Waushara County, Wisconsin Obamacare 2024 Rates

ADVERTISEMENT

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 Waushara County, WI.

The health insurance rates listed below are for calendar year 2024.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 91 Plans and 2024 Rates for Waushara County, Wisconsin

Below, you’ll find a summary of the 91 plans for Waushara County, Wisconsin and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |



ADVERTISEMENT

HealthPartners

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

Toc - Plan #1 HealthPartners
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

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

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

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

(PPO) Robin Select $3,600 Plus Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386.77
$438.98
$494.29
$690.77
$1,049.69
$682.65
$734.86
$790.17
$986.65
$978.53
$1,030.74
$1,086.05
$1,282.53
$1,274.41
$1,326.62
$1,381.93
$1,578.41
$295.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$773.54
$877.96
$988.58
$1,381.54
$2,099.38
$1,069.42
$1,173.84
$1,284.46
$1,677.42
$1,365.30
$1,469.72
$1,580.34
$1,973.30
$1,661.18
$1,765.60
$1,876.22
$2,269.18
$295.88
Toc - Plan #4 HealthPartners
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386.40
$438.56
$493.82
$690.11
$1,048.69
$682.00
$734.16
$789.42
$985.71
$977.60
$1,029.76
$1,085.02
$1,281.31
$1,273.20
$1,325.36
$1,380.62
$1,576.91
$295.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$772.80
$877.12
$987.64
$1,380.22
$2,097.38
$1,068.40
$1,172.72
$1,283.24
$1,675.82
$1,364.00
$1,468.32
$1,578.84
$1,971.42
$1,659.60
$1,763.92
$1,874.44
$2,267.02
$295.60
Toc - Plan #5 HealthPartners
Expanded Bronze

(PPO) Robin Select $6,350 Plus Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

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

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$300.05
$340.56
$383.46
$535.89
$814.34
$529.59
$570.10
$613.00
$765.43
$759.13
$799.64
$842.54
$994.97
$988.67
$1,029.18
$1,072.08
$1,224.51
$229.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$600.10
$681.12
$766.92
$1,071.78
$1,628.68
$829.64
$910.66
$996.46
$1,301.32
$1,059.18
$1,140.20
$1,226.00
$1,530.86
$1,288.72
$1,369.74
$1,455.54
$1,760.40
$229.54
Toc - Plan #7 HealthPartners
Silver

(PPO) Robin Select $3,800 HSA Silver

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

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.56
$427.40
$481.24
$672.54
$1,021.98
$664.63
$715.47
$769.31
$960.61
$952.70
$1,003.54
$1,057.38
$1,248.68
$1,240.77
$1,291.61
$1,345.45
$1,536.75
$288.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.12
$854.80
$962.48
$1,345.08
$2,043.96
$1,041.19
$1,142.87
$1,250.55
$1,633.15
$1,329.26
$1,430.94
$1,538.62
$1,921.22
$1,617.33
$1,719.01
$1,826.69
$2,209.29
$288.07
Toc - Plan #8 HealthPartners
Expanded Bronze

(PPO) Robin Select $8,000 HSA Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$284.47
$322.87
$363.55
$508.06
$772.05
$502.09
$540.49
$581.17
$725.68
$719.71
$758.11
$798.79
$943.30
$937.33
$975.73
$1,016.41
$1,160.92
$217.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$568.94
$645.74
$727.10
$1,016.12
$1,544.10
$786.56
$863.36
$944.72
$1,233.74
$1,004.18
$1,080.98
$1,162.34
$1,451.36
$1,221.80
$1,298.60
$1,379.96
$1,668.98
$217.62
Toc - Plan #9 HealthPartners
Catastrophic

(PPO) Robin Select $9,450 Catastrophic

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

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

ADVERTISEMENT

Quartz

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

Toc - Plan #10 Quartz
Gold

(HMO) QUARTZ ONE GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL

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

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$497.68
$564.87
$636.03
$888.85
$1,350.70
$878.40
$945.59
$1,016.75
$1,269.57
$1,259.12
$1,326.31
$1,397.47
$1,650.29
$1,639.84
$1,707.03
$1,778.19
$2,031.01
$380.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$995.36
$1,129.74
$1,272.06
$1,777.70
$2,701.40
$1,376.08
$1,510.46
$1,652.78
$2,158.42
$1,756.80
$1,891.18
$2,033.50
$2,539.14
$2,137.52
$2,271.90
$2,414.22
$2,919.86
$380.72
Toc - Plan #11 Quartz
Gold

(HMO) QUARTZ ONE GOLD I410 STANDARD W/DENTAL

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$501.56
$569.26
$640.99
$895.78
$1,361.22
$885.25
$952.95
$1,024.68
$1,279.47
$1,268.94
$1,336.64
$1,408.37
$1,663.16
$1,652.63
$1,720.33
$1,792.06
$2,046.85
$383.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,003.12
$1,138.52
$1,281.98
$1,791.56
$2,722.44
$1,386.81
$1,522.21
$1,665.67
$2,175.25
$1,770.50
$1,905.90
$2,049.36
$2,558.94
$2,154.19
$2,289.59
$2,433.05
$2,942.63
$383.69
Toc - Plan #12 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 VALUE TIER RX W/DENTAL

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$530.19
$601.76
$677.57
$946.90
$1,438.91
$935.78
$1,007.35
$1,083.16
$1,352.49
$1,341.37
$1,412.94
$1,488.75
$1,758.08
$1,746.96
$1,818.53
$1,894.34
$2,163.67
$405.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,060.38
$1,203.52
$1,355.14
$1,893.80
$2,877.82
$1,465.97
$1,609.11
$1,760.73
$2,299.39
$1,871.56
$2,014.70
$2,166.32
$2,704.98
$2,277.15
$2,420.29
$2,571.91
$3,110.57
$405.59
Toc - Plan #13 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 VALUE TIER RX W/DENTAL

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.48
$447.73
$504.14
$704.53
$1,070.60
$696.25
$749.50
$805.91
$1,006.30
$998.02
$1,051.27
$1,107.68
$1,308.07
$1,299.79
$1,353.04
$1,409.45
$1,609.84
$301.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.96
$895.46
$1,008.28
$1,409.06
$2,141.20
$1,090.73
$1,197.23
$1,310.05
$1,710.83
$1,392.50
$1,499.00
$1,611.82
$2,012.60
$1,694.27
$1,800.77
$1,913.59
$2,314.37
$301.77
Toc - Plan #14 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 VALUE TIER RX W/DENTAL

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.93
$435.75
$490.65
$685.69
$1,041.97
$677.63
$729.45
$784.35
$979.39
$971.33
$1,023.15
$1,078.05
$1,273.09
$1,265.03
$1,316.85
$1,371.75
$1,566.79
$293.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.86
$871.50
$981.30
$1,371.38
$2,083.94
$1,061.56
$1,165.20
$1,275.00
$1,665.08
$1,355.26
$1,458.90
$1,568.70
$1,958.78
$1,648.96
$1,752.60
$1,862.40
$2,252.48
$293.70
Toc - Plan #15 Quartz
Silver

(HMO) QUARTZ ONE SILVER I320 VALUE TIER RX W/DENTAL

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$542.80
$616.07
$693.69
$969.43
$1,473.15
$958.04
$1,031.31
$1,108.93
$1,384.67
$1,373.28
$1,446.55
$1,524.17
$1,799.91
$1,788.52
$1,861.79
$1,939.41
$2,215.15
$415.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,085.60
$1,232.14
$1,387.38
$1,938.86
$2,946.30
$1,500.84
$1,647.38
$1,802.62
$2,354.10
$1,916.08
$2,062.62
$2,217.86
$2,769.34
$2,331.32
$2,477.86
$2,633.10
$3,184.58
$415.24
Toc - Plan #16 Quartz
Gold

(HMO) QUARTZ ONE GOLD I420 VALUE TIER RX

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$456.02
$517.58
$582.79
$814.45
$1,237.63
$804.87
$866.43
$931.64
$1,163.30
$1,153.72
$1,215.28
$1,280.49
$1,512.15
$1,502.57
$1,564.13
$1,629.34
$1,861.00
$348.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$912.04
$1,035.16
$1,165.58
$1,628.90
$2,475.26
$1,260.89
$1,384.01
$1,514.43
$1,977.75
$1,609.74
$1,732.86
$1,863.28
$2,326.60
$1,958.59
$2,081.71
$2,212.13
$2,675.45
$348.85
Toc - Plan #17 Quartz
Gold

(HMO) QUARTZ ONE GOLD I402 MAINTENANCE VALUE TIER RX

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

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$473.96
$537.94
$605.71
$846.48
$1,286.31
$836.54
$900.52
$968.29
$1,209.06
$1,199.12
$1,263.10
$1,330.87
$1,571.64
$1,561.70
$1,625.68
$1,693.45
$1,934.22
$362.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$947.92
$1,075.88
$1,211.42
$1,692.96
$2,572.62
$1,310.50
$1,438.46
$1,574.00
$2,055.54
$1,673.08
$1,801.04
$1,936.58
$2,418.12
$2,035.66
$2,163.62
$2,299.16
$2,780.70
$362.58
Toc - Plan #18 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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$477.65
$542.13
$610.43
$853.08
$1,296.33
$843.05
$907.53
$975.83
$1,218.48
$1,208.45
$1,272.93
$1,341.23
$1,583.88
$1,573.85
$1,638.33
$1,706.63
$1,949.28
$365.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$955.30
$1,084.26
$1,220.86
$1,706.16
$2,592.66
$1,320.70
$1,449.66
$1,586.26
$2,071.56
$1,686.10
$1,815.06
$1,951.66
$2,436.96
$2,051.50
$2,180.46
$2,317.06
$2,802.36
$365.40
Toc - Plan #19 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 VALUE TIER RX

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$504.91
$573.07
$645.27
$901.77
$1,370.32
$891.16
$959.32
$1,031.52
$1,288.02
$1,277.41
$1,345.57
$1,417.77
$1,674.27
$1,663.66
$1,731.82
$1,804.02
$2,060.52
$386.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,009.82
$1,146.14
$1,290.54
$1,803.54
$2,740.64
$1,396.07
$1,532.39
$1,676.79
$2,189.79
$1,782.32
$1,918.64
$2,063.04
$2,576.04
$2,168.57
$2,304.89
$2,449.29
$2,962.29
$386.25
Toc - Plan #20 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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$491.45
$557.79
$628.06
$877.71
$1,333.77
$867.40
$933.74
$1,004.01
$1,253.66
$1,243.35
$1,309.69
$1,379.96
$1,629.61
$1,619.30
$1,685.64
$1,755.91
$2,005.56
$375.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$982.90
$1,115.58
$1,256.12
$1,755.42
$2,667.54
$1,358.85
$1,491.53
$1,632.07
$2,131.37
$1,734.80
$1,867.48
$2,008.02
$2,507.32
$2,110.75
$2,243.43
$2,383.97
$2,883.27
$375.95
Toc - Plan #21 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 VALUE TIER RX

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.67
$426.39
$480.11
$670.95
$1,019.57
$663.06
$713.78
$767.50
$958.34
$950.45
$1,001.17
$1,054.89
$1,245.73
$1,237.84
$1,288.56
$1,342.28
$1,533.12
$287.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$751.34
$852.78
$960.22
$1,341.90
$2,039.14
$1,038.73
$1,140.17
$1,247.61
$1,629.29
$1,326.12
$1,427.56
$1,535.00
$1,916.68
$1,613.51
$1,714.95
$1,822.39
$2,204.07
$287.39
Toc - Plan #22 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 VALUE TIER RX

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$365.63
$414.98
$467.26
$653.00
$992.30
$645.33
$694.68
$746.96
$932.70
$925.03
$974.38
$1,026.66
$1,212.40
$1,204.73
$1,254.08
$1,306.36
$1,492.10
$279.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.26
$829.96
$934.52
$1,306.00
$1,984.60
$1,010.96
$1,109.66
$1,214.22
$1,585.70
$1,290.66
$1,389.36
$1,493.92
$1,865.40
$1,570.36
$1,669.06
$1,773.62
$2,145.10
$279.70
Toc - Plan #23 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$348.96
$396.06
$445.96
$623.23
$947.06
$615.91
$663.01
$712.91
$890.18
$882.86
$929.96
$979.86
$1,157.13
$1,149.81
$1,196.91
$1,246.81
$1,424.08
$266.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$697.92
$792.12
$891.92
$1,246.46
$1,894.12
$964.87
$1,059.07
$1,158.87
$1,513.41
$1,231.82
$1,326.02
$1,425.82
$1,780.36
$1,498.77
$1,592.97
$1,692.77
$2,047.31
$266.95
Toc - Plan #24 Quartz
Silver

(HMO) QUARTZ ONE SILVER I320 VALUE TIER RX

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$516.93
$586.71
$660.63
$923.22
$1,402.92
$912.37
$982.15
$1,056.07
$1,318.66
$1,307.81
$1,377.59
$1,451.51
$1,714.10
$1,703.25
$1,773.03
$1,846.95
$2,109.54
$395.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,033.86
$1,173.42
$1,321.26
$1,846.44
$2,805.84
$1,429.30
$1,568.86
$1,716.70
$2,241.88
$1,824.74
$1,964.30
$2,112.14
$2,637.32
$2,220.18
$2,359.74
$2,507.58
$3,032.76
$395.44
Toc - Plan #25 Quartz
Gold

(HMO) QUARTZ ONE GOLD I401 VALUE TIER RX

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$449.12
$509.75
$573.97
$802.12
$1,218.91
$792.70
$853.33
$917.55
$1,145.70
$1,136.28
$1,196.91
$1,261.13
$1,489.28
$1,479.86
$1,540.49
$1,604.71
$1,832.86
$343.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$898.24
$1,019.50
$1,147.94
$1,604.24
$2,437.82
$1,241.82
$1,363.08
$1,491.52
$1,947.82
$1,585.40
$1,706.66
$1,835.10
$2,291.40
$1,928.98
$2,050.24
$2,178.68
$2,634.98
$343.58
Toc - Plan #26 Quartz
Silver

(HMO) QUARTZ ONE SILVER I303 VALUE TIER RX

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$480.34
$545.18
$613.86
$857.87
$1,303.62
$847.79
$912.63
$981.31
$1,225.32
$1,215.24
$1,280.08
$1,348.76
$1,592.77
$1,582.69
$1,647.53
$1,716.21
$1,960.22
$367.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$960.68
$1,090.36
$1,227.72
$1,715.74
$2,607.24
$1,328.13
$1,457.81
$1,595.17
$2,083.19
$1,695.58
$1,825.26
$1,962.62
$2,450.64
$2,063.03
$2,192.71
$2,330.07
$2,818.09
$367.45
Toc - Plan #27 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I201 VALUE TIER RX

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

Annual Out of Pocket Expenses:

Individual Family
$9,400 $18,800 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328.83
$373.22
$420.24
$587.28
$892.43
$580.38
$624.77
$671.79
$838.83
$831.93
$876.32
$923.34
$1,090.38
$1,083.48
$1,127.87
$1,174.89
$1,341.93
$251.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$657.66
$746.44
$840.48
$1,174.56
$1,784.86
$909.21
$997.99
$1,092.03
$1,426.11
$1,160.76
$1,249.54
$1,343.58
$1,677.66
$1,412.31
$1,501.09
$1,595.13
$1,929.21
$251.55
Toc - Plan #28 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I203 HSA

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

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.40
$405.64
$456.74
$638.30
$969.96
$630.80
$679.04
$730.14
$911.70
$904.20
$952.44
$1,003.54
$1,185.10
$1,177.60
$1,225.84
$1,276.94
$1,458.50
$273.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714.80
$811.28
$913.48
$1,276.60
$1,939.92
$988.20
$1,084.68
$1,186.88
$1,550.00
$1,261.60
$1,358.08
$1,460.28
$1,823.40
$1,535.00
$1,631.48
$1,733.68
$2,096.80
$273.40
Toc - Plan #29 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
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$259.49
$294.51
$331.62
$463.43
$704.23
$457.99
$493.01
$530.12
$661.93
$656.49
$691.51
$728.62
$860.43
$854.99
$890.01
$927.12
$1,058.93
$198.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$518.98
$589.02
$663.24
$926.86
$1,408.46
$717.48
$787.52
$861.74
$1,125.36
$915.98
$986.02
$1,060.24
$1,323.86
$1,114.48
$1,184.52
$1,258.74
$1,522.36
$198.50
Toc - Plan #30 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
$5,500 $11,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$509.45
$578.22
$651.07
$909.87
$1,382.63
$899.18
$967.95
$1,040.80
$1,299.60
$1,288.91
$1,357.68
$1,430.53
$1,689.33
$1,678.64
$1,747.41
$1,820.26
$2,079.06
$389.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,018.90
$1,156.44
$1,302.14
$1,819.74
$2,765.26
$1,408.63
$1,546.17
$1,691.87
$2,209.47
$1,798.36
$1,935.90
$2,081.60
$2,599.20
$2,188.09
$2,325.63
$2,471.33
$2,988.93
$389.73
Toc - Plan #31 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
$467.39
$530.48
$597.32
$834.75
$1,268.49
$824.94
$888.03
$954.87
$1,192.30
$1,182.49
$1,245.58
$1,312.42
$1,549.85
$1,540.04
$1,603.13
$1,669.97
$1,907.40
$357.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$934.78
$1,060.96
$1,194.64
$1,669.50
$2,536.98
$1,292.33
$1,418.51
$1,552.19
$2,027.05
$1,649.88
$1,776.06
$1,909.74
$2,384.60
$2,007.43
$2,133.61
$2,267.29
$2,742.15
$357.55

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #32 Molina Healthcare
Gold

(HMO) Gold 1

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

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$470.22
$533.70
$600.94
$839.81
$1,276.17
$829.94
$893.42
$960.66
$1,199.53
$1,189.66
$1,253.14
$1,320.38
$1,559.25
$1,549.38
$1,612.86
$1,680.10
$1,918.97
$359.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$940.44
$1,067.40
$1,201.88
$1,679.62
$2,552.34
$1,300.16
$1,427.12
$1,561.60
$2,039.34
$1,659.88
$1,786.84
$1,921.32
$2,399.06
$2,019.60
$2,146.56
$2,281.04
$2,758.78
$359.72
Toc - Plan #33 Molina Healthcare
Silver

(HMO) Silver 1

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$399.21
$453.10
$510.19
$712.99
$1,083.46
$704.61
$758.50
$815.59
$1,018.39
$1,010.01
$1,063.90
$1,120.99
$1,323.79
$1,315.41
$1,369.30
$1,426.39
$1,629.19
$305.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798.42
$906.20
$1,020.38
$1,425.98
$2,166.92
$1,103.82
$1,211.60
$1,325.78
$1,731.38
$1,409.22
$1,517.00
$1,631.18
$2,036.78
$1,714.62
$1,822.40
$1,936.58
$2,342.18
$305.40
Toc - Plan #34 Molina Healthcare
Gold

(HMO) Gold 8

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$485.37
$550.90
$620.31
$866.88
$1,317.31
$856.68
$922.21
$991.62
$1,238.19
$1,227.99
$1,293.52
$1,362.93
$1,609.50
$1,599.30
$1,664.83
$1,734.24
$1,980.81
$371.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$970.74
$1,101.80
$1,240.62
$1,733.76
$2,634.62
$1,342.05
$1,473.11
$1,611.93
$2,105.07
$1,713.36
$1,844.42
$1,983.24
$2,476.38
$2,084.67
$2,215.73
$2,354.55
$2,847.69
$371.31
Toc - Plan #35 Molina Healthcare
Silver

(HMO) Silver 8

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389.83
$442.45
$498.20
$696.23
$1,057.99
$688.05
$740.67
$796.42
$994.45
$986.27
$1,038.89
$1,094.64
$1,292.67
$1,284.49
$1,337.11
$1,392.86
$1,590.89
$298.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$779.66
$884.90
$996.40
$1,392.46
$2,115.98
$1,077.88
$1,183.12
$1,294.62
$1,690.68
$1,376.10
$1,481.34
$1,592.84
$1,988.90
$1,674.32
$1,779.56
$1,891.06
$2,287.12
$298.22
Toc - Plan #36 Molina Healthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393.02
$446.08
$502.29
$701.94
$1,066.67
$693.68
$746.74
$802.95
$1,002.60
$994.34
$1,047.40
$1,103.61
$1,303.26
$1,295.00
$1,348.06
$1,404.27
$1,603.92
$300.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.04
$892.16
$1,004.58
$1,403.88
$2,133.34
$1,086.70
$1,192.82
$1,305.24
$1,704.54
$1,387.36
$1,493.48
$1,605.90
$2,005.20
$1,688.02
$1,794.14
$1,906.56
$2,305.86
$300.66
Toc - Plan #37 Molina Healthcare
Gold

(HMO) Gold 1 with Adult Vision Services

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

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$472.91
$536.75
$604.38
$844.62
$1,283.48
$834.69
$898.53
$966.16
$1,206.40
$1,196.47
$1,260.31
$1,327.94
$1,568.18
$1,558.25
$1,622.09
$1,689.72
$1,929.96
$361.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$945.82
$1,073.50
$1,208.76
$1,689.24
$2,566.96
$1,307.60
$1,435.28
$1,570.54
$2,051.02
$1,669.38
$1,797.06
$1,932.32
$2,412.80
$2,031.16
$2,158.84
$2,294.10
$2,774.58
$361.78
Toc - Plan #38 Molina Healthcare
Silver

(HMO) Silver 1 with Adult Vision Services

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$401.65
$455.87
$513.30
$717.34
$1,090.07
$708.91
$763.13
$820.56
$1,024.60
$1,016.17
$1,070.39
$1,127.82
$1,331.86
$1,323.43
$1,377.65
$1,435.08
$1,639.12
$307.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.30
$911.74
$1,026.60
$1,434.68
$2,180.14
$1,110.56
$1,219.00
$1,333.86
$1,741.94
$1,417.82
$1,526.26
$1,641.12
$2,049.20
$1,725.08
$1,833.52
$1,948.38
$2,356.46
$307.26

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

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

Toc - Plan #39 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Blue Preferred/Broad 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.51
$435.28
$490.13
$684.95
$1,040.85
$676.90
$728.67
$783.52
$978.34
$970.29
$1,022.06
$1,076.91
$1,271.73
$1,263.68
$1,315.45
$1,370.30
$1,565.12
$293.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.02
$870.56
$980.26
$1,369.90
$2,081.70
$1,060.41
$1,163.95
$1,273.65
$1,663.29
$1,353.80
$1,457.34
$1,567.04
$1,956.68
$1,647.19
$1,750.73
$1,860.43
$2,250.07
$293.39
Toc - Plan #40 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,700 $15,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$453.95
$515.23
$580.15
$810.75
$1,232.02
$801.22
$862.50
$927.42
$1,158.02
$1,148.49
$1,209.77
$1,274.69
$1,505.29
$1,495.76
$1,557.04
$1,621.96
$1,852.56
$347.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$907.90
$1,030.46
$1,160.30
$1,621.50
$2,464.04
$1,255.17
$1,377.73
$1,507.57
$1,968.77
$1,602.44
$1,725.00
$1,854.84
$2,316.04
$1,949.71
$2,072.27
$2,202.11
$2,663.31
$347.27
Toc - Plan #41 Anthem Blue Cross and Blue Shield
Bronze

(POS) Anthem Bronze Blue Preferred/Broad 9450 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$347.53
$394.45
$444.14
$620.69
$943.20
$613.39
$660.31
$710.00
$886.55
$879.25
$926.17
$975.86
$1,152.41
$1,145.11
$1,192.03
$1,241.72
$1,418.27
$265.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$695.06
$788.90
$888.28
$1,241.38
$1,886.40
$960.92
$1,054.76
$1,154.14
$1,507.24
$1,226.78
$1,320.62
$1,420.00
$1,773.10
$1,492.64
$1,586.48
$1,685.86
$2,038.96
$265.86
Toc - Plan #42 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Blue Preferred/Broad 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364.55
$413.76
$465.89
$651.09
$989.39
$643.43
$692.64
$744.77
$929.97
$922.31
$971.52
$1,023.65
$1,208.85
$1,201.19
$1,250.40
$1,302.53
$1,487.73
$278.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.10
$827.52
$931.78
$1,302.18
$1,978.78
$1,007.98
$1,106.40
$1,210.66
$1,581.06
$1,286.86
$1,385.28
$1,489.54
$1,859.94
$1,565.74
$1,664.16
$1,768.42
$2,138.82
$278.88
Toc - Plan #43 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Blue Preferred/Broad 5000 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$365.95
$415.35
$467.68
$653.59
$993.19
$645.90
$695.30
$747.63
$933.54
$925.85
$975.25
$1,027.58
$1,213.49
$1,205.80
$1,255.20
$1,307.53
$1,493.44
$279.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.90
$830.70
$935.36
$1,307.18
$1,986.38
$1,011.85
$1,110.65
$1,215.31
$1,587.13
$1,291.80
$1,390.60
$1,495.26
$1,867.08
$1,571.75
$1,670.55
$1,775.21
$2,147.03
$279.95
Toc - Plan #44 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 5300 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$443.29
$503.13
$566.52
$791.72
$1,203.09
$782.41
$842.25
$905.64
$1,130.84
$1,121.53
$1,181.37
$1,244.76
$1,469.96
$1,460.65
$1,520.49
$1,583.88
$1,809.08
$339.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.58
$1,006.26
$1,133.04
$1,583.44
$2,406.18
$1,225.70
$1,345.38
$1,472.16
$1,922.56
$1,564.82
$1,684.50
$1,811.28
$2,261.68
$1,903.94
$2,023.62
$2,150.40
$2,600.80
$339.12
Toc - Plan #45 Anthem Blue Cross and Blue Shield
Gold

(POS) Anthem Gold Blue Preferred/Broad 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,800 $13,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$485.43
$550.96
$620.38
$866.98
$1,317.46
$856.78
$922.31
$991.73
$1,238.33
$1,228.13
$1,293.66
$1,363.08
$1,609.68
$1,599.48
$1,665.01
$1,734.43
$1,981.03
$371.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$970.86
$1,101.92
$1,240.76
$1,733.96
$2,634.92
$1,342.21
$1,473.27
$1,612.11
$2,105.31
$1,713.56
$1,844.62
$1,983.46
$2,476.66
$2,084.91
$2,215.97
$2,354.81
$2,848.01
$371.35
Toc - Plan #46 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Blue Preferred/Broad 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364.88
$414.14
$466.32
$651.68
$990.28
$644.01
$693.27
$745.45
$930.81
$923.14
$972.40
$1,024.58
$1,209.94
$1,202.27
$1,251.53
$1,303.71
$1,489.07
$279.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.76
$828.28
$932.64
$1,303.36
$1,980.56
$1,008.89
$1,107.41
$1,211.77
$1,582.49
$1,288.02
$1,386.54
$1,490.90
$1,861.62
$1,567.15
$1,665.67
$1,770.03
$2,140.75
$279.13
Toc - Plan #47 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 5900/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$442.93
$502.73
$566.06
$791.07
$1,202.11
$781.77
$841.57
$904.90
$1,129.91
$1,120.61
$1,180.41
$1,243.74
$1,468.75
$1,459.45
$1,519.25
$1,582.58
$1,807.59
$338.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$885.86
$1,005.46
$1,132.12
$1,582.14
$2,404.22
$1,224.70
$1,344.30
$1,470.96
$1,920.98
$1,563.54
$1,683.14
$1,809.80
$2,259.82
$1,902.38
$2,021.98
$2,148.64
$2,598.66
$338.84
Toc - Plan #48 Anthem Blue Cross and Blue Shield
Gold

(POS) Anthem Gold Blue Preferred/Broad 1500/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$494.55
$561.31
$632.03
$883.27
$1,342.21
$872.88
$939.64
$1,010.36
$1,261.60
$1,251.21
$1,317.97
$1,388.69
$1,639.93
$1,629.54
$1,696.30
$1,767.02
$2,018.26
$378.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$989.10
$1,122.62
$1,264.06
$1,766.54
$2,684.42
$1,367.43
$1,500.95
$1,642.39
$2,144.87
$1,745.76
$1,879.28
$2,020.72
$2,523.20
$2,124.09
$2,257.61
$2,399.05
$2,901.53
$378.33
Toc - Plan #49 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$453.70
$514.95
$579.83
$810.31
$1,231.34
$800.78
$862.03
$926.91
$1,157.39
$1,147.86
$1,209.11
$1,273.99
$1,504.47
$1,494.94
$1,556.19
$1,621.07
$1,851.55
$347.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$907.40
$1,029.90
$1,159.66
$1,620.62
$2,462.68
$1,254.48
$1,376.98
$1,506.74
$1,967.70
$1,601.56
$1,724.06
$1,853.82
$2,314.78
$1,948.64
$2,071.14
$2,200.90
$2,661.86
$347.08

ADVERTISEMENT

Aspirus Health Plan

Local: 1-866-631-4611 | Toll Free: 1-866-631-4611 | TTY: 1-866-631-8597

Toc - Plan #50 Aspirus Health Plan
Silver

(HMO) HMO Silver 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,400 $16,800 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
$407.43
$462.43
$520.69
$727.67
$1,105.76
$719.11
$774.11
$832.37
$1,039.35
$1,030.79
$1,085.79
$1,144.05
$1,351.03
$1,342.47
$1,397.47
$1,455.73
$1,662.71
$311.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.86
$924.86
$1,041.38
$1,455.34
$2,211.52
$1,126.54
$1,236.54
$1,353.06
$1,767.02
$1,438.22
$1,548.22
$1,664.74
$2,078.70
$1,749.90
$1,859.90
$1,976.42
$2,390.38
$311.68
Toc - Plan #51 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 6250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$326.09
$370.11
$416.74
$582.39
$885.00
$575.55
$619.57
$666.20
$831.85
$825.01
$869.03
$915.66
$1,081.31
$1,074.47
$1,118.49
$1,165.12
$1,330.77
$249.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$652.18
$740.22
$833.48
$1,164.78
$1,770.00
$901.64
$989.68
$1,082.94
$1,414.24
$1,151.10
$1,239.14
$1,332.40
$1,663.70
$1,400.56
$1,488.60
$1,581.86
$1,913.16
$249.46
Toc - Plan #52 Aspirus Health Plan
Bronze

(HMO) HMO Bronze 9450

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$299.87
$340.36
$383.24
$535.57
$813.86
$529.27
$569.76
$612.64
$764.97
$758.67
$799.16
$842.04
$994.37
$988.07
$1,028.56
$1,071.44
$1,223.77
$229.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$599.74
$680.72
$766.48
$1,071.14
$1,627.72
$829.14
$910.12
$995.88
$1,300.54
$1,058.54
$1,139.52
$1,225.28
$1,529.94
$1,287.94
$1,368.92
$1,454.68
$1,759.34
$229.40
Toc - Plan #53 Aspirus Health Plan
Gold

(HMO) HMO Gold 2400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 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
$424.24
$481.51
$542.17
$757.69
$1,151.38
$748.78
$806.05
$866.71
$1,082.23
$1,073.32
$1,130.59
$1,191.25
$1,406.77
$1,397.86
$1,455.13
$1,515.79
$1,731.31
$324.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$848.48
$963.02
$1,084.34
$1,515.38
$2,302.76
$1,173.02
$1,287.56
$1,408.88
$1,839.92
$1,497.56
$1,612.10
$1,733.42
$2,164.46
$1,822.10
$1,936.64
$2,057.96
$2,489.00
$324.54
Toc - Plan #54 Aspirus Health Plan
Catastrophic

(HMO) HMO Catastrophic 9450 with 3 free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$217.08
$246.39
$277.43
$387.71
$589.16
$383.15
$412.46
$443.50
$553.78
$549.22
$578.53
$609.57
$719.85
$715.29
$744.60
$775.64
$885.92
$166.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$434.16
$492.78
$554.86
$775.42
$1,178.32
$600.23
$658.85
$720.93
$941.49
$766.30
$824.92
$887.00
$1,107.56
$932.37
$990.99
$1,053.07
$1,273.63
$166.07
Toc - Plan #55 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 7200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$7,200 $14,400 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
$324.81
$368.65
$415.10
$580.10
$881.52
$573.29
$617.13
$663.58
$828.58
$821.77
$865.61
$912.06
$1,077.06
$1,070.25
$1,114.09
$1,160.54
$1,325.54
$248.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$649.62
$737.30
$830.20
$1,160.20
$1,763.04
$898.10
$985.78
$1,078.68
$1,408.68
$1,146.58
$1,234.26
$1,327.16
$1,657.16
$1,395.06
$1,482.74
$1,575.64
$1,905.64
$248.48
Toc - Plan #56 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.57
$362.71
$408.41
$570.75
$867.31
$564.04
$607.18
$652.88
$815.22
$808.51
$851.65
$897.35
$1,059.69
$1,052.98
$1,096.12
$1,141.82
$1,304.16
$244.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$639.14
$725.42
$816.82
$1,141.50
$1,734.62
$883.61
$969.89
$1,061.29
$1,385.97
$1,128.08
$1,214.36
$1,305.76
$1,630.44
$1,372.55
$1,458.83
$1,550.23
$1,874.91
$244.47
Toc - Plan #57 Aspirus Health Plan
Silver

(HMO) HMO Silver 5900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$406.37
$461.23
$519.34
$725.78
$1,102.89
$717.24
$772.10
$830.21
$1,036.65
$1,028.11
$1,082.97
$1,141.08
$1,347.52
$1,338.98
$1,393.84
$1,451.95
$1,658.39
$310.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$812.74
$922.46
$1,038.68
$1,451.56
$2,205.78
$1,123.61
$1,233.33
$1,349.55
$1,762.43
$1,434.48
$1,544.20
$1,660.42
$2,073.30
$1,745.35
$1,855.07
$1,971.29
$2,384.17
$310.87
Toc - Plan #58 Aspirus Health Plan
Silver

(HMO) HMO HDHP Silver 5400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 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
$413.30
$469.10
$528.20
$738.16
$1,121.70
$729.48
$785.28
$844.38
$1,054.34
$1,045.66
$1,101.46
$1,160.56
$1,370.52
$1,361.84
$1,417.64
$1,476.74
$1,686.70
$316.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.60
$938.20
$1,056.40
$1,476.32
$2,243.40
$1,142.78
$1,254.38
$1,372.58
$1,792.50
$1,458.96
$1,570.56
$1,688.76
$2,108.68
$1,775.14
$1,886.74
$2,004.94
$2,424.86
$316.18
Toc - Plan #59 Aspirus Health Plan
Gold

(HMO) HMO Gold 1500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.77
$480.98
$541.58
$756.85
$1,150.11
$747.95
$805.16
$865.76
$1,081.03
$1,072.13
$1,129.34
$1,189.94
$1,405.21
$1,396.31
$1,453.52
$1,514.12
$1,729.39
$324.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$847.54
$961.96
$1,083.16
$1,513.70
$2,300.22
$1,171.72
$1,286.14
$1,407.34
$1,837.88
$1,495.90
$1,610.32
$1,731.52
$2,162.06
$1,820.08
$1,934.50
$2,055.70
$2,486.24
$324.18
Toc - Plan #60 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$320.85
$364.16
$410.04
$573.04
$870.78
$566.30
$609.61
$655.49
$818.49
$811.75
$855.06
$900.94
$1,063.94
$1,057.20
$1,100.51
$1,146.39
$1,309.39
$245.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.70
$728.32
$820.08
$1,146.08
$1,741.56
$887.15
$973.77
$1,065.53
$1,391.53
$1,132.60
$1,219.22
$1,310.98
$1,636.98
$1,378.05
$1,464.67
$1,556.43
$1,882.43
$245.45
Toc - Plan #61 Aspirus Health Plan
Silver

(POS) POS Silver 5900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$465.31
$528.13
$594.67
$831.05
$1,262.86
$821.28
$884.10
$950.64
$1,187.02
$1,177.25
$1,240.07
$1,306.61
$1,542.99
$1,533.22
$1,596.04
$1,662.58
$1,898.96
$355.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$930.62
$1,056.26
$1,189.34
$1,662.10
$2,525.72
$1,286.59
$1,412.23
$1,545.31
$2,018.07
$1,642.56
$1,768.20
$1,901.28
$2,374.04
$1,998.53
$2,124.17
$2,257.25
$2,730.01
$355.97
Toc - Plan #62 Aspirus Health Plan
Expanded Bronze

(POS) POS HDHP Bronze 6250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.90
$407.35
$458.67
$640.99
$974.05
$633.46
$681.91
$733.23
$915.55
$908.02
$956.47
$1,007.79
$1,190.11
$1,182.58
$1,231.03
$1,282.35
$1,464.67
$274.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.80
$814.70
$917.34
$1,281.98
$1,948.10
$992.36
$1,089.26
$1,191.90
$1,556.54
$1,266.92
$1,363.82
$1,466.46
$1,831.10
$1,541.48
$1,638.38
$1,741.02
$2,105.66
$274.56
Toc - Plan #63 Aspirus Health Plan
Expanded Bronze

(POS) POS Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$365.54
$414.89
$467.16
$652.85
$992.07
$645.18
$694.53
$746.80
$932.49
$924.82
$974.17
$1,026.44
$1,212.13
$1,204.46
$1,253.81
$1,306.08
$1,491.77
$279.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.08
$829.78
$934.32
$1,305.70
$1,984.14
$1,010.72
$1,109.42
$1,213.96
$1,585.34
$1,290.36
$1,389.06
$1,493.60
$1,864.98
$1,570.00
$1,668.70
$1,773.24
$2,144.62
$279.64

ADVERTISEMENT

Common Ground Healthcare Cooperative

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

Toc - Plan #64 Common Ground Healthcare Cooperative
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$301.75
$342.48
$385.63
$538.91
$818.93
$532.58
$573.31
$616.46
$769.74
$763.41
$804.14
$847.29
$1,000.57
$994.24
$1,034.97
$1,078.12
$1,231.40
$230.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$603.50
$684.96
$771.26
$1,077.82
$1,637.86
$834.33
$915.79
$1,002.09
$1,308.65
$1,065.16
$1,146.62
$1,232.92
$1,539.48
$1,295.99
$1,377.45
$1,463.75
$1,770.31
$230.83
Toc - Plan #65 Common Ground Healthcare Cooperative
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$471.34
$534.96
$602.36
$841.79
$1,279.18
$831.90
$895.52
$962.92
$1,202.35
$1,192.46
$1,256.08
$1,323.48
$1,562.91
$1,553.02
$1,616.64
$1,684.04
$1,923.47
$360.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$942.68
$1,069.92
$1,204.72
$1,683.58
$2,558.36
$1,303.24
$1,430.48
$1,565.28
$2,044.14
$1,663.80
$1,791.04
$1,925.84
$2,404.70
$2,024.36
$2,151.60
$2,286.40
$2,765.26
$360.56
Toc - Plan #66 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $3000 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,300 $18,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.53
$465.94
$524.65
$733.19
$1,114.16
$724.58
$779.99
$838.70
$1,047.24
$1,038.63
$1,094.04
$1,152.75
$1,361.29
$1,352.68
$1,408.09
$1,466.80
$1,675.34
$314.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.06
$931.88
$1,049.30
$1,466.38
$2,228.32
$1,135.11
$1,245.93
$1,363.35
$1,780.43
$1,449.16
$1,559.98
$1,677.40
$2,094.48
$1,763.21
$1,874.03
$1,991.45
$2,408.53
$314.05
Toc - Plan #67 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $1800 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.82
$504.86
$568.47
$794.43
$1,207.21
$785.10
$845.14
$908.75
$1,134.71
$1,125.38
$1,185.42
$1,249.03
$1,474.99
$1,465.66
$1,525.70
$1,589.31
$1,815.27
$340.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$889.64
$1,009.72
$1,136.94
$1,588.86
$2,414.42
$1,229.92
$1,350.00
$1,477.22
$1,929.14
$1,570.20
$1,690.28
$1,817.50
$2,269.42
$1,910.48
$2,030.56
$2,157.78
$2,609.70
$340.28
Toc - Plan #68 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $4000 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.03
$459.70
$517.62
$723.37
$1,099.23
$714.87
$769.54
$827.46
$1,033.21
$1,024.71
$1,079.38
$1,137.30
$1,343.05
$1,334.55
$1,389.22
$1,447.14
$1,652.89
$309.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.06
$919.40
$1,035.24
$1,446.74
$2,198.46
$1,119.90
$1,229.24
$1,345.08
$1,756.58
$1,429.74
$1,539.08
$1,654.92
$2,066.42
$1,739.58
$1,848.92
$1,964.76
$2,376.26
$309.84
Toc - Plan #69 Common Ground Healthcare Cooperative
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.28
$389.61
$438.70
$613.08
$931.64
$605.88
$652.21
$701.30
$875.68
$868.48
$914.81
$963.90
$1,138.28
$1,131.08
$1,177.41
$1,226.50
$1,400.88
$262.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.56
$779.22
$877.40
$1,226.16
$1,863.28
$949.16
$1,041.82
$1,140.00
$1,488.76
$1,211.76
$1,304.42
$1,402.60
$1,751.36
$1,474.36
$1,567.02
$1,665.20
$2,013.96
$262.60
Toc - Plan #70 Common Ground Healthcare Cooperative
Catastrophic

(EPO) CGHC Catastrophic $9450 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$194.10
$220.29
$248.05
$346.65
$526.76
$342.58
$368.77
$396.53
$495.13
$491.06
$517.25
$545.01
$643.61
$639.54
$665.73
$693.49
$792.09
$148.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$388.20
$440.58
$496.10
$693.30
$1,053.52
$536.68
$589.06
$644.58
$841.78
$685.16
$737.54
$793.06
$990.26
$833.64
$886.02
$941.54
$1,138.74
$148.48
Toc - Plan #71 Common Ground Healthcare Cooperative
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.36
$327.28
$368.51
$514.99
$782.58
$508.95
$547.87
$589.10
$735.58
$729.54
$768.46
$809.69
$956.17
$950.13
$989.05
$1,030.28
$1,176.76
$220.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.72
$654.56
$737.02
$1,029.98
$1,565.16
$797.31
$875.15
$957.61
$1,250.57
$1,017.90
$1,095.74
$1,178.20
$1,471.16
$1,238.49
$1,316.33
$1,398.79
$1,691.75
$220.59
Toc - Plan #72 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$300.54
$341.11
$384.08
$536.75
$815.65
$530.45
$571.02
$613.99
$766.66
$760.36
$800.93
$843.90
$996.57
$990.27
$1,030.84
$1,073.81
$1,226.48
$229.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$601.08
$682.22
$768.16
$1,073.50
$1,631.30
$830.99
$912.13
$998.07
$1,303.41
$1,060.90
$1,142.04
$1,227.98
$1,533.32
$1,290.81
$1,371.95
$1,457.89
$1,763.23
$229.91
Toc - Plan #73 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $3200 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$469.19
$532.52
$599.61
$837.96
$1,273.36
$828.11
$891.44
$958.53
$1,196.88
$1,187.03
$1,250.36
$1,317.45
$1,555.80
$1,545.95
$1,609.28
$1,676.37
$1,914.72
$358.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$938.38
$1,065.04
$1,199.22
$1,675.92
$2,546.72
$1,297.30
$1,423.96
$1,558.14
$2,034.84
$1,656.22
$1,782.88
$1,917.06
$2,393.76
$2,015.14
$2,141.80
$2,275.98
$2,752.68
$358.92
Toc - Plan #74 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3200 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.27
$483.81
$544.76
$761.30
$1,156.88
$752.36
$809.90
$870.85
$1,087.39
$1,078.45
$1,135.99
$1,196.94
$1,413.48
$1,404.54
$1,462.08
$1,523.03
$1,739.57
$326.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.54
$967.62
$1,089.52
$1,522.60
$2,313.76
$1,178.63
$1,293.71
$1,415.61
$1,848.69
$1,504.72
$1,619.80
$1,741.70
$2,174.78
$1,830.81
$1,945.89
$2,067.79
$2,500.87
$326.09
Toc - Plan #75 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $6000 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$296.03
$335.98
$378.32
$528.70
$803.40
$522.49
$562.44
$604.78
$755.16
$748.95
$788.90
$831.24
$981.62
$975.41
$1,015.36
$1,057.70
$1,208.08
$226.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$592.06
$671.96
$756.64
$1,057.40
$1,606.80
$818.52
$898.42
$983.10
$1,283.86
$1,044.98
$1,124.88
$1,209.56
$1,510.32
$1,271.44
$1,351.34
$1,436.02
$1,736.78
$226.46
Toc - Plan #76 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze Standard $7500 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.94
$331.34
$373.09
$521.39
$792.30
$515.27
$554.67
$596.42
$744.72
$738.60
$778.00
$819.75
$968.05
$961.93
$1,001.33
$1,043.08
$1,191.38
$223.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$583.88
$662.68
$746.18
$1,042.78
$1,584.60
$807.21
$886.01
$969.51
$1,266.11
$1,030.54
$1,109.34
$1,192.84
$1,489.44
$1,253.87
$1,332.67
$1,416.17
$1,712.77
$223.33
Toc - Plan #77 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver Standard $5900 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$359.71
$408.26
$459.70
$642.42
$976.23
$634.88
$683.43
$734.87
$917.59
$910.05
$958.60
$1,010.04
$1,192.76
$1,185.22
$1,233.77
$1,285.21
$1,467.93
$275.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$719.42
$816.52
$919.40
$1,284.84
$1,952.46
$994.59
$1,091.69
$1,194.57
$1,560.01
$1,269.76
$1,366.86
$1,469.74
$1,835.18
$1,544.93
$1,642.03
$1,744.91
$2,110.35
$275.17
Toc - Plan #78 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold Standard $1500 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$422.20
$479.19
$539.56
$754.03
$1,145.83
$745.18
$802.17
$862.54
$1,077.01
$1,068.16
$1,125.15
$1,185.52
$1,399.99
$1,391.14
$1,448.13
$1,508.50
$1,722.97
$322.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$844.40
$958.38
$1,079.12
$1,508.06
$2,291.66
$1,167.38
$1,281.36
$1,402.10
$1,831.04
$1,490.36
$1,604.34
$1,725.08
$2,154.02
$1,813.34
$1,927.32
$2,048.06
$2,477.00
$322.98
Toc - Plan #79 Common Ground Healthcare Cooperative
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.17
$389.48
$438.55
$612.88
$931.32
$605.68
$651.99
$701.06
$875.39
$868.19
$914.50
$963.57
$1,137.90
$1,130.70
$1,177.01
$1,226.08
$1,400.41
$262.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.34
$778.96
$877.10
$1,225.76
$1,862.64
$948.85
$1,041.47
$1,139.61
$1,488.27
$1,211.36
$1,303.98
$1,402.12
$1,750.78
$1,473.87
$1,566.49
$1,664.63
$2,013.29
$262.51
Toc - Plan #80 Common Ground Healthcare Cooperative
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$447.66
$508.09
$572.10
$799.51
$1,214.93
$790.12
$850.55
$914.56
$1,141.97
$1,132.58
$1,193.01
$1,257.02
$1,484.43
$1,475.04
$1,535.47
$1,599.48
$1,826.89
$342.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$895.32
$1,016.18
$1,144.20
$1,599.02
$2,429.86
$1,237.78
$1,358.64
$1,486.66
$1,941.48
$1,580.24
$1,701.10
$1,829.12
$2,283.94
$1,922.70
$2,043.56
$2,171.58
$2,626.40
$342.46
Toc - Plan #81 Common Ground Healthcare Cooperative
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,300 $18,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413.35
$469.14
$528.25
$738.22
$1,121.80
$729.55
$785.34
$844.45
$1,054.42
$1,045.75
$1,101.54
$1,160.65
$1,370.62
$1,361.95
$1,417.74
$1,476.85
$1,686.82
$316.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.70
$938.28
$1,056.50
$1,476.44
$2,243.60
$1,142.90
$1,254.48
$1,372.70
$1,792.64
$1,459.10
$1,570.68
$1,688.90
$2,108.84
$1,775.30
$1,886.88
$2,005.10
$2,425.04
$316.20
Toc - Plan #82 Common Ground Healthcare Cooperative
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.85
$462.90
$521.22
$728.40
$1,106.88
$719.85
$774.90
$833.22
$1,040.40
$1,031.85
$1,086.90
$1,145.22
$1,352.40
$1,343.85
$1,398.90
$1,457.22
$1,664.40
$312.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$815.70
$925.80
$1,042.44
$1,456.80
$2,213.76
$1,127.70
$1,237.80
$1,354.44
$1,768.80
$1,439.70
$1,549.80
$1,666.44
$2,080.80
$1,751.70
$1,861.80
$1,978.44
$2,392.80
$312.00
Toc - Plan #83 Common Ground Healthcare Cooperative
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$345.94
$392.63
$442.10
$617.84
$938.86
$610.58
$657.27
$706.74
$882.48
$875.22
$921.91
$971.38
$1,147.12
$1,139.86
$1,186.55
$1,236.02
$1,411.76
$264.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$691.88
$785.26
$884.20
$1,235.68
$1,877.72
$956.52
$1,049.90
$1,148.84
$1,500.32
$1,221.16
$1,314.54
$1,413.48
$1,764.96
$1,485.80
$1,579.18
$1,678.12
$2,029.60
$264.64
Toc - Plan #84 Common Ground Healthcare Cooperative
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$346.07
$392.78
$442.26
$618.06
$939.20
$610.80
$657.51
$706.99
$882.79
$875.53
$922.24
$971.72
$1,147.52
$1,140.26
$1,186.97
$1,236.45
$1,412.25
$264.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$692.14
$785.56
$884.52
$1,236.12
$1,878.40
$956.87
$1,050.29
$1,149.25
$1,500.85
$1,221.60
$1,315.02
$1,413.98
$1,765.58
$1,486.33
$1,579.75
$1,678.71
$2,030.31
$264.73
Toc - Plan #85 Common Ground Healthcare Cooperative
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.11
$330.40
$372.02
$519.90
$790.04
$513.80
$553.09
$594.71
$742.59
$736.49
$775.78
$817.40
$965.28
$959.18
$998.47
$1,040.09
$1,187.97
$222.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.22
$660.80
$744.04
$1,039.80
$1,580.08
$804.91
$883.49
$966.73
$1,262.49
$1,027.60
$1,106.18
$1,189.42
$1,485.18
$1,250.29
$1,328.87
$1,412.11
$1,707.87
$222.69
Toc - Plan #86 Common Ground Healthcare Cooperative
Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$298.79
$339.12
$381.84
$533.62
$810.89
$527.36
$567.69
$610.41
$762.19
$755.93
$796.26
$838.98
$990.76
$984.50
$1,024.83
$1,067.55
$1,219.33
$228.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$597.58
$678.24
$763.68
$1,067.24
$1,621.78
$826.15
$906.81
$992.25
$1,295.81
$1,054.72
$1,135.38
$1,220.82
$1,524.38
$1,283.29
$1,363.95
$1,449.39
$1,752.95
$228.57
Toc - Plan #87 Common Ground Healthcare Cooperative
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.30
$344.24
$387.61
$541.68
$823.14
$535.32
$576.26
$619.63
$773.70
$767.34
$808.28
$851.65
$1,005.72
$999.36
$1,040.30
$1,083.67
$1,237.74
$232.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$606.60
$688.48
$775.22
$1,083.36
$1,646.28
$838.62
$920.50
$1,007.24
$1,315.38
$1,070.64
$1,152.52
$1,239.26
$1,547.40
$1,302.66
$1,384.54
$1,471.28
$1,779.42
$232.02
Toc - Plan #88 Common Ground Healthcare Cooperative
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.10
$487.02
$548.37
$766.35
$1,164.55
$757.35
$815.27
$876.62
$1,094.60
$1,085.60
$1,143.52
$1,204.87
$1,422.85
$1,413.85
$1,471.77
$1,533.12
$1,751.10
$328.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.20
$974.04
$1,096.74
$1,532.70
$2,329.10
$1,186.45
$1,302.29
$1,424.99
$1,860.95
$1,514.70
$1,630.54
$1,753.24
$2,189.20
$1,842.95
$1,958.79
$2,081.49
$2,517.45
$328.25
Toc - Plan #89 Common Ground Healthcare Cooperative
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$472.04
$535.75
$603.25
$843.04
$1,281.08
$833.14
$896.85
$964.35
$1,204.14
$1,194.24
$1,257.95
$1,325.45
$1,565.24
$1,555.34
$1,619.05
$1,686.55
$1,926.34
$361.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$944.08
$1,071.50
$1,206.50
$1,686.08
$2,562.16
$1,305.18
$1,432.60
$1,567.60
$2,047.18
$1,666.28
$1,793.70
$1,928.70
$2,408.28
$2,027.38
$2,154.80
$2,289.80
$2,769.38
$361.10
Toc - Plan #90 Common Ground Healthcare Cooperative
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304.51
$345.61
$389.15
$543.84
$826.41
$537.45
$578.55
$622.09
$776.78
$770.39
$811.49
$855.03
$1,009.72
$1,003.33
$1,044.43
$1,087.97
$1,242.66
$232.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$609.02
$691.22
$778.30
$1,087.68
$1,652.82
$841.96
$924.16
$1,011.24
$1,320.62
$1,074.90
$1,157.10
$1,244.18
$1,553.56
$1,307.84
$1,390.04
$1,477.12
$1,786.50
$232.94
Toc - Plan #91 Common Ground Healthcare Cooperative
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$474.19
$538.20
$606.00
$846.89
$1,286.93
$836.94
$900.95
$968.75
$1,209.64
$1,199.69
$1,263.70
$1,331.50
$1,572.39
$1,562.44
$1,626.45
$1,694.25
$1,935.14
$362.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$948.38
$1,076.40
$1,212.00
$1,693.78
$2,573.86
$1,311.13
$1,439.15
$1,574.75
$2,056.53
$1,673.88
$1,801.90
$1,937.50
$2,419.28
$2,036.63
$2,164.65
$2,300.25
$2,782.03
$362.75

‡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 Waushara County here.

Waushara County is in “Rating Area 15” of Wisconsin.

Currently, there are 91 plans offered in Rating Area 15.

Top

2024 Obamacare Plans for Waushara County, WI

Plan Browser: 91 Plans
scroll down for more

Speak with a Health Insurance Expert 800-943-6832Ads by +HealthNetwork Speak with a Health Insurance Expert 800-943-6832Ads by +HealthNetwork