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Obamacare 2023 Rates for Pepin County

Obamacare > Rates > Wisconsin > Pepin 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 Pepin 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, 86 Plans and 2023 Rates for Pepin County, Wisconsin

Below, you’ll find a summary of the 86 plans for Pepin County, Wisconsin and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Quartz

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

Toc - Plan #1 Quartz
Gold

(HMO) QUARTZ ONE GOLD 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
$585.42
$664.44
$748.16
$1,045.55
$1,588.81
$1,033.26
$1,112.28
$1,196.00
$1,493.39
$1,481.10
$1,560.12
$1,643.84
$1,941.23
$1,928.94
$2,007.96
$2,091.68
$2,389.07
$447.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,170.84
$1,328.88
$1,496.32
$2,091.10
$3,177.62
$1,618.68
$1,776.72
$1,944.16
$2,538.94
$2,066.52
$2,224.56
$2,392.00
$2,986.78
$2,514.36
$2,672.40
$2,839.84
$3,434.62
$447.84
Toc - Plan #2 Quartz
Gold

(HMO) QUARTZ ONE 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
$579.93
$658.21
$741.14
$1,035.74
$1,573.91
$1,023.57
$1,101.85
$1,184.78
$1,479.38
$1,467.21
$1,545.49
$1,628.42
$1,923.02
$1,910.85
$1,989.13
$2,072.06
$2,366.66
$443.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,159.86
$1,316.42
$1,482.28
$2,071.48
$3,147.82
$1,603.50
$1,760.06
$1,925.92
$2,515.12
$2,047.14
$2,203.70
$2,369.56
$2,958.76
$2,490.78
$2,647.34
$2,813.20
$3,402.40
$443.64
Toc - Plan #3 Quartz
Gold

(HMO) QUARTZ ONE 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
$584.75
$663.68
$747.30
$1,044.35
$1,586.99
$1,032.08
$1,111.01
$1,194.63
$1,491.68
$1,479.41
$1,558.34
$1,641.96
$1,939.01
$1,926.74
$2,005.67
$2,089.29
$2,386.34
$447.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,169.50
$1,327.36
$1,494.60
$2,088.70
$3,173.98
$1,616.83
$1,774.69
$1,941.93
$2,536.03
$2,064.16
$2,222.02
$2,389.26
$2,983.36
$2,511.49
$2,669.35
$2,836.59
$3,430.69
$447.33
Toc - Plan #4 Quartz
Gold

(HMO) Quartz One 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
$599.72
$680.68
$766.44
$1,071.09
$1,627.63
$1,058.50
$1,139.46
$1,225.22
$1,529.87
$1,517.28
$1,598.24
$1,684.00
$1,988.65
$1,976.06
$2,057.02
$2,142.78
$2,447.43
$458.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,199.44
$1,361.36
$1,532.88
$2,142.18
$3,255.26
$1,658.22
$1,820.14
$1,991.66
$2,600.96
$2,117.00
$2,278.92
$2,450.44
$3,059.74
$2,575.78
$2,737.70
$2,909.22
$3,518.52
$458.78
Toc - Plan #5 Quartz
Silver

(HMO) QUARTZ ONE 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
$602.57
$683.92
$770.08
$1,076.19
$1,635.37
$1,063.53
$1,144.88
$1,231.04
$1,537.15
$1,524.49
$1,605.84
$1,692.00
$1,998.11
$1,985.45
$2,066.80
$2,152.96
$2,459.07
$460.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,205.14
$1,367.84
$1,540.16
$2,152.38
$3,270.74
$1,666.10
$1,828.80
$2,001.12
$2,613.34
$2,127.06
$2,289.76
$2,462.08
$3,074.30
$2,588.02
$2,750.72
$2,923.04
$3,535.26
$460.96
Toc - Plan #6 Quartz
Silver

(HMO) QUARTZ ONE 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
$597.47
$678.13
$763.57
$1,067.08
$1,621.53
$1,054.53
$1,135.19
$1,220.63
$1,524.14
$1,511.59
$1,592.25
$1,677.69
$1,981.20
$1,968.65
$2,049.31
$2,134.75
$2,438.26
$457.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,194.94
$1,356.26
$1,527.14
$2,134.16
$3,243.06
$1,652.00
$1,813.32
$1,984.20
$2,591.22
$2,109.06
$2,270.38
$2,441.26
$3,048.28
$2,566.12
$2,727.44
$2,898.32
$3,505.34
$457.06
Toc - Plan #7 Quartz
Silver

(HMO) QUARTZ ONE 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
$626.86
$711.48
$801.12
$1,119.56
$1,701.29
$1,106.40
$1,191.02
$1,280.66
$1,599.10
$1,585.94
$1,670.56
$1,760.20
$2,078.64
$2,065.48
$2,150.10
$2,239.74
$2,558.18
$479.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,253.72
$1,422.96
$1,602.24
$2,239.12
$3,402.58
$1,733.26
$1,902.50
$2,081.78
$2,718.66
$2,212.80
$2,382.04
$2,561.32
$3,198.20
$2,692.34
$2,861.58
$3,040.86
$3,677.74
$479.54
Toc - Plan #8 Quartz
Silver

(HMO) Quartz One 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
$656.54
$745.17
$839.05
$1,172.57
$1,781.84
$1,158.79
$1,247.42
$1,341.30
$1,674.82
$1,661.04
$1,749.67
$1,843.55
$2,177.07
$2,163.29
$2,251.92
$2,345.80
$2,679.32
$502.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,313.08
$1,490.34
$1,678.10
$2,345.14
$3,563.68
$1,815.33
$1,992.59
$2,180.35
$2,847.39
$2,317.58
$2,494.84
$2,682.60
$3,349.64
$2,819.83
$2,997.09
$3,184.85
$3,851.89
$502.25
Toc - Plan #9 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$444.37
$504.36
$567.90
$793.64
$1,206.02
$784.31
$844.30
$907.84
$1,133.58
$1,124.25
$1,184.24
$1,247.78
$1,473.52
$1,464.19
$1,524.18
$1,587.72
$1,813.46
$339.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.74
$1,008.72
$1,135.80
$1,587.28
$2,412.04
$1,228.68
$1,348.66
$1,475.74
$1,927.22
$1,568.62
$1,688.60
$1,815.68
$2,267.16
$1,908.56
$2,028.54
$2,155.62
$2,607.10
$339.94
Toc - Plan #10 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$448.77
$509.35
$573.52
$801.50
$1,217.95
$792.08
$852.66
$916.83
$1,144.81
$1,135.39
$1,195.97
$1,260.14
$1,488.12
$1,478.70
$1,539.28
$1,603.45
$1,831.43
$343.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$897.54
$1,018.70
$1,147.04
$1,603.00
$2,435.90
$1,240.85
$1,362.01
$1,490.35
$1,946.31
$1,584.16
$1,705.32
$1,833.66
$2,289.62
$1,927.47
$2,048.63
$2,176.97
$2,632.93
$343.31
Toc - Plan #11 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$470.41
$533.90
$601.17
$840.14
$1,276.67
$830.27
$893.76
$961.03
$1,200.00
$1,190.13
$1,253.62
$1,320.89
$1,559.86
$1,549.99
$1,613.48
$1,680.75
$1,919.72
$359.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$940.82
$1,067.80
$1,202.34
$1,680.28
$2,553.34
$1,300.68
$1,427.66
$1,562.20
$2,040.14
$1,660.54
$1,787.52
$1,922.06
$2,400.00
$2,020.40
$2,147.38
$2,281.92
$2,759.86
$359.86
Toc - Plan #12 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$465.60
$528.45
$595.03
$831.55
$1,263.62
$821.78
$884.63
$951.21
$1,187.73
$1,177.96
$1,240.81
$1,307.39
$1,543.91
$1,534.14
$1,596.99
$1,663.57
$1,900.09
$356.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$931.20
$1,056.90
$1,190.06
$1,663.10
$2,527.24
$1,287.38
$1,413.08
$1,546.24
$2,019.28
$1,643.56
$1,769.26
$1,902.42
$2,375.46
$1,999.74
$2,125.44
$2,258.60
$2,731.64
$356.18
Toc - Plan #13 Quartz
Expanded Bronze

(HMO) Quartz One 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
$484.77
$550.20
$619.52
$865.78
$1,315.64
$855.61
$921.04
$990.36
$1,236.62
$1,226.45
$1,291.88
$1,361.20
$1,607.46
$1,597.29
$1,662.72
$1,732.04
$1,978.30
$370.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$969.54
$1,100.40
$1,239.04
$1,731.56
$2,631.28
$1,340.38
$1,471.24
$1,609.88
$2,102.40
$1,711.22
$1,842.08
$1,980.72
$2,473.24
$2,082.06
$2,212.92
$2,351.56
$2,844.08
$370.84
Toc - Plan #14 Quartz
Gold

(HMO) QUARTZ ONE 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
$559.46
$634.98
$714.99
$999.19
$1,518.37
$987.44
$1,062.96
$1,142.97
$1,427.17
$1,415.42
$1,490.94
$1,570.95
$1,855.15
$1,843.40
$1,918.92
$1,998.93
$2,283.13
$427.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,118.92
$1,269.96
$1,429.98
$1,998.38
$3,036.74
$1,546.90
$1,697.94
$1,857.96
$2,426.36
$1,974.88
$2,125.92
$2,285.94
$2,854.34
$2,402.86
$2,553.90
$2,713.92
$3,282.32
$427.98
Toc - Plan #15 Quartz
Gold

(HMO) QUARTZ ONE 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
$554.22
$629.03
$708.28
$989.82
$1,504.13
$978.19
$1,053.00
$1,132.25
$1,413.79
$1,402.16
$1,476.97
$1,556.22
$1,837.76
$1,826.13
$1,900.94
$1,980.19
$2,261.73
$423.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,108.44
$1,258.06
$1,416.56
$1,979.64
$3,008.26
$1,532.41
$1,682.03
$1,840.53
$2,403.61
$1,956.38
$2,106.00
$2,264.50
$2,827.58
$2,380.35
$2,529.97
$2,688.47
$3,251.55
$423.97
Toc - Plan #16 Quartz
Gold

(HMO) QUARTZ ONE 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
$558.82
$634.26
$714.17
$998.05
$1,516.63
$986.32
$1,061.76
$1,141.67
$1,425.55
$1,413.82
$1,489.26
$1,569.17
$1,853.05
$1,841.32
$1,916.76
$1,996.67
$2,280.55
$427.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,117.64
$1,268.52
$1,428.34
$1,996.10
$3,033.26
$1,545.14
$1,696.02
$1,855.84
$2,423.60
$1,972.64
$2,123.52
$2,283.34
$2,851.10
$2,400.14
$2,551.02
$2,710.84
$3,278.60
$427.50
Toc - Plan #17 Quartz
Gold

(HMO) Quartz One Gold I410 Standard

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

Annual Out of Pocket Expenses:

Individual Family
$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
$573.13
$650.50
$732.46
$1,023.61
$1,555.47
$1,011.57
$1,088.94
$1,170.90
$1,462.05
$1,450.01
$1,527.38
$1,609.34
$1,900.49
$1,888.45
$1,965.82
$2,047.78
$2,338.93
$438.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,146.26
$1,301.00
$1,464.92
$2,047.22
$3,110.94
$1,584.70
$1,739.44
$1,903.36
$2,485.66
$2,023.14
$2,177.88
$2,341.80
$2,924.10
$2,461.58
$2,616.32
$2,780.24
$3,362.54
$438.44
Toc - Plan #18 Quartz
Silver

(HMO) QUARTZ ONE 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
$575.86
$653.59
$735.94
$1,028.47
$1,562.86
$1,016.39
$1,094.12
$1,176.47
$1,469.00
$1,456.92
$1,534.65
$1,617.00
$1,909.53
$1,897.45
$1,975.18
$2,057.53
$2,350.06
$440.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,151.72
$1,307.18
$1,471.88
$2,056.94
$3,125.72
$1,592.25
$1,747.71
$1,912.41
$2,497.47
$2,032.78
$2,188.24
$2,352.94
$2,938.00
$2,473.31
$2,628.77
$2,793.47
$3,378.53
$440.53
Toc - Plan #19 Quartz
Silver

(HMO) QUARTZ ONE 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
$570.98
$648.06
$729.71
$1,019.77
$1,549.64
$1,007.78
$1,084.86
$1,166.51
$1,456.57
$1,444.58
$1,521.66
$1,603.31
$1,893.37
$1,881.38
$1,958.46
$2,040.11
$2,330.17
$436.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,141.96
$1,296.12
$1,459.42
$2,039.54
$3,099.28
$1,578.76
$1,732.92
$1,896.22
$2,476.34
$2,015.56
$2,169.72
$2,333.02
$2,913.14
$2,452.36
$2,606.52
$2,769.82
$3,349.94
$436.80
Toc - Plan #20 Quartz
Silver

(HMO) QUARTZ ONE 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
$599.07
$679.94
$765.60
$1,069.93
$1,625.86
$1,057.35
$1,138.22
$1,223.88
$1,528.21
$1,515.63
$1,596.50
$1,682.16
$1,986.49
$1,973.91
$2,054.78
$2,140.44
$2,444.77
$458.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,198.14
$1,359.88
$1,531.20
$2,139.86
$3,251.72
$1,656.42
$1,818.16
$1,989.48
$2,598.14
$2,114.70
$2,276.44
$2,447.76
$3,056.42
$2,572.98
$2,734.72
$2,906.04
$3,514.70
$458.28
Toc - Plan #21 Quartz
Silver

(HMO) Quartz One Silver I309 Standard

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $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
$627.43
$712.13
$801.85
$1,120.59
$1,702.84
$1,107.41
$1,192.11
$1,281.83
$1,600.57
$1,587.39
$1,672.09
$1,761.81
$2,080.55
$2,067.37
$2,152.07
$2,241.79
$2,560.53
$479.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,254.86
$1,424.26
$1,603.70
$2,241.18
$3,405.68
$1,734.84
$1,904.24
$2,083.68
$2,721.16
$2,214.82
$2,384.22
$2,563.66
$3,201.14
$2,694.80
$2,864.20
$3,043.64
$3,681.12
$479.98
Toc - Plan #22 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$424.67
$482.00
$542.72
$758.46
$1,152.55
$749.54
$806.87
$867.59
$1,083.33
$1,074.41
$1,131.74
$1,192.46
$1,408.20
$1,399.28
$1,456.61
$1,517.33
$1,733.07
$324.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.34
$964.00
$1,085.44
$1,516.92
$2,305.10
$1,174.21
$1,288.87
$1,410.31
$1,841.79
$1,499.08
$1,613.74
$1,735.18
$2,166.66
$1,823.95
$1,938.61
$2,060.05
$2,491.53
$324.87
Toc - Plan #23 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$428.87
$486.77
$548.10
$765.96
$1,163.95
$756.96
$814.86
$876.19
$1,094.05
$1,085.05
$1,142.95
$1,204.28
$1,422.14
$1,413.14
$1,471.04
$1,532.37
$1,750.23
$328.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$857.74
$973.54
$1,096.20
$1,531.92
$2,327.90
$1,185.83
$1,301.63
$1,424.29
$1,860.01
$1,513.92
$1,629.72
$1,752.38
$2,188.10
$1,842.01
$1,957.81
$2,080.47
$2,516.19
$328.09
Toc - Plan #24 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$449.55
$510.23
$574.52
$802.89
$1,220.07
$793.45
$854.13
$918.42
$1,146.79
$1,137.35
$1,198.03
$1,262.32
$1,490.69
$1,481.25
$1,541.93
$1,606.22
$1,834.59
$343.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$899.10
$1,020.46
$1,149.04
$1,605.78
$2,440.14
$1,243.00
$1,364.36
$1,492.94
$1,949.68
$1,586.90
$1,708.26
$1,836.84
$2,293.58
$1,930.80
$2,052.16
$2,180.74
$2,637.48
$343.90
Toc - Plan #25 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$444.96
$505.02
$568.65
$794.68
$1,207.60
$785.35
$845.41
$909.04
$1,135.07
$1,125.74
$1,185.80
$1,249.43
$1,475.46
$1,466.13
$1,526.19
$1,589.82
$1,815.85
$340.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$889.92
$1,010.04
$1,137.30
$1,589.36
$2,415.20
$1,230.31
$1,350.43
$1,477.69
$1,929.75
$1,570.70
$1,690.82
$1,818.08
$2,270.14
$1,911.09
$2,031.21
$2,158.47
$2,610.53
$340.39
Toc - Plan #26 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I206 Standard

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $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
$463.27
$525.81
$592.06
$827.40
$1,257.31
$817.67
$880.21
$946.46
$1,181.80
$1,172.07
$1,234.61
$1,300.86
$1,536.20
$1,526.47
$1,589.01
$1,655.26
$1,890.60
$354.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$926.54
$1,051.62
$1,184.12
$1,654.80
$2,514.62
$1,280.94
$1,406.02
$1,538.52
$2,009.20
$1,635.34
$1,760.42
$1,892.92
$2,363.60
$1,989.74
$2,114.82
$2,247.32
$2,718.00
$354.40
Toc - Plan #27 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$446.28
$506.53
$570.35
$797.06
$1,211.20
$787.68
$847.93
$911.75
$1,138.46
$1,129.08
$1,189.33
$1,253.15
$1,479.86
$1,470.48
$1,530.73
$1,594.55
$1,821.26
$341.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$892.56
$1,013.06
$1,140.70
$1,594.12
$2,422.40
$1,233.96
$1,354.46
$1,482.10
$1,935.52
$1,575.36
$1,695.86
$1,823.50
$2,276.92
$1,916.76
$2,037.26
$2,164.90
$2,618.32
$341.40
Toc - Plan #28 Quartz
Catastrophic

(HMO) QUARTZ ONE CATASTROPHIC I101

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $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
$328.99
$373.40
$420.45
$587.57
$892.87
$580.67
$625.08
$672.13
$839.25
$832.35
$876.76
$923.81
$1,090.93
$1,084.03
$1,128.44
$1,175.49
$1,342.61
$251.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$657.98
$746.80
$840.90
$1,175.14
$1,785.74
$909.66
$998.48
$1,092.58
$1,426.82
$1,161.34
$1,250.16
$1,344.26
$1,678.50
$1,413.02
$1,501.84
$1,595.94
$1,930.18
$251.68
Toc - Plan #29 Quartz
Silver

(HMO) QUARTZ ONE SILVER I304 HSA

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $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
$630.83
$715.98
$806.19
$1,126.65
$1,712.05
$1,113.41
$1,198.56
$1,288.77
$1,609.23
$1,595.99
$1,681.14
$1,771.35
$2,091.81
$2,078.57
$2,163.72
$2,253.93
$2,574.39
$482.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,261.66
$1,431.96
$1,612.38
$2,253.30
$3,424.10
$1,744.24
$1,914.54
$2,094.96
$2,735.88
$2,226.82
$2,397.12
$2,577.54
$3,218.46
$2,709.40
$2,879.70
$3,060.12
$3,701.04
$482.58
Toc - Plan #30 Quartz
Gold

(HMO) QUARTZ ONE GOLD I403 HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$593.75
$673.90
$758.80
$1,060.43
$1,611.42
$1,047.96
$1,128.11
$1,213.01
$1,514.64
$1,502.17
$1,582.32
$1,667.22
$1,968.85
$1,956.38
$2,036.53
$2,121.43
$2,423.06
$454.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,187.50
$1,347.80
$1,517.60
$2,120.86
$3,222.84
$1,641.71
$1,802.01
$1,971.81
$2,575.07
$2,095.92
$2,256.22
$2,426.02
$3,029.28
$2,550.13
$2,710.43
$2,880.23
$3,483.49
$454.21
Toc - Plan #31 Quartz
Silver

(HMO) QUARTZ ONE 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
$633.58
$719.10
$809.70
$1,131.56
$1,719.51
$1,118.26
$1,203.78
$1,294.38
$1,616.24
$1,602.94
$1,688.46
$1,779.06
$2,100.92
$2,087.62
$2,173.14
$2,263.74
$2,585.60
$484.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,267.16
$1,438.20
$1,619.40
$2,263.12
$3,439.02
$1,751.84
$1,922.88
$2,104.08
$2,747.80
$2,236.52
$2,407.56
$2,588.76
$3,232.48
$2,721.20
$2,892.24
$3,073.44
$3,717.16
$484.68
Toc - Plan #32 Quartz
Gold

(HMO) QUARTZ ONE 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
$565.96
$642.36
$723.29
$1,010.80
$1,536.00
$998.92
$1,075.32
$1,156.25
$1,443.76
$1,431.88
$1,508.28
$1,589.21
$1,876.72
$1,864.84
$1,941.24
$2,022.17
$2,309.68
$432.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,131.92
$1,284.72
$1,446.58
$2,021.60
$3,072.00
$1,564.88
$1,717.68
$1,879.54
$2,454.56
$1,997.84
$2,150.64
$2,312.50
$2,887.52
$2,430.80
$2,583.60
$2,745.46
$3,320.48
$432.96
Toc - Plan #33 Quartz
Gold

(HMO) QUARTZ ONE 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
$560.65
$636.34
$716.51
$1,001.32
$1,521.60
$989.55
$1,065.24
$1,145.41
$1,430.22
$1,418.45
$1,494.14
$1,574.31
$1,859.12
$1,847.35
$1,923.04
$2,003.21
$2,288.02
$428.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,121.30
$1,272.68
$1,433.02
$2,002.64
$3,043.20
$1,550.20
$1,701.58
$1,861.92
$2,431.54
$1,979.10
$2,130.48
$2,290.82
$2,860.44
$2,408.00
$2,559.38
$2,719.72
$3,289.34
$428.90
Toc - Plan #34 Quartz
Gold

(HMO) QUARTZ ONE 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
$565.31
$641.63
$722.46
$1,009.64
$1,534.25
$997.77
$1,074.09
$1,154.92
$1,442.10
$1,430.23
$1,506.55
$1,587.38
$1,874.56
$1,862.69
$1,939.01
$2,019.84
$2,307.02
$432.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,130.62
$1,283.26
$1,444.92
$2,019.28
$3,068.50
$1,563.08
$1,715.72
$1,877.38
$2,451.74
$1,995.54
$2,148.18
$2,309.84
$2,884.20
$2,428.00
$2,580.64
$2,742.30
$3,316.66
$432.46
Toc - Plan #35 Quartz
Gold

(HMO) Quartz One 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
$579.79
$658.06
$740.97
$1,035.50
$1,573.54
$1,023.33
$1,101.60
$1,184.51
$1,479.04
$1,466.87
$1,545.14
$1,628.05
$1,922.58
$1,910.41
$1,988.68
$2,071.59
$2,366.12
$443.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,159.58
$1,316.12
$1,481.94
$2,071.00
$3,147.08
$1,603.12
$1,759.66
$1,925.48
$2,514.54
$2,046.66
$2,203.20
$2,369.02
$2,958.08
$2,490.20
$2,646.74
$2,812.56
$3,401.62
$443.54
Toc - Plan #36 Quartz
Silver

(HMO) QUARTZ ONE 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
$582.55
$661.19
$744.49
$1,040.42
$1,581.02
$1,028.19
$1,106.83
$1,190.13
$1,486.06
$1,473.83
$1,552.47
$1,635.77
$1,931.70
$1,919.47
$1,998.11
$2,081.41
$2,377.34
$445.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,165.10
$1,322.38
$1,488.98
$2,080.84
$3,162.04
$1,610.74
$1,768.02
$1,934.62
$2,526.48
$2,056.38
$2,213.66
$2,380.26
$2,972.12
$2,502.02
$2,659.30
$2,825.90
$3,417.76
$445.64
Toc - Plan #37 Quartz
Silver

(HMO) QUARTZ ONE 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
$577.62
$655.59
$738.19
$1,031.62
$1,567.64
$1,019.49
$1,097.46
$1,180.06
$1,473.49
$1,461.36
$1,539.33
$1,621.93
$1,915.36
$1,903.23
$1,981.20
$2,063.80
$2,357.23
$441.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,155.24
$1,311.18
$1,476.38
$2,063.24
$3,135.28
$1,597.11
$1,753.05
$1,918.25
$2,505.11
$2,038.98
$2,194.92
$2,360.12
$2,946.98
$2,480.85
$2,636.79
$2,801.99
$3,388.85
$441.87
Toc - Plan #38 Quartz
Silver

(HMO) QUARTZ ONE 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
$606.03
$687.84
$774.50
$1,082.36
$1,644.74
$1,069.64
$1,151.45
$1,238.11
$1,545.97
$1,533.25
$1,615.06
$1,701.72
$2,009.58
$1,996.86
$2,078.67
$2,165.33
$2,473.19
$463.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,212.06
$1,375.68
$1,549.00
$2,164.72
$3,289.48
$1,675.67
$1,839.29
$2,012.61
$2,628.33
$2,139.28
$2,302.90
$2,476.22
$3,091.94
$2,602.89
$2,766.51
$2,939.83
$3,555.55
$463.61
Toc - Plan #39 Quartz
Silver

(HMO) Quartz One 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
$634.72
$720.40
$811.17
$1,133.60
$1,722.62
$1,120.28
$1,205.96
$1,296.73
$1,619.16
$1,605.84
$1,691.52
$1,782.29
$2,104.72
$2,091.40
$2,177.08
$2,267.85
$2,590.28
$485.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,269.44
$1,440.80
$1,622.34
$2,267.20
$3,445.24
$1,755.00
$1,926.36
$2,107.90
$2,752.76
$2,240.56
$2,411.92
$2,593.46
$3,238.32
$2,726.12
$2,897.48
$3,079.02
$3,723.88
$485.56
Toc - Plan #40 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$429.60
$487.60
$549.03
$767.27
$1,165.93
$758.24
$816.24
$877.67
$1,095.91
$1,086.88
$1,144.88
$1,206.31
$1,424.55
$1,415.52
$1,473.52
$1,534.95
$1,753.19
$328.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.20
$975.20
$1,098.06
$1,534.54
$2,331.86
$1,187.84
$1,303.84
$1,426.70
$1,863.18
$1,516.48
$1,632.48
$1,755.34
$2,191.82
$1,845.12
$1,961.12
$2,083.98
$2,520.46
$328.64
Toc - Plan #41 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$433.86
$492.42
$554.46
$774.86
$1,177.47
$765.76
$824.32
$886.36
$1,106.76
$1,097.66
$1,156.22
$1,218.26
$1,438.66
$1,429.56
$1,488.12
$1,550.16
$1,770.56
$331.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.72
$984.84
$1,108.92
$1,549.72
$2,354.94
$1,199.62
$1,316.74
$1,440.82
$1,881.62
$1,531.52
$1,648.64
$1,772.72
$2,213.52
$1,863.42
$1,980.54
$2,104.62
$2,545.42
$331.90
Toc - Plan #42 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$454.77
$516.16
$581.19
$812.21
$1,234.24
$802.67
$864.06
$929.09
$1,160.11
$1,150.57
$1,211.96
$1,276.99
$1,508.01
$1,498.47
$1,559.86
$1,624.89
$1,855.91
$347.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$909.54
$1,032.32
$1,162.38
$1,624.42
$2,468.48
$1,257.44
$1,380.22
$1,510.28
$1,972.32
$1,605.34
$1,728.12
$1,858.18
$2,320.22
$1,953.24
$2,076.02
$2,206.08
$2,668.12
$347.90
Toc - Plan #43 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$450.12
$510.89
$575.25
$803.91
$1,221.62
$794.46
$855.23
$919.59
$1,148.25
$1,138.80
$1,199.57
$1,263.93
$1,492.59
$1,483.14
$1,543.91
$1,608.27
$1,836.93
$344.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$900.24
$1,021.78
$1,150.50
$1,607.82
$2,443.24
$1,244.58
$1,366.12
$1,494.84
$1,952.16
$1,588.92
$1,710.46
$1,839.18
$2,296.50
$1,933.26
$2,054.80
$2,183.52
$2,640.84
$344.34
Toc - Plan #44 Quartz
Expanded Bronze

(HMO) Quartz One 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
$468.65
$531.92
$598.93
$837.01
$1,271.92
$827.17
$890.44
$957.45
$1,195.53
$1,185.69
$1,248.96
$1,315.97
$1,554.05
$1,544.21
$1,607.48
$1,674.49
$1,912.57
$358.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$937.30
$1,063.84
$1,197.86
$1,674.02
$2,543.84
$1,295.82
$1,422.36
$1,556.38
$2,032.54
$1,654.34
$1,780.88
$1,914.90
$2,391.06
$2,012.86
$2,139.40
$2,273.42
$2,749.58
$358.52
Toc - Plan #45 Quartz
Gold

(HMO) QUARTZ ONE 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
$600.65
$681.73
$767.62
$1,072.74
$1,630.14
$1,060.14
$1,141.22
$1,227.11
$1,532.23
$1,519.63
$1,600.71
$1,686.60
$1,991.72
$1,979.12
$2,060.20
$2,146.09
$2,451.21
$459.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,201.30
$1,363.46
$1,535.24
$2,145.48
$3,260.28
$1,660.79
$1,822.95
$1,994.73
$2,604.97
$2,120.28
$2,282.44
$2,454.22
$3,064.46
$2,579.77
$2,741.93
$2,913.71
$3,523.95
$459.49
Toc - Plan #46 Quartz
Silver

(HMO) QUARTZ ONE 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
$638.15
$724.30
$815.55
$1,139.73
$1,731.94
$1,126.33
$1,212.48
$1,303.73
$1,627.91
$1,614.51
$1,700.66
$1,791.91
$2,116.09
$2,102.69
$2,188.84
$2,280.09
$2,604.27
$488.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,276.30
$1,448.60
$1,631.10
$2,279.46
$3,463.88
$1,764.48
$1,936.78
$2,119.28
$2,767.64
$2,252.66
$2,424.96
$2,607.46
$3,255.82
$2,740.84
$2,913.14
$3,095.64
$3,744.00
$488.18
Toc - Plan #47 Quartz
Silver

(HMO) QUARTZ ONE 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
$640.93
$727.46
$819.11
$1,144.70
$1,739.48
$1,131.24
$1,217.77
$1,309.42
$1,635.01
$1,621.55
$1,708.08
$1,799.73
$2,125.32
$2,111.86
$2,198.39
$2,290.04
$2,615.63
$490.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,281.86
$1,454.92
$1,638.22
$2,289.40
$3,478.96
$1,772.17
$1,945.23
$2,128.53
$2,779.71
$2,262.48
$2,435.54
$2,618.84
$3,270.02
$2,752.79
$2,925.85
$3,109.15
$3,760.33
$490.31
Toc - Plan #48 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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
$451.47
$512.41
$576.97
$806.31
$1,225.27
$796.84
$857.78
$922.34
$1,151.68
$1,142.21
$1,203.15
$1,267.71
$1,497.05
$1,487.58
$1,548.52
$1,613.08
$1,842.42
$345.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$902.94
$1,024.82
$1,153.94
$1,612.62
$2,450.54
$1,248.31
$1,370.19
$1,499.31
$1,957.99
$1,593.68
$1,715.56
$1,844.68
$2,303.36
$1,939.05
$2,060.93
$2,190.05
$2,648.73
$345.37

ADVERTISEMENT

Security Health Plan

Local: 1-715-221-9258x19258 | Toll Free: 1-844-293-9624 | TTY: 1-877-727-2232

Toc - Plan #49 Security Health Plan
Catastrophic

(EPO) Select Protection

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$219.33
$248.93
$280.30
$391.71
$595.24
$387.11
$416.71
$448.08
$559.49
$554.89
$584.49
$615.86
$727.27
$722.67
$752.27
$783.64
$895.05
$167.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$438.66
$497.86
$560.60
$783.42
$1,190.48
$606.44
$665.64
$728.38
$951.20
$774.22
$833.42
$896.16
$1,118.98
$942.00
$1,001.20
$1,063.94
$1,286.76
$167.78
Toc - Plan #50 Security Health Plan
Bronze

(EPO) Select $9,100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$320.61
$363.88
$409.73
$572.59
$870.11
$565.87
$609.14
$654.99
$817.85
$811.13
$854.40
$900.25
$1,063.11
$1,056.39
$1,099.66
$1,145.51
$1,308.37
$245.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.22
$727.76
$819.46
$1,145.18
$1,740.22
$886.48
$973.02
$1,064.72
$1,390.44
$1,131.74
$1,218.28
$1,309.98
$1,635.70
$1,377.00
$1,463.54
$1,555.24
$1,880.96
$245.26
Toc - Plan #51 Security Health Plan
Silver

(EPO) Select $4,100 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$546.03
$619.73
$697.81
$975.19
$1,481.89
$963.73
$1,037.43
$1,115.51
$1,392.89
$1,381.43
$1,455.13
$1,533.21
$1,810.59
$1,799.13
$1,872.83
$1,950.91
$2,228.29
$417.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,092.06
$1,239.46
$1,395.62
$1,950.38
$2,963.78
$1,509.76
$1,657.16
$1,813.32
$2,368.08
$1,927.46
$2,074.86
$2,231.02
$2,785.78
$2,345.16
$2,492.56
$2,648.72
$3,203.48
$417.70
Toc - Plan #52 Security Health Plan
Expanded Bronze

(EPO) Select $6,200 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.20
$422.44
$475.66
$664.73
$1,010.12
$656.92
$707.16
$760.38
$949.45
$941.64
$991.88
$1,045.10
$1,234.17
$1,226.36
$1,276.60
$1,329.82
$1,518.89
$284.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.40
$844.88
$951.32
$1,329.46
$2,020.24
$1,029.12
$1,129.60
$1,236.04
$1,614.18
$1,313.84
$1,414.32
$1,520.76
$1,898.90
$1,598.56
$1,699.04
$1,805.48
$2,183.62
$284.72
Toc - Plan #53 Security Health Plan
Gold

(EPO) Select $3,500 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$449.58
$510.26
$574.55
$802.93
$1,220.14
$793.50
$854.18
$918.47
$1,146.85
$1,137.42
$1,198.10
$1,262.39
$1,490.77
$1,481.34
$1,542.02
$1,606.31
$1,834.69
$343.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$899.16
$1,020.52
$1,149.10
$1,605.86
$2,440.28
$1,243.08
$1,364.44
$1,493.02
$1,949.78
$1,587.00
$1,708.36
$1,836.94
$2,293.70
$1,930.92
$2,052.28
$2,180.86
$2,637.62
$343.92
Toc - Plan #54 Security Health Plan
Gold

(EPO) Select $2,000 - 25%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$477.34
$541.77
$610.02
$852.51
$1,295.47
$842.50
$906.93
$975.18
$1,217.67
$1,207.66
$1,272.09
$1,340.34
$1,582.83
$1,572.82
$1,637.25
$1,705.50
$1,947.99
$365.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$954.68
$1,083.54
$1,220.04
$1,705.02
$2,590.94
$1,319.84
$1,448.70
$1,585.20
$2,070.18
$1,685.00
$1,813.86
$1,950.36
$2,435.34
$2,050.16
$2,179.02
$2,315.52
$2,800.50
$365.16
Toc - Plan #55 Security Health Plan
Silver

(EPO) Select $5,800 - 40%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$473.23
$537.10
$604.77
$845.16
$1,284.31
$835.24
$899.11
$966.78
$1,207.17
$1,197.25
$1,261.12
$1,328.79
$1,569.18
$1,559.26
$1,623.13
$1,690.80
$1,931.19
$362.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$946.46
$1,074.20
$1,209.54
$1,690.32
$2,568.62
$1,308.47
$1,436.21
$1,571.55
$2,052.33
$1,670.48
$1,798.22
$1,933.56
$2,414.34
$2,032.49
$2,160.23
$2,295.57
$2,776.35
$362.01
Toc - Plan #56 Security Health Plan
Expanded Bronze

(EPO) Select $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$327.67
$371.89
$418.75
$585.20
$889.26
$578.33
$622.55
$669.41
$835.86
$828.99
$873.21
$920.07
$1,086.52
$1,079.65
$1,123.87
$1,170.73
$1,337.18
$250.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$655.34
$743.78
$837.50
$1,170.40
$1,778.52
$906.00
$994.44
$1,088.16
$1,421.06
$1,156.66
$1,245.10
$1,338.82
$1,671.72
$1,407.32
$1,495.76
$1,589.48
$1,922.38
$250.66
Toc - Plan #57 Security Health Plan
Gold

(HMO) Premier $2,000 - 25%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$549.17
$623.30
$701.83
$980.81
$1,490.43
$969.28
$1,043.41
$1,121.94
$1,400.92
$1,389.39
$1,463.52
$1,542.05
$1,821.03
$1,809.50
$1,883.63
$1,962.16
$2,241.14
$420.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,098.34
$1,246.60
$1,403.66
$1,961.62
$2,980.86
$1,518.45
$1,666.71
$1,823.77
$2,381.73
$1,938.56
$2,086.82
$2,243.88
$2,801.84
$2,358.67
$2,506.93
$2,663.99
$3,221.95
$420.11
Toc - Plan #58 Security Health Plan
Gold

(HMO) Premier $3,500 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$517.24
$587.06
$661.02
$923.77
$1,403.76
$912.92
$982.74
$1,056.70
$1,319.45
$1,308.60
$1,378.42
$1,452.38
$1,715.13
$1,704.28
$1,774.10
$1,848.06
$2,110.81
$395.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,034.48
$1,174.12
$1,322.04
$1,847.54
$2,807.52
$1,430.16
$1,569.80
$1,717.72
$2,243.22
$1,825.84
$1,965.48
$2,113.40
$2,638.90
$2,221.52
$2,361.16
$2,509.08
$3,034.58
$395.68
Toc - Plan #59 Security Health Plan
Silver

(HMO) Premier $5,800 - 40%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$544.44
$617.93
$695.78
$972.36
$1,477.59
$960.93
$1,034.42
$1,112.27
$1,388.85
$1,377.42
$1,450.91
$1,528.76
$1,805.34
$1,793.91
$1,867.40
$1,945.25
$2,221.83
$416.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,088.88
$1,235.86
$1,391.56
$1,944.72
$2,955.18
$1,505.37
$1,652.35
$1,808.05
$2,361.21
$1,921.86
$2,068.84
$2,224.54
$2,777.70
$2,338.35
$2,485.33
$2,641.03
$3,194.19
$416.49
Toc - Plan #60 Security Health Plan
Silver

(HMO) Premier $4,100 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$628.20
$713.00
$802.83
$1,121.95
$1,704.91
$1,108.77
$1,193.57
$1,283.40
$1,602.52
$1,589.34
$1,674.14
$1,763.97
$2,083.09
$2,069.91
$2,154.71
$2,244.54
$2,563.66
$480.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,256.40
$1,426.00
$1,605.66
$2,243.90
$3,409.82
$1,736.97
$1,906.57
$2,086.23
$2,724.47
$2,217.54
$2,387.14
$2,566.80
$3,205.04
$2,698.11
$2,867.71
$3,047.37
$3,685.61
$480.57
Toc - Plan #61 Security Health Plan
Expanded Bronze

(HMO) Premier $6,200 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$428.21
$486.01
$547.24
$764.77
$1,162.14
$755.78
$813.58
$874.81
$1,092.34
$1,083.35
$1,141.15
$1,202.38
$1,419.91
$1,410.92
$1,468.72
$1,529.95
$1,747.48
$327.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.42
$972.02
$1,094.48
$1,529.54
$2,324.28
$1,183.99
$1,299.59
$1,422.05
$1,857.11
$1,511.56
$1,627.16
$1,749.62
$2,184.68
$1,839.13
$1,954.73
$2,077.19
$2,512.25
$327.57
Toc - Plan #62 Security Health Plan
Expanded Bronze

(HMO) Premier $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$376.98
$427.86
$481.77
$673.27
$1,023.09
$665.36
$716.24
$770.15
$961.65
$953.74
$1,004.62
$1,058.53
$1,250.03
$1,242.12
$1,293.00
$1,346.91
$1,538.41
$288.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.96
$855.72
$963.54
$1,346.54
$2,046.18
$1,042.34
$1,144.10
$1,251.92
$1,634.92
$1,330.72
$1,432.48
$1,540.30
$1,923.30
$1,619.10
$1,720.86
$1,828.68
$2,211.68
$288.38
Toc - Plan #63 Security Health Plan
Bronze

(HMO) Premier $9,100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$368.86
$418.65
$471.39
$658.77
$1,001.06
$651.03
$700.82
$753.56
$940.94
$933.20
$982.99
$1,035.73
$1,223.11
$1,215.37
$1,265.16
$1,317.90
$1,505.28
$282.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737.72
$837.30
$942.78
$1,317.54
$2,002.12
$1,019.89
$1,119.47
$1,224.95
$1,599.71
$1,302.06
$1,401.64
$1,507.12
$1,881.88
$1,584.23
$1,683.81
$1,789.29
$2,164.05
$282.17
Toc - Plan #64 Security Health Plan
Catastrophic

(HMO) Premier Protection

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$252.34
$286.40
$322.48
$450.66
$684.83
$445.37
$479.43
$515.51
$643.69
$638.40
$672.46
$708.54
$836.72
$831.43
$865.49
$901.57
$1,029.75
$193.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$504.68
$572.80
$644.96
$901.32
$1,369.66
$697.71
$765.83
$837.99
$1,094.35
$890.74
$958.86
$1,031.02
$1,287.38
$1,083.77
$1,151.89
$1,224.05
$1,480.41
$193.03

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-947-3529

Toc - Plan #65 Medica
Gold

(EPO) Engage by Medica Gold Copay ($0 Virtual Care with Designated Providers + $0 Preferred Generic Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 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
$507.23
$575.70
$648.23
$905.90
$1,376.60
$895.25
$963.72
$1,036.25
$1,293.92
$1,283.27
$1,351.74
$1,424.27
$1,681.94
$1,671.29
$1,739.76
$1,812.29
$2,069.96
$388.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,014.46
$1,151.40
$1,296.46
$1,811.80
$2,753.20
$1,402.48
$1,539.42
$1,684.48
$2,199.82
$1,790.50
$1,927.44
$2,072.50
$2,587.84
$2,178.52
$2,315.46
$2,460.52
$2,975.86
$388.02
Toc - Plan #66 Medica
Expanded Bronze

(EPO) Engage by Medica Bronze Copay ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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
$387.65
$439.97
$495.41
$692.33
$1,052.06
$684.20
$736.52
$791.96
$988.88
$980.75
$1,033.07
$1,088.51
$1,285.43
$1,277.30
$1,329.62
$1,385.06
$1,581.98
$296.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.30
$879.94
$990.82
$1,384.66
$2,104.12
$1,071.85
$1,176.49
$1,287.37
$1,681.21
$1,368.40
$1,473.04
$1,583.92
$1,977.76
$1,664.95
$1,769.59
$1,880.47
$2,274.31
$296.55
Toc - Plan #67 Medica
Expanded Bronze

(EPO) Engage by Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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
$441.55
$501.15
$564.29
$788.59
$1,198.34
$779.33
$838.93
$902.07
$1,126.37
$1,117.11
$1,176.71
$1,239.85
$1,464.15
$1,454.89
$1,514.49
$1,577.63
$1,801.93
$337.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$883.10
$1,002.30
$1,128.58
$1,577.18
$2,396.68
$1,220.88
$1,340.08
$1,466.36
$1,914.96
$1,558.66
$1,677.86
$1,804.14
$2,252.74
$1,896.44
$2,015.64
$2,141.92
$2,590.52
$337.78
Toc - Plan #68 Medica
Catastrophic

(EPO) Engage by Medica Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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
$247.63
$281.05
$316.46
$442.25
$672.04
$437.06
$470.48
$505.89
$631.68
$626.49
$659.91
$695.32
$821.11
$815.92
$849.34
$884.75
$1,010.54
$189.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$495.26
$562.10
$632.92
$884.50
$1,344.08
$684.69
$751.53
$822.35
$1,073.93
$874.12
$940.96
$1,011.78
$1,263.36
$1,063.55
$1,130.39
$1,201.21
$1,452.79
$189.43
Toc - Plan #69 Medica
Silver

(EPO) Engage by Medica Silver Share ($0 Virtual Care with Designated Providers + $5 Preferred Generic Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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
$507.02
$575.46
$647.96
$905.53
$1,376.04
$894.89
$963.33
$1,035.83
$1,293.40
$1,282.76
$1,351.20
$1,423.70
$1,681.27
$1,670.63
$1,739.07
$1,811.57
$2,069.14
$387.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,014.04
$1,150.92
$1,295.92
$1,811.06
$2,752.08
$1,401.91
$1,538.79
$1,683.79
$2,198.93
$1,789.78
$1,926.66
$2,071.66
$2,586.80
$2,177.65
$2,314.53
$2,459.53
$2,974.67
$387.87
Toc - Plan #70 Medica
Expanded Bronze

(EPO) Engage by Medica Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 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
$397.58
$451.24
$508.09
$710.06
$1,079.00
$701.72
$755.38
$812.23
$1,014.20
$1,005.86
$1,059.52
$1,116.37
$1,318.34
$1,310.00
$1,363.66
$1,420.51
$1,622.48
$304.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.16
$902.48
$1,016.18
$1,420.12
$2,158.00
$1,099.30
$1,206.62
$1,320.32
$1,724.26
$1,403.44
$1,510.76
$1,624.46
$2,028.40
$1,707.58
$1,814.90
$1,928.60
$2,332.54
$304.14
Toc - Plan #71 Medica
Gold

(EPO) Engage by Medica Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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
$506.46
$574.82
$647.24
$904.52
$1,374.50
$893.89
$962.25
$1,034.67
$1,291.95
$1,281.32
$1,349.68
$1,422.10
$1,679.38
$1,668.75
$1,737.11
$1,809.53
$2,066.81
$387.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,012.92
$1,149.64
$1,294.48
$1,809.04
$2,749.00
$1,400.35
$1,537.07
$1,681.91
$2,196.47
$1,787.78
$1,924.50
$2,069.34
$2,583.90
$2,175.21
$2,311.93
$2,456.77
$2,971.33
$387.43
Toc - Plan #72 Medica
Silver

(EPO) Engage by Medica Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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
$488.71
$554.68
$624.56
$872.83
$1,326.34
$862.57
$928.54
$998.42
$1,246.69
$1,236.43
$1,302.40
$1,372.28
$1,620.55
$1,610.29
$1,676.26
$1,746.14
$1,994.41
$373.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$977.42
$1,109.36
$1,249.12
$1,745.66
$2,652.68
$1,351.28
$1,483.22
$1,622.98
$2,119.52
$1,725.14
$1,857.08
$1,996.84
$2,493.38
$2,099.00
$2,230.94
$2,370.70
$2,867.24
$373.86
Toc - Plan #73 Medica
Bronze

(EPO) Engage by Medica Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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
$378.29
$429.35
$483.44
$675.61
$1,026.65
$667.67
$718.73
$772.82
$964.99
$957.05
$1,008.11
$1,062.20
$1,254.37
$1,246.43
$1,297.49
$1,351.58
$1,543.75
$289.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.58
$858.70
$966.88
$1,351.22
$2,053.30
$1,045.96
$1,148.08
$1,256.26
$1,640.60
$1,335.34
$1,437.46
$1,545.64
$1,929.98
$1,624.72
$1,726.84
$1,835.02
$2,219.36
$289.38

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

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

Toc - Plan #74 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
$428.32
$486.14
$547.39
$764.98
$1,162.46
$755.98
$813.80
$875.05
$1,092.64
$1,083.64
$1,141.46
$1,202.71
$1,420.30
$1,411.30
$1,469.12
$1,530.37
$1,747.96
$327.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.64
$972.28
$1,094.78
$1,529.96
$2,324.92
$1,184.30
$1,299.94
$1,422.44
$1,857.62
$1,511.96
$1,627.60
$1,750.10
$2,185.28
$1,839.62
$1,955.26
$2,077.76
$2,512.94
$327.66
Toc - Plan #75 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
$415.30
$471.37
$530.75
$741.73
$1,127.12
$733.00
$789.07
$848.45
$1,059.43
$1,050.70
$1,106.77
$1,166.15
$1,377.13
$1,368.40
$1,424.47
$1,483.85
$1,694.83
$317.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$830.60
$942.74
$1,061.50
$1,483.46
$2,254.24
$1,148.30
$1,260.44
$1,379.20
$1,801.16
$1,466.00
$1,578.14
$1,696.90
$2,118.86
$1,783.70
$1,895.84
$2,014.60
$2,436.56
$317.70
Toc - Plan #76 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
$407.85
$462.91
$521.23
$728.42
$1,106.90
$719.86
$774.92
$833.24
$1,040.43
$1,031.87
$1,086.93
$1,145.25
$1,352.44
$1,343.88
$1,398.94
$1,457.26
$1,664.45
$312.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$815.70
$925.82
$1,042.46
$1,456.84
$2,213.80
$1,127.71
$1,237.83
$1,354.47
$1,768.85
$1,439.72
$1,549.84
$1,666.48
$2,080.86
$1,751.73
$1,861.85
$1,978.49
$2,392.87
$312.01
Toc - Plan #77 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
$386.59
$438.78
$494.06
$690.45
$1,049.21
$682.33
$734.52
$789.80
$986.19
$978.07
$1,030.26
$1,085.54
$1,281.93
$1,273.81
$1,326.00
$1,381.28
$1,577.67
$295.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$773.18
$877.56
$988.12
$1,380.90
$2,098.42
$1,068.92
$1,173.30
$1,283.86
$1,676.64
$1,364.66
$1,469.04
$1,579.60
$1,972.38
$1,660.40
$1,764.78
$1,875.34
$2,268.12
$295.74
Toc - Plan #78 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
$407.01
$461.96
$520.16
$726.92
$1,104.63
$718.37
$773.32
$831.52
$1,038.28
$1,029.73
$1,084.68
$1,142.88
$1,349.64
$1,341.09
$1,396.04
$1,454.24
$1,661.00
$311.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.02
$923.92
$1,040.32
$1,453.84
$2,209.26
$1,125.38
$1,235.28
$1,351.68
$1,765.20
$1,436.74
$1,546.64
$1,663.04
$2,076.56
$1,748.10
$1,858.00
$1,974.40
$2,387.92
$311.36
Toc - Plan #79 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
$527.97
$599.25
$674.75
$942.95
$1,432.91
$931.87
$1,003.15
$1,078.65
$1,346.85
$1,335.77
$1,407.05
$1,482.55
$1,750.75
$1,739.67
$1,810.95
$1,886.45
$2,154.65
$403.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,055.94
$1,198.50
$1,349.50
$1,885.90
$2,865.82
$1,459.84
$1,602.40
$1,753.40
$2,289.80
$1,863.74
$2,006.30
$2,157.30
$2,693.70
$2,267.64
$2,410.20
$2,561.20
$3,097.60
$403.90
Toc - Plan #80 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
$509.74
$578.55
$651.45
$910.40
$1,383.43
$899.69
$968.50
$1,041.40
$1,300.35
$1,289.64
$1,358.45
$1,431.35
$1,690.30
$1,679.59
$1,748.40
$1,821.30
$2,080.25
$389.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,019.48
$1,157.10
$1,302.90
$1,820.80
$2,766.86
$1,409.43
$1,547.05
$1,692.85
$2,210.75
$1,799.38
$1,937.00
$2,082.80
$2,600.70
$2,189.33
$2,326.95
$2,472.75
$2,990.65
$389.95
Toc - Plan #81 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
$515.87
$585.51
$659.28
$921.34
$1,400.07
$910.51
$980.15
$1,053.92
$1,315.98
$1,305.15
$1,374.79
$1,448.56
$1,710.62
$1,699.79
$1,769.43
$1,843.20
$2,105.26
$394.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,031.74
$1,171.02
$1,318.56
$1,842.68
$2,800.14
$1,426.38
$1,565.66
$1,713.20
$2,237.32
$1,821.02
$1,960.30
$2,107.84
$2,631.96
$2,215.66
$2,354.94
$2,502.48
$3,026.60
$394.64
Toc - Plan #82 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
$506.74
$575.15
$647.61
$905.04
$1,375.29
$894.40
$962.81
$1,035.27
$1,292.70
$1,282.06
$1,350.47
$1,422.93
$1,680.36
$1,669.72
$1,738.13
$1,810.59
$2,068.02
$387.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,013.48
$1,150.30
$1,295.22
$1,810.08
$2,750.58
$1,401.14
$1,537.96
$1,682.88
$2,197.74
$1,788.80
$1,925.62
$2,070.54
$2,585.40
$2,176.46
$2,313.28
$2,458.20
$2,973.06
$387.66
Toc - Plan #83 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
$387.14
$439.40
$494.76
$691.43
$1,050.70
$683.30
$735.56
$790.92
$987.59
$979.46
$1,031.72
$1,087.08
$1,283.75
$1,275.62
$1,327.88
$1,383.24
$1,579.91
$296.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774.28
$878.80
$989.52
$1,382.86
$2,101.40
$1,070.44
$1,174.96
$1,285.68
$1,679.02
$1,366.60
$1,471.12
$1,581.84
$1,975.18
$1,662.76
$1,767.28
$1,878.00
$2,271.34
$296.16
Toc - Plan #84 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
$420.79
$477.60
$537.77
$751.53
$1,142.02
$742.69
$799.50
$859.67
$1,073.43
$1,064.59
$1,121.40
$1,181.57
$1,395.33
$1,386.49
$1,443.30
$1,503.47
$1,717.23
$321.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$841.58
$955.20
$1,075.54
$1,503.06
$2,284.04
$1,163.48
$1,277.10
$1,397.44
$1,824.96
$1,485.38
$1,599.00
$1,719.34
$2,146.86
$1,807.28
$1,920.90
$2,041.24
$2,468.76
$321.90
Toc - Plan #85 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
$502.43
$570.26
$642.11
$897.34
$1,363.60
$886.79
$954.62
$1,026.47
$1,281.70
$1,271.15
$1,338.98
$1,410.83
$1,666.06
$1,655.51
$1,723.34
$1,795.19
$2,050.42
$384.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,004.86
$1,140.52
$1,284.22
$1,794.68
$2,727.20
$1,389.22
$1,524.88
$1,668.58
$2,179.04
$1,773.58
$1,909.24
$2,052.94
$2,563.40
$2,157.94
$2,293.60
$2,437.30
$2,947.76
$384.36
Toc - Plan #86 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
$528.35
$599.68
$675.23
$943.63
$1,433.94
$932.54
$1,003.87
$1,079.42
$1,347.82
$1,336.73
$1,408.06
$1,483.61
$1,752.01
$1,740.92
$1,812.25
$1,887.80
$2,156.20
$404.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,056.70
$1,199.36
$1,350.46
$1,887.26
$2,867.88
$1,460.89
$1,603.55
$1,754.65
$2,291.45
$1,865.08
$2,007.74
$2,158.84
$2,695.64
$2,269.27
$2,411.93
$2,563.03
$3,099.83
$404.19

‡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 Pepin County here.

Pepin County is in “Rating Area 6” of Wisconsin.

Currently, there are 86 plans offered in Rating Area 6.

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2023 Obamacare Plans for Pepin County, WI

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