888.01
$935.39
$985.59
$1,163.89

$1,156.52
$1,203.90
$1,254.10
$1,432.40

$268.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$701.98
$796.74
$897.14
$1,253.74
$1,905.18

$970.49
$1,065.25
$1,165.65
$1,522.25

$1,239.00
$1,333.76
$1,434.16
$1,790.76

$1,507.51
$1,602.27
$1,702.67
$2,059.27

$268.51

Toc - Plan #91 Anthem Blue Cross and Blue Shield

Silver

(HMO) Anthem Silver Pathway/Lean 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 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

$333.76
$378.82
$426.55
$596.10
$905.82

$589.09
$634.15
$681.88
$851.43

$844.42
$889.48
$937.21
$1,106.76

$1,099.75
$1,144.81
$1,192.54
$1,362.09

$255.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$667.52
$757.64
$853.10
$1,192.20
$1,811.64

$922.85
$1,012.97
$1,108.43
$1,447.53

$1,178.18
$1,268.30
$1,363.76
$1,702.86

$1,433.51
$1,523.63
$1,619.09
$1,958.19

$255.33

Toc - Plan #92 Anthem Blue Cross and Blue Shield

Expanded Bronze

(HMO) Anthem Bronze Pathway/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

$9,000 $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

$302.91
$343.80
$387.12
$541.00
$822.10

$534.64
$575.53
$618.85
$772.73

$766.37
$807.26
$850.58
$1,004.46

$998.10
$1,038.99
$1,082.31
$1,236.19

$231.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$605.82
$687.60
$774.24
$1,082.00
$1,644.20

$837.55
$919.33
$1,005.97
$1,313.73

$1,069.28
$1,151.06
$1,237.70
$1,545.46

$1,301.01
$1,382.79
$1,469.43
$1,777.19

$231.73

Network Health

Local: 1-920-720-1400x1400 | Toll Free: 1-855-275-1400 | TTY: 1-800-947-3529

Toc - Plan #93 Network Health

Expanded Bronze

(HMO) Prestige Bronze 20 HDHP + Dental + Vision + Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$382.96
$434.66
$489.42
$683.96
$1,039.34

$675.92
$727.62
$782.38
$976.92

$968.88
$1,020.58
$1,075.34
$1,269.88

$1,261.84
$1,313.54
$1,368.30
$1,562.84

$292.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.92
$869.32
$978.84
$1,367.92
$2,078.68

$1,058.88
$1,162.28
$1,271.80
$1,660.88

$1,351.84
$1,455.24
$1,564.76
$1,953.84

$1,644.80
$1,748.20
$1,857.72
$2,246.80

$292.96

Toc - Plan #94 Network Health

Expanded Bronze

(HMO) Prestige Bronze Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$7,750 $15,500 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

$370.60
$420.63
$473.63
$661.89
$1,005.81

$654.11
$704.14
$757.14
$945.40

$937.62
$987.65
$1,040.65
$1,228.91

$1,221.13
$1,271.16
$1,324.16
$1,512.42

$283.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$741.20
$841.26
$947.26
$1,323.78
$2,011.62

$1,024.71
$1,124.77
$1,230.77
$1,607.29

$1,308.22
$1,408.28
$1,514.28
$1,890.80

$1,591.73
$1,691.79
$1,797.79
$2,174.31

$283.51

Toc - Plan #95 Network Health

Silver

(HMO) Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$4,600 $9,200 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

$571.44
$648.58
$730.30
$1,020.59
$1,550.88

$1,008.59
$1,085.73
$1,167.45
$1,457.74

$1,445.74
$1,522.88
$1,604.60
$1,894.89

$1,882.89
$1,960.03
$2,041.75
$2,332.04

$437.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,142.88
$1,297.16
$1,460.60
$2,041.18
$3,101.76

$1,580.03
$1,734.31
$1,897.75
$2,478.33

$2,017.18
$2,171.46
$2,334.90
$2,915.48

$2,454.33
$2,608.61
$2,772.05
$3,352.63

$437.15

Toc - Plan #96 Network Health

Gold

(HMO) Prestige Gold Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$1,750 $3,500 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

$525.15
$596.05
$671.15
$937.92
$1,425.26

$926.89
$997.79
$1,072.89
$1,339.66

$1,328.63
$1,399.53
$1,474.63
$1,741.40

$1,730.37
$1,801.27
$1,876.37
$2,143.14

$401.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,050.30
$1,192.10
$1,342.30
$1,875.84
$2,850.52

$1,452.04
$1,593.84
$1,744.04
$2,277.58

$1,853.78
$1,995.58
$2,145.78
$2,679.32

$2,255.52
$2,397.32
$2,547.52
$3,081.06

$401.74

Toc - Plan #97 Network Health

Gold

(HMO) Prestige Gold 50 + Dental + Vision + Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$4,300 $8,600 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

$541.35
$614.44
$691.85
$966.86
$1,469.23

$955.49
$1,028.58
$1,105.99
$1,381.00

$1,369.63
$1,442.72
$1,520.13
$1,795.14

$1,783.77
$1,856.86
$1,934.27
$2,209.28

$414.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,082.70
$1,228.88
$1,383.70
$1,933.72
$2,938.46

$1,496.84
$1,643.02
$1,797.84
$2,347.86

$1,910.98
$2,057.16
$2,211.98
$2,762.00

$2,325.12
$2,471.30
$2,626.12
$3,176.14

$414.14

Toc - Plan #98 Network Health

Expanded Bronze

(HMO) Signature Prestige Bronze Copay + Dental + Vision + Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$372.88
$423.22
$476.55
$665.97
$1,012.00

$658.14
$708.48
$761.81
$951.23

$943.40
$993.74
$1,047.07
$1,236.49

$1,228.66
$1,279.00
$1,332.33
$1,521.75

$285.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$745.76
$846.44
$953.10
$1,331.94
$2,024.00

$1,031.02
$1,131.70
$1,238.36
$1,617.20

$1,316.28
$1,416.96
$1,523.62
$1,902.46

$1,601.54
$1,702.22
$1,808.88
$2,187.72

$285.26

Toc - Plan #99 Network Health

Bronze

(HMO) Prestige Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

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

$337.92
$383.54
$431.86
$603.52
$917.11

$596.43
$642.05
$690.37
$862.03

$854.94
$900.56
$948.88
$1,120.54

$1,113.45
$1,159.07
$1,207.39
$1,379.05

$258.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$675.84
$767.08
$863.72
$1,207.04
$1,834.22

$934.35
$1,025.59
$1,122.23
$1,465.55

$1,192.86
$1,284.10
$1,380.74
$1,724.06

$1,451.37
$1,542.61
$1,639.25
$1,982.57

$258.51

Toc - Plan #100 Network Health

Expanded Bronze

(HMO) Prestige Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$362.35
$411.27
$463.08
$647.16
$983.41

$639.55
$688.47
$740.28
$924.36

$916.75
$965.67
$1,017.48
$1,201.56

$1,193.95
$1,242.87
$1,294.68
$1,478.76

$277.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$724.70
$822.54
$926.16
$1,294.32
$1,966.82

$1,001.90
$1,099.74
$1,203.36
$1,571.52

$1,279.10
$1,376.94
$1,480.56
$1,848.72

$1,556.30
$1,654.14
$1,757.76
$2,125.92

$277.20

Toc - Plan #101 Network Health

Silver

(HMO) Prestige Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 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

$586.46
$665.63
$749.50
$1,047.41
$1,591.65

$1,035.10
$1,114.27
$1,198.14
$1,496.05

$1,483.74
$1,562.91
$1,646.78
$1,944.69

$1,932.38
$2,011.55
$2,095.42
$2,393.33

$448.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,172.92
$1,331.26
$1,499.00
$2,094.82
$3,183.30

$1,621.56
$1,779.90
$1,947.64
$2,543.46

$2,070.20
$2,228.54
$2,396.28
$2,992.10

$2,518.84
$2,677.18
$2,844.92
$3,440.74

$448.64

Toc - Plan #102 Network Health

Gold

(HMO) Prestige Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$524.52
$595.33
$670.33
$936.78
$1,423.53

$925.78
$996.59
$1,071.59
$1,338.04

$1,327.04
$1,397.85
$1,472.85
$1,739.30

$1,728.30
$1,799.11
$1,874.11
$2,140.56

$401.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,049.04
$1,190.66
$1,340.66
$1,873.56
$2,847.06

$1,450.30
$1,591.92
$1,741.92
$2,274.82

$1,851.56
$1,993.18
$2,143.18
$2,676.08

$2,252.82
$2,394.44
$2,544.44
$3,077.34

$401.26

Common Ground Healthcare Cooperative

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

Toc - Plan #103 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Copay Bronze $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

$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

$314.22
$356.62
$401.56
$561.17
$852.76

$554.59
$596.99
$641.93
$801.54

$794.96
$837.36
$882.30
$1,041.91

$1,035.33
$1,077.73
$1,122.67
$1,282.28

$240.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$628.44
$713.24
$803.12
$1,122.34
$1,705.52

$868.81
$953.61
$1,043.49
$1,362.71

$1,109.18
$1,193.98
$1,283.86
$1,603.08

$1,349.55
$1,434.35
$1,524.23
$1,843.45

$240.37

Toc - Plan #104 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Copay Silver $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

$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

$446.12
$506.33
$570.13
$796.75
$1,210.74

$787.39
$847.60
$911.40
$1,138.02

$1,128.66
$1,188.87
$1,252.67
$1,479.29

$1,469.93
$1,530.14
$1,593.94
$1,820.56

$341.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$892.24
$1,012.66
$1,140.26
$1,593.50
$2,421.48

$1,233.51
$1,353.93
$1,481.53
$1,934.77

$1,574.78
$1,695.20
$1,822.80
$2,276.04

$1,916.05
$2,036.47
$2,164.07
$2,617.31

$341.27

Toc - Plan #105 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

$8,000 $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

$480.80
$545.69
$614.45
$858.69
$1,304.86

$848.60
$913.49
$982.25
$1,226.49

$1,216.40
$1,281.29
$1,350.05
$1,594.29

$1,584.20
$1,649.09
$1,717.85
$1,962.09

$367.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$961.60
$1,091.38
$1,228.90
$1,717.38
$2,609.72

$1,329.40
$1,459.18
$1,596.70
$2,085.18

$1,697.20
$1,826.98
$1,964.50
$2,452.98

$2,065.00
$2,194.78
$2,332.30
$2,820.78

$367.80

Toc - Plan #106 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

$9,100 $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

$414.73
$470.71
$530.01
$740.69
$1,125.56

$731.99
$787.97
$847.27
$1,057.95

$1,049.25
$1,105.23
$1,164.53
$1,375.21

$1,366.51
$1,422.49
$1,481.79
$1,692.47

$317.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$829.46
$941.42
$1,060.02
$1,481.38
$2,251.12

$1,146.72
$1,258.68
$1,377.28
$1,798.64

$1,463.98
$1,575.94
$1,694.54
$2,115.90

$1,781.24
$1,893.20
$2,011.80
$2,433.16

$317.26

Toc - Plan #107 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

$454.26
$515.57
$580.53
$811.29
$1,232.83

$801.76
$863.07
$928.03
$1,158.79

$1,149.26
$1,210.57
$1,275.53
$1,506.29

$1,496.76
$1,558.07
$1,623.03
$1,853.79

$347.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$908.52
$1,031.14
$1,161.06
$1,622.58
$2,465.66

$1,256.02
$1,378.64
$1,508.56
$1,970.08

$1,603.52
$1,726.14
$1,856.06
$2,317.58

$1,951.02
$2,073.64
$2,203.56
$2,665.08

$347.50

Toc - Plan #108 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

$9,100 $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

$409.25
$464.48
$523.00
$730.90
$1,110.67

$722.32
$777.55
$836.07
$1,043.97

$1,035.39
$1,090.62
$1,149.14
$1,357.04

$1,348.46
$1,403.69
$1,462.21
$1,670.11

$313.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$818.50
$928.96
$1,046.00
$1,461.80
$2,221.34

$1,131.57
$1,242.03
$1,359.07
$1,774.87

$1,444.64
$1,555.10
$1,672.14
$2,087.94

$1,757.71
$1,868.17
$1,985.21
$2,401.01

$313.07

Toc - Plan #109 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5000 - 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

$9,100 $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

$350.11
$397.37
$447.43
$625.29
$950.18

$617.94
$665.20
$715.26
$893.12

$885.77
$933.03
$983.09
$1,160.95

$1,153.60
$1,200.86
$1,250.92
$1,428.78

$267.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$700.22
$794.74
$894.86
$1,250.58
$1,900.36

$968.05
$1,062.57
$1,162.69
$1,518.41

$1,235.88
$1,330.40
$1,430.52
$1,786.24

$1,503.71
$1,598.23
$1,698.35
$2,054.07

$267.83

Toc - Plan #110 Common Ground Healthcare Cooperative

Catastrophic

(EPO) CGHC Catastrophic $9100 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$205.93
$233.72
$263.16
$367.77
$558.86

$363.46
$391.25
$420.69
$525.30

$520.99
$548.78
$578.22
$682.83

$678.52
$706.31
$735.75
$840.36

$157.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$411.86
$467.44
$526.32
$735.54
$1,117.72

$569.39
$624.97
$683.85
$893.07

$726.92
$782.50
$841.38
$1,050.60

$884.45
$940.03
$998.91
$1,208.13

$157.53

Toc - Plan #111 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Bronze $9100 ($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

$9,100 $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

$294.36
$334.09
$376.18
$525.71
$798.86

$519.54
$559.27
$601.36
$750.89

$744.72
$784.45
$826.54
$976.07

$969.90
$1,009.63
$1,051.72
$1,201.25

$225.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$588.72
$668.18
$752.36
$1,051.42
$1,597.72

$813.90
$893.36
$977.54
$1,276.60

$1,039.08
$1,118.54
$1,202.72
$1,501.78

$1,264.26
$1,343.72
$1,427.90
$1,726.96

$225.18

Toc - Plan #112 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Bronze $8150 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$8,150 $16,300 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

$305.50
$346.73
$390.42
$545.60
$829.10

$539.20
$580.43
$624.12
$779.30

$772.90
$814.13
$857.82
$1,013.00

$1,006.60
$1,047.83
$1,091.52
$1,246.70

$233.70

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$611.00
$693.46
$780.84
$1,091.20
$1,658.20

$844.70
$927.16
$1,014.54
$1,324.90

$1,078.40
$1,160.86
$1,248.24
$1,558.60

$1,312.10
$1,394.56
$1,481.94
$1,792.30

$233.70

Toc - Plan #113 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

$303.89
$344.91
$388.36
$542.74
$824.74

$536.36
$577.38
$620.83
$775.21

$768.83
$809.85
$853.30
$1,007.68

$1,001.30
$1,042.32
$1,085.77
$1,240.15

$232.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$607.78
$689.82
$776.72
$1,085.48
$1,649.48

$840.25
$922.29
$1,009.19
$1,317.95

$1,072.72
$1,154.76
$1,241.66
$1,550.42

$1,305.19
$1,387.23
$1,474.13
$1,782.89

$232.47

Toc - Plan #114 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC HSA 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

$3,000 $6,000 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

$482.93
$548.11
$617.17
$862.49
$1,310.64

$852.36
$917.54
$986.60
$1,231.92

$1,221.79
$1,286.97
$1,356.03
$1,601.35

$1,591.22
$1,656.40
$1,725.46
$1,970.78

$369.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$965.86
$1,096.22
$1,234.34
$1,724.98
$2,621.28

$1,335.29
$1,465.65
$1,603.77
$2,094.41

$1,704.72
$1,835.08
$1,973.20
$2,463.84

$2,074.15
$2,204.51
$2,342.63
$2,833.27

$369.43

Toc - Plan #115 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC HSA Silver $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

$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

$468.33
$531.54
$598.51
$836.41
$1,271.01

$826.59
$889.80
$956.77
$1,194.67

$1,184.85
$1,248.06
$1,315.03
$1,552.93

$1,543.11
$1,606.32
$1,673.29
$1,911.19

$358.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$936.66
$1,063.08
$1,197.02
$1,672.82
$2,542.02

$1,294.92
$1,421.34
$1,555.28
$2,031.08

$1,653.18
$1,779.60
$1,913.54
$2,389.34

$2,011.44
$2,137.86
$2,271.80
$2,747.60

$358.26

Toc - Plan #116 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

$9,100 $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

$301.69
$342.41
$385.55
$538.80
$818.76

$532.48
$573.20
$616.34
$769.59

$763.27
$803.99
$847.13
$1,000.38

$994.06
$1,034.78
$1,077.92
$1,231.17

$230.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$603.38
$684.82
$771.10
$1,077.60
$1,637.52

$834.17
$915.61
$1,001.89
$1,308.39

$1,064.96
$1,146.40
$1,232.68
$1,539.18

$1,295.75
$1,377.19
$1,463.47
$1,769.97

$230.79

Toc - Plan #117 Common Ground Healthcare Cooperative

Bronze

(EPO) Bronze Standard Plan - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$292.23
$331.67
$373.46
$521.90
$793.08

$515.78
$555.22
$597.01
$745.45

$739.33
$778.77
$820.56
$969.00

$962.88
$1,002.32
$1,044.11
$1,192.55

$223.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$584.46
$663.34
$746.92
$1,043.80
$1,586.16

$808.01
$886.89
$970.47
$1,267.35

$1,031.56
$1,110.44
$1,194.02
$1,490.90

$1,255.11
$1,333.99
$1,417.57
$1,714.45

$223.55

Toc - Plan #118 Common Ground Healthcare Cooperative

Silver

(EPO) Silver Standard Plan - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 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

$353.64
$401.37
$451.94
$631.58
$959.75

$624.17
$671.90
$722.47
$902.11

$894.70
$942.43
$993.00
$1,172.64

$1,165.23
$1,212.96
$1,263.53
$1,443.17

$270.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$707.28
$802.74
$903.88
$1,263.16
$1,919.50

$977.81
$1,073.27
$1,174.41
$1,533.69

$1,248.34
$1,343.80
$1,444.94
$1,804.22

$1,518.87
$1,614.33
$1,715.47
$2,074.75

$270.53

Toc - Plan #119 Common Ground Healthcare Cooperative

Gold

(EPO) Gold Standard Plan - Envision Network

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$422.80
$479.87
$540.32
$755.10
$1,147.45

$746.23
$803.30
$863.75
$1,078.53

$1,069.66
$1,126.73
$1,187.18
$1,401.96

$1,393.09
$1,450.16
$1,510.61
$1,725.39

$323.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$845.60
$959.74
$1,080.64
$1,510.20
$2,294.90

$1,169.03
$1,283.17
$1,404.07
$1,833.63

$1,492.46
$1,606.60
$1,727.50
$2,157.06

$1,815.89
$1,930.03
$2,050.93
$2,480.49

$323.43

Toc - Plan #120 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5650 - 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

$9,100 $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

$349.88
$397.11
$447.14
$624.87
$949.56

$617.53
$664.76
$714.79
$892.52

$885.18
$932.41
$982.44
$1,160.17

$1,152.83
$1,200.06
$1,250.09
$1,427.82

$267.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$699.76
$794.22
$894.28
$1,249.74
$1,899.12

$967.41
$1,061.87
$1,161.93
$1,517.39

$1,235.06
$1,329.52
$1,429.58
$1,785.04

$1,502.71
$1,597.17
$1,697.23
$2,052.69

$267.65

Toc - Plan #121 Common Ground Healthcare Cooperative

Gold

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

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

$457.49
$519.24
$584.66
$817.06
$1,241.60

$807.46
$869.21
$934.63
$1,167.03

$1,157.43
$1,219.18
$1,284.60
$1,517.00

$1,507.40
$1,569.15
$1,634.57
$1,866.97

$349.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$914.98
$1,038.48
$1,169.32
$1,634.12
$2,483.20

$1,264.95
$1,388.45
$1,519.29
$1,984.09

$1,614.92
$1,738.42
$1,869.26
$2,334.06

$1,964.89
$2,088.39
$2,219.23
$2,684.03

$349.97

Toc - Plan #122 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC Gold $2000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$425.60
$483.04
$543.90
$760.10
$1,155.05

$751.18
$808.62
$869.48
$1,085.68

$1,076.76
$1,134.20
$1,195.06
$1,411.26

$1,402.34
$1,459.78
$1,520.64
$1,736.84

$325.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$851.20
$966.08
$1,087.80
$1,520.20
$2,310.10

$1,176.78
$1,291.66
$1,413.38
$1,845.78

$1,502.36
$1,617.24
$1,738.96
$2,171.36

$1,827.94
$1,942.82
$2,064.54
$2,496.94

$325.58

Toc - Plan #123 Common Ground Healthcare Cooperative

Gold

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

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

$9,100 $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

$417.93
$474.34
$534.10
$746.41
$1,134.24

$737.64
$794.05
$853.81
$1,066.12

$1,057.35
$1,113.76
$1,173.52
$1,385.83

$1,377.06
$1,433.47
$1,493.23
$1,705.54

$319.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$835.86
$948.68
$1,068.20
$1,492.82
$2,268.48

$1,155.57
$1,268.39
$1,387.91
$1,812.53

$1,475.28
$1,588.10
$1,707.62
$2,132.24

$1,794.99
$1,907.81
$2,027.33
$2,451.95

$319.71

Toc - Plan #124 Common Ground Healthcare Cooperative

Silver

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

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

$9,100 $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

$412.45
$468.11
$527.09
$736.61
$1,119.35

$727.96
$783.62
$842.60
$1,052.12

$1,043.47
$1,099.13
$1,158.11
$1,367.63

$1,358.98
$1,414.64
$1,473.62
$1,683.14

$315.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$824.90
$936.22
$1,054.18
$1,473.22
$2,238.70

$1,140.41
$1,251.73
$1,369.69
$1,788.73

$1,455.92
$1,567.24
$1,685.20
$2,104.24

$1,771.43
$1,882.75
$2,000.71
$2,419.75

$315.51

Toc - Plan #125 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5650 (Vision Exam + Allergy Test) - 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

$9,100 $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

$353.04
$400.69
$451.17
$630.51
$958.12

$623.11
$670.76
$721.24
$900.58

$893.18
$940.83
$991.31
$1,170.65

$1,163.25
$1,210.90
$1,261.38
$1,440.72

$270.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$706.08
$801.38
$902.34
$1,261.02
$1,916.24

$976.15
$1,071.45
$1,172.41
$1,531.09

$1,246.22
$1,341.52
$1,442.48
$1,801.16

$1,516.29
$1,611.59
$1,712.55
$2,071.23

$270.07

Toc - Plan #126 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5000 - Envision Network (Vision Exam + Allergy Test)

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

$9,100 $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

$353.27
$400.95
$451.47
$630.92
$958.75

$623.51
$671.19
$721.71
$901.16

$893.75
$941.43
$991.95
$1,171.40

$1,163.99
$1,211.67
$1,262.19
$1,441.64

$270.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$706.54
$801.90
$902.94
$1,261.84
$1,917.50

$976.78
$1,072.14
$1,173.18
$1,532.08

$1,247.02
$1,342.38
$1,443.42
$1,802.32

$1,517.26
$1,612.62
$1,713.66
$2,072.56

$270.24

Toc - Plan #127 Common Ground Healthcare Cooperative

Bronze

(EPO) CGHC Bronze $9100 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$295.36
$335.22
$377.45
$527.49
$801.57

$521.30
$561.16
$603.39
$753.43

$747.24
$787.10
$829.33
$979.37

$973.18
$1,013.04
$1,055.27
$1,205.31

$225.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$590.72
$670.44
$754.90
$1,054.98
$1,603.14

$816.66
$896.38
$980.84
$1,280.92

$1,042.60
$1,122.32
$1,206.78
$1,506.86

$1,268.54
$1,348.26
$1,432.72
$1,732.80

$225.94

Toc - Plan #128 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Bronze $9100 ($35 PCP Copay) - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

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

$297.49
$337.63
$380.17
$531.29
$807.35

$525.06
$565.20
$607.74
$758.86

$752.63
$792.77
$835.31
$986.43

$980.20
$1,020.34
$1,062.88
$1,214.00

$227.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.98
$675.26
$760.34
$1,062.58
$1,614.70

$822.55
$902.83
$987.91
$1,290.15

$1,050.12
$1,130.40
$1,215.48
$1,517.72

$1,277.69
$1,357.97
$1,443.05
$1,745.29

$227.57

Toc - Plan #129 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Bronze $8150 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$8,150 $16,300 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

$308.64
$350.29
$394.42
$551.21
$837.61

$544.74
$586.39
$630.52
$787.31

$780.84
$822.49
$866.62
$1,023.41

$1,016.94
$1,058.59
$1,102.72
$1,259.51

$236.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$617.28
$700.58
$788.84
$1,102.42
$1,675.22

$853.38
$936.68
$1,024.94
$1,338.52

$1,089.48
$1,172.78
$1,261.04
$1,574.62

$1,325.58
$1,408.88
$1,497.14
$1,810.72

$236.10

Toc - Plan #130 Common Ground Healthcare Cooperative

Bronze

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

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

$9,100 $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

$304.82
$345.96
$389.54
$544.39
$827.25

$538.00
$579.14
$622.72
$777.57

$771.18
$812.32
$855.90
$1,010.75

$1,004.36
$1,045.50
$1,089.08
$1,243.93

$233.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$609.64
$691.92
$779.08
$1,088.78
$1,654.50

$842.82
$925.10
$1,012.26
$1,321.96

$1,076.00
$1,158.28
$1,245.44
$1,555.14

$1,309.18
$1,391.46
$1,478.62
$1,788.32

$233.18

Toc - Plan #131 Common Ground Healthcare Cooperative

Expanded Bronze

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

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

$307.02
$348.46
$392.36
$548.32
$833.23

$541.88
$583.32
$627.22
$783.18

$776.74
$818.18
$862.08
$1,018.04

$1,011.60
$1,053.04
$1,096.94
$1,252.90

$234.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$614.04
$696.92
$784.72
$1,096.64
$1,666.46

$848.90
$931.78
$1,019.58
$1,331.50

$1,083.76
$1,166.64
$1,254.44
$1,566.36

$1,318.62
$1,401.50
$1,489.30
$1,801.22

$234.86

Toc - Plan #132 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC HSA Silver $3000 - Envision Network (Vision Exam + Allergy Test)

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

$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

$471.57
$535.22
$602.65
$842.20
$1,279.81

$832.31
$895.96
$963.39
$1,202.94

$1,193.05
$1,256.70
$1,324.13
$1,563.68

$1,553.79
$1,617.44
$1,684.87
$1,924.42

$360.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$943.14
$1,070.44
$1,205.30
$1,684.40
$2,559.62

$1,303.88
$1,431.18
$1,566.04
$2,045.14

$1,664.62
$1,791.92
$1,926.78
$2,405.88

$2,025.36
$2,152.66
$2,287.52
$2,766.62

$360.74

Toc - Plan #133 Common Ground Healthcare Cooperative

Gold

(EPO) CGHC HSA Gold $3000 - Envision Network (Vision Exam + Allergy Test)

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

$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$486.18
$551.80
$621.32
$868.30
$1,319.46

$858.10
$923.72
$993.24
$1,240.22

$1,230.02
$1,295.64
$1,365.16
$1,612.14

$1,601.94
$1,667.56
$1,737.08
$1,984.06

$371.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$972.36
$1,103.60
$1,242.64
$1,736.60
$2,638.92

$1,344.28
$1,475.52
$1,614.56
$2,108.52

$1,716.20
$1,847.44
$1,986.48
$2,480.44

$2,088.12
$2,219.36
$2,358.40
$2,852.36

$371.92

Toc - Plan #134 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$317.35
$360.18
$405.56
$566.78
$861.27

$560.12
$602.95
$648.33
$809.55

$802.89
$845.72
$891.10
$1,052.32

$1,045.66
$1,088.49
$1,133.87
$1,295.09

$242.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$634.70
$720.36
$811.12
$1,133.56
$1,722.54

$877.47
$963.13
$1,053.89
$1,376.33

$1,120.24
$1,205.90
$1,296.66
$1,619.10

$1,363.01
$1,448.67
$1,539.43
$1,861.87

$242.77

Toc - Plan #135 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Copay Silver $0 Ded - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$449.34
$509.99
$574.24
$802.50
$1,219.48

$793.08
$853.73
$917.98
$1,146.24

$1,136.82
$1,197.47
$1,261.72
$1,489.98

$1,480.56
$1,541.21
$1,605.46
$1,833.72

$343.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$898.68
$1,019.98
$1,148.48
$1,605.00
$2,438.96

$1,242.42
$1,363.72
$1,492.22
$1,948.74

$1,586.16
$1,707.46
$1,835.96
$2,292.48

$1,929.90
$2,051.20
$2,179.70
$2,636.22

$343.74

Toc - Plan #136 Common Ground Healthcare Cooperative

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,000 $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

$484.04
$549.37
$618.59
$864.48
$1,313.66

$854.32
$919.65
$988.87
$1,234.76

$1,224.60
$1,289.93
$1,359.15
$1,605.04

$1,594.88
$1,660.21
$1,729.43
$1,975.32

$370.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$968.08
$1,098.74
$1,237.18
$1,728.96
$2,627.32

$1,338.36
$1,469.02
$1,607.46
$2,099.24

$1,708.64
$1,839.30
$1,977.74
$2,469.52

$2,078.92
$2,209.58
$2,348.02
$2,839.80

$370.28

Toc - Plan #137 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5650 - Envision Network (Dental/Vision Exam + Allergy Test)

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

$9,100 $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

$362.78
$411.74
$463.61
$647.90
$984.54

$640.30
$689.26
$741.13
$925.42

$917.82
$966.78
$1,018.65
$1,202.94

$1,195.34
$1,244.30
$1,296.17
$1,480.46

$277.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$725.56
$823.48
$927.22
$1,295.80
$1,969.08

$1,003.08
$1,101.00
$1,204.74
$1,573.32

$1,280.60
$1,378.52
$1,482.26
$1,850.84

$1,558.12
$1,656.04
$1,759.78
$2,128.36

$277.52

Toc - Plan #138 Common Ground Healthcare Cooperative

Silver

(EPO) CGHC Silver $5000 - Envision Network (Dental/Vision Exam + Allergy Test)

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

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$363.01
$412.00
$463.91
$648.31
$985.17

$640.70
$689.69
$741.60
$926.00

$918.39
$967.38
$1,019.29
$1,203.69

$1,196.08
$1,245.07
$1,296.98
$1,481.38

$277.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$726.02
$824.00
$927.82
$1,296.62
$1,970.34

$1,003.71
$1,101.69
$1,205.51
$1,574.31

$1,281.40
$1,379.38
$1,483.20
$1,852.00

$1,559.09
$1,657.07
$1,760.89
$2,129.69

$277.69

Toc - Plan #139 Common Ground Healthcare Cooperative

Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded - Envision Network (Dental/Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$327.10
$371.25
$418.02
$584.18
$887.72

$577.32
$621.47
$668.24
$834.40

$827.54
$871.69
$918.46
$1,084.62

$1,077.76
$1,121.91
$1,168.68
$1,334.84

$250.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$654.20
$742.50
$836.04
$1,168.36
$1,775.44

$904.42
$992.72
$1,086.26
$1,418.58

$1,154.64
$1,242.94
$1,336.48
$1,668.80

$1,404.86
$1,493.16
$1,586.70
$1,919.02

$250.22

‡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 Ozaukee County here.

Ozaukee County is in “Rating Area 12” of Wisconsin.

Currently, there are 139 plans offered in Rating Area 12.

Top

2023 Obamacare Plans for Ozaukee County, WI

Plan Browser: 139 Plans

Together with CCHP

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

1. Expanded Bronze Chorus Bronze

2. Silver Chorus Standard Silver

3. Silver Chorus Silver

4. Gold Chorus Gold

5. Expanded Bronze Chorus Bronze HDHP

6. Silver Chorus Silver Select

7. Catastrophic Chorus Catastrophic

8. Expanded Bronze Chorus Bronze Copay

9. Silver Chorus Silver Copay

10. Bronze Chorus Core Bronze

11. Silver Chorus Core Silver

12. Gold Chorus Core Gold

Quartz

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

13. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Dental & Vision

14. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Dental & Vision

15. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Dental & Vision

16. Gold Quartz One with Aurora Health Care Gold I410 Standard with Dental & Vision

17. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Dental & Vision

18. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Dental & Vision

19. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Dental & Vision

20. Silver Quartz One with Aurora Health Care Silver I309 Standard with Dental & Vision

21. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Dental & Vision

22. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Dental & Vision

23. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Dental & Vision

24. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Dental & Vision

25. Expanded Bronze Quartz One with Aurora Health Care Bronze I206 Standard with Dental & Vision

26. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401

27. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance

28. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405

29. Gold Quartz One with Aurora Health Care Gold I410 Standard

30. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301

31. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303

32. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308

33. Silver Quartz One with Aurora Health Care Silver I309 Standard

34. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201

35. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202

36. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204

37. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205

38. Expanded Bronze Quartz One with Aurora Health Care Bronze I206 Standard

39. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I403 HSA

40. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I304 HSA

41. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203

42. Catastrophic QUARTZ ONE WITH AURORA HEALTH CARE CATASTROPHIC I101

43. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307

44. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Vision

45. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Vision

46. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Vision

47. Gold Quartz One with Aurora Health Care Gold I410 Standard with Vision

48. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Vision

49. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Vision

50. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Vision

51. Silver Quartz One with Aurora Health Care Silver I309 Standard with Vision

52. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Vision

53. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Vision

54. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Vision

55. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Vision

56. Expanded Bronze Quartz One with Aurora Health Care Bronze I206 Standard with Vision

57. Gold QUARTZ ONE WITH AURORA HEALTH CARE GOLD I403 HSA with Vision

58. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I304 HSA with Vision

59. Silver QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307 with Vision

60. Expanded Bronze QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203 with Vision

Molina Healthcare

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

61. Gold Confident Care Gold 1

62. Silver Constant Care Silver 1

63. Gold Confident Care Gold 8

64. Silver Constant Care Silver 8

65. Gold Confident Care Gold 1 + Vision

66. Silver Constant Care Silver 1 + Vision

Anthem Blue Cross and Blue Shield

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

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

68. Expanded Bronze Anthem Bronze Blue Preferred/Broad 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

69. Expanded Bronze Anthem Bronze Blue Preferred/Broad 6550 ($0 Virtual PCP + $0 Select Drugs + Incentives)

70. Bronze Anthem Bronze Blue Preferred/Broad 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

71. Expanded Bronze Anthem Bronze Blue Preferred/Broad 0% for HSA

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

73. Silver Anthem Silver Blue Preferred/Broad 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

75. Silver Anthem Silver Blue Preferred/Broad 5300 ($0 Virtual PCP + $0 Select Drugs + Incentives)

76. Expanded Bronze Anthem Bronze Pathway/Lean 0% for HSA

77. Expanded Bronze Anthem Bronze Pathway/Lean 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

78. Expanded Bronze Anthem Bronze Pathway/Lean 6550 ($0 Virtual PCP + $0 Select Drugs + Incentives)

79. Bronze Anthem Bronze Pathway/Lean 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

80. Silver Anthem Silver Pathway/Lean 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

81. Silver Anthem Silver Pathway/Lean 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

82. Silver Anthem Silver Pathway/Lean 5300 ($0 Virtual PCP + $0 Select Drugs + Incentives)

83. Gold Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

84. Expanded Bronze Anthem Bronze Pathway/Lean 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

85. Bronze Anthem Bronze Blue Preferred/Broad 9100/0% Standard

86. Expanded Bronze Anthem Bronze Blue Preferred/Broad 7500/50% Standard

87. Silver Anthem Silver Blue Preferred/Broad 5800/40% Standard

88. Gold Anthem Gold Blue Preferred/Broad 2000/25% Standard

89. Bronze Anthem Bronze Pathway/Lean 9100/0% Standard

90. Gold Anthem Gold Pathway/Lean 2000/25% Standard

91. Silver Anthem Silver Pathway/Lean 5800/40% Standard

92. Expanded Bronze Anthem Bronze Pathway/Lean 7500/50% Standard

Network Health

Local: 1-920-720-1400x1400 | Toll Free: 1-855-275-1400 | TTY: 1-800-947-3529

93. Expanded Bronze Prestige Bronze 20 HDHP + Dental + Vision + Fitness

94. Expanded Bronze Prestige Bronze Essential + Dental + Vision + Fitness + 3 Free PCP Visits

95. Silver Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits

96. Gold Prestige Gold Essential + Dental + Vision + Fitness + 3 Free PCP Visits

97. Gold Prestige Gold 50 + Dental + Vision + Fitness

98. Expanded Bronze Signature Prestige Bronze Copay + Dental + Vision + Fitness

99. Bronze Prestige Bronze

100. Expanded Bronze Prestige Bronze Plus

101. Silver Prestige Silver

102. Gold Prestige Gold

Common Ground Healthcare Cooperative

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

103. Expanded Bronze CGHC Copay Bronze $0 Ded - Envision Network

104. Silver CGHC Copay Silver $0 Ded - Envision Network

105. Gold CGHC Copay Gold $0 Ded - Envision Network

106. Gold CGHC Gold $3000 - Envision Network

107. Gold CGHC Gold $1800 - Envision Network

108. Silver CGHC Silver $4000 - Envision Network

109. Silver CGHC Silver $5000 - Envision Network

110. Catastrophic CGHC Catastrophic $9100 - Envision Network

111. Expanded Bronze CGHC Bronze $9100 ($35 PCP Copay) - Envision Network

112. Expanded Bronze CGHC Bronze $8150 - Envision Network

113. Expanded Bronze CGHC HSA Bronze $7500 - Envision Network

114. Gold CGHC HSA Gold $3000 - Envision Network

115. Silver CGHC HSA Silver $3000 - Envision Network

116. Bronze CGHC Bronze $6000 - Envision Network

117. Bronze Bronze Standard Plan - Envision Network

118. Silver Silver Standard Plan - Envision Network

119. Gold Gold Standard Plan - Envision Network

120. Silver CGHC Silver $5650 - Envision Network

121. Gold CGHC Gold $1800 - Envision Network (Vision Exam + Allergy Test)

122. Gold CGHC Gold $2000 - Envision Network (Vision Exam + Allergy Test)

123. Gold CGHC Gold $3000 - Envision Network (Vision Exam + Allergy Test)

124. Silver CGHC Silver $4000 - Envision Network (Vision Exam + Allergy Test)

125. Silver CGHC Silver $5650 (Vision Exam + Allergy Test) - Envision Network

126. Silver CGHC Silver $5000 - Envision Network (Vision Exam + Allergy Test)

127. Bronze CGHC Bronze $9100 - Envision Network (Vision Exam + Allergy Test)

128. Expanded Bronze CGHC Bronze $9100 ($35 PCP Copay) - Envision Network (Vision Exam + Allergy Test)

129. Expanded Bronze CGHC Bronze $8150 - Envision Network (Vision Exam + Allergy Test)

130. Bronze CGHC Bronze $6000 - Envision Network (Vision Exam + Allergy Test)

131. Expanded Bronze CGHC HSA Bronze $7500 - Envision Network (Vision Exam + Allergy Test)

132. Silver CGHC HSA Silver $3000 - Envision Network (Vision Exam + Allergy Test)

133. Gold CGHC HSA Gold $3000 - Envision Network (Vision Exam + Allergy Test)

134. Expanded Bronze CGHC Copay Bronze $0 Ded - Envision Network (Vision Exam + Allergy Test)

135. Silver CGHC Copay Silver $0 Ded - Envision Network (Vision Exam + Allergy Test)

136. Gold CGHC Copay Gold $0 Ded - Envision Network (Vision Exam + Allergy Test)

137. Silver CGHC Silver $5650 - Envision Network (Dental/Vision Exam + Allergy Test)

138. Silver CGHC Silver $5000 - Envision Network (Dental/Vision Exam + Allergy Test)

139. Expanded Bronze CGHC Copay Bronze $0 Ded - Envision Network (Dental/Vision Exam + Allergy Test)

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

Obamacare Providers, 139 Plans and 2023 Rates for Ozaukee County, Wisconsin

You may also be interested in:

Do I Qualify For a Tax Credit to Pay My Premiums?

How do I sign up in Wisconsin?

Using a Broker to Help You Sign Up

Obamacare Rates and Providers for Other Years

How To Sign Up for Obamacare in Wisconsin for 2023

Where's the Wisconsin Health Care Exchange?

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

Wisconsin Has Not Expanded Medicaid

Get Help Finding a Health Insurance Plan in Wisconsin

Get Help From Wisconsin's Health Insurance Exchange

Get Help From a Licensed Insurance Broker

More Information

Together with CCHP

(EPO) Chorus Bronze

Annual Out of Pocket Expenses:

Individual Family $7,500 $15,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Chorus Standard Silver

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:

(EPO) Chorus Silver

Annual Out of Pocket Expenses:

Individual Family $5,000 $10,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Chorus Gold

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:

(EPO) Chorus Bronze HDHP

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Chorus Silver Select

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:

(EPO) Chorus Catastrophic

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:

(EPO) Chorus Bronze Copay

Annual Out of Pocket Expenses:

Individual Family $0 $0 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Chorus Silver Copay

Annual Out of Pocket Expenses:

Individual Family $0 $0 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Chorus Core Bronze

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:

(EPO) Chorus Core Silver

Annual Out of Pocket Expenses:

Individual Family $5,800 $11,600 Annual Deductible $8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Chorus Core Gold

Annual Out of Pocket Expenses:

Individual Family $2,000 $4,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Quartz

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Dental & Vision

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:

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Dental & Vision

Annual Out of Pocket Expenses:

Individual Family $1,500 $3,000 Annual Deductible $8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Dental & Vision

Annual Out of Pocket Expenses:

Individual Family $2,000 $4,000 Annual Deductible $6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Quartz One with Aurora Health Care Gold I410 Standard with Dental & Vision

Annual Out of Pocket Expenses:

Individual Family $2,000 $4,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$4,000 $8,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,000 $10,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$7,000 $14,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$3,250 $6,500 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$8,000 $16,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$8,000 $16,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$3,000 $6,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$8,000 $16,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year