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Georgia Obamacare 2023 Rates

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Cigna HealthCare of Georgia, Inc

Local:  | Toll Free: 

Toc - Plan #1 Cigna HealthCare of Georgia, Inc
Bronze

(HMO) Cigna Connect 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$275.95
$313.20
$352.66
$492.84
$748.92
$487.05
$524.30
$563.76
$703.94
$698.15
$735.40
$774.86
$915.04
$909.25
$946.50
$985.96
$1,126.14
$211.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$551.90
$626.40
$705.32
$985.68
$1,497.84
$763.00
$837.50
$916.42
$1,196.78
$974.10
$1,048.60
$1,127.52
$1,407.88
$1,185.20
$1,259.70
$1,338.62
$1,618.98
$211.10
Toc - Plan #2 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 7800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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
$285.68
$324.25
$365.10
$510.23
$775.35
$504.23
$542.80
$583.65
$728.78
$722.78
$761.35
$802.20
$947.33
$941.33
$979.90
$1,020.75
$1,165.88
$218.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$571.36
$648.50
$730.20
$1,020.46
$1,550.70
$789.91
$867.05
$948.75
$1,239.01
$1,008.46
$1,085.60
$1,167.30
$1,457.56
$1,227.01
$1,304.15
$1,385.85
$1,676.11
$218.55
Toc - Plan #3 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$286.65
$325.35
$366.34
$511.96
$777.97
$505.94
$544.64
$585.63
$731.25
$725.23
$763.93
$804.92
$950.54
$944.52
$983.22
$1,024.21
$1,169.83
$219.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$573.30
$650.70
$732.68
$1,023.92
$1,555.94
$792.59
$869.99
$951.97
$1,243.21
$1,011.88
$1,089.28
$1,171.26
$1,462.50
$1,231.17
$1,308.57
$1,390.55
$1,681.79
$219.29
Toc - Plan #4 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect HSA 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$289.74
$328.86
$370.29
$517.48
$786.36
$511.39
$550.51
$591.94
$739.13
$733.04
$772.16
$813.59
$960.78
$954.69
$993.81
$1,035.24
$1,182.43
$221.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$579.48
$657.72
$740.58
$1,034.96
$1,572.72
$801.13
$879.37
$962.23
$1,256.61
$1,022.78
$1,101.02
$1,183.88
$1,478.26
$1,244.43
$1,322.67
$1,405.53
$1,699.91
$221.65
Toc - Plan #5 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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
$289.47
$328.55
$369.94
$516.99
$785.62
$510.92
$550.00
$591.39
$738.44
$732.37
$771.45
$812.84
$959.89
$953.82
$992.90
$1,034.29
$1,181.34
$221.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$578.94
$657.10
$739.88
$1,033.98
$1,571.24
$800.39
$878.55
$961.33
$1,255.43
$1,021.84
$1,100.00
$1,182.78
$1,476.88
$1,243.29
$1,321.45
$1,404.23
$1,698.33
$221.45
Toc - Plan #6 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 3700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$334.53
$379.69
$427.53
$597.47
$907.91
$590.44
$635.60
$683.44
$853.38
$846.35
$891.51
$939.35
$1,109.29
$1,102.26
$1,147.42
$1,195.26
$1,365.20
$255.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$669.06
$759.38
$855.06
$1,194.94
$1,815.82
$924.97
$1,015.29
$1,110.97
$1,450.85
$1,180.88
$1,271.20
$1,366.88
$1,706.76
$1,436.79
$1,527.11
$1,622.79
$1,962.67
$255.91
Toc - Plan #7 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$334.57
$379.73
$427.58
$597.54
$908.01
$590.51
$635.67
$683.52
$853.48
$846.45
$891.61
$939.46
$1,109.42
$1,102.39
$1,147.55
$1,195.40
$1,365.36
$255.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$669.14
$759.46
$855.16
$1,195.08
$1,816.02
$925.08
$1,015.40
$1,111.10
$1,451.02
$1,181.02
$1,271.34
$1,367.04
$1,706.96
$1,436.96
$1,527.28
$1,622.98
$1,962.90
$255.94
Toc - Plan #8 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$335.07
$380.30
$428.22
$598.43
$909.38
$591.40
$636.63
$684.55
$854.76
$847.73
$892.96
$940.88
$1,111.09
$1,104.06
$1,149.29
$1,197.21
$1,367.42
$256.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.14
$760.60
$856.44
$1,196.86
$1,818.76
$926.47
$1,016.93
$1,112.77
$1,453.19
$1,182.80
$1,273.26
$1,369.10
$1,709.52
$1,439.13
$1,529.59
$1,625.43
$1,965.85
$256.33
Toc - Plan #9 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 7200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$339.44
$385.26
$433.80
$606.23
$921.23
$599.11
$644.93
$693.47
$865.90
$858.78
$904.60
$953.14
$1,125.57
$1,118.45
$1,164.27
$1,212.81
$1,385.24
$259.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$678.88
$770.52
$867.60
$1,212.46
$1,842.46
$938.55
$1,030.19
$1,127.27
$1,472.13
$1,198.22
$1,289.86
$1,386.94
$1,731.80
$1,457.89
$1,549.53
$1,646.61
$1,991.47
$259.67
Toc - Plan #10 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$337.81
$383.42
$431.72
$603.33
$916.82
$596.24
$641.85
$690.15
$861.76
$854.67
$900.28
$948.58
$1,120.19
$1,113.10
$1,158.71
$1,207.01
$1,378.62
$258.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$675.62
$766.84
$863.44
$1,206.66
$1,833.64
$934.05
$1,025.27
$1,121.87
$1,465.09
$1,192.48
$1,283.70
$1,380.30
$1,723.52
$1,450.91
$1,542.13
$1,638.73
$1,981.95
$258.43
Toc - Plan #11 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$336.23
$381.62
$429.70
$600.50
$912.52
$593.44
$638.83
$686.91
$857.71
$850.65
$896.04
$944.12
$1,114.92
$1,107.86
$1,153.25
$1,201.33
$1,372.13
$257.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.46
$763.24
$859.40
$1,201.00
$1,825.04
$929.67
$1,020.45
$1,116.61
$1,458.21
$1,186.88
$1,277.66
$1,373.82
$1,715.42
$1,444.09
$1,534.87
$1,631.03
$1,972.63
$257.21
Toc - Plan #12 Cigna HealthCare of Georgia, Inc
Gold

(HMO) Cigna Connect 1600

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 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
$423.75
$480.96
$541.56
$756.82
$1,150.07
$747.92
$805.13
$865.73
$1,080.99
$1,072.09
$1,129.30
$1,189.90
$1,405.16
$1,396.26
$1,453.47
$1,514.07
$1,729.33
$324.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$847.50
$961.92
$1,083.12
$1,513.64
$2,300.14
$1,171.67
$1,286.09
$1,407.29
$1,837.81
$1,495.84
$1,610.26
$1,731.46
$2,161.98
$1,820.01
$1,934.43
$2,055.63
$2,486.15
$324.17
Toc - Plan #13 Cigna HealthCare of Georgia, Inc
Gold

(HMO) Cigna Connect 1900 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.46
$484.03
$545.01
$761.65
$1,157.41
$752.70
$810.27
$871.25
$1,087.89
$1,078.94
$1,136.51
$1,197.49
$1,414.13
$1,405.18
$1,462.75
$1,523.73
$1,740.37
$326.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.92
$968.06
$1,090.02
$1,523.30
$2,314.82
$1,179.16
$1,294.30
$1,416.26
$1,849.54
$1,505.40
$1,620.54
$1,742.50
$2,175.78
$1,831.64
$1,946.78
$2,068.74
$2,502.02
$326.24
Toc - Plan #14 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 7600 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.20
$329.38
$370.88
$518.31
$787.62
$512.21
$551.39
$592.89
$740.32
$734.22
$773.40
$814.90
$962.33
$956.23
$995.41
$1,036.91
$1,184.34
$222.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.40
$658.76
$741.76
$1,036.62
$1,575.24
$802.41
$880.77
$963.77
$1,258.63
$1,024.42
$1,102.78
$1,185.78
$1,480.64
$1,246.43
$1,324.79
$1,407.79
$1,702.65
$222.01
Toc - Plan #15 Cigna HealthCare of Georgia, Inc
Bronze

(HMO) Cigna Simple Choice 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$275.95
$313.20
$352.66
$492.84
$748.92
$487.05
$524.30
$563.76
$703.94
$698.15
$735.40
$774.86
$915.04
$909.25
$946.50
$985.96
$1,126.14
$211.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$551.90
$626.40
$705.32
$985.68
$1,497.84
$763.00
$837.50
$916.42
$1,196.78
$974.10
$1,048.60
$1,127.52
$1,407.88
$1,185.20
$1,259.70
$1,338.62
$1,618.98
$211.10
Toc - Plan #16 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Simple Choice 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$287.54
$326.36
$367.47
$513.54
$780.38
$507.51
$546.33
$587.44
$733.51
$727.48
$766.30
$807.41
$953.48
$947.45
$986.27
$1,027.38
$1,173.45
$219.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$575.08
$652.72
$734.94
$1,027.08
$1,560.76
$795.05
$872.69
$954.91
$1,247.05
$1,015.02
$1,092.66
$1,174.88
$1,467.02
$1,234.99
$1,312.63
$1,394.85
$1,686.99
$219.97
Toc - Plan #17 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$308.95
$350.65
$394.83
$551.78
$838.48
$545.29
$586.99
$631.17
$788.12
$781.63
$823.33
$867.51
$1,024.46
$1,017.97
$1,059.67
$1,103.85
$1,260.80
$236.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$617.90
$701.30
$789.66
$1,103.56
$1,676.96
$854.24
$937.64
$1,026.00
$1,339.90
$1,090.58
$1,173.98
$1,262.34
$1,576.24
$1,326.92
$1,410.32
$1,498.68
$1,812.58
$236.34
Toc - Plan #18 Cigna HealthCare of Georgia, Inc
Gold

(HMO) Cigna Simple Choice 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$421.78
$478.72
$539.04
$753.30
$1,144.72
$744.44
$801.38
$861.70
$1,075.96
$1,067.10
$1,124.04
$1,184.36
$1,398.62
$1,389.76
$1,446.70
$1,507.02
$1,721.28
$322.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$843.56
$957.44
$1,078.08
$1,506.60
$2,289.44
$1,166.22
$1,280.10
$1,400.74
$1,829.26
$1,488.88
$1,602.76
$1,723.40
$2,151.92
$1,811.54
$1,925.42
$2,046.06
$2,474.58
$322.66
Toc - Plan #19 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Simple Choice 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$335.07
$380.30
$428.22
$598.43
$909.38
$591.40
$636.63
$684.55
$854.76
$847.73
$892.96
$940.88
$1,111.09
$1,104.06
$1,149.29
$1,197.21
$1,367.42
$256.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.14
$760.60
$856.44
$1,196.86
$1,818.76
$926.47
$1,016.93
$1,112.77
$1,453.19
$1,182.80
$1,273.26
$1,369.10
$1,709.52
$1,439.13
$1,529.59
$1,625.43
$1,965.85
$256.33

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-609-9754 | Toll Free: 1-800-609-9754 | TTY: 1-800-609-9754

Toc - Plan #20 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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
$550.66
$624.99
$703.74
$983.47
$1,494.48
$971.91
$1,046.24
$1,124.99
$1,404.72
$1,393.16
$1,467.49
$1,546.24
$1,825.97
$1,814.41
$1,888.74
$1,967.49
$2,247.22
$421.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,101.32
$1,249.98
$1,407.48
$1,966.94
$2,988.96
$1,522.57
$1,671.23
$1,828.73
$2,388.19
$1,943.82
$2,092.48
$2,249.98
$2,809.44
$2,365.07
$2,513.73
$2,671.23
$3,230.69
$421.25
Toc - Plan #21 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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
$572.27
$649.53
$731.36
$1,022.08
$1,553.15
$1,010.06
$1,087.32
$1,169.15
$1,459.87
$1,447.85
$1,525.11
$1,606.94
$1,897.66
$1,885.64
$1,962.90
$2,044.73
$2,335.45
$437.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,144.54
$1,299.06
$1,462.72
$2,044.16
$3,106.30
$1,582.33
$1,736.85
$1,900.51
$2,481.95
$2,020.12
$2,174.64
$2,338.30
$2,919.74
$2,457.91
$2,612.43
$2,776.09
$3,357.53
$437.79
Toc - Plan #22 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$525.92
$596.92
$672.12
$939.29
$1,427.34
$928.25
$999.25
$1,074.45
$1,341.62
$1,330.58
$1,401.58
$1,476.78
$1,743.95
$1,732.91
$1,803.91
$1,879.11
$2,146.28
$402.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,051.84
$1,193.84
$1,344.24
$1,878.58
$2,854.68
$1,454.17
$1,596.17
$1,746.57
$2,280.91
$1,856.50
$1,998.50
$2,148.90
$2,683.24
$2,258.83
$2,400.83
$2,551.23
$3,085.57
$402.33
Toc - Plan #23 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,200 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 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
$525.81
$596.79
$671.98
$939.09
$1,427.03
$928.05
$999.03
$1,074.22
$1,341.33
$1,330.29
$1,401.27
$1,476.46
$1,743.57
$1,732.53
$1,803.51
$1,878.70
$2,145.81
$402.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,051.62
$1,193.58
$1,343.96
$1,878.18
$2,854.06
$1,453.86
$1,595.82
$1,746.20
$2,280.42
$1,856.10
$1,998.06
$2,148.44
$2,682.66
$2,258.34
$2,400.30
$2,550.68
$3,084.90
$402.24
Toc - Plan #24 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en espaņol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$486.80
$552.52
$622.13
$869.42
$1,321.17
$859.20
$924.92
$994.53
$1,241.82
$1,231.60
$1,297.32
$1,366.93
$1,614.22
$1,604.00
$1,669.72
$1,739.33
$1,986.62
$372.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$973.60
$1,105.04
$1,244.26
$1,738.84
$2,642.34
$1,346.00
$1,477.44
$1,616.66
$2,111.24
$1,718.40
$1,849.84
$1,989.06
$2,483.64
$2,090.80
$2,222.24
$2,361.46
$2,856.04
$372.40
Toc - Plan #25 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$424.72
$482.05
$542.79
$758.55
$1,152.68
$749.63
$806.96
$867.70
$1,083.46
$1,074.54
$1,131.87
$1,192.61
$1,408.37
$1,399.45
$1,456.78
$1,517.52
$1,733.28
$324.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.44
$964.10
$1,085.58
$1,517.10
$2,305.36
$1,174.35
$1,289.01
$1,410.49
$1,842.01
$1,499.26
$1,613.92
$1,735.40
$2,166.92
$1,824.17
$1,938.83
$2,060.31
$2,491.83
$324.91
Toc - Plan #26 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en espaņol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.07
$464.30
$522.80
$730.60
$1,110.22
$722.01
$777.24
$835.74
$1,043.54
$1,034.95
$1,090.18
$1,148.68
$1,356.48
$1,347.89
$1,403.12
$1,461.62
$1,669.42
$312.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.14
$928.60
$1,045.60
$1,461.20
$2,220.44
$1,131.08
$1,241.54
$1,358.54
$1,774.14
$1,444.02
$1,554.48
$1,671.48
$2,087.08
$1,756.96
$1,867.42
$1,984.42
$2,400.02
$312.94
Toc - Plan #27 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$536.47
$608.89
$685.61
$958.13
$1,455.98
$946.87
$1,019.29
$1,096.01
$1,368.53
$1,357.27
$1,429.69
$1,506.41
$1,778.93
$1,767.67
$1,840.09
$1,916.81
$2,189.33
$410.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,072.94
$1,217.78
$1,371.22
$1,916.26
$2,911.96
$1,483.34
$1,628.18
$1,781.62
$2,326.66
$1,893.74
$2,038.58
$2,192.02
$2,737.06
$2,304.14
$2,448.98
$2,602.42
$3,147.46
$410.40
Toc - Plan #28 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$499.71
$567.18
$638.63
$892.49
$1,356.22
$881.99
$949.46
$1,020.91
$1,274.77
$1,264.27
$1,331.74
$1,403.19
$1,657.05
$1,646.55
$1,714.02
$1,785.47
$2,039.33
$382.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$999.42
$1,134.36
$1,277.26
$1,784.98
$2,712.44
$1,381.70
$1,516.64
$1,659.54
$2,167.26
$1,763.98
$1,898.92
$2,041.82
$2,549.54
$2,146.26
$2,281.20
$2,424.10
$2,931.82
$382.28
Toc - Plan #29 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$514.31
$583.75
$657.29
$918.57
$1,395.85
$907.76
$977.20
$1,050.74
$1,312.02
$1,301.21
$1,370.65
$1,444.19
$1,705.47
$1,694.66
$1,764.10
$1,837.64
$2,098.92
$393.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,028.62
$1,167.50
$1,314.58
$1,837.14
$2,791.70
$1,422.07
$1,560.95
$1,708.03
$2,230.59
$1,815.52
$1,954.40
$2,101.48
$2,624.04
$2,208.97
$2,347.85
$2,494.93
$3,017.49
$393.45
Toc - Plan #30 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$495.86
$562.80
$633.71
$885.61
$1,345.76
$875.19
$942.13
$1,013.04
$1,264.94
$1,254.52
$1,321.46
$1,392.37
$1,644.27
$1,633.85
$1,700.79
$1,771.70
$2,023.60
$379.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$991.72
$1,125.60
$1,267.42
$1,771.22
$2,691.52
$1,371.05
$1,504.93
$1,646.75
$2,150.55
$1,750.38
$1,884.26
$2,026.08
$2,529.88
$2,129.71
$2,263.59
$2,405.41
$2,909.21
$379.33
Toc - Plan #31 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$497.16
$564.28
$635.37
$887.93
$1,349.30
$877.49
$944.61
$1,015.70
$1,268.26
$1,257.82
$1,324.94
$1,396.03
$1,648.59
$1,638.15
$1,705.27
$1,776.36
$2,028.92
$380.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$994.32
$1,128.56
$1,270.74
$1,775.86
$2,698.60
$1,374.65
$1,508.89
$1,651.07
$2,156.19
$1,754.98
$1,889.22
$2,031.40
$2,536.52
$2,135.31
$2,269.55
$2,411.73
$2,916.85
$380.33
Toc - Plan #32 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,350 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$3,350 $6,700 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
$495.12
$561.96
$632.76
$884.28
$1,343.74
$873.88
$940.72
$1,011.52
$1,263.04
$1,252.64
$1,319.48
$1,390.28
$1,641.80
$1,631.40
$1,698.24
$1,769.04
$2,020.56
$378.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$990.24
$1,123.92
$1,265.52
$1,768.56
$2,687.48
$1,369.00
$1,502.68
$1,644.28
$2,147.32
$1,747.76
$1,881.44
$2,023.04
$2,526.08
$2,126.52
$2,260.20
$2,401.80
$2,904.84
$378.76
Toc - Plan #33 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$497.38
$564.53
$635.65
$888.32
$1,349.89
$877.87
$945.02
$1,016.14
$1,268.81
$1,258.36
$1,325.51
$1,396.63
$1,649.30
$1,638.85
$1,706.00
$1,777.12
$2,029.79
$380.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$994.76
$1,129.06
$1,271.30
$1,776.64
$2,699.78
$1,375.25
$1,509.55
$1,651.79
$2,157.13
$1,755.74
$1,890.04
$2,032.28
$2,537.62
$2,136.23
$2,270.53
$2,412.77
$2,918.11
$380.49
Toc - Plan #34 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $9,100 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.16
$466.67
$525.46
$734.33
$1,115.89
$725.70
$781.21
$840.00
$1,048.87
$1,040.24
$1,095.75
$1,154.54
$1,363.41
$1,354.78
$1,410.29
$1,469.08
$1,677.95
$314.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.32
$933.34
$1,050.92
$1,468.66
$2,231.78
$1,136.86
$1,247.88
$1,365.46
$1,783.20
$1,451.40
$1,562.42
$1,680.00
$2,097.74
$1,765.94
$1,876.96
$1,994.54
$2,412.28
$314.54
Toc - Plan #35 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $6,350 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.50
$464.78
$523.34
$731.36
$1,111.37
$722.77
$778.05
$836.61
$1,044.63
$1,036.04
$1,091.32
$1,149.88
$1,357.90
$1,349.31
$1,404.59
$1,463.15
$1,671.17
$313.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$819.00
$929.56
$1,046.68
$1,462.72
$2,222.74
$1,132.27
$1,242.83
$1,359.95
$1,775.99
$1,445.54
$1,556.10
$1,673.22
$2,089.26
$1,758.81
$1,869.37
$1,986.49
$2,402.53
$313.27
Toc - Plan #36 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$422.36
$479.38
$539.78
$754.34
$1,146.29
$745.47
$802.49
$862.89
$1,077.45
$1,068.58
$1,125.60
$1,186.00
$1,400.56
$1,391.69
$1,448.71
$1,509.11
$1,723.67
$323.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$844.72
$958.76
$1,079.56
$1,508.68
$2,292.58
$1,167.83
$1,281.87
$1,402.67
$1,831.79
$1,490.94
$1,604.98
$1,725.78
$2,154.90
$1,814.05
$1,928.09
$2,048.89
$2,478.01
$323.11
Toc - Plan #37 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$400.99
$455.13
$512.47
$716.17
$1,088.29
$707.75
$761.89
$819.23
$1,022.93
$1,014.51
$1,068.65
$1,125.99
$1,329.69
$1,321.27
$1,375.41
$1,432.75
$1,636.45
$306.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$801.98
$910.26
$1,024.94
$1,432.34
$2,176.58
$1,108.74
$1,217.02
$1,331.70
$1,739.10
$1,415.50
$1,523.78
$1,638.46
$2,045.86
$1,722.26
$1,830.54
$1,945.22
$2,352.62
$306.76
Toc - Plan #38 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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
$525.17
$596.07
$671.17
$937.96
$1,425.32
$926.93
$997.83
$1,072.93
$1,339.72
$1,328.69
$1,399.59
$1,474.69
$1,741.48
$1,730.45
$1,801.35
$1,876.45
$2,143.24
$401.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,050.34
$1,192.14
$1,342.34
$1,875.92
$2,850.64
$1,452.10
$1,593.90
$1,744.10
$2,277.68
$1,853.86
$1,995.66
$2,145.86
$2,679.44
$2,255.62
$2,397.42
$2,547.62
$3,081.20
$401.76

ADVERTISEMENT

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Local: 1-855-738-6652 | Toll Free: 1-855-738-6652

Toc - Plan #39 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354.57
$402.44
$453.14
$633.26
$962.30
$625.82
$673.69
$724.39
$904.51
$897.07
$944.94
$995.64
$1,175.76
$1,168.32
$1,216.19
$1,266.89
$1,447.01
$271.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.14
$804.88
$906.28
$1,266.52
$1,924.60
$980.39
$1,076.13
$1,177.53
$1,537.77
$1,251.64
$1,347.38
$1,448.78
$1,809.02
$1,522.89
$1,618.63
$1,720.03
$2,080.27
$271.25
Toc - Plan #40 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 3000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.73
$480.93
$541.53
$756.78
$1,150.00
$747.88
$805.08
$865.68
$1,080.93
$1,072.03
$1,129.23
$1,189.83
$1,405.08
$1,396.18
$1,453.38
$1,513.98
$1,729.23
$324.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$847.46
$961.86
$1,083.06
$1,513.56
$2,300.00
$1,171.61
$1,286.01
$1,407.21
$1,837.71
$1,495.76
$1,610.16
$1,731.36
$2,161.86
$1,819.91
$1,934.31
$2,055.51
$2,486.01
$324.15
Toc - Plan #41 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 5500($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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
$426.97
$484.61
$545.67
$762.57
$1,158.80
$753.60
$811.24
$872.30
$1,089.20
$1,080.23
$1,137.87
$1,198.93
$1,415.83
$1,406.86
$1,464.50
$1,525.56
$1,742.46
$326.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.94
$969.22
$1,091.34
$1,525.14
$2,317.60
$1,180.57
$1,295.85
$1,417.97
$1,851.77
$1,507.20
$1,622.48
$1,744.60
$2,178.40
$1,833.83
$1,949.11
$2,071.23
$2,505.03
$326.63
Toc - Plan #42 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 5600($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$5,600 $11,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.48
$389.85
$438.97
$613.46
$932.20
$606.24
$652.61
$701.73
$876.22
$869.00
$915.37
$964.49
$1,138.98
$1,131.76
$1,178.13
$1,227.25
$1,401.74
$262.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.96
$779.70
$877.94
$1,226.92
$1,864.40
$949.72
$1,042.46
$1,140.70
$1,489.68
$1,212.48
$1,305.22
$1,403.46
$1,752.44
$1,475.24
$1,567.98
$1,666.22
$2,015.20
$262.76
Toc - Plan #43 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 6000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$337.55
$383.12
$431.39
$602.86
$916.11
$595.78
$641.35
$689.62
$861.09
$854.01
$899.58
$947.85
$1,119.32
$1,112.24
$1,157.81
$1,206.08
$1,377.55
$258.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$675.10
$766.24
$862.78
$1,205.72
$1,832.22
$933.33
$1,024.47
$1,121.01
$1,463.95
$1,191.56
$1,282.70
$1,379.24
$1,722.18
$1,449.79
$1,540.93
$1,637.47
$1,980.41
$258.23
Toc - Plan #44 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Catastrophic

(HMO) Anthem Catastrophic Pathway X Guided Access HMO 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$243.95
$276.88
$311.77
$435.69
$662.08
$430.57
$463.50
$498.39
$622.31
$617.19
$650.12
$685.01
$808.93
$803.81
$836.74
$871.63
$995.55
$186.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$487.90
$553.76
$623.54
$871.38
$1,324.16
$674.52
$740.38
$810.16
$1,058.00
$861.14
$927.00
$996.78
$1,244.62
$1,047.76
$1,113.62
$1,183.40
$1,431.24
$186.62
Toc - Plan #45 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 8000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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
$324.24
$368.01
$414.38
$579.09
$879.99
$572.28
$616.05
$662.42
$827.13
$820.32
$864.09
$910.46
$1,075.17
$1,068.36
$1,112.13
$1,158.50
$1,323.21
$248.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.48
$736.02
$828.76
$1,158.18
$1,759.98
$896.52
$984.06
$1,076.80
$1,406.22
$1,144.56
$1,232.10
$1,324.84
$1,654.26
$1,392.60
$1,480.14
$1,572.88
$1,902.30
$248.04
Toc - Plan #46 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 4950($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$4,950 $9,900 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.62
$487.62
$549.05
$767.30
$1,165.99
$758.28
$816.28
$877.71
$1,095.96
$1,086.94
$1,144.94
$1,206.37
$1,424.62
$1,415.60
$1,473.60
$1,535.03
$1,753.28
$328.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.24
$975.24
$1,098.10
$1,534.60
$2,331.98
$1,187.90
$1,303.90
$1,426.76
$1,863.26
$1,516.56
$1,632.56
$1,755.42
$2,191.92
$1,845.22
$1,961.22
$2,084.08
$2,520.58
$328.66
Toc - Plan #47 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Gold

(HMO) Anthem Gold Pathway X Guided Access HMO 1600($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 Annual Deductible
$8,800 $17,600 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
$471.51
$535.16
$602.59
$842.12
$1,279.68
$832.22
$895.87
$963.30
$1,202.83
$1,192.93
$1,256.58
$1,324.01
$1,563.54
$1,553.64
$1,617.29
$1,684.72
$1,924.25
$360.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$943.02
$1,070.32
$1,205.18
$1,684.24
$2,559.36
$1,303.73
$1,431.03
$1,565.89
$2,044.95
$1,664.44
$1,791.74
$1,926.60
$2,405.66
$2,025.15
$2,152.45
$2,287.31
$2,766.37
$360.71
Toc - Plan #48 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 5000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.99
$406.32
$457.51
$639.37
$971.58
$631.85
$680.18
$731.37
$913.23
$905.71
$954.04
$1,005.23
$1,187.09
$1,179.57
$1,227.90
$1,279.09
$1,460.95
$273.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.98
$812.64
$915.02
$1,278.74
$1,943.16
$989.84
$1,086.50
$1,188.88
$1,552.60
$1,263.70
$1,360.36
$1,462.74
$1,826.46
$1,537.56
$1,634.22
$1,736.60
$2,100.32
$273.86
Toc - Plan #49 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 2600($0 PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$2,600 $5,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$450.06
$510.82
$575.18
$803.81
$1,221.46
$794.36
$855.12
$919.48
$1,148.11
$1,138.66
$1,199.42
$1,263.78
$1,492.41
$1,482.96
$1,543.72
$1,608.08
$1,836.71
$344.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$900.12
$1,021.64
$1,150.36
$1,607.62
$2,442.92
$1,244.42
$1,365.94
$1,494.66
$1,951.92
$1,588.72
$1,710.24
$1,838.96
$2,296.22
$1,933.02
$2,054.54
$2,183.26
$2,640.52
$344.30
Toc - Plan #50 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 6500($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$421.94
$478.90
$539.24
$753.58
$1,145.15
$744.72
$801.68
$862.02
$1,076.36
$1,067.50
$1,124.46
$1,184.80
$1,399.14
$1,390.28
$1,447.24
$1,507.58
$1,721.92
$322.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$843.88
$957.80
$1,078.48
$1,507.16
$2,290.30
$1,166.66
$1,280.58
$1,401.26
$1,829.94
$1,489.44
$1,603.36
$1,724.04
$2,152.72
$1,812.22
$1,926.14
$2,046.82
$2,475.50
$322.78
Toc - Plan #51 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.93
$379.01
$426.76
$596.40
$906.29
$589.39
$634.47
$682.22
$851.86
$844.85
$889.93
$937.68
$1,107.32
$1,100.31
$1,145.39
$1,193.14
$1,362.78
$255.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$667.86
$758.02
$853.52
$1,192.80
$1,812.58
$923.32
$1,013.48
$1,108.98
$1,448.26
$1,178.78
$1,268.94
$1,364.44
$1,703.72
$1,434.24
$1,524.40
$1,619.90
$1,959.18
$255.46
Toc - Plan #52 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$365.28
$414.59
$466.83
$652.39
$991.37
$644.72
$694.03
$746.27
$931.83
$924.16
$973.47
$1,025.71
$1,211.27
$1,203.60
$1,252.91
$1,305.15
$1,490.71
$279.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.56
$829.18
$933.66
$1,304.78
$1,982.74
$1,010.00
$1,108.62
$1,213.10
$1,584.22
$1,289.44
$1,388.06
$1,492.54
$1,863.66
$1,568.88
$1,667.50
$1,771.98
$2,143.10
$279.44
Toc - Plan #53 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$428.51
$486.36
$547.64
$765.32
$1,162.98
$756.32
$814.17
$875.45
$1,093.13
$1,084.13
$1,141.98
$1,203.26
$1,420.94
$1,411.94
$1,469.79
$1,531.07
$1,748.75
$327.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$857.02
$972.72
$1,095.28
$1,530.64
$2,325.96
$1,184.83
$1,300.53
$1,423.09
$1,858.45
$1,512.64
$1,628.34
$1,750.90
$2,186.26
$1,840.45
$1,956.15
$2,078.71
$2,514.07
$327.81
Toc - Plan #54 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Gold

(HMO) Anthem Gold Pathway X Guided Access HMO 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$484.53
$549.94
$619.23
$865.37
$1,315.01
$855.20
$920.61
$989.90
$1,236.04
$1,225.87
$1,291.28
$1,360.57
$1,606.71
$1,596.54
$1,661.95
$1,731.24
$1,977.38
$370.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$969.06
$1,099.88
$1,238.46
$1,730.74
$2,630.02
$1,339.73
$1,470.55
$1,609.13
$2,101.41
$1,710.40
$1,841.22
$1,979.80
$2,472.08
$2,081.07
$2,211.89
$2,350.47
$2,842.75
$370.67

ADVERTISEMENT

Oscar Health Plan of Georgia

Local: 1-855-672-2755 | Toll Free: 

Toc - Plan #55 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Classic- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$278.71
$316.32
$356.18
$497.76
$756.39
$491.92
$529.53
$569.39
$710.97
$705.13
$742.74
$782.60
$924.18
$918.34
$955.95
$995.81
$1,137.39
$213.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$557.42
$632.64
$712.36
$995.52
$1,512.78
$770.63
$845.85
$925.57
$1,208.73
$983.84
$1,059.06
$1,138.78
$1,421.94
$1,197.05
$1,272.27
$1,351.99
$1,635.15
$213.21
Toc - Plan #56 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$273.45
$310.35
$349.46
$488.36
$742.12
$482.63
$519.53
$558.64
$697.54
$691.81
$728.71
$767.82
$906.72
$900.99
$937.89
$977.00
$1,115.90
$209.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$546.90
$620.70
$698.92
$976.72
$1,484.24
$756.08
$829.88
$908.10
$1,185.90
$965.26
$1,039.06
$1,117.28
$1,395.08
$1,174.44
$1,248.24
$1,326.46
$1,604.26
$209.18
Toc - Plan #57 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Elite- $0 Ded+PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$326.55
$370.62
$417.31
$583.20
$886.22
$576.35
$620.42
$667.11
$833.00
$826.15
$870.22
$916.91
$1,082.80
$1,075.95
$1,120.02
$1,166.71
$1,332.60
$249.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$653.10
$741.24
$834.62
$1,166.40
$1,772.44
$902.90
$991.04
$1,084.42
$1,416.20
$1,152.70
$1,240.84
$1,334.22
$1,666.00
$1,402.50
$1,490.64
$1,584.02
$1,915.80
$249.80
Toc - Plan #58 Oscar Health Plan of Georgia
Silver

(HMO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$352.36
$399.91
$450.30
$629.29
$956.27
$621.91
$669.46
$719.85
$898.84
$891.46
$939.01
$989.40
$1,168.39
$1,161.01
$1,208.56
$1,258.95
$1,437.94
$269.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704.72
$799.82
$900.60
$1,258.58
$1,912.54
$974.27
$1,069.37
$1,170.15
$1,528.13
$1,243.82
$1,338.92
$1,439.70
$1,797.68
$1,513.37
$1,608.47
$1,709.25
$2,067.23
$269.55
Toc - Plan #59 Oscar Health Plan of Georgia
Silver

(HMO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$348.08
$395.06
$444.83
$621.65
$944.66
$614.35
$661.33
$711.10
$887.92
$880.62
$927.60
$977.37
$1,154.19
$1,146.89
$1,193.87
$1,243.64
$1,420.46
$266.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696.16
$790.12
$889.66
$1,243.30
$1,889.32
$962.43
$1,056.39
$1,155.93
$1,509.57
$1,228.70
$1,322.66
$1,422.20
$1,775.84
$1,494.97
$1,588.93
$1,688.47
$2,042.11
$266.27
Toc - Plan #60 Oscar Health Plan of Georgia
Catastrophic

(HMO) Secure

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$236.62
$268.55
$302.39
$422.59
$642.16
$417.63
$449.56
$483.40
$603.60
$598.64
$630.57
$664.41
$784.61
$779.65
$811.58
$845.42
$965.62
$181.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$473.24
$537.10
$604.78
$845.18
$1,284.32
$654.25
$718.11
$785.79
$1,026.19
$835.26
$899.12
$966.80
$1,207.20
$1,016.27
$1,080.13
$1,147.81
$1,388.21
$181.01
Toc - Plan #61 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Elite- $0 Ded+Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$326.30
$370.34
$417.00
$582.75
$885.55
$575.91
$619.95
$666.61
$832.36
$825.52
$869.56
$916.22
$1,081.97
$1,075.13
$1,119.17
$1,165.83
$1,331.58
$249.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$652.60
$740.68
$834.00
$1,165.50
$1,771.10
$902.21
$990.29
$1,083.61
$1,415.11
$1,151.82
$1,239.90
$1,333.22
$1,664.72
$1,401.43
$1,489.51
$1,582.83
$1,914.33
$249.61
Toc - Plan #62 Oscar Health Plan of Georgia
Gold

(HMO) Gold Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$371.93
$422.13
$475.31
$664.25
$1,009.38
$656.45
$706.65
$759.83
$948.77
$940.97
$991.17
$1,044.35
$1,233.29
$1,225.49
$1,275.69
$1,328.87
$1,517.81
$284.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$743.86
$844.26
$950.62
$1,328.50
$2,018.76
$1,028.38
$1,128.78
$1,235.14
$1,613.02
$1,312.90
$1,413.30
$1,519.66
$1,897.54
$1,597.42
$1,697.82
$1,804.18
$2,182.06
$284.52
Toc - Plan #63 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$289.49
$328.56
$369.95
$517.01
$785.64
$510.94
$550.01
$591.40
$738.46
$732.39
$771.46
$812.85
$959.91
$953.84
$992.91
$1,034.30
$1,181.36
$221.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$578.98
$657.12
$739.90
$1,034.02
$1,571.28
$800.43
$878.57
$961.35
$1,255.47
$1,021.88
$1,100.02
$1,182.80
$1,476.92
$1,243.33
$1,321.47
$1,404.25
$1,698.37
$221.45
Toc - Plan #64 Oscar Health Plan of Georgia
Silver

(HMO) Silver Simple

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 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
$348.26
$395.26
$445.06
$621.97
$945.14
$614.67
$661.67
$711.47
$888.38
$881.08
$928.08
$977.88
$1,154.79
$1,147.49
$1,194.49
$1,244.29
$1,421.20
$266.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696.52
$790.52
$890.12
$1,243.94
$1,890.28
$962.93
$1,056.93
$1,156.53
$1,510.35
$1,229.34
$1,323.34
$1,422.94
$1,776.76
$1,495.75
$1,589.75
$1,689.35
$2,043.17
$266.41
Toc - Plan #65 Oscar Health Plan of Georgia
Silver

(HMO) Silver Classic- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364.97
$414.23
$466.42
$651.83
$990.51
$644.17
$693.43
$745.62
$931.03
$923.37
$972.63
$1,024.82
$1,210.23
$1,202.57
$1,251.83
$1,304.02
$1,489.43
$279.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.94
$828.46
$932.84
$1,303.66
$1,981.02
$1,009.14
$1,107.66
$1,212.04
$1,582.86
$1,288.34
$1,386.86
$1,491.24
$1,862.06
$1,567.54
$1,666.06
$1,770.44
$2,141.26
$279.20
Toc - Plan #66 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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
$288.15
$327.04
$368.24
$514.62
$782.01
$508.58
$547.47
$588.67
$735.05
$729.01
$767.90
$809.10
$955.48
$949.44
$988.33
$1,029.53
$1,175.91
$220.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.30
$654.08
$736.48
$1,029.24
$1,564.02
$796.73
$874.51
$956.91
$1,249.67
$1,017.16
$1,094.94
$1,177.34
$1,470.10
$1,237.59
$1,315.37
$1,397.77
$1,690.53
$220.43
Toc - Plan #67 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Classic- $3000 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$318.15
$361.09
$406.58
$568.20
$863.43
$561.53
$604.47
$649.96
$811.58
$804.91
$847.85
$893.34
$1,054.96
$1,048.29
$1,091.23
$1,136.72
$1,298.34
$243.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636.30
$722.18
$813.16
$1,136.40
$1,726.86
$879.68
$965.56
$1,056.54
$1,379.78
$1,123.06
$1,208.94
$1,299.92
$1,623.16
$1,366.44
$1,452.32
$1,543.30
$1,866.54
$243.38
Toc - Plan #68 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Classic- $4700 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$293.13
$332.69
$374.61
$523.52
$795.53
$517.37
$556.93
$598.85
$747.76
$741.61
$781.17
$823.09
$972.00
$965.85
$1,005.41
$1,047.33
$1,196.24
$224.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$586.26
$665.38
$749.22
$1,047.04
$1,591.06
$810.50
$889.62
$973.46
$1,271.28
$1,034.74
$1,113.86
$1,197.70
$1,495.52
$1,258.98
$1,338.10
$1,421.94
$1,719.76
$224.24
Toc - Plan #69 Oscar Health Plan of Georgia
Silver

(HMO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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
$341.07
$387.11
$435.88
$609.14
$925.64
$601.98
$648.02
$696.79
$870.05
$862.89
$908.93
$957.70
$1,130.96
$1,123.80
$1,169.84
$1,218.61
$1,391.87
$260.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.14
$774.22
$871.76
$1,218.28
$1,851.28
$943.05
$1,035.13
$1,132.67
$1,479.19
$1,203.96
$1,296.04
$1,393.58
$1,740.10
$1,464.87
$1,556.95
$1,654.49
$2,001.01
$260.91
Toc - Plan #70 Oscar Health Plan of Georgia
Silver

(HMO) Silver Elite- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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
$360.54
$409.20
$460.76
$643.90
$978.47
$636.34
$685.00
$736.56
$919.70
$912.14
$960.80
$1,012.36
$1,195.50
$1,187.94
$1,236.60
$1,288.16
$1,471.30
$275.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.08
$818.40
$921.52
$1,287.80
$1,956.94
$996.88
$1,094.20
$1,197.32
$1,563.60
$1,272.68
$1,370.00
$1,473.12
$1,839.40
$1,548.48
$1,645.80
$1,748.92
$2,115.20
$275.80
Toc - Plan #71 Oscar Health Plan of Georgia
Silver

(HMO) Silver Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,850 $9,700 Annual Deductible
$4,850 $9,700 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
$353.90
$401.66
$452.27
$632.04
$960.45
$624.62
$672.38
$722.99
$902.76
$895.34
$943.10
$993.71
$1,173.48
$1,166.06
$1,213.82
$1,264.43
$1,444.20
$270.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.80
$803.32
$904.54
$1,264.08
$1,920.90
$978.52
$1,074.04
$1,175.26
$1,534.80
$1,249.24
$1,344.76
$1,445.98
$1,805.52
$1,519.96
$1,615.48
$1,716.70
$2,076.24
$270.72
Toc - Plan #72 Oscar Health Plan of Georgia
Silver

(HMO) Silver Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.03
$402.94
$453.71
$634.06
$963.51
$626.62
$674.53
$725.30
$905.65
$898.21
$946.12
$996.89
$1,177.24
$1,169.80
$1,217.71
$1,268.48
$1,448.83
$271.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.06
$805.88
$907.42
$1,268.12
$1,927.02
$981.65
$1,077.47
$1,179.01
$1,539.71
$1,253.24
$1,349.06
$1,450.60
$1,811.30
$1,524.83
$1,620.65
$1,722.19
$2,082.89
$271.59
Toc - Plan #73 Oscar Health Plan of Georgia
Gold

(HMO) Gold Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$404.89
$459.54
$517.44
$723.12
$1,098.86
$714.63
$769.28
$827.18
$1,032.86
$1,024.37
$1,079.02
$1,136.92
$1,342.60
$1,334.11
$1,388.76
$1,446.66
$1,652.34
$309.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$809.78
$919.08
$1,034.88
$1,446.24
$2,197.72
$1,119.52
$1,228.82
$1,344.62
$1,755.98
$1,429.26
$1,538.56
$1,654.36
$2,065.72
$1,739.00
$1,848.30
$1,964.10
$2,375.46
$309.74
Toc - Plan #74 Oscar Health Plan of Georgia
Gold

(HMO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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
$383.01
$434.70
$489.47
$684.03
$1,039.45
$676.00
$727.69
$782.46
$977.02
$968.99
$1,020.68
$1,075.45
$1,270.01
$1,261.98
$1,313.67
$1,368.44
$1,563.00
$292.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.02
$869.40
$978.94
$1,368.06
$2,078.90
$1,059.01
$1,162.39
$1,271.93
$1,661.05
$1,352.00
$1,455.38
$1,564.92
$1,954.04
$1,644.99
$1,748.37
$1,857.91
$2,247.03
$292.99
Toc - Plan #75 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Elite- $1000 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$323.63
$367.31
$413.59
$577.99
$878.31
$571.20
$614.88
$661.16
$825.56
$818.77
$862.45
$908.73
$1,073.13
$1,066.34
$1,110.02
$1,156.30
$1,320.70
$247.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$647.26
$734.62
$827.18
$1,155.98
$1,756.62
$894.83
$982.19
$1,074.75
$1,403.55
$1,142.40
$1,229.76
$1,322.32
$1,651.12
$1,389.97
$1,477.33
$1,569.89
$1,898.69
$247.57
Toc - Plan #76 Oscar Health Plan of Georgia
Silver

(HMO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$349.09
$396.20
$446.12
$623.45
$947.40
$616.14
$663.25
$713.17
$890.50
$883.19
$930.30
$980.22
$1,157.55
$1,150.24
$1,197.35
$1,247.27
$1,424.60
$267.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.18
$792.40
$892.24
$1,246.90
$1,894.80
$965.23
$1,059.45
$1,159.29
$1,513.95
$1,232.28
$1,326.50
$1,426.34
$1,781.00
$1,499.33
$1,593.55
$1,693.39
$2,048.05
$267.05
Toc - Plan #77 Oscar Health Plan of Georgia
Expanded Bronze

(HMO) Bronze Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$287.08
$325.82
$366.88
$512.71
$779.11
$506.69
$545.43
$586.49
$732.32
$726.30
$765.04
$806.10
$951.93
$945.91
$984.65
$1,025.71
$1,171.54
$219.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$574.16
$651.64
$733.76
$1,025.42
$1,558.22
$793.77
$871.25
$953.37
$1,245.03
$1,013.38
$1,090.86
$1,172.98
$1,464.64
$1,232.99
$1,310.47
$1,392.59
$1,684.25
$219.61
Toc - Plan #78 Oscar Health Plan of Georgia
Bronze

(HMO) Bronze Simple- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$261.55
$296.85
$334.25
$467.11
$709.82
$461.63
$496.93
$534.33
$667.19
$661.71
$697.01
$734.41
$867.27
$861.79
$897.09
$934.49
$1,067.35
$200.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$523.10
$593.70
$668.50
$934.22
$1,419.64
$723.18
$793.78
$868.58
$1,134.30
$923.26
$993.86
$1,068.66
$1,334.38
$1,123.34
$1,193.94
$1,268.74
$1,534.46
$200.08
Toc - Plan #79 Oscar Health Plan of Georgia
Silver

(HMO) Silver Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.69
$390.08
$439.23
$613.82
$932.76
$606.61
$653.00
$702.15
$876.74
$869.53
$915.92
$965.07
$1,139.66
$1,132.45
$1,178.84
$1,227.99
$1,402.58
$262.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.38
$780.16
$878.46
$1,227.64
$1,865.52
$950.30
$1,043.08
$1,141.38
$1,490.56
$1,213.22
$1,306.00
$1,404.30
$1,753.48
$1,476.14
$1,568.92
$1,667.22
$2,016.40
$262.92
Toc - Plan #80 Oscar Health Plan of Georgia
Gold

(HMO) Gold Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.26
$400.94
$451.46
$630.91
$958.73
$623.50
$671.18
$721.70
$901.15
$893.74
$941.42
$991.94
$1,171.39
$1,163.98
$1,211.66
$1,262.18
$1,441.63
$270.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.52
$801.88
$902.92
$1,261.82
$1,917.46
$976.76
$1,072.12
$1,173.16
$1,532.06
$1,247.00
$1,342.36
$1,443.40
$1,802.30
$1,517.24
$1,612.60
$1,713.64
$2,072.54
$270.24

ADVERTISEMENT

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-255-0056

Toc - Plan #81 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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
$312.08
$354.20
$398.83
$557.36
$846.97
$550.82
$592.94
$637.57
$796.10
$789.56
$831.68
$876.31
$1,034.84
$1,028.30
$1,070.42
$1,115.05
$1,273.58
$238.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$624.16
$708.40
$797.66
$1,114.72
$1,693.94
$862.90
$947.14
$1,036.40
$1,353.46
$1,101.64
$1,185.88
$1,275.14
$1,592.20
$1,340.38
$1,424.62
$1,513.88
$1,830.94
$238.74
Toc - Plan #82 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$424.86
$482.21
$542.97
$758.80
$1,153.06
$749.88
$807.23
$867.99
$1,083.82
$1,074.90
$1,132.25
$1,193.01
$1,408.84
$1,399.92
$1,457.27
$1,518.03
$1,733.86
$325.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.72
$964.42
$1,085.94
$1,517.60
$2,306.12
$1,174.74
$1,289.44
$1,410.96
$1,842.62
$1,499.76
$1,614.46
$1,735.98
$2,167.64
$1,824.78
$1,939.48
$2,061.00
$2,492.66
$325.02
Toc - Plan #83 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$424.53
$481.84
$542.54
$758.20
$1,152.16
$749.29
$806.60
$867.30
$1,082.96
$1,074.05
$1,131.36
$1,192.06
$1,407.72
$1,398.81
$1,456.12
$1,516.82
$1,732.48
$324.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.06
$963.68
$1,085.08
$1,516.40
$2,304.32
$1,173.82
$1,288.44
$1,409.84
$1,841.16
$1,498.58
$1,613.20
$1,734.60
$2,165.92
$1,823.34
$1,937.96
$2,059.36
$2,490.68
$324.76
Toc - Plan #84 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.49
$493.15
$555.28
$776.00
$1,179.20
$766.87
$825.53
$887.66
$1,108.38
$1,099.25
$1,157.91
$1,220.04
$1,440.76
$1,431.63
$1,490.29
$1,552.42
$1,773.14
$332.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.98
$986.30
$1,110.56
$1,552.00
$2,358.40
$1,201.36
$1,318.68
$1,442.94
$1,884.38
$1,533.74
$1,651.06
$1,775.32
$2,216.76
$1,866.12
$1,983.44
$2,107.70
$2,549.14
$332.38
Toc - Plan #85 CareSource
Expanded Bronze

(HMO) CareSource Marketplace HSA Eligible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$344.08
$390.53
$439.73
$614.52
$933.82
$607.30
$653.75
$702.95
$877.74
$870.52
$916.97
$966.17
$1,140.96
$1,133.74
$1,180.19
$1,229.39
$1,404.18
$263.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.16
$781.06
$879.46
$1,229.04
$1,867.64
$951.38
$1,044.28
$1,142.68
$1,492.26
$1,214.60
$1,307.50
$1,405.90
$1,755.48
$1,477.82
$1,570.72
$1,669.12
$2,018.70
$263.22
Toc - Plan #86 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$294.89
$334.70
$376.87
$526.67
$800.33
$520.48
$560.29
$602.46
$752.26
$746.07
$785.88
$828.05
$977.85
$971.66
$1,011.47
$1,053.64
$1,203.44
$225.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$589.78
$669.40
$753.74
$1,053.34
$1,600.66
$815.37
$894.99
$979.33
$1,278.93
$1,040.96
$1,120.58
$1,204.92
$1,504.52
$1,266.55
$1,346.17
$1,430.51
$1,730.11
$225.59
Toc - Plan #87 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$462.91
$525.40
$591.59
$826.75
$1,256.33
$817.03
$879.52
$945.71
$1,180.87
$1,171.15
$1,233.64
$1,299.83
$1,534.99
$1,525.27
$1,587.76
$1,653.95
$1,889.11
$354.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$925.82
$1,050.80
$1,183.18
$1,653.50
$2,512.66
$1,279.94
$1,404.92
$1,537.30
$2,007.62
$1,634.06
$1,759.04
$1,891.42
$2,361.74
$1,988.18
$2,113.16
$2,245.54
$2,715.86
$354.12
Toc - Plan #88 CareSource
Silver

(HMO) CareSource Marketplace Federal Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.08
$492.67
$554.75
$775.26
$1,178.08
$766.15
$824.74
$886.82
$1,107.33
$1,098.22
$1,156.81
$1,218.89
$1,439.40
$1,430.29
$1,488.88
$1,550.96
$1,771.47
$332.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.16
$985.34
$1,109.50
$1,550.52
$2,356.16
$1,200.23
$1,317.41
$1,441.57
$1,882.59
$1,532.30
$1,649.48
$1,773.64
$2,214.66
$1,864.37
$1,981.55
$2,105.71
$2,546.73
$332.07
Toc - Plan #89 CareSource
Gold

(HMO) CareSource Marketplace Federal Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.07
$491.53
$553.46
$773.46
$1,175.34
$764.37
$822.83
$884.76
$1,104.76
$1,095.67
$1,154.13
$1,216.06
$1,436.06
$1,426.97
$1,485.43
$1,547.36
$1,767.36
$331.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$866.14
$983.06
$1,106.92
$1,546.92
$2,350.68
$1,197.44
$1,314.36
$1,438.22
$1,878.22
$1,528.74
$1,645.66
$1,769.52
$2,209.52
$1,860.04
$1,976.96
$2,100.82
$2,540.82
$331.30
Toc - Plan #90 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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
$322.34
$365.86
$411.95
$575.70
$874.83
$568.93
$612.45
$658.54
$822.29
$815.52
$859.04
$905.13
$1,068.88
$1,062.11
$1,105.63
$1,151.72
$1,315.47
$246.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$644.68
$731.72
$823.90
$1,151.40
$1,749.66
$891.27
$978.31
$1,070.49
$1,397.99
$1,137.86
$1,224.90
$1,317.08
$1,644.58
$1,384.45
$1,471.49
$1,563.67
$1,891.17
$246.59
Toc - Plan #91 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.50
$494.29
$556.56
$777.80
$1,181.94
$768.66
$827.45
$889.72
$1,110.96
$1,101.82
$1,160.61
$1,222.88
$1,444.12
$1,434.98
$1,493.77
$1,556.04
$1,777.28
$333.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871.00
$988.58
$1,113.12
$1,555.60
$2,363.88
$1,204.16
$1,321.74
$1,446.28
$1,888.76
$1,537.32
$1,654.90
$1,779.44
$2,221.92
$1,870.48
$1,988.06
$2,112.60
$2,555.08
$333.16
Toc - Plan #92 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$434.66
$493.33
$555.49
$776.29
$1,179.65
$767.17
$825.84
$888.00
$1,108.80
$1,099.68
$1,158.35
$1,220.51
$1,441.31
$1,432.19
$1,490.86
$1,553.02
$1,773.82
$332.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869.32
$986.66
$1,110.98
$1,552.58
$2,359.30
$1,201.83
$1,319.17
$1,443.49
$1,885.09
$1,534.34
$1,651.68
$1,776.00
$2,217.60
$1,866.85
$1,984.19
$2,108.51
$2,550.11
$332.51
Toc - Plan #93 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.62
$504.64
$568.22
$794.09
$1,206.70
$784.75
$844.77
$908.35
$1,134.22
$1,124.88
$1,184.90
$1,248.48
$1,474.35
$1,465.01
$1,525.03
$1,588.61
$1,814.48
$340.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$889.24
$1,009.28
$1,136.44
$1,588.18
$2,413.40
$1,229.37
$1,349.41
$1,476.57
$1,928.31
$1,569.50
$1,689.54
$1,816.70
$2,268.44
$1,909.63
$2,029.67
$2,156.83
$2,608.57
$340.13
Toc - Plan #94 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304.33
$345.41
$388.92
$543.52
$825.93
$537.14
$578.22
$621.73
$776.33
$769.95
$811.03
$854.54
$1,009.14
$1,002.76
$1,043.84
$1,087.35
$1,241.95
$232.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$608.66
$690.82
$777.84
$1,087.04
$1,651.86
$841.47
$923.63
$1,010.65
$1,319.85
$1,074.28
$1,156.44
$1,243.46
$1,552.66
$1,307.09
$1,389.25
$1,476.27
$1,785.47
$232.81
Toc - Plan #95 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$472.54
$536.33
$603.90
$843.95
$1,282.47
$834.03
$897.82
$965.39
$1,205.44
$1,195.52
$1,259.31
$1,326.88
$1,566.93
$1,557.01
$1,620.80
$1,688.37
$1,928.42
$361.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$945.08
$1,072.66
$1,207.80
$1,687.90
$2,564.94
$1,306.57
$1,434.15
$1,569.29
$2,049.39
$1,668.06
$1,795.64
$1,930.78
$2,410.88
$2,029.55
$2,157.13
$2,292.27
$2,772.37
$361.49
Toc - Plan #96 CareSource
Silver

(HMO) CareSource Marketplace Federal Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.21
$504.17
$567.69
$793.35
$1,205.57
$784.03
$843.99
$907.51
$1,133.17
$1,123.85
$1,183.81
$1,247.33
$1,472.99
$1,463.67
$1,523.63
$1,587.15
$1,812.81
$339.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.42
$1,008.34
$1,135.38
$1,586.70
$2,411.14
$1,228.24
$1,348.16
$1,475.20
$1,926.52
$1,568.06
$1,687.98
$1,815.02
$2,266.34
$1,907.88
$2,027.80
$2,154.84
$2,606.16
$339.82
Toc - Plan #97 CareSource
Gold

(HMO) CareSource Marketplace Federal Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$443.71
$503.61
$567.05
$792.46
$1,204.22
$783.14
$843.04
$906.48
$1,131.89
$1,122.57
$1,182.47
$1,245.91
$1,471.32
$1,462.00
$1,521.90
$1,585.34
$1,810.75
$339.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$887.42
$1,007.22
$1,134.10
$1,584.92
$2,408.44
$1,226.85
$1,346.65
$1,473.53
$1,924.35
$1,566.28
$1,686.08
$1,812.96
$2,263.78
$1,905.71
$2,025.51
$2,152.39
$2,603.21
$339.43

ADVERTISEMENT

Ambetter from Peach State Health Plan

Local: 1-877-687-1180 | Toll Free: 1-877-687-1180 | TTY: 1-877-941-9231

Toc - Plan #98 Ambetter from Peach State Health Plan
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328.58
$372.93
$419.92
$586.83
$891.75
$579.94
$624.29
$671.28
$838.19
$831.30
$875.65
$922.64
$1,089.55
$1,082.66
$1,127.01
$1,174.00
$1,340.91
$251.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$657.16
$745.86
$839.84
$1,173.66
$1,783.50
$908.52
$997.22
$1,091.20
$1,425.02
$1,159.88
$1,248.58
$1,342.56
$1,676.38
$1,411.24
$1,499.94
$1,593.92
$1,927.74
$251.36
Toc - Plan #99 Ambetter from Peach State Health Plan
Silver

(HMO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.60
$447.86
$504.28
$704.74
$1,070.91
$696.46
$749.72
$806.14
$1,006.60
$998.32
$1,051.58
$1,108.00
$1,308.46
$1,300.18
$1,353.44
$1,409.86
$1,610.32
$301.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$789.20
$895.72
$1,008.56
$1,409.48
$2,141.82
$1,091.06
$1,197.58
$1,310.42
$1,711.34
$1,392.92
$1,499.44
$1,612.28
$2,013.20
$1,694.78
$1,801.30
$1,914.14
$2,315.06
$301.86
Toc - Plan #100 Ambetter from Peach State Health Plan
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$390.22
$442.89
$498.69
$696.91
$1,059.03
$688.73
$741.40
$797.20
$995.42
$987.24
$1,039.91
$1,095.71
$1,293.93
$1,285.75
$1,338.42
$1,394.22
$1,592.44
$298.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.44
$885.78
$997.38
$1,393.82
$2,118.06
$1,078.95
$1,184.29
$1,295.89
$1,692.33
$1,377.46
$1,482.80
$1,594.40
$1,990.84
$1,675.97
$1,781.31
$1,892.91
$2,289.35
$298.51
Toc - Plan #101 Ambetter from Peach State Health Plan
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 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
$412.87
$468.59
$527.63
$737.36
$1,120.50
$728.71
$784.43
$843.47
$1,053.20
$1,044.55
$1,100.27
$1,159.31
$1,369.04
$1,360.39
$1,416.11
$1,475.15
$1,684.88
$315.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$825.74
$937.18
$1,055.26
$1,474.72
$2,241.00
$1,141.58
$1,253.02
$1,371.10
$1,790.56
$1,457.42
$1,568.86
$1,686.94
$2,106.40
$1,773.26
$1,884.70
$2,002.78
$2,422.24
$315.84
Toc - Plan #102 Ambetter from Peach State Health Plan
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$386.15
$438.27
$493.49
$689.65
$1,048.00
$681.55
$733.67
$788.89
$985.05
$976.95
$1,029.07
$1,084.29
$1,280.45
$1,272.35
$1,324.47
$1,379.69
$1,575.85
$295.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$772.30
$876.54
$986.98
$1,379.30
$2,096.00
$1,067.70
$1,171.94
$1,282.38
$1,674.70
$1,363.10
$1,467.34
$1,577.78
$1,970.10
$1,658.50
$1,762.74
$1,873.18
$2,265.50
$295.40
Toc - Plan #103 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.06
$409.79
$461.42
$644.83
$979.89
$637.26
$685.99
$737.62
$921.03
$913.46
$962.19
$1,013.82
$1,197.23
$1,189.66
$1,238.39
$1,290.02
$1,473.43
$276.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.12
$819.58
$922.84
$1,289.66
$1,959.78
$998.32
$1,095.78
$1,199.04
$1,565.86
$1,274.52
$1,371.98
$1,475.24
$1,842.06
$1,550.72
$1,648.18
$1,751.44
$2,118.26
$276.20
Toc - Plan #104 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 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
$353.52
$401.24
$451.79
$631.37
$959.43
$623.96
$671.68
$722.23
$901.81
$894.40
$942.12
$992.67
$1,172.25
$1,164.84
$1,212.56
$1,263.11
$1,442.69
$270.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.04
$802.48
$903.58
$1,262.74
$1,918.86
$977.48
$1,072.92
$1,174.02
$1,533.18
$1,247.92
$1,343.36
$1,444.46
$1,803.62
$1,518.36
$1,613.80
$1,714.90
$2,074.06
$270.44
Toc - Plan #105 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$400.00
$453.99
$511.19
$714.39
$1,085.58
$706.00
$759.99
$817.19
$1,020.39
$1,012.00
$1,065.99
$1,123.19
$1,326.39
$1,318.00
$1,371.99
$1,429.19
$1,632.39
$306.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$800.00
$907.98
$1,022.38
$1,428.78
$2,171.16
$1,106.00
$1,213.98
$1,328.38
$1,734.78
$1,412.00
$1,519.98
$1,634.38
$2,040.78
$1,718.00
$1,825.98
$1,940.38
$2,346.78
$306.00
Toc - Plan #106 Ambetter from Peach State Health Plan
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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
$380.39
$431.74
$486.13
$679.36
$1,032.36
$671.38
$722.73
$777.12
$970.35
$962.37
$1,013.72
$1,068.11
$1,261.34
$1,253.36
$1,304.71
$1,359.10
$1,552.33
$290.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.78
$863.48
$972.26
$1,358.72
$2,064.72
$1,051.77
$1,154.47
$1,263.25
$1,649.71
$1,342.76
$1,445.46
$1,554.24
$1,940.70
$1,633.75
$1,736.45
$1,845.23
$2,231.69
$290.99
Toc - Plan #107 Ambetter from Peach State Health Plan
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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
$384.69
$436.62
$491.63
$687.05
$1,044.03
$678.97
$730.90
$785.91
$981.33
$973.25
$1,025.18
$1,080.19
$1,275.61
$1,267.53
$1,319.46
$1,374.47
$1,569.89
$294.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$769.38
$873.24
$983.26
$1,374.10
$2,088.06
$1,063.66
$1,167.52
$1,277.54
$1,668.38
$1,357.94
$1,461.80
$1,571.82
$1,962.66
$1,652.22
$1,756.08
$1,866.10
$2,256.94
$294.28
Toc - Plan #108 Ambetter from Peach State Health Plan
Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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
$394.64
$447.90
$504.33
$704.81
$1,071.02
$696.53
$749.79
$806.22
$1,006.70
$998.42
$1,051.68
$1,108.11
$1,308.59
$1,300.31
$1,353.57
$1,410.00
$1,610.48
$301.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$789.28
$895.80
$1,008.66
$1,409.62
$2,142.04
$1,091.17
$1,197.69
$1,310.55
$1,711.51
$1,393.06
$1,499.58
$1,612.44
$2,013.40
$1,694.95
$1,801.47
$1,914.33
$2,315.29
$301.89
Toc - Plan #109 Ambetter from Peach State Health Plan
Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.06
$442.71
$498.48
$696.63
$1,058.60
$688.45
$741.10
$796.87
$995.02
$986.84
$1,039.49
$1,095.26
$1,293.41
$1,285.23
$1,337.88
$1,393.65
$1,591.80
$298.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.12
$885.42
$996.96
$1,393.26
$2,117.20
$1,078.51
$1,183.81
$1,295.35
$1,691.65
$1,376.90
$1,482.20
$1,593.74
$1,990.04
$1,675.29
$1,780.59
$1,892.13
$2,288.43
$298.39
Toc - Plan #110 Ambetter from Peach State Health Plan
Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$455.48
$516.96
$582.10
$813.48
$1,236.16
$803.92
$865.40
$930.54
$1,161.92
$1,152.36
$1,213.84
$1,278.98
$1,510.36
$1,500.80
$1,562.28
$1,627.42
$1,858.80
$348.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$910.96
$1,033.92
$1,164.20
$1,626.96
$2,472.32
$1,259.40
$1,382.36
$1,512.64
$1,975.40
$1,607.84
$1,730.80
$1,861.08
$2,323.84
$1,956.28
$2,079.24
$2,209.52
$2,672.28
$348.44
Toc - Plan #111 Ambetter from Peach State Health Plan
Bronze

(HMO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312.80
$355.02
$399.75
$558.64
$848.91
$552.08
$594.30
$639.03
$797.92
$791.36
$833.58
$878.31
$1,037.20
$1,030.64
$1,072.86
$1,117.59
$1,276.48
$239.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625.60
$710.04
$799.50
$1,117.28
$1,697.82
$864.88
$949.32
$1,038.78
$1,356.56
$1,104.16
$1,188.60
$1,278.06
$1,595.84
$1,343.44
$1,427.88
$1,517.34
$1,835.12
$239.28
Toc - Plan #112 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$346.10
$392.82
$442.31
$618.12
$939.30
$610.86
$657.58
$707.07
$882.88
$875.62
$922.34
$971.83
$1,147.64
$1,140.38
$1,187.10
$1,236.59
$1,412.40
$264.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$692.20
$785.64
$884.62
$1,236.24
$1,878.60
$956.96
$1,050.40
$1,149.38
$1,501.00
$1,221.72
$1,315.16
$1,414.14
$1,765.76
$1,486.48
$1,579.92
$1,678.90
$2,030.52
$264.76
Toc - Plan #113 Ambetter from Peach State Health Plan
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.22
$432.68
$487.19
$680.84
$1,034.61
$672.85
$724.31
$778.82
$972.47
$964.48
$1,015.94
$1,070.45
$1,264.10
$1,256.11
$1,307.57
$1,362.08
$1,555.73
$291.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.44
$865.36
$974.38
$1,361.68
$2,069.22
$1,054.07
$1,156.99
$1,266.01
$1,653.31
$1,345.70
$1,448.62
$1,557.64
$1,944.94
$1,637.33
$1,740.25
$1,849.27
$2,236.57
$291.63
Toc - Plan #114 Ambetter from Peach State Health Plan
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.93
$443.69
$499.59
$698.18
$1,060.95
$689.98
$742.74
$798.64
$997.23
$989.03
$1,041.79
$1,097.69
$1,296.28
$1,288.08
$1,340.84
$1,396.74
$1,595.33
$299.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.86
$887.38
$999.18
$1,396.36
$2,121.90
$1,080.91
$1,186.43
$1,298.23
$1,695.41
$1,379.96
$1,485.48
$1,597.28
$1,994.46
$1,679.01
$1,784.53
$1,896.33
$2,293.51
$299.05
Toc - Plan #115 Ambetter from Peach State Health Plan
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$401.45
$455.63
$513.04
$716.97
$1,089.51
$708.55
$762.73
$820.14
$1,024.07
$1,015.65
$1,069.83
$1,127.24
$1,331.17
$1,322.75
$1,376.93
$1,434.34
$1,638.27
$307.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802.90
$911.26
$1,026.08
$1,433.94
$2,179.02
$1,110.00
$1,218.36
$1,333.18
$1,741.04
$1,417.10
$1,525.46
$1,640.28
$2,048.14
$1,724.20
$1,832.56
$1,947.38
$2,355.24
$307.10
Toc - Plan #116 Ambetter from Peach State Health Plan
Silver

(HMO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.23
$465.60
$524.26
$732.65
$1,113.33
$724.05
$779.42
$838.08
$1,046.47
$1,037.87
$1,093.24
$1,151.90
$1,360.29
$1,351.69
$1,407.06
$1,465.72
$1,674.11
$313.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$820.46
$931.20
$1,048.52
$1,465.30
$2,226.66
$1,134.28
$1,245.02
$1,362.34
$1,779.12
$1,448.10
$1,558.84
$1,676.16
$2,092.94
$1,761.92
$1,872.66
$1,989.98
$2,406.76
$313.82
Toc - Plan #117 Ambetter from Peach State Health Plan
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$405.67
$460.43
$518.44
$724.52
$1,100.97
$716.00
$770.76
$828.77
$1,034.85
$1,026.33
$1,081.09
$1,139.10
$1,345.18
$1,336.66
$1,391.42
$1,449.43
$1,655.51
$310.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.34
$920.86
$1,036.88
$1,449.04
$2,201.94
$1,121.67
$1,231.19
$1,347.21
$1,759.37
$1,432.00
$1,541.52
$1,657.54
$2,069.70
$1,742.33
$1,851.85
$1,967.87
$2,380.03
$310.33
Toc - Plan #118 Ambetter from Peach State Health Plan
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 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
$341.60
$387.70
$436.55
$610.08
$927.07
$602.92
$649.02
$697.87
$871.40
$864.24
$910.34
$959.19
$1,132.72
$1,125.56
$1,171.66
$1,220.51
$1,394.04
$261.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.20
$775.40
$873.10
$1,220.16
$1,854.14
$944.52
$1,036.72
$1,134.42
$1,481.48
$1,205.84
$1,298.04
$1,395.74
$1,742.80
$1,467.16
$1,559.36
$1,657.06
$2,004.12
$261.32
Toc - Plan #119 Ambetter from Peach State Health Plan
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 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
$429.22
$487.15
$548.53
$766.57
$1,164.88
$757.57
$815.50
$876.88
$1,094.92
$1,085.92
$1,143.85
$1,205.23
$1,423.27
$1,414.27
$1,472.20
$1,533.58
$1,751.62
$328.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.44
$974.30
$1,097.06
$1,533.14
$2,329.76
$1,186.79
$1,302.65
$1,425.41
$1,861.49
$1,515.14
$1,631.00
$1,753.76
$2,189.84
$1,843.49
$1,959.35
$2,082.11
$2,518.19
$328.35
Toc - Plan #120 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.36
$426.02
$479.70
$670.37
$1,018.70
$662.50
$713.16
$766.84
$957.51
$949.64
$1,000.30
$1,053.98
$1,244.65
$1,236.78
$1,287.44
$1,341.12
$1,531.79
$287.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.72
$852.04
$959.40
$1,340.74
$2,037.40
$1,037.86
$1,139.18
$1,246.54
$1,627.88
$1,325.00
$1,426.32
$1,533.68
$1,915.02
$1,612.14
$1,713.46
$1,820.82
$2,202.16
$287.14
Toc - Plan #121 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 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
$367.52
$417.13
$469.68
$656.38
$997.43
$648.67
$698.28
$750.83
$937.53
$929.82
$979.43
$1,031.98
$1,218.68
$1,210.97
$1,260.58
$1,313.13
$1,499.83
$281.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.04
$834.26
$939.36
$1,312.76
$1,994.86
$1,016.19
$1,115.41
$1,220.51
$1,593.91
$1,297.34
$1,396.56
$1,501.66
$1,875.06
$1,578.49
$1,677.71
$1,782.81
$2,156.21
$281.15
Toc - Plan #122 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415.85
$471.98
$531.44
$742.69
$1,128.58
$733.97
$790.10
$849.56
$1,060.81
$1,052.09
$1,108.22
$1,167.68
$1,378.93
$1,370.21
$1,426.34
$1,485.80
$1,697.05
$318.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$831.70
$943.96
$1,062.88
$1,485.38
$2,257.16
$1,149.82
$1,262.08
$1,381.00
$1,803.50
$1,467.94
$1,580.20
$1,699.12
$2,121.62
$1,786.06
$1,898.32
$2,017.24
$2,439.74
$318.12
Toc - Plan #123 Ambetter from Peach State Health Plan
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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
$399.93
$453.91
$511.10
$714.26
$1,085.39
$705.87
$759.85
$817.04
$1,020.20
$1,011.81
$1,065.79
$1,122.98
$1,326.14
$1,317.75
$1,371.73
$1,428.92
$1,632.08
$305.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$799.86
$907.82
$1,022.20
$1,428.52
$2,170.78
$1,105.80
$1,213.76
$1,328.14
$1,734.46
$1,411.74
$1,519.70
$1,634.08
$2,040.40
$1,717.68
$1,825.64
$1,940.02
$2,346.34
$305.94
Toc - Plan #124 Ambetter from Peach State Health Plan
Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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
$410.27
$465.64
$524.31
$732.72
$1,113.44
$724.12
$779.49
$838.16
$1,046.57
$1,037.97
$1,093.34
$1,152.01
$1,360.42
$1,351.82
$1,407.19
$1,465.86
$1,674.27
$313.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$820.54
$931.28
$1,048.62
$1,465.44
$2,226.88
$1,134.39
$1,245.13
$1,362.47
$1,779.29
$1,448.24
$1,558.98
$1,676.32
$2,093.14
$1,762.09
$1,872.83
$1,990.17
$2,406.99
$313.85
Toc - Plan #125 Ambetter from Peach State Health Plan
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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
$395.46
$448.84
$505.39
$706.27
$1,073.25
$697.98
$751.36
$807.91
$1,008.79
$1,000.50
$1,053.88
$1,110.43
$1,311.31
$1,303.02
$1,356.40
$1,412.95
$1,613.83
$302.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$790.92
$897.68
$1,010.78
$1,412.54
$2,146.50
$1,093.44
$1,200.20
$1,313.30
$1,715.06
$1,395.96
$1,502.72
$1,615.82
$2,017.58
$1,698.48
$1,805.24
$1,918.34
$2,320.10
$302.52
Toc - Plan #126 Ambetter from Peach State Health Plan
Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.51
$460.24
$518.23
$724.22
$1,100.53
$715.72
$770.45
$828.44
$1,034.43
$1,025.93
$1,080.66
$1,138.65
$1,344.64
$1,336.14
$1,390.87
$1,448.86
$1,654.85
$310.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.02
$920.48
$1,036.46
$1,448.44
$2,201.06
$1,121.23
$1,230.69
$1,346.67
$1,758.65
$1,431.44
$1,540.90
$1,656.88
$2,068.86
$1,741.65
$1,851.11
$1,967.09
$2,379.07
$310.21
Toc - Plan #127 Ambetter from Peach State Health Plan
Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$473.52
$537.44
$605.15
$845.70
$1,285.12
$835.76
$899.68
$967.39
$1,207.94
$1,198.00
$1,261.92
$1,329.63
$1,570.18
$1,560.24
$1,624.16
$1,691.87
$1,932.42
$362.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$947.04
$1,074.88
$1,210.30
$1,691.40
$2,570.24
$1,309.28
$1,437.12
$1,572.54
$2,053.64
$1,671.52
$1,799.36
$1,934.78
$2,415.88
$2,033.76
$2,161.60
$2,297.02
$2,778.12
$362.24
Toc - Plan #128 Ambetter from Peach State Health Plan
Silver

(HMO) Complete Wellstar SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$372.07
$422.29
$475.49
$664.49
$1,009.76
$656.69
$706.91
$760.11
$949.11
$941.31
$991.53
$1,044.73
$1,233.73
$1,225.93
$1,276.15
$1,329.35
$1,518.35
$284.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.14
$844.58
$950.98
$1,328.98
$2,019.52
$1,028.76
$1,129.20
$1,235.60
$1,613.60
$1,313.38
$1,413.82
$1,520.22
$1,898.22
$1,598.00
$1,698.44
$1,804.84
$2,182.84
$284.62
Toc - Plan #129 Ambetter from Peach State Health Plan
Silver

(HMO) Clear Wellstar SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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
$362.72
$411.67
$463.54
$647.79
$984.38
$640.19
$689.14
$741.01
$925.26
$917.66
$966.61
$1,018.48
$1,202.73
$1,195.13
$1,244.08
$1,295.95
$1,480.20
$277.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$725.44
$823.34
$927.08
$1,295.58
$1,968.76
$1,002.91
$1,100.81
$1,204.55
$1,573.05
$1,280.38
$1,378.28
$1,482.02
$1,850.52
$1,557.85
$1,655.75
$1,759.49
$2,127.99
$277.47
Toc - Plan #130 Ambetter from Peach State Health Plan
Silver

(HMO) Focused Wellstar SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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
$366.82
$416.33
$468.78
$655.12
$995.52
$647.43
$696.94
$749.39
$935.73
$928.04
$977.55
$1,030.00
$1,216.34
$1,208.65
$1,258.16
$1,310.61
$1,496.95
$280.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.64
$832.66
$937.56
$1,310.24
$1,991.04
$1,014.25
$1,113.27
$1,218.17
$1,590.85
$1,294.86
$1,393.88
$1,498.78
$1,871.46
$1,575.47
$1,674.49
$1,779.39
$2,152.07
$280.61
Toc - Plan #131 Ambetter from Peach State Health Plan
Gold

(HMO) Everyday Wellsta