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Providers for Zip Code 54166

Obamacare 2017 Marketplace Rates For Shawano County, Wisconsin

Monday, December 5th, 2016

Click for Shawano, Wisconsin Forecast

Obamacare Providers, Plans and 2017 Rates for Shawano County

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

2017 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

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

Currently, there are 67 plans offered in Shawano County.

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

 

The table below shows premiums for the following scenarios:

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

Each scenario is covered for age

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

 

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

 

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

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

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

Security Health Plan of Wisconsin, Inc.

Local: 1-715-221-9258 x19258 | Toll Free: 1-844-293-9624

TTY: 1-877-727-2232

Plan: (HMO) Classic $1,500 - 20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$476.34
$540.64
$608.75
$850.73
$1292.76
$952.68
$1081.28
$1217.50
$1701.46
$2585.52
$1255.15
$1383.75
$1519.97
$2003.93
$1557.62
$1686.22
$1822.44
$2306.40
$1860.09
$1988.69
$2124.91
$2608.87
$778.81
$843.11
$911.22
$1153.20
$1081.28
$1145.58
$1213.69
$1455.67
$1383.75
$1448.05
$1516.16
$1758.14
$302.47

Plan: (HMO) Classic $3,750 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$419.89
$476.56
$536.61
$749.90
$1139.55
$839.78
$953.12
$1073.22
$1499.80
$2279.10
$1106.40
$1219.74
$1339.84
$1766.42
$1373.02
$1486.36
$1606.46
$2033.04
$1639.64
$1752.98
$1873.08
$2299.66
$686.51
$743.18
$803.23
$1016.52
$953.13
$1009.80
$1069.85
$1283.14
$1219.75
$1276.42
$1336.47
$1549.76
$266.62

Plan: (EPO) Select $5,500 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$281.27
$319.23
$359.44
$502.32
$763.33
$562.54
$638.46
$718.88
$1004.64
$1526.66
$741.14
$817.06
$897.48
$1183.24
$919.74
$995.66
$1076.08
$1361.84
$1098.34
$1174.26
$1254.68
$1540.44
$459.87
$497.83
$538.04
$680.92
$638.47
$676.43
$716.64
$859.52
$817.07
$855.03
$895.24
$1038.12
$178.60

Plan: (HMO) Classic $2,500 - 20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$394.84
$448.13
$504.59
$705.16
$1071.56
$789.68
$896.26
$1009.18
$1410.32
$2143.12
$1040.40
$1146.98
$1259.90
$1661.04
$1291.12
$1397.70
$1510.62
$1911.76
$1541.84
$1648.42
$1761.34
$2162.48
$645.56
$698.85
$755.31
$955.88
$896.28
$949.57
$1006.03
$1206.60
$1147.00
$1200.29
$1256.75
$1457.32
$250.72

Plan: (HMO) Classic $2,000 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$394.17
$447.37
$503.74
$703.97
$1069.75
$788.34
$894.74
$1007.48
$1407.94
$2139.50
$1038.63
$1145.03
$1257.77
$1658.23
$1288.92
$1395.32
$1508.06
$1908.52
$1539.21
$1645.61
$1758.35
$2158.81
$644.46
$697.66
$754.03
$954.26
$894.75
$947.95
$1004.32
$1204.55
$1145.04
$1198.24
$1254.61
$1454.84
$250.29

Plan: (HMO) Classic $6,000 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$334.04
$379.13
$426.89
$596.58
$906.57
$668.08
$758.26
$853.78
$1193.16
$1813.14
$880.19
$970.37
$1065.89
$1405.27
$1092.30
$1182.48
$1278.00
$1617.38
$1304.41
$1394.59
$1490.11
$1829.49
$546.15
$591.24
$639.00
$808.69
$758.26
$803.35
$851.11
$1020.80
$970.37
$1015.46
$1063.22
$1232.91
$212.11

Plan: (HMO) Classic $5,500 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$344.06
$390.50
$439.70
$614.48
$933.76
$688.12
$781.00
$879.40
$1228.96
$1867.52
$906.59
$999.47
$1097.87
$1447.43
$1125.06
$1217.94
$1316.34
$1665.90
$1343.53
$1436.41
$1534.81
$1884.37
$562.53
$608.97
$658.17
$832.95
$781.00
$827.44
$876.64
$1051.42
$999.47
$1045.91
$1095.11
$1269.89
$218.47

Plan: (HMO) Classic Protection

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$227.15
$257.81
$290.29
$405.68
$616.46
$454.30
$515.62
$580.58
$811.36
$1232.92
$598.54
$659.86
$724.82
$955.60
$742.78
$804.10
$869.06
$1099.84
$887.02
$948.34
$1013.30
$1244.08
$371.39
$402.05
$434.53
$549.92
$515.63
$546.29
$578.77
$694.16
$659.87
$690.53
$723.01
$838.40
$144.24

Plan: (HMO) Classic $4,500 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$391.16
$443.96
$499.89
$698.60
$1061.59
$782.32
$887.92
$999.78
$1397.20
$2123.18
$1030.70
$1136.30
$1248.16
$1645.58
$1279.08
$1384.68
$1496.54
$1893.96
$1527.46
$1633.06
$1744.92
$2142.34
$639.54
$692.34
$748.27
$946.98
$887.92
$940.72
$996.65
$1195.36
$1136.30
$1189.10
$1245.03
$1443.74
$248.38

Plan: (HMO) Classic $6,500 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$319.68
$362.82
$408.54
$570.93
$867.58
$639.36
$725.64
$817.08
$1141.86
$1735.16
$842.35
$928.63
$1020.07
$1344.85
$1045.34
$1131.62
$1223.06
$1547.84
$1248.33
$1334.61
$1426.05
$1750.83
$522.67
$565.81
$611.53
$773.92
$725.66
$768.80
$814.52
$976.91
$928.65
$971.79
$1017.51
$1179.90
$202.99

Plan: (HMO) Classic $7,150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$309.66
$351.45
$395.73
$553.03
$840.39
$619.32
$702.90
$791.46
$1106.06
$1680.78
$815.95
$899.53
$988.09
$1302.69
$1012.58
$1096.16
$1184.72
$1499.32
$1209.21
$1292.79
$1381.35
$1695.95
$506.29
$548.08
$592.36
$749.66
$702.92
$744.71
$788.99
$946.29
$899.55
$941.34
$985.62
$1142.92
$196.63

Plan: (HMO) Classic $5,500 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$376.80
$427.66
$481.54
$672.95
$1022.61
$753.60
$855.32
$963.08
$1345.90
$2045.22
$992.86
$1094.58
$1202.34
$1585.16
$1232.12
$1333.84
$1441.60
$1824.42
$1471.38
$1573.10
$1680.86
$2063.68
$616.06
$666.92
$720.80
$912.21
$855.32
$906.18
$960.06
$1151.47
$1094.58
$1145.44
$1199.32
$1390.73
$239.26

Plan: (EPO) Select $1,500 - 20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$389.16
$441.68
$497.33
$695.02
$1056.15
$778.32
$883.36
$994.66
$1390.04
$2112.30
$1025.43
$1130.47
$1241.77
$1637.15
$1272.54
$1377.58
$1488.88
$1884.26
$1519.65
$1624.69
$1735.99
$2131.37
$636.27
$688.79
$744.44
$942.13
$883.38
$935.90
$991.55
$1189.24
$1130.49
$1183.01
$1238.66
$1436.35
$247.11

Plan: (EPO) Select $3,750 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$343.06
$389.36
$438.42
$612.69
$931.04
$686.12
$778.72
$876.84
$1225.38
$1862.08
$903.96
$996.56
$1094.68
$1443.22
$1121.80
$1214.40
$1312.52
$1661.06
$1339.64
$1432.24
$1530.36
$1878.90
$560.90
$607.20
$656.26
$830.53
$778.74
$825.04
$874.10
$1048.37
$996.58
$1042.88
$1091.94
$1266.21
$217.84

Plan: (EPO) Select $2,500 - 20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$322.69
$366.24
$412.38
$576.30
$875.74
$645.38
$732.48
$824.76
$1152.60
$1751.48
$850.28
$937.38
$1029.66
$1357.50
$1055.18
$1142.28
$1234.56
$1562.40
$1260.08
$1347.18
$1439.46
$1767.30
$527.59
$571.14
$617.28
$781.20
$732.49
$776.04
$822.18
$986.10
$937.39
$980.94
$1027.08
$1191.00
$204.90

Plan: (EPO) Select $2,000 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$322.02
$365.48
$411.53
$575.11
$873.93
$644.04
$730.96
$823.06
$1150.22
$1747.86
$848.51
$935.43
$1027.53
$1354.69
$1052.98
$1139.90
$1232.00
$1559.16
$1257.45
$1344.37
$1436.47
$1763.63
$526.49
$569.95
$616.00
$779.58
$730.96
$774.42
$820.47
$984.05
$935.43
$978.89
$1024.94
$1188.52
$204.47

Plan: (EPO) Select $6,000 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$272.91
$309.75
$348.77
$487.41
$740.66
$545.82
$619.50
$697.54
$974.82
$1481.32
$719.11
$792.79
$870.83
$1148.11
$892.40
$966.08
$1044.12
$1321.40
$1065.69
$1139.37
$1217.41
$1494.69
$446.20
$483.04
$522.06
$660.70
$619.49
$656.33
$695.35
$833.99
$792.78
$829.62
$868.64
$1007.28
$173.29

Plan: (EPO) Select Protection

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$185.40
$210.42
$236.93
$331.10
$503.14
$370.80
$420.84
$473.86
$662.20
$1006.28
$488.52
$538.56
$591.58
$779.92
$606.24
$656.28
$709.30
$897.64
$723.96
$774.00
$827.02
$1015.36
$303.12
$328.14
$354.65
$448.82
$420.84
$445.86
$472.37
$566.54
$538.56
$563.58
$590.09
$684.26
$117.72

Plan: (EPO) Select $4,500 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$319.68
$362.82
$408.54
$570.93
$867.58
$639.36
$725.64
$817.08
$1141.86
$1735.16
$842.35
$928.63
$1020.07
$1344.85
$1045.34
$1131.62
$1223.06
$1547.84
$1248.33
$1334.61
$1426.05
$1750.83
$522.67
$565.81
$611.53
$773.92
$725.66
$768.80
$814.52
$976.91
$928.65
$971.79
$1017.51
$1179.90
$202.99

Plan: (EPO) Select $6,500 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$261.22
$296.48
$333.83
$466.53
$708.93
$522.44
$592.96
$667.66
$933.06
$1417.86
$688.31
$758.83
$833.53
$1098.93
$854.18
$924.70
$999.40
$1264.80
$1020.05
$1090.57
$1165.27
$1430.67
$427.09
$462.35
$499.70
$632.40
$592.96
$628.22
$665.57
$798.27
$758.83
$794.09
$831.44
$964.14
$165.87

Plan: (EPO) Select $7,150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$253.21
$287.38
$323.59
$452.21
$687.18
$506.42
$574.76
$647.18
$904.42
$1374.36
$667.20
$735.54
$807.96
$1065.20
$827.98
$896.32
$968.74
$1225.98
$988.76
$1057.10
$1129.52
$1386.76
$413.99
$448.16
$484.37
$612.99
$574.77
$608.94
$645.15
$773.77
$735.55
$769.72
$805.93
$934.55
$160.78

Plan: (EPO) Select $5,500 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$307.99
$349.56
$393.60
$550.05
$835.85
$615.98
$699.12
$787.20
$1100.10
$1671.70
$811.55
$894.69
$982.77
$1295.67
$1007.12
$1090.26
$1178.34
$1491.24
$1202.69
$1285.83
$1373.91
$1686.81
$503.56
$545.13
$589.17
$745.62
$699.13
$740.70
$784.74
$941.19
$894.70
$936.27
$980.31
$1136.76
$195.57

Molina Healthcare of Wisconsin, Inc.

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

Plan: (HMO) Molina Marketplace Gold

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-560-2043 - Provider Directory for This Plan: (Molina Healthcare of Wisconsin, Inc.)

Deductible: Individual: $1,025 : Family: $2,050
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$388.82
$441.31
$496.91
$694.43
$1055.26
$777.64
$882.62
$993.82
$1388.86
$2110.52
$1024.54
$1129.52
$1240.72
$1635.76
$1271.44
$1376.42
$1487.62
$1882.66
$1518.34
$1623.32
$1734.52
$2129.56
$635.72
$688.21
$743.81
$941.33
$882.62
$935.11
$990.71
$1188.23
$1129.52
$1182.01
$1237.61
$1435.13
$246.90

Plan: (HMO) Molina Marketplace Silver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-560-2043 - Provider Directory for This Plan: (Molina Healthcare of Wisconsin, Inc.)

Deductible: Individual: $2,400 : Family: $4,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$304.80
$345.94
$389.53
$544.37
$827.22
$609.60
$691.88
$779.06
$1088.74
$1654.44
$803.15
$885.43
$972.61
$1282.29
$996.70
$1078.98
$1166.16
$1475.84
$1190.25
$1272.53
$1359.71
$1669.39
$498.35
$539.49
$583.08
$737.92
$691.90
$733.04
$776.63
$931.47
$885.45
$926.59
$970.18
$1125.02
$193.55

Plan: (HMO) Molina Marketplace Bronze

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-560-2043 - Provider Directory for This Plan: (Molina Healthcare of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$260.67
$295.86
$333.14
$465.56
$707.47
$521.34
$591.72
$666.28
$931.12
$1414.94
$686.87
$757.25
$831.81
$1096.65
$852.40
$922.78
$997.34
$1262.18
$1017.93
$1088.31
$1162.87
$1427.71
$426.20
$461.39
$498.67
$631.09
$591.73
$626.92
$664.20
$796.62
$757.26
$792.45
$829.73
$962.15
$165.53

Plan: (HMO) Molina Marketplace Options Silver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-560-2043 - Provider Directory for This Plan: (Molina Healthcare of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$307.64
$349.17
$393.17
$549.45
$834.94
$615.28
$698.34
$786.34
$1098.90
$1669.88
$810.63
$893.69
$981.69
$1294.25
$1005.98
$1089.04
$1177.04
$1489.60
$1201.33
$1284.39
$1372.39
$1684.95
$502.99
$544.52
$588.52
$744.80
$698.34
$739.87
$783.87
$940.15
$893.69
$935.22
$979.22
$1135.50
$195.35

Plan: (HMO) Molina Marketplace Options Bronze

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-560-2043 - Provider Directory for This Plan: (Molina Healthcare of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$268.21
$304.42
$342.77
$479.03
$727.93
$536.42
$608.84
$685.54
$958.06
$1455.86
$706.73
$779.15
$855.85
$1128.37
$877.04
$949.46
$1026.16
$1298.68
$1047.35
$1119.77
$1196.47
$1468.99
$438.52
$474.73
$513.08
$649.34
$608.83
$645.04
$683.39
$819.65
$779.14
$815.35
$853.70
$989.96
$170.31

Compcare Health Serv Ins Co(Anthem BCBS)

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

Plan: (HMO) Anthem Catastrophic Blue Priority WI 7150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$240.72
$273.22
$307.64
$429.93
$653.31
$481.44
$546.44
$615.28
$859.86
$1306.62
$634.30
$699.30
$768.14
$1012.72
$787.16
$852.16
$921.00
$1165.58
$940.02
$1005.02
$1073.86
$1318.44
$393.58
$426.08
$460.50
$582.79
$546.44
$578.94
$613.36
$735.65
$699.30
$731.80
$766.22
$888.51
$152.86

Plan: (HMO) Anthem Bronze Blue Priority WI 0 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$304.14
$345.20
$388.69
$543.19
$825.44
$608.28
$690.40
$777.38
$1086.38
$1650.88
$801.41
$883.53
$970.51
$1279.51
$994.54
$1076.66
$1163.64
$1472.64
$1187.67
$1269.79
$1356.77
$1665.77
$497.27
$538.33
$581.82
$736.32
$690.40
$731.46
$774.95
$929.45
$883.53
$924.59
$968.08
$1122.58
$193.13

Plan: (HMO) Anthem Bronze Blue Priority WI 30 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $5,150 : Family: $10,300
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$308.26
$349.88
$393.96
$550.55
$836.62
$616.52
$699.76
$787.92
$1101.10
$1673.24
$812.27
$895.51
$983.67
$1296.85
$1008.02
$1091.26
$1179.42
$1492.60
$1203.77
$1287.01
$1375.17
$1688.35
$504.01
$545.63
$589.71
$746.30
$699.76
$741.38
$785.46
$942.05
$895.51
$937.13
$981.21
$1137.80
$195.75

Plan: (HMO) Anthem Silver Blue Priority WI 3750

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $3,750 : Family: $7,500
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$344.01
$390.45
$439.64
$614.40
$933.64
$688.02
$780.90
$879.28
$1228.80
$1867.28
$906.47
$999.35
$1097.73
$1447.25
$1124.92
$1217.80
$1316.18
$1665.70
$1343.37
$1436.25
$1534.63
$1884.15
$562.46
$608.90
$658.09
$832.85
$780.91
$827.35
$876.54
$1051.30
$999.36
$1045.80
$1094.99
$1269.75
$218.45

Plan: (HMO) Anthem Silver Blue Priority WI 2500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$351.72
$399.20
$449.50
$628.17
$954.57
$703.44
$798.40
$899.00
$1256.34
$1909.14
$926.78
$1021.74
$1122.34
$1479.68
$1150.12
$1245.08
$1345.68
$1703.02
$1373.46
$1468.42
$1569.02
$1926.36
$575.06
$622.54
$672.84
$851.51
$798.40
$845.88
$896.18
$1074.85
$1021.74
$1069.22
$1119.52
$1298.19
$223.34

Plan: (HMO) Anthem Silver Blue Priority WI for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$348.10
$395.09
$444.87
$621.71
$944.74
$696.20
$790.18
$889.74
$1243.42
$1889.48
$917.24
$1011.22
$1110.78
$1464.46
$1138.28
$1232.26
$1331.82
$1685.50
$1359.32
$1453.30
$1552.86
$1906.54
$569.14
$616.13
$665.91
$842.75
$790.18
$837.17
$886.95
$1063.79
$1011.22
$1058.21
$1107.99
$1284.83
$221.04

Plan: (HMO) Anthem Bronze Blue Priority WI 40 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$305.76
$347.04
$390.76
$546.09
$829.83
$611.52
$694.08
$781.52
$1092.18
$1659.66
$805.68
$888.24
$975.68
$1286.34
$999.84
$1082.40
$1169.84
$1480.50
$1194.00
$1276.56
$1364.00
$1674.66
$499.92
$541.20
$584.92
$740.25
$694.08
$735.36
$779.08
$934.41
$888.24
$929.52
$973.24
$1128.57
$194.16

Plan: (HMO) Anthem Bronze Blue Priority WI 5450

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $5,450 : Family: $10,900
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$300.49
$341.06
$384.03
$536.68
$815.53
$600.98
$682.12
$768.06
$1073.36
$1631.06
$791.79
$872.93
$958.87
$1264.17
$982.60
$1063.74
$1149.68
$1454.98
$1173.41
$1254.55
$1340.49
$1645.79
$491.30
$531.87
$574.84
$727.49
$682.11
$722.68
$765.65
$918.30
$872.92
$913.49
$956.46
$1109.11
$190.81

Plan: (HMO) Anthem Silver Blue Priority WI 4000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$336.17
$381.55
$429.63
$600.40
$912.37
$672.34
$763.10
$859.26
$1200.80
$1824.74
$885.81
$976.57
$1072.73
$1414.27
$1099.28
$1190.04
$1286.20
$1627.74
$1312.75
$1403.51
$1499.67
$1841.21
$549.64
$595.02
$643.10
$813.87
$763.11
$808.49
$856.57
$1027.34
$976.58
$1021.96
$1070.04
$1240.81
$213.47

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442

TTY: 1-855-643-5001

Plan: (PPO) Envision Aurora Bellin PPO - Catastrophic 7150/100

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$229.54
$260.52
$293.34
$409.94
$622.94
$459.08
$521.04
$586.68
$819.88
$1245.88
$604.83
$666.79
$732.43
$965.63
$750.58
$812.54
$878.18
$1111.38
$896.33
$958.29
$1023.93
$1257.13
$375.29
$406.27
$439.09
$555.69
$521.04
$552.02
$584.84
$701.44
$666.79
$697.77
$730.59
$847.19
$145.75
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Compcare Health Serv Ins Co(Anthem BCBS)

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

Plan: (HMO) Anthem Silver Blue Priority WI 5300

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $5,300 : Family: $10,600
Out of Pocket Maximum per year: Individual: $6,650 : Family: $13,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$318.61
$361.62
$407.18
$569.04
$864.71
$637.22
$723.24
$814.36
$1138.08
$1729.42
$839.54
$925.56
$1016.68
$1340.40
$1041.86
$1127.88
$1219.00
$1542.72
$1244.18
$1330.20
$1421.32
$1745.04
$520.93
$563.94
$609.50
$771.36
$723.25
$766.26
$811.82
$973.68
$925.57
$968.58
$1014.14
$1176.00
$202.32

Plan: (HMO) Anthem Silver Blue Priority WI 3200

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $3,200 : Family: $6,400
Out of Pocket Maximum per year: Individual: $6,650 : Family: $13,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$331.79
$376.58
$424.03
$592.58
$900.48
$663.58
$753.16
$848.06
$1185.16
$1800.96
$874.27
$963.85
$1058.75
$1395.85
$1084.96
$1174.54
$1269.44
$1606.54
$1295.65
$1385.23
$1480.13
$1817.23
$542.48
$587.27
$634.72
$803.27
$753.17
$797.96
$845.41
$1013.96
$963.86
$1008.65
$1056.10
$1224.65
$210.69

Plan: (HMO) Anthem Blue Cross and Blue Shield Silver DirectAccess, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $1,850 : Family: $3,700
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$358.24
$406.60
$457.83
$639.82
$972.26
$716.48
$813.20
$915.66
$1279.64
$1944.52
$943.96
$1040.68
$1143.14
$1507.12
$1171.44
$1268.16
$1370.62
$1734.60
$1398.92
$1495.64
$1598.10
$1962.08
$585.72
$634.08
$685.31
$867.30
$813.20
$861.56
$912.79
$1094.78
$1040.68
$1089.04
$1140.27
$1322.26
$227.48

Plan: (HMO) Anthem Blue Cross and Blue Shield Gold DirectAccess, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $1,000 : Family: $3,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$496.36
$563.37
$634.35
$886.50
$1347.12
$992.72
$1126.74
$1268.70
$1773.00
$2694.24
$1307.91
$1441.93
$1583.89
$2088.19
$1623.10
$1757.12
$1899.08
$2403.38
$1938.29
$2072.31
$2214.27
$2718.57
$811.55
$878.56
$949.54
$1201.69
$1126.74
$1193.75
$1264.73
$1516.88
$1441.93
$1508.94
$1579.92
$1832.07
$315.19
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Aspirus Arise Health Plan of Wisconsin, Inc.

Local: 1-715-972-8140 | Toll Free: 1-800-332-6290

TTY: 1-888-332-0144

Plan: (HMO) HMO Silver 7000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $7,000 : Family: $14,000
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$306.80
$348.22
$392.09
$547.94
$832.66
$613.60
$696.44
$784.18
$1095.88
$1665.32
$808.42
$891.26
$979.00
$1290.70
$1003.24
$1086.08
$1173.82
$1485.52
$1198.06
$1280.90
$1368.64
$1680.34
$501.62
$543.04
$586.91
$742.76
$696.44
$737.86
$781.73
$937.58
$891.26
$932.68
$976.55
$1132.40
$194.82

Plan: (HMO) HMO Silver 4500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$318.66
$361.68
$407.25
$569.13
$864.84
$637.32
$723.36
$814.50
$1138.26
$1729.68
$839.67
$925.71
$1016.85
$1340.61
$1042.02
$1128.06
$1219.20
$1542.96
$1244.37
$1330.41
$1421.55
$1745.31
$521.01
$564.03
$609.60
$771.48
$723.36
$766.38
$811.95
$973.83
$925.71
$968.73
$1014.30
$1176.18
$202.35

Plan: (HMO) HMO HDHP Bronze 5500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$259.08
$294.06
$331.10
$462.72
$703.14
$518.16
$588.12
$662.20
$925.44
$1406.28
$682.68
$752.64
$826.72
$1089.96
$847.20
$917.16
$991.24
$1254.48
$1011.72
$1081.68
$1155.76
$1419.00
$423.60
$458.58
$495.62
$627.24
$588.12
$623.10
$660.14
$791.76
$752.64
$787.62
$824.66
$956.28
$164.52

Plan: (HMO) HMO HDHP Silver 2700

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,700 : Family: $5,400
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$313.89
$356.27
$401.15
$560.61
$851.90
$627.78
$712.54
$802.30
$1121.22
$1703.80
$827.10
$911.86
$1001.62
$1320.54
$1026.42
$1111.18
$1200.94
$1519.86
$1225.74
$1310.50
$1400.26
$1719.18
$513.21
$555.59
$600.47
$759.93
$712.53
$754.91
$799.79
$959.25
$911.85
$954.23
$999.11
$1158.57
$199.32

Plan: (HMO) HMO Bronze 7150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$249.25
$282.90
$318.54
$445.16
$676.46
$498.50
$565.80
$637.08
$890.32
$1352.92
$656.77
$724.07
$795.35
$1048.59
$815.04
$882.34
$953.62
$1206.86
$973.31
$1040.61
$1111.89
$1365.13
$407.52
$441.17
$476.81
$603.43
$565.79
$599.44
$635.08
$761.70
$724.06
$757.71
$793.35
$919.97
$158.27

Plan: (HMO) HMO Bronze 6250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $6,250 : Family: $12,500
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$254.24
$288.56
$324.92
$454.07
$690.01
$508.48
$577.12
$649.84
$908.14
$1380.02
$669.92
$738.56
$811.28
$1069.58
$831.36
$900.00
$972.72
$1231.02
$992.80
$1061.44
$1134.16
$1392.46
$415.68
$450.00
$486.36
$615.51
$577.12
$611.44
$647.80
$776.95
$738.56
$772.88
$809.24
$938.39
$161.44

Plan: (HMO) HMO Gold 2000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $3,850 : Family: $7,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$478.05
$542.59
$610.95
$853.80
$1297.43
$956.10
$1085.18
$1221.90
$1707.60
$2594.86
$1259.66
$1388.74
$1525.46
$2011.16
$1563.22
$1692.30
$1829.02
$2314.72
$1866.78
$1995.86
$2132.58
$2618.28
$781.61
$846.15
$914.51
$1157.36
$1085.17
$1149.71
$1218.07
$1460.92
$1388.73
$1453.27
$1521.63
$1764.48
$303.56

Plan: (HMO) HMO Catastrophic 7150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$218.65
$248.17
$279.43
$390.51
$593.42
$437.30
$496.34
$558.86
$781.02
$1186.84
$576.14
$635.18
$697.70
$919.86
$714.98
$774.02
$836.54
$1058.70
$853.82
$912.86
$975.38
$1197.54
$357.49
$387.01
$418.27
$529.35
$496.33
$525.85
$557.11
$668.19
$635.17
$664.69
$695.95
$807.03
$138.84

Plan: (HMO) HMO HDHP Bronze 6550

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$253.49
$287.71
$323.96
$452.73
$687.97
$506.98
$575.42
$647.92
$905.46
$1375.94
$667.95
$736.39
$808.89
$1066.43
$828.92
$897.36
$969.86
$1227.40
$989.89
$1058.33
$1130.83
$1388.37
$414.46
$448.68
$484.93
$613.70
$575.43
$609.65
$645.90
$774.67
$736.40
$770.62
$806.87
$935.64
$160.97
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Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442

TTY: 1-855-643-5001

Plan: (PPO) Envision Aurora Bellin PPO - Bronze 7150/100

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$280.65
$318.52
$358.65
$501.22
$761.64
$561.30
$637.04
$717.30
$1002.44
$1523.28
$739.50
$815.24
$895.50
$1180.64
$917.70
$993.44
$1073.70
$1358.84
$1095.90
$1171.64
$1251.90
$1537.04
$458.85
$496.72
$536.85
$679.42
$637.05
$674.92
$715.05
$857.62
$815.25
$853.12
$893.25
$1035.82
$178.20
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Aspirus Arise Health Plan of Wisconsin, Inc.

Local: 1-715-972-8140 | Toll Free: 1-800-332-6290

TTY: 1-888-332-0144

Plan: (HMO) HMO HDHP Silver 4000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$317.06
$359.86
$405.20
$566.27
$860.50
$634.12
$719.72
$810.40
$1132.54
$1721.00
$835.45
$921.05
$1011.73
$1333.87
$1036.78
$1122.38
$1213.06
$1535.20
$1238.11
$1323.71
$1414.39
$1736.53
$518.39
$561.19
$606.53
$767.60
$719.72
$762.52
$807.86
$968.93
$921.05
$963.85
$1009.19
$1170.26
$201.33

Plan: (HMO) HMO STANDARD Bronze 6650

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$258.16
$293.01
$329.93
$461.07
$700.65
$516.32
$586.02
$659.86
$922.14
$1401.30
$680.25
$749.95
$823.79
$1086.07
$844.18
$913.88
$987.72
$1250.00
$1008.11
$1077.81
$1151.65
$1413.93
$422.09
$456.94
$493.86
$625.00
$586.02
$620.87
$657.79
$788.93
$749.95
$784.80
$821.72
$952.86
$163.93

Plan: (HMO) HMO STANDARD Silver 3500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$315.12
$357.66
$402.72
$562.80
$855.24
$630.24
$715.32
$805.44
$1125.60
$1710.48
$830.34
$915.42
$1005.54
$1325.70
$1030.44
$1115.52
$1205.64
$1525.80
$1230.54
$1315.62
$1405.74
$1725.90
$515.22
$557.76
$602.82
$762.90
$715.32
$757.86
$802.92
$963.00
$915.42
$957.96
$1003.02
$1163.10
$200.10

Plan: (POS) POS Silver 7000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $7,000 : Family: $14,000
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$337.51
$383.07
$431.34
$602.79
$916.00
$675.02
$766.14
$862.68
$1205.58
$1832.00
$889.34
$980.46
$1077.00
$1419.90
$1103.66
$1194.78
$1291.32
$1634.22
$1317.98
$1409.10
$1505.64
$1848.54
$551.83
$597.39
$645.66
$817.11
$766.15
$811.71
$859.98
$1031.43
$980.47
$1026.03
$1074.30
$1245.75
$214.32

Plan: (POS) POS Silver 4500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$350.55
$397.87
$448.00
$626.08
$951.39
$701.10
$795.74
$896.00
$1252.16
$1902.78
$923.70
$1018.34
$1118.60
$1474.76
$1146.30
$1240.94
$1341.20
$1697.36
$1368.90
$1463.54
$1563.80
$1919.96
$573.15
$620.47
$670.60
$848.68
$795.75
$843.07
$893.20
$1071.28
$1018.35
$1065.67
$1115.80
$1293.88
$222.60

Plan: (POS) POS HDHP Bronze 5500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$285.01
$323.49
$364.24
$509.03
$773.52
$570.02
$646.98
$728.48
$1018.06
$1547.04
$751.00
$827.96
$909.46
$1199.04
$931.98
$1008.94
$1090.44
$1380.02
$1112.96
$1189.92
$1271.42
$1561.00
$465.99
$504.47
$545.22
$690.01
$646.97
$685.45
$726.20
$870.99
$827.95
$866.43
$907.18
$1051.97
$180.98

Plan: (POS) POS HDHP Silver 2700

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-332-6290 - Provider Directory for This Plan: (Aspirus Arise Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,700 : Family: $5,400
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$347.38
$394.28
$443.95
$620.42
$942.79
$694.76
$788.56
$887.90
$1240.84
$1885.58
$915.35
$1009.15
$1108.49
$1461.43
$1135.94
$1229.74
$1329.08
$1682.02
$1356.53
$1450.33
$1549.67
$1902.61
$567.97
$614.87
$664.54
$841.01
$788.56
$835.46
$885.13
$1061.60
$1009.15
$1056.05
$1105.72
$1282.19
$220.59
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Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442

TTY: 1-855-643-5001

Plan: (PPO) Envision Aurora Bellin PPO - Gold 1000/90

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$428.60
$486.45
$547.74
$765.46
$1163.19
$857.20
$972.90
$1095.48
$1530.92
$2326.38
$1129.35
$1245.05
$1367.63
$1803.07
$1401.50
$1517.20
$1639.78
$2075.22
$1673.65
$1789.35
$1911.93
$2347.37
$700.75
$758.60
$819.89
$1037.61
$972.90
$1030.75
$1092.04
$1309.76
$1245.05
$1302.90
$1364.19
$1581.91
$272.15

Plan: (PPO) Envision Aurora Bellin PPO - Silver 3800/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $3,800 : Family: $7,600
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$342.05
$388.22
$437.13
$610.88
$928.30
$684.10
$776.44
$874.26
$1221.76
$1856.60
$901.30
$993.64
$1091.46
$1438.96
$1118.50
$1210.84
$1308.66
$1656.16
$1335.70
$1428.04
$1525.86
$1873.36
$559.25
$605.42
$654.33
$828.08
$776.45
$822.62
$871.53
$1045.28
$993.65
$1039.82
$1088.73
$1262.48
$217.20

Plan: (PPO) Envision Aurora Bellin PPO - Silver 2500/80/Copy35

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$354.96
$402.87
$453.63
$633.94
$963.34
$709.92
$805.74
$907.26
$1267.88
$1926.68
$935.31
$1031.13
$1132.65
$1493.27
$1160.70
$1256.52
$1358.04
$1718.66
$1386.09
$1481.91
$1583.43
$1944.05
$580.35
$628.26
$679.02
$859.33
$805.74
$853.65
$904.41
$1084.72
$1031.13
$1079.04
$1129.80
$1310.11
$225.39

Plan: (PPO) Envision Aurora Bellin PPO - Silver 2400/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $2,400 : Family: $4,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$354.42
$402.26
$452.94
$632.98
$961.88
$708.84
$804.52
$905.88
$1265.96
$1923.76
$933.89
$1029.57
$1130.93
$1491.01
$1158.94
$1254.62
$1355.98
$1716.06
$1383.99
$1479.67
$1581.03
$1941.11
$579.47
$627.31
$677.99
$858.03
$804.52
$852.36
$903.04
$1083.08
$1029.57
$1077.41
$1128.09
$1308.13
$225.05

Plan: (PPO) Envision Aurora Bellin PPO - Silver 2000/70

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$344.19
$390.65
$439.87
$614.71
$934.12
$688.38
$781.30
$879.74
$1229.42
$1868.24
$906.94
$999.86
$1098.30
$1447.98
$1125.50
$1218.42
$1316.86
$1666.54
$1344.06
$1436.98
$1535.42
$1885.10
$562.75
$609.21
$658.43
$833.27
$781.31
$827.77
$876.99
$1051.83
$999.87
$1046.33
$1095.55
$1270.39
$218.56

Plan: (PPO) Envision Aurora Bellin PPO - HSA Silver 3000/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $5,600 : Family: $11,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$353.79
$401.54
$452.13
$631.84
$960.15
$707.58
$803.08
$904.26
$1263.68
$1920.30
$932.23
$1027.73
$1128.91
$1488.33
$1156.88
$1252.38
$1353.56
$1712.98
$1381.53
$1477.03
$1578.21
$1937.63
$578.44
$626.19
$676.78
$856.49
$803.09
$850.84
$901.43
$1081.14
$1027.74
$1075.49
$1126.08
$1305.79
$224.65

Plan: (PPO) Envision Aurora Bellin PPO - HSA Bronze 6500/100

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$284.58
$322.99
$363.69
$508.25
$772.33
$569.16
$645.98
$727.38
$1016.50
$1544.66
$749.86
$826.68
$908.08
$1197.20
$930.56
$1007.38
$1088.78
$1377.90
$1111.26
$1188.08
$1269.48
$1558.60
$465.28
$503.69
$544.39
$688.95
$645.98
$684.39
$725.09
$869.65
$826.68
$865.09
$905.79
$1050.35
$180.70

Plan: (PPO) Envision Aurora Bellin PPO - Silver 3500/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$350.57
$397.88
$448.01
$626.09
$951.41
$701.14
$795.76
$896.02
$1252.18
$1902.82
$923.74
$1018.36
$1118.62
$1474.78
$1146.34
$1240.96
$1341.22
$1697.38
$1368.94
$1463.56
$1563.82
$1919.98
$573.17
$620.48
$670.61
$848.69
$795.77
$843.08
$893.21
$1071.29
$1018.37
$1065.68
$1115.81
$1293.89
$222.60

Plan: (PPO) Envision Aurora Bellin PPO - Silver 5200/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $5,200 : Family: $10,400
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$282.34
$320.45
$360.82
$504.24
$766.24
$564.68
$640.90
$721.64
$1008.48
$1532.48
$743.96
$820.18
$900.92
$1187.76
$923.24
$999.46
$1080.20
$1367.04
$1102.52
$1178.74
$1259.48
$1546.32
$461.62
$499.73
$540.10
$683.52
$640.90
$679.01
$719.38
$862.80
$820.18
$858.29
$898.66
$1042.08
$179.28