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Oscar Health Plan, Inc.

Local: 1-855-672-2755 | Toll Free: 

Toc - Plan #1 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite + PCP Saver Plus (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.71
$386.69
$435.41
$608.48
$924.65 		$601.34
$647.32
$696.04
$869.11 		$861.97
$907.95
$956.67
$1,129.74 		$1,122.60
$1,168.58
$1,217.30
$1,390.37 		$260.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.42
$773.38
$870.82
$1,216.96
$1,849.30 		$942.05
$1,034.01
$1,131.45
$1,477.59 		$1,202.68
$1,294.64
$1,392.08
$1,738.22 		$1,463.31
$1,555.27
$1,652.71
$1,998.85 		$260.63
Toc - Plan #2 Oscar Health Plan, Inc.
Catastrophic

(HMO) Secure (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$268.71
$304.97
$343.39
$479.89
$729.24 		$474.26
$510.52
$548.94
$685.44 		$679.81
$716.07
$754.49
$890.99 		$885.36
$921.62
$960.04
$1,096.54 		$205.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$537.42
$609.94
$686.78
$959.78
$1,458.48 		$742.97
$815.49
$892.33
$1,165.33 		$948.52
$1,021.04
$1,097.88
$1,370.88 		$1,154.07
$1,226.59
$1,303.43
$1,576.43 		$205.55
Toc - Plan #3 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple PCP Saver (Choice)

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 		$366.40
$415.86
$468.25
$654.38
$994.39 		$646.69
$696.15
$748.54
$934.67 		$926.98
$976.44
$1,028.83
$1,214.96 		$1,207.27
$1,256.73
$1,309.12
$1,495.25 		$280.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.80
$831.72
$936.50
$1,308.76
$1,988.78 		$1,013.09
$1,112.01
$1,216.79
$1,589.05 		$1,293.38
$1,392.30
$1,497.08
$1,869.34 		$1,573.67
$1,672.59
$1,777.37
$2,149.63 		$280.29
Toc - Plan #4 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite Saver Plus Rx Copay (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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 		$382.00
$433.56
$488.19
$682.24
$1,036.73 		$674.23
$725.79
$780.42
$974.47 		$966.46
$1,018.02
$1,072.65
$1,266.70 		$1,258.69
$1,310.25
$1,364.88
$1,558.93 		$292.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.00
$867.12
$976.38
$1,364.48
$2,073.46 		$1,056.23
$1,159.35
$1,268.61
$1,656.71 		$1,348.46
$1,451.58
$1,560.84
$1,948.94 		$1,640.69
$1,743.81
$1,853.07
$2,241.17 		$292.23
Toc - Plan #5 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$306.87
$348.28
$392.16
$548.05
$832.81 		$541.62
$583.03
$626.91
$782.80 		$776.37
$817.78
$861.66
$1,017.55 		$1,011.12
$1,052.53
$1,096.41
$1,252.30 		$234.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.74
$696.56
$784.32
$1,096.10
$1,665.62 		$848.49
$931.31
$1,019.07
$1,330.85 		$1,083.24
$1,166.06
$1,253.82
$1,565.60 		$1,317.99
$1,400.81
$1,488.57
$1,800.35 		$234.75
Toc - Plan #6 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.81
$412.92
$464.94
$649.75
$987.36 		$642.12
$691.23
$743.25
$928.06 		$920.43
$969.54
$1,021.56
$1,206.37 		$1,198.74
$1,247.85
$1,299.87
$1,484.68 		$278.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.62
$825.84
$929.88
$1,299.50
$1,974.72 		$1,005.93
$1,104.15
$1,208.19
$1,577.81 		$1,284.24
$1,382.46
$1,486.50
$1,856.12 		$1,562.55
$1,660.77
$1,764.81
$2,134.43 		$278.31
Toc - Plan #7 Oscar Health Plan, Inc.
Gold

(HMO) Gold Classic Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.68
$446.81
$503.11
$703.09
$1,068.42 		$694.84
$747.97
$804.27
$1,004.25 		$996.00
$1,049.13
$1,105.43
$1,305.41 		$1,297.16
$1,350.29
$1,406.59
$1,606.57 		$301.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.36
$893.62
$1,006.22
$1,406.18
$2,136.84 		$1,088.52
$1,194.78
$1,307.38
$1,707.34 		$1,389.68
$1,495.94
$1,608.54
$2,008.50 		$1,690.84
$1,797.10
$1,909.70
$2,309.66 		$301.16
Toc - Plan #8 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite + PCP Saver Plus (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.01
$340.50
$383.40
$535.80
$814.20 		$529.51
$570.00
$612.90
$765.30 		$759.01
$799.50
$842.40
$994.80 		$988.51
$1,029.00
$1,071.90
$1,224.30 		$229.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.02
$681.00
$766.80
$1,071.60
$1,628.40 		$829.52
$910.50
$996.30
$1,301.10 		$1,059.02
$1,140.00
$1,225.80
$1,530.60 		$1,288.52
$1,369.50
$1,455.30
$1,760.10 		$229.50
Toc - Plan #9 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic PCP Saver Plus Rx Copay (Select)

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 		$273.27
$310.15
$349.22
$488.04
$741.62 		$482.31
$519.19
$558.26
$697.08 		$691.35
$728.23
$767.30
$906.12 		$900.39
$937.27
$976.34
$1,115.16 		$209.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.54
$620.30
$698.44
$976.08
$1,483.24 		$755.58
$829.34
$907.48
$1,185.12 		$964.62
$1,038.38
$1,116.52
$1,394.16 		$1,173.66
$1,247.42
$1,325.56
$1,603.20 		$209.04
Toc - Plan #10 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic 4700 (Select)

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 		$276.89
$314.26
$353.86
$494.51
$751.46 		$488.71
$526.08
$565.68
$706.33 		$700.53
$737.90
$777.50
$918.15 		$912.35
$949.72
$989.32
$1,129.97 		$211.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.78
$628.52
$707.72
$989.02
$1,502.92 		$765.60
$840.34
$919.54
$1,200.84 		$977.42
$1,052.16
$1,131.36
$1,412.66 		$1,189.24
$1,263.98
$1,343.18
$1,624.48 		$211.82
Toc - Plan #11 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple PCP Saver (Select)

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 		$322.48
$366.00
$412.11
$575.92
$875.17 		$569.17
$612.69
$658.80
$822.61 		$815.86
$859.38
$905.49
$1,069.30 		$1,062.55
$1,106.07
$1,152.18
$1,315.99 		$246.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.96
$732.00
$824.22
$1,151.84
$1,750.34 		$891.65
$978.69
$1,070.91
$1,398.53 		$1,138.34
$1,225.38
$1,317.60
$1,645.22 		$1,385.03
$1,472.07
$1,564.29
$1,891.91 		$246.69
Toc - Plan #12 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite Saver Plus Rx Copay (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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 		$336.11
$381.48
$429.54
$600.28
$912.19 		$593.23
$638.60
$686.66
$857.40 		$850.35
$895.72
$943.78
$1,114.52 		$1,107.47
$1,152.84
$1,200.90
$1,371.64 		$257.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.22
$762.96
$859.08
$1,200.56
$1,824.38 		$929.34
$1,020.08
$1,116.20
$1,457.68 		$1,186.46
$1,277.20
$1,373.32
$1,714.80 		$1,443.58
$1,534.32
$1,630.44
$1,971.92 		$257.12
Toc - Plan #13 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic Standard (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$270.42
$306.92
$345.59
$482.96
$733.90 		$477.29
$513.79
$552.46
$689.83 		$684.16
$720.66
$759.33
$896.70 		$891.03
$927.53
$966.20
$1,103.57 		$206.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.84
$613.84
$691.18
$965.92
$1,467.80 		$747.71
$820.71
$898.05
$1,172.79 		$954.58
$1,027.58
$1,104.92
$1,379.66 		$1,161.45
$1,234.45
$1,311.79
$1,586.53 		$206.87
Toc - Plan #14 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic Standard (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.21
$363.43
$409.22
$571.88
$869.03 		$565.16
$608.38
$654.17
$816.83 		$810.11
$853.33
$899.12
$1,061.78 		$1,055.06
$1,098.28
$1,144.07
$1,306.73 		$244.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.42
$726.86
$818.44
$1,143.76
$1,738.06 		$885.37
$971.81
$1,063.39
$1,388.71 		$1,130.32
$1,216.76
$1,308.34
$1,633.66 		$1,375.27
$1,461.71
$1,553.29
$1,878.61 		$244.95
Toc - Plan #15 Oscar Health Plan, Inc.
Gold

(HMO) Gold Classic Standard (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$346.32
$393.06
$442.59
$618.51
$939.89 		$611.25
$657.99
$707.52
$883.44 		$876.18
$922.92
$972.45
$1,148.37 		$1,141.11
$1,187.85
$1,237.38
$1,413.30 		$264.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.64
$786.12
$885.18
$1,237.02
$1,879.78 		$957.57
$1,051.05
$1,150.11
$1,501.95 		$1,222.50
$1,315.98
$1,415.04
$1,766.88 		$1,487.43
$1,580.91
$1,679.97
$2,031.81 		$264.93

ADVERTISEMENT

Ambetter of Illinois

Local: 1-855-745-5507 | Toll Free: 1-855-745-5507 | TTY: 1-844-517-3431
Toc - Plan #16 Ambetter of Illinois
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

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 		$403.42
$457.87
$515.55
$720.48
$1,094.85 		$712.03
$766.48
$824.16
$1,029.09 		$1,020.64
$1,075.09
$1,132.77
$1,337.70 		$1,329.25
$1,383.70
$1,441.38
$1,646.31 		$308.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.84
$915.74
$1,031.10
$1,440.96
$2,189.70 		$1,115.45
$1,224.35
$1,339.71
$1,749.57 		$1,424.06
$1,532.96
$1,648.32
$2,058.18 		$1,732.67
$1,841.57
$1,956.93
$2,366.79 		$308.61
Toc - Plan #17 Ambetter of Illinois
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$283.51
$321.78
$362.32
$506.34
$769.43 		$500.39
$538.66
$579.20
$723.22 		$717.27
$755.54
$796.08
$940.10 		$934.15
$972.42
$1,012.96
$1,156.98 		$216.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.02
$643.56
$724.64
$1,012.68
$1,538.86 		$783.90
$860.44
$941.52
$1,229.56 		$1,000.78
$1,077.32
$1,158.40
$1,446.44 		$1,217.66
$1,294.20
$1,375.28
$1,663.32 		$216.88
Toc - Plan #18 Ambetter of Illinois
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$335.87
$381.20
$429.23
$599.85
$911.53 		$592.81
$638.14
$686.17
$856.79 		$849.75
$895.08
$943.11
$1,113.73 		$1,106.69
$1,152.02
$1,200.05
$1,370.67 		$256.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.74
$762.40
$858.46
$1,199.70
$1,823.06 		$928.68
$1,019.34
$1,115.40
$1,456.64 		$1,185.62
$1,276.28
$1,372.34
$1,713.58 		$1,442.56
$1,533.22
$1,629.28
$1,970.52 		$256.94
Toc - Plan #19 Ambetter of Illinois
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

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 		$317.97
$360.89
$406.36
$567.88
$862.95 		$561.21
$604.13
$649.60
$811.12 		$804.45
$847.37
$892.84
$1,054.36 		$1,047.69
$1,090.61
$1,136.08
$1,297.60 		$243.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.94
$721.78
$812.72
$1,135.76
$1,725.90 		$879.18
$965.02
$1,055.96
$1,379.00 		$1,122.42
$1,208.26
$1,299.20
$1,622.24 		$1,365.66
$1,451.50
$1,542.44
$1,865.48 		$243.24
Toc - Plan #20 Ambetter of Illinois
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.48
$369.41
$415.96
$581.30
$883.34 		$574.47
$618.40
$664.95
$830.29 		$823.46
$867.39
$913.94
$1,079.28 		$1,072.45
$1,116.38
$1,162.93
$1,328.27 		$248.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.96
$738.82
$831.92
$1,162.60
$1,766.68 		$899.95
$987.81
$1,080.91
$1,411.59 		$1,148.94
$1,236.80
$1,329.90
$1,660.58 		$1,397.93
$1,485.79
$1,578.89
$1,909.57 		$248.99
Toc - Plan #21 Ambetter of Illinois
Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

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 		$382.64
$434.28
$489.00
$683.38
$1,038.45 		$675.35
$726.99
$781.71
$976.09 		$968.06
$1,019.70
$1,074.42
$1,268.80 		$1,260.77
$1,312.41
$1,367.13
$1,561.51 		$292.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.28
$868.56
$978.00
$1,366.76
$2,076.90 		$1,057.99
$1,161.27
$1,270.71
$1,659.47 		$1,350.70
$1,453.98
$1,563.42
$1,952.18 		$1,643.41
$1,746.69
$1,856.13
$2,244.89 		$292.71
Toc - Plan #22 Ambetter of Illinois
Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$451.14
$512.03
$576.55
$805.72
$1,224.37 		$796.26
$857.15
$921.67
$1,150.84 		$1,141.38
$1,202.27
$1,266.79
$1,495.96 		$1,486.50
$1,547.39
$1,611.91
$1,841.08 		$345.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902.28
$1,024.06
$1,153.10
$1,611.44
$2,448.74 		$1,247.40
$1,369.18
$1,498.22
$1,956.56 		$1,592.52
$1,714.30
$1,843.34
$2,301.68 		$1,937.64
$2,059.42
$2,188.46
$2,646.80 		$345.12
Toc - Plan #23 Ambetter of Illinois
Expanded Bronze

(HMO) Central Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$281.28
$319.24
$359.46
$502.34
$763.36 		$496.45
$534.41
$574.63
$717.51 		$711.62
$749.58
$789.80
$932.68 		$926.79
$964.75
$1,004.97
$1,147.85 		$215.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.56
$638.48
$718.92
$1,004.68
$1,526.72 		$777.73
$853.65
$934.09
$1,219.85 		$992.90
$1,068.82
$1,149.26
$1,435.02 		$1,208.07
$1,283.99
$1,364.43
$1,650.19 		$215.17
Toc - Plan #24 Ambetter of Illinois
Silver

(HMO) Central Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$343.86
$390.27
$439.45
$614.12
$933.22 		$606.91
$653.32
$702.50
$877.17 		$869.96
$916.37
$965.55
$1,140.22 		$1,133.01
$1,179.42
$1,228.60
$1,403.27 		$263.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687.72
$780.54
$878.90
$1,228.24
$1,866.44 		$950.77
$1,043.59
$1,141.95
$1,491.29 		$1,213.82
$1,306.64
$1,405.00
$1,754.34 		$1,476.87
$1,569.69
$1,668.05
$2,017.39 		$263.05
Toc - Plan #25 Ambetter of Illinois
Gold

(HMO) Central Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$389.77
$442.37
$498.11
$696.11
$1,057.80 		$687.93
$740.53
$796.27
$994.27 		$986.09
$1,038.69
$1,094.43
$1,292.43 		$1,284.25
$1,336.85
$1,392.59
$1,590.59 		$298.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.54
$884.74
$996.22
$1,392.22
$2,115.60 		$1,077.70
$1,182.90
$1,294.38
$1,690.38 		$1,375.86
$1,481.06
$1,592.54
$1,988.54 		$1,674.02
$1,779.22
$1,890.70
$2,286.70 		$298.16
Toc - Plan #26 Ambetter of Illinois
Expanded Bronze

(HMO) Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$275.87
$313.11
$352.55
$492.69
$748.69 		$486.91
$524.15
$563.59
$703.73 		$697.95
$735.19
$774.63
$914.77 		$908.99
$946.23
$985.67
$1,125.81 		$211.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.74
$626.22
$705.10
$985.38
$1,497.38 		$762.78
$837.26
$916.14
$1,196.42 		$973.82
$1,048.30
$1,127.18
$1,407.46 		$1,184.86
$1,259.34
$1,338.22
$1,618.50 		$211.04
Toc - Plan #27 Ambetter of Illinois
Silver

(HMO) Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319.67
$362.81
$408.52
$570.91
$867.55 		$564.21
$607.35
$653.06
$815.45 		$808.75
$851.89
$897.60
$1,059.99 		$1,053.29
$1,096.43
$1,142.14
$1,304.53 		$244.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.34
$725.62
$817.04
$1,141.82
$1,735.10 		$883.88
$970.16
$1,061.58
$1,386.36 		$1,128.42
$1,214.70
$1,306.12
$1,630.90 		$1,372.96
$1,459.24
$1,550.66
$1,875.44 		$244.54
Toc - Plan #28 Ambetter of Illinois
Gold

(HMO) Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$379.99
$431.27
$485.61
$678.64
$1,031.25 		$670.67
$721.95
$776.29
$969.32 		$961.35
$1,012.63
$1,066.97
$1,260.00 		$1,252.03
$1,303.31
$1,357.65
$1,550.68 		$290.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$759.98
$862.54
$971.22
$1,357.28
$2,062.50 		$1,050.66
$1,153.22
$1,261.90
$1,647.96 		$1,341.34
$1,443.90
$1,552.58
$1,938.64 		$1,632.02
$1,734.58
$1,843.26
$2,229.32 		$290.68
Toc - Plan #29 Ambetter of Illinois
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

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 		$416.23
$472.40
$531.92
$743.36
$1,129.61 		$734.63
$790.80
$850.32
$1,061.76 		$1,053.03
$1,109.20
$1,168.72
$1,380.16 		$1,371.43
$1,427.60
$1,487.12
$1,698.56 		$318.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.46
$944.80
$1,063.84
$1,486.72
$2,259.22 		$1,150.86
$1,263.20
$1,382.24
$1,805.12 		$1,469.26
$1,581.60
$1,700.64
$2,123.52 		$1,787.66
$1,900.00
$2,019.04
$2,441.92 		$318.40
Toc - Plan #30 Ambetter of Illinois
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$292.52
$331.99
$373.82
$522.41
$793.86 		$516.29
$555.76
$597.59
$746.18 		$740.06
$779.53
$821.36
$969.95 		$963.83
$1,003.30
$1,045.13
$1,193.72 		$223.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.04
$663.98
$747.64
$1,044.82
$1,587.72 		$808.81
$887.75
$971.41
$1,268.59 		$1,032.58
$1,111.52
$1,195.18
$1,492.36 		$1,256.35
$1,335.29
$1,418.95
$1,716.13 		$223.77
Toc - Plan #31 Ambetter of Illinois
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$346.54
$393.31
$442.86
$618.90
$940.48 		$611.63
$658.40
$707.95
$883.99 		$876.72
$923.49
$973.04
$1,149.08 		$1,141.81
$1,188.58
$1,238.13
$1,414.17 		$265.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$693.08
$786.62
$885.72
$1,237.80
$1,880.96 		$958.17
$1,051.71
$1,150.81
$1,502.89 		$1,223.26
$1,316.80
$1,415.90
$1,767.98 		$1,488.35
$1,581.89
$1,680.99
$2,033.07 		$265.09
Toc - Plan #32 Ambetter of Illinois
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$335.82
$381.14
$429.16
$599.75
$911.38 		$592.71
$638.03
$686.05
$856.64 		$849.60
$894.92
$942.94
$1,113.53 		$1,106.49
$1,151.81
$1,199.83
$1,370.42 		$256.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.64
$762.28
$858.32
$1,199.50
$1,822.76 		$928.53
$1,019.17
$1,115.21
$1,456.39 		$1,185.42
$1,276.06
$1,372.10
$1,713.28 		$1,442.31
$1,532.95
$1,628.99
$1,970.17 		$256.89
Toc - Plan #33 Ambetter of Illinois
Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

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 		$394.79
$448.07
$504.53
$705.07
$1,071.43 		$696.80
$750.08
$806.54
$1,007.08 		$998.81
$1,052.09
$1,108.55
$1,309.09 		$1,300.82
$1,354.10
$1,410.56
$1,611.10 		$302.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.58
$896.14
$1,009.06
$1,410.14
$2,142.86 		$1,091.59
$1,198.15
$1,311.07
$1,712.15 		$1,393.60
$1,500.16
$1,613.08
$2,014.16 		$1,695.61
$1,802.17
$1,915.09
$2,316.17 		$302.01
Toc - Plan #34 Ambetter of Illinois
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

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 		$328.07
$372.35
$419.26
$585.91
$890.35 		$579.03
$623.31
$670.22
$836.87 		$829.99
$874.27
$921.18
$1,087.83 		$1,080.95
$1,125.23
$1,172.14
$1,338.79 		$250.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$656.14
$744.70
$838.52
$1,171.82
$1,780.70 		$907.10
$995.66
$1,089.48
$1,422.78 		$1,158.06
$1,246.62
$1,340.44
$1,673.74 		$1,409.02
$1,497.58
$1,591.40
$1,924.70 		$250.96
Toc - Plan #35 Ambetter of Illinois
Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$465.47
$528.29
$594.85
$831.30
$1,263.25 		$821.54
$884.36
$950.92
$1,187.37 		$1,177.61
$1,240.43
$1,306.99
$1,543.44 		$1,533.68
$1,596.50
$1,663.06
$1,899.51 		$356.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$930.94
$1,056.58
$1,189.70
$1,662.60
$2,526.50 		$1,287.01
$1,412.65
$1,545.77
$2,018.67 		$1,643.08
$1,768.72
$1,901.84
$2,374.74 		$1,999.15
$2,124.79
$2,257.91
$2,730.81 		$356.07
Toc - Plan #36 Ambetter of Illinois
Expanded Bronze

(HMO) Central Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$290.21
$329.37
$370.87
$518.29
$787.59 		$512.21
$551.37
$592.87
$740.29 		$734.21
$773.37
$814.87
$962.29 		$956.21
$995.37
$1,036.87
$1,184.29 		$222.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.42
$658.74
$741.74
$1,036.58
$1,575.18 		$802.42
$880.74
$963.74
$1,258.58 		$1,024.42
$1,102.74
$1,185.74
$1,480.58 		$1,246.42
$1,324.74
$1,407.74
$1,702.58 		$222.00
Toc - Plan #37 Ambetter of Illinois
Silver

(HMO) Central Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.78
$402.67
$453.40
$633.62
$962.85 		$626.18
$674.07
$724.80
$905.02 		$897.58
$945.47
$996.20
$1,176.42 		$1,168.98
$1,216.87
$1,267.60
$1,447.82 		$271.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.56
$805.34
$906.80
$1,267.24
$1,925.70 		$980.96
$1,076.74
$1,178.20
$1,538.64 		$1,252.36
$1,348.14
$1,449.60
$1,810.04 		$1,523.76
$1,619.54
$1,721.00
$2,081.44 		$271.40
Toc - Plan #38 Ambetter of Illinois
Gold

(HMO) Central Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$402.14
$456.42
$513.93
$718.21
$1,091.39 		$709.77
$764.05
$821.56
$1,025.84 		$1,017.40
$1,071.68
$1,129.19
$1,333.47 		$1,325.03
$1,379.31
$1,436.82
$1,641.10 		$307.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.28
$912.84
$1,027.86
$1,436.42
$2,182.78 		$1,111.91
$1,220.47
$1,335.49
$1,744.05 		$1,419.54
$1,528.10
$1,643.12
$2,051.68 		$1,727.17
$1,835.73
$1,950.75
$2,359.31 		$307.63
Toc - Plan #39 Ambetter of Illinois
Expanded Bronze

(HMO) Standard Expanded Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$284.63
$323.05
$363.75
$508.34
$772.47 		$502.37
$540.79
$581.49
$726.08 		$720.11
$758.53
$799.23
$943.82 		$937.85
$976.27
$1,016.97
$1,161.56 		$217.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569.26
$646.10
$727.50
$1,016.68
$1,544.94 		$787.00
$863.84
$945.24
$1,234.42 		$1,004.74
$1,081.58
$1,162.98
$1,452.16 		$1,222.48
$1,299.32
$1,380.72
$1,669.90 		$217.74
Toc - Plan #40 Ambetter of Illinois
Silver

(HMO) Standard Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$329.82
$374.33
$421.49
$589.03
$895.09 		$582.12
$626.63
$673.79
$841.33 		$834.42
$878.93
$926.09
$1,093.63 		$1,086.72
$1,131.23
$1,178.39
$1,345.93 		$252.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.64
$748.66
$842.98
$1,178.06
$1,790.18 		$911.94
$1,000.96
$1,095.28
$1,430.36 		$1,164.24
$1,253.26
$1,347.58
$1,682.66 		$1,416.54
$1,505.56
$1,599.88
$1,934.96 		$252.30
Toc - Plan #41 Ambetter of Illinois
Gold

(HMO) Standard Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$392.05
$444.97
$501.03
$700.18
$1,064.00 		$691.96
$744.88
$800.94
$1,000.09 		$991.87
$1,044.79
$1,100.85
$1,300.00 		$1,291.78
$1,344.70
$1,400.76
$1,599.91 		$299.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784.10
$889.94
$1,002.06
$1,400.36
$2,128.00 		$1,084.01
$1,189.85
$1,301.97
$1,700.27 		$1,383.92
$1,489.76
$1,601.88
$2,000.18 		$1,683.83
$1,789.67
$1,901.79
$2,300.09 		$299.91

ADVERTISEMENT

Molina Healthcare

Local: 1-833-644-1623 | Toll Free: 1-833-644-1623 | TTY: 1-800-877-8339
Toc - Plan #42 Molina Healthcare
Gold

(HMO) Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361.94
$410.81
$462.56
$646.43
$982.32 		$638.83
$687.70
$739.45
$923.32 		$915.72
$964.59
$1,016.34
$1,200.21 		$1,192.61
$1,241.48
$1,293.23
$1,477.10 		$276.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.88
$821.62
$925.12
$1,292.86
$1,964.64 		$1,000.77
$1,098.51
$1,202.01
$1,569.75 		$1,277.66
$1,375.40
$1,478.90
$1,846.64 		$1,554.55
$1,652.29
$1,755.79
$2,123.53 		$276.89
Toc - Plan #43 Molina Healthcare
Silver

(HMO) Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.14
$363.36
$409.14
$571.77
$868.86 		$565.05
$608.27
$654.05
$816.68 		$809.96
$853.18
$898.96
$1,061.59 		$1,054.87
$1,098.09
$1,143.87
$1,306.50 		$244.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.28
$726.72
$818.28
$1,143.54
$1,737.72 		$885.19
$971.63
$1,063.19
$1,388.45 		$1,130.10
$1,216.54
$1,308.10
$1,633.36 		$1,375.01
$1,461.45
$1,553.01
$1,878.27 		$244.91
Toc - Plan #44 Molina Healthcare
Gold

(HMO) Gold 8 with Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375.94
$426.69
$480.45
$671.43
$1,020.31 		$663.54
$714.29
$768.05
$959.03 		$951.14
$1,001.89
$1,055.65
$1,246.63 		$1,238.74
$1,289.49
$1,343.25
$1,534.23 		$287.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.88
$853.38
$960.90
$1,342.86
$2,040.62 		$1,039.48
$1,140.98
$1,248.50
$1,630.46 		$1,327.08
$1,428.58
$1,536.10
$1,918.06 		$1,614.68
$1,716.18
$1,823.70
$2,205.66 		$287.60
Toc - Plan #45 Molina Healthcare
Silver

(HMO) Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.83
$356.19
$401.07
$560.49
$851.72 		$553.91
$596.27
$641.15
$800.57 		$793.99
$836.35
$881.23
$1,040.65 		$1,034.07
$1,076.43
$1,121.31
$1,280.73 		$240.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.66
$712.38
$802.14
$1,120.98
$1,703.44 		$867.74
$952.46
$1,042.22
$1,361.06 		$1,107.82
$1,192.54
$1,282.30
$1,601.14 		$1,347.90
$1,432.62
$1,522.38
$1,841.22 		$240.08
Toc - Plan #46 Molina Healthcare
Silver

(HMO) Silver 12 with first 4 free PCP or MH visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$314.00
$356.39
$401.29
$560.80
$852.19 		$554.21
$596.60
$641.50
$801.01 		$794.42
$836.81
$881.71
$1,041.22 		$1,034.63
$1,077.02
$1,121.92
$1,281.43 		$240.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.00
$712.78
$802.58
$1,121.60
$1,704.38 		$868.21
$952.99
$1,042.79
$1,361.81 		$1,108.42
$1,193.20
$1,283.00
$1,602.02 		$1,348.63
$1,433.41
$1,523.21
$1,842.23 		$240.21
Toc - Plan #47 Molina Healthcare
Gold

(HMO) Gold 1 with Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.75
$413.99
$466.15
$651.45
$989.94 		$643.79
$693.03
$745.19
$930.49 		$922.83
$972.07
$1,024.23
$1,209.53 		$1,201.87
$1,251.11
$1,303.27
$1,488.57 		$279.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.50
$827.98
$932.30
$1,302.90
$1,979.88 		$1,008.54
$1,107.02
$1,211.34
$1,581.94 		$1,287.58
$1,386.06
$1,490.38
$1,860.98 		$1,566.62
$1,665.10
$1,769.42
$2,140.02 		$279.04
Toc - Plan #48 Molina Healthcare
Silver

(HMO) Silver 1 with Rx Copay and Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$323.22
$366.85
$413.07
$577.27
$877.21 		$570.48
$614.11
$660.33
$824.53 		$817.74
$861.37
$907.59
$1,071.79 		$1,065.00
$1,108.63
$1,154.85
$1,319.05 		$247.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.44
$733.70
$826.14
$1,154.54
$1,754.42 		$893.70
$980.96
$1,073.40
$1,401.80 		$1,140.96
$1,228.22
$1,320.66
$1,649.06 		$1,388.22
$1,475.48
$1,567.92
$1,896.32 		$247.26

ADVERTISEMENT

Blue Cross and Blue Shield of Illinois

Local: 1-800-538-8833 | Toll Free: 1-800-538-8833 | TTY: 1-800-526-0844
Toc - Plan #49 Blue Cross and Blue Shield of Illinois
Gold

(HMO) Blue Precision Gold HMO? 207

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$437.80
$496.90
$559.50
$781.90
$1,188.18 		$772.71
$831.81
$894.41
$1,116.81 		$1,107.62
$1,166.72
$1,229.32
$1,451.72 		$1,442.53
$1,501.63
$1,564.23
$1,786.63 		$334.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$875.60
$993.80
$1,119.00
$1,563.80
$2,376.36 		$1,210.51
$1,328.71
$1,453.91
$1,898.71 		$1,545.42
$1,663.62
$1,788.82
$2,233.62 		$1,880.33
$1,998.53
$2,123.73
$2,568.53 		$334.91
Toc - Plan #50 Blue Cross and Blue Shield of Illinois
Silver

(HMO) Blue Precision Silver HMO? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.99
$416.53
$469.01
$655.44
$996.01 		$647.74
$697.28
$749.76
$936.19 		$928.49
$978.03
$1,030.51
$1,216.94 		$1,209.24
$1,258.78
$1,311.26
$1,497.69 		$280.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.98
$833.06
$938.02
$1,310.88
$1,992.02 		$1,014.73
$1,113.81
$1,218.77
$1,591.63 		$1,295.48
$1,394.56
$1,499.52
$1,872.38 		$1,576.23
$1,675.31
$1,780.27
$2,153.13 		$280.75
Toc - Plan #51 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) Blue Precision Bronze HMO? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.60
$359.35
$404.62
$565.45
$859.26 		$558.80
$601.55
$646.82
$807.65 		$801.00
$843.75
$889.02
$1,049.85 		$1,043.20
$1,085.95
$1,131.22
$1,292.05 		$242.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.20
$718.70
$809.24
$1,130.90
$1,718.52 		$875.40
$960.90
$1,051.44
$1,373.10 		$1,117.60
$1,203.10
$1,293.64
$1,615.30 		$1,359.80
$1,445.30
$1,535.84
$1,857.50 		$242.20
Toc - Plan #52 Blue Cross and Blue Shield of Illinois
Gold

(HMO) Blue Precision Gold HMO? 703 - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$448.39
$508.92
$573.04
$800.83
$1,216.93 		$791.41
$851.94
$916.06
$1,143.85 		$1,134.43
$1,194.96
$1,259.08
$1,486.87 		$1,477.45
$1,537.98
$1,602.10
$1,829.89 		$343.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896.78
$1,017.84
$1,146.08
$1,601.66
$2,433.86 		$1,239.80
$1,360.86
$1,489.10
$1,944.68 		$1,582.82
$1,703.88
$1,832.12
$2,287.70 		$1,925.84
$2,046.90
$2,175.14
$2,630.72 		$343.02
Toc - Plan #53 Blue Cross and Blue Shield of Illinois
Silver

(HMO) Blue Precision Silver HMO 704? - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.49
$435.26
$490.09
$684.91
$1,040.78 		$676.86
$728.63
$783.46
$978.28 		$970.23
$1,022.00
$1,076.83
$1,271.65 		$1,263.60
$1,315.37
$1,370.20
$1,565.02 		$293.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.98
$870.52
$980.18
$1,369.82
$2,081.56 		$1,060.35
$1,163.89
$1,273.55
$1,663.19 		$1,353.72
$1,457.26
$1,566.92
$1,956.56 		$1,647.09
$1,750.63
$1,860.29
$2,249.93 		$293.37
Toc - Plan #54 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) Blue Precision Bronze HMO? 701 - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.20
$353.21
$397.71
$555.80
$844.59 		$549.27
$591.28
$635.78
$793.87 		$787.34
$829.35
$873.85
$1,031.94 		$1,025.41
$1,067.42
$1,111.92
$1,270.01 		$238.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.40
$706.42
$795.42
$1,111.60
$1,689.18 		$860.47
$944.49
$1,033.49
$1,349.67 		$1,098.54
$1,182.56
$1,271.56
$1,587.74 		$1,336.61
$1,420.63
$1,509.63
$1,825.81 		$238.07
Toc - Plan #55 Blue Cross and Blue Shield of Illinois
Gold

(HMO) Blue Precision Gold HMO? 707

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$441.66
$501.29
$564.45
$788.81
$1,198.68 		$779.53
$839.16
$902.32
$1,126.68 		$1,117.40
$1,177.03
$1,240.19
$1,464.55 		$1,455.27
$1,514.90
$1,578.06
$1,802.42 		$337.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.32
$1,002.58
$1,128.90
$1,577.62
$2,397.36 		$1,221.19
$1,340.45
$1,466.77
$1,915.49 		$1,559.06
$1,678.32
$1,804.64
$2,253.36 		$1,896.93
$2,016.19
$2,142.51
$2,591.23 		$337.87
Toc - Plan #56 Blue Cross and Blue Shield of Illinois
Silver

(HMO) Blue Precision Silver HMO? 706

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.93
$447.11
$503.44
$703.55
$1,069.12 		$695.28
$748.46
$804.79
$1,004.90 		$996.63
$1,049.81
$1,106.14
$1,306.25 		$1,297.98
$1,351.16
$1,407.49
$1,607.60 		$301.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.86
$894.22
$1,006.88
$1,407.10
$2,138.24 		$1,089.21
$1,195.57
$1,308.23
$1,708.45 		$1,390.56
$1,496.92
$1,609.58
$2,009.80 		$1,691.91
$1,798.27
$1,910.93
$2,311.15 		$301.35
Toc - Plan #57 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) Blue Precision Bronze HMO? 708

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$334.29
$379.42
$427.23
$597.05
$907.27 		$590.02
$635.15
$682.96
$852.78 		$845.75
$890.88
$938.69
$1,108.51 		$1,101.48
$1,146.61
$1,194.42
$1,364.24 		$255.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.58
$758.84
$854.46
$1,194.10
$1,814.54 		$924.31
$1,014.57
$1,110.19
$1,449.83 		$1,180.04
$1,270.30
$1,365.92
$1,705.56 		$1,435.77
$1,526.03
$1,621.65
$1,961.29 		$255.73
Toc - Plan #58 Blue Cross and Blue Shield of Illinois
Silver

(HMO) BlueCare Direct Silver? 212 with Advocate - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.57
$409.25
$460.81
$643.99
$978.60 		$636.41
$685.09
$736.65
$919.83 		$912.25
$960.93
$1,012.49
$1,195.67 		$1,188.09
$1,236.77
$1,288.33
$1,471.51 		$275.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.14
$818.50
$921.62
$1,287.98
$1,957.20 		$996.98
$1,094.34
$1,197.46
$1,563.82 		$1,272.82
$1,370.18
$1,473.30
$1,839.66 		$1,548.66
$1,646.02
$1,749.14
$2,115.50 		$275.84
Toc - Plan #59 Blue Cross and Blue Shield of Illinois
Gold

(HMO) BlueCare Direct Gold? 409 with Advocate - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$430.54
$488.66
$550.23
$768.94
$1,168.47 		$759.90
$818.02
$879.59
$1,098.30 		$1,089.26
$1,147.38
$1,208.95
$1,427.66 		$1,418.62
$1,476.74
$1,538.31
$1,757.02 		$329.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.08
$977.32
$1,100.46
$1,537.88
$2,336.94 		$1,190.44
$1,306.68
$1,429.82
$1,867.24 		$1,519.80
$1,636.04
$1,759.18
$2,196.60 		$1,849.16
$1,965.40
$2,088.54
$2,525.96 		$329.36
Toc - Plan #60 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) BlueCare Direct Bronze? 401 with Advocate - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.60
$351.40
$395.67
$552.95
$840.26 		$546.44
$588.24
$632.51
$789.79 		$783.28
$825.08
$869.35
$1,026.63 		$1,020.12
$1,061.92
$1,106.19
$1,263.47 		$236.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.20
$702.80
$791.34
$1,105.90
$1,680.52 		$856.04
$939.64
$1,028.18
$1,342.74 		$1,092.88
$1,176.48
$1,265.02
$1,579.58 		$1,329.72
$1,413.32
$1,501.86
$1,816.42 		$236.84
Toc - Plan #61 Blue Cross and Blue Shield of Illinois
Gold

(HMO) Blue FocusCare Gold? 211

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.79
$407.22
$458.53
$640.79
$973.74 		$633.26
$681.69
$733.00
$915.26 		$907.73
$956.16
$1,007.47
$1,189.73 		$1,182.20
$1,230.63
$1,281.94
$1,464.20 		$274.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.58
$814.44
$917.06
$1,281.58
$1,947.48 		$992.05
$1,088.91
$1,191.53
$1,556.05 		$1,266.52
$1,363.38
$1,466.00
$1,830.52 		$1,540.99
$1,637.85
$1,740.47
$2,104.99 		$274.47
Toc - Plan #62 Blue Cross and Blue Shield of Illinois
Silver

(HMO) Blue FocusCare Silver? 210

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$296.43
$336.44
$378.83
$529.42
$804.50 		$523.20
$563.21
$605.60
$756.19 		$749.97
$789.98
$832.37
$982.96 		$976.74
$1,016.75
$1,059.14
$1,209.73 		$226.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.86
$672.88
$757.66
$1,058.84
$1,609.00 		$819.63
$899.65
$984.43
$1,285.61 		$1,046.40
$1,126.42
$1,211.20
$1,512.38 		$1,273.17
$1,353.19
$1,437.97
$1,739.15 		$226.77
Toc - Plan #63 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) Blue FocusCare Bronze? 209

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$227.29
$257.97
$290.47
$405.93
$616.85 		$401.16
$431.84
$464.34
$579.80 		$575.03
$605.71
$638.21
$753.67 		$748.90
$779.58
$812.08
$927.54 		$173.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$454.58
$515.94
$580.94
$811.86
$1,233.70 		$628.45
$689.81
$754.81
$985.73 		$802.32
$863.68
$928.68
$1,159.60 		$976.19
$1,037.55
$1,102.55
$1,333.47 		$173.87
Toc - Plan #64 Blue Cross and Blue Shield of Illinois
Gold

(HMO) BlueCare Direct Gold? 804 with Advocate

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$436.20
$495.08
$557.46
$779.05
$1,183.84 		$769.89
$828.77
$891.15
$1,112.74 		$1,103.58
$1,162.46
$1,224.84
$1,446.43 		$1,437.27
$1,496.15
$1,558.53
$1,780.12 		$333.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$872.40
$990.16
$1,114.92
$1,558.10
$2,367.68 		$1,206.09
$1,323.85
$1,448.61
$1,891.79 		$1,539.78
$1,657.54
$1,782.30
$2,225.48 		$1,873.47
$1,991.23
$2,115.99
$2,559.17 		$333.69
Toc - Plan #65 Blue Cross and Blue Shield of Illinois
Silver

(HMO) BlueCare Direct Silver? 803 with Advocate

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$381.41
$432.90
$487.44
$681.19
$1,035.14 		$673.19
$724.68
$779.22
$972.97 		$964.97
$1,016.46
$1,071.00
$1,264.75 		$1,256.75
$1,308.24
$1,362.78
$1,556.53 		$291.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.82
$865.80
$974.88
$1,362.38
$2,070.28 		$1,054.60
$1,157.58
$1,266.66
$1,654.16 		$1,346.38
$1,449.36
$1,558.44
$1,945.94 		$1,638.16
$1,741.14
$1,850.22
$2,237.72 		$291.78
Toc - Plan #66 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) BlueCare Direct Bronze? 802 with Advocate

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$285.25
$323.76
$364.56
$509.46
$774.18 		$503.47
$541.98
$582.78
$727.68 		$721.69
$760.20
$801.00
$945.90 		$939.91
$978.42
$1,019.22
$1,164.12 		$218.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.50
$647.52
$729.12
$1,018.92
$1,548.36 		$788.72
$865.74
$947.34
$1,237.14 		$1,006.94
$1,083.96
$1,165.56
$1,455.36 		$1,225.16
$1,302.18
$1,383.78
$1,673.58 		$218.22
Toc - Plan #67 Blue Cross and Blue Shield of Illinois
Gold

(PPO) Blue Choice Preferred Gold PPO? 204 - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$603.62
$685.11
$771.43
$1,078.07
$1,638.23 		$1,065.39
$1,146.88
$1,233.20
$1,539.84 		$1,527.16
$1,608.65
$1,694.97
$2,001.61 		$1,988.93
$2,070.42
$2,156.74
$2,463.38 		$461.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,207.24
$1,370.22
$1,542.86
$2,156.14
$3,276.46 		$1,669.01
$1,831.99
$2,004.63
$2,617.91 		$2,130.78
$2,293.76
$2,466.40
$3,079.68 		$2,592.55
$2,755.53
$2,928.17
$3,541.45 		$461.77
Toc - Plan #68 Blue Cross and Blue Shield of Illinois
Silver

(PPO) Blue Choice Preferred Silver PPO? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$2,250 $4,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$505.84
$574.12
$646.46
$903.42
$1,372.84 		$892.80
$961.08
$1,033.42
$1,290.38 		$1,279.76
$1,348.04
$1,420.38
$1,677.34 		$1,666.72
$1,735.00
$1,807.34
$2,064.30 		$386.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,011.68
$1,148.24
$1,292.92
$1,806.84
$2,745.68 		$1,398.64
$1,535.20
$1,679.88
$2,193.80 		$1,785.60
$1,922.16
$2,066.84
$2,580.76 		$2,172.56
$2,309.12
$2,453.80
$2,967.72 		$386.96
Toc - Plan #69 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$439.11
$498.39
$561.18
$784.25
$1,191.74 		$775.03
$834.31
$897.10
$1,120.17 		$1,110.95
$1,170.23
$1,233.02
$1,456.09 		$1,446.87
$1,506.15
$1,568.94
$1,792.01 		$335.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.22
$996.78
$1,122.36
$1,568.50
$2,383.48 		$1,214.14
$1,332.70
$1,458.28
$1,904.42 		$1,550.06
$1,668.62
$1,794.20
$2,240.34 		$1,885.98
$2,004.54
$2,130.12
$2,576.26 		$335.92
Toc - Plan #70 Blue Cross and Blue Shield of Illinois
Catastrophic

(PPO) Blue Choice Preferred Security PPO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.13
$408.74
$460.24
$643.19
$977.38 		$635.63
$684.24
$735.74
$918.69 		$911.13
$959.74
$1,011.24
$1,194.19 		$1,186.63
$1,235.24
$1,286.74
$1,469.69 		$275.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.26
$817.48
$920.48
$1,286.38
$1,954.76 		$995.76
$1,092.98
$1,195.98
$1,561.88 		$1,271.26
$1,368.48
$1,471.48
$1,837.38 		$1,546.76
$1,643.98
$1,746.98
$2,112.88 		$275.50
Toc - Plan #71 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.46
$447.71
$504.12
$704.50
$1,070.56 		$696.22
$749.47
$805.88
$1,006.26 		$997.98
$1,051.23
$1,107.64
$1,308.02 		$1,299.74
$1,352.99
$1,409.40
$1,609.78 		$301.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.92
$895.42
$1,008.24
$1,409.00
$2,141.12 		$1,090.68
$1,197.18
$1,310.00
$1,710.76 		$1,392.44
$1,498.94
$1,611.76
$2,012.52 		$1,694.20
$1,800.70
$1,913.52
$2,314.28 		$301.76
Toc - Plan #72 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 601 - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$385.88
$437.97
$493.15
$689.18
$1,047.28 		$681.08
$733.17
$788.35
$984.38 		$976.28
$1,028.37
$1,083.55
$1,279.58 		$1,271.48
$1,323.57
$1,378.75
$1,574.78 		$295.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.76
$875.94
$986.30
$1,378.36
$2,094.56 		$1,066.96
$1,171.14
$1,281.50
$1,673.56 		$1,362.16
$1,466.34
$1,576.70
$1,968.76 		$1,657.36
$1,761.54
$1,871.90
$2,263.96 		$295.20
Toc - Plan #73 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 701 - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361.85
$410.69
$462.44
$646.26
$982.05 		$638.66
$687.50
$739.25
$923.07 		$915.47
$964.31
$1,016.06
$1,199.88 		$1,192.28
$1,241.12
$1,292.87
$1,476.69 		$276.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.70
$821.38
$924.88
$1,292.52
$1,964.10 		$1,000.51
$1,098.19
$1,201.69
$1,569.33 		$1,277.32
$1,375.00
$1,478.50
$1,846.14 		$1,554.13
$1,651.81
$1,755.31
$2,122.95 		$276.81
Toc - Plan #74 Blue Cross and Blue Shield of Illinois
Gold

(PPO) Blue Choice Preferred Gold PPO? 707

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$589.75
$669.36
$753.69
$1,053.29
$1,600.57 		$1,040.91
$1,120.52
$1,204.85
$1,504.45 		$1,492.07
$1,571.68
$1,656.01
$1,955.61 		$1,943.23
$2,022.84
$2,107.17
$2,406.77 		$451.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,179.50
$1,338.72
$1,507.38
$2,106.58
$3,201.14 		$1,630.66
$1,789.88
$1,958.54
$2,557.74 		$2,081.82
$2,241.04
$2,409.70
$3,008.90 		$2,532.98
$2,692.20
$2,860.86
$3,460.06 		$451.16
Toc - Plan #75 Blue Cross and Blue Shield of Illinois
Silver

(PPO) Blue Choice Preferred Silver PPO? 706

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$513.74
$583.09
$656.56
$917.54
$1,394.29 		$906.75
$976.10
$1,049.57
$1,310.55 		$1,299.76
$1,369.11
$1,442.58
$1,703.56 		$1,692.77
$1,762.12
$1,835.59
$2,096.57 		$393.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,027.48
$1,166.18
$1,313.12
$1,835.08
$2,788.58 		$1,420.49
$1,559.19
$1,706.13
$2,228.09 		$1,813.50
$1,952.20
$2,099.14
$2,621.10 		$2,206.51
$2,345.21
$2,492.15
$3,014.11 		$393.01
Toc - Plan #76 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 708

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$442.99
$502.79
$566.14
$791.17
$1,202.26 		$781.87
$841.67
$905.02
$1,130.05 		$1,120.75
$1,180.55
$1,243.90
$1,468.93 		$1,459.63
$1,519.43
$1,582.78
$1,807.81 		$338.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$885.98
$1,005.58
$1,132.28
$1,582.34
$2,404.52 		$1,224.86
$1,344.46
$1,471.16
$1,921.22 		$1,563.74
$1,683.34
$1,810.04
$2,260.10 		$1,902.62
$2,022.22
$2,148.92
$2,598.98 		$338.88
Toc - Plan #77 Blue Cross and Blue Shield of Illinois
Silver

(PPO) Blue Choice Preferred Silver PPO? 801 - Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$498.37
$565.65
$636.92
$890.09
$1,352.58 		$879.62
$946.90
$1,018.17
$1,271.34 		$1,260.87
$1,328.15
$1,399.42
$1,652.59 		$1,642.12
$1,709.40
$1,780.67
$2,033.84 		$381.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$996.74
$1,131.30
$1,273.84
$1,780.18
$2,705.16 		$1,377.99
$1,512.55
$1,655.09
$2,161.43 		$1,759.24
$1,893.80
$2,036.34
$2,542.68 		$2,140.49
$2,275.05
$2,417.59
$2,923.93 		$381.25

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0325 | Toll Free: 1-888-200-0325 | TTY: 1-888-200-0325
Toc - Plan #78 UnitedHealthcare
Silver

(HMO) UHC Silver Value (Virtual Urgent Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.48
$402.34
$453.03
$633.11
$962.07 		$625.66
$673.52
$724.21
$904.29 		$896.84
$944.70
$995.39
$1,175.47 		$1,168.02
$1,215.88
$1,266.57
$1,446.65 		$271.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.96
$804.68
$906.06
$1,266.22
$1,924.14 		$980.14
$1,075.86
$1,177.24
$1,537.40 		$1,251.32
$1,347.04
$1,448.42
$1,808.58 		$1,522.50
$1,618.22
$1,719.60
$2,079.76 		$271.18
Toc - Plan #79 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited App-based Care) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

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 		$349.30
$396.45
$446.40
$623.84
$947.99 		$616.51
$663.66
$713.61
$891.05 		$883.72
$930.87
$980.82
$1,158.26 		$1,150.93
$1,198.08
$1,248.03
$1,425.47 		$267.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.60
$792.90
$892.80
$1,247.68
$1,895.98 		$965.81
$1,060.11
$1,160.01
$1,514.89 		$1,233.02
$1,327.32
$1,427.22
$1,782.10 		$1,500.23
$1,594.53
$1,694.43
$2,049.31 		$267.21
Toc - Plan #80 UnitedHealthcare
Gold

(HMO) UHC Gold Standard (Rx Copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.44
$470.39
$529.66
$740.19
$1,124.79 		$731.49
$787.44
$846.71
$1,057.24 		$1,048.54
$1,104.49
$1,163.76
$1,374.29 		$1,365.59
$1,421.54
$1,480.81
$1,691.34 		$317.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.88
$940.78
$1,059.32
$1,480.38
$2,249.58 		$1,145.93
$1,257.83
$1,376.37
$1,797.43 		$1,462.98
$1,574.88
$1,693.42
$2,114.48 		$1,780.03
$1,891.93
$2,010.47
$2,431.53 		$317.05
Toc - Plan #81 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus (Virtual Urgent Care + PCP Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.89
$413.02
$465.05
$649.91
$987.60 		$642.27
$691.40
$743.43
$928.29 		$920.65
$969.78
$1,021.81
$1,206.67 		$1,199.03
$1,248.16
$1,300.19
$1,485.05 		$278.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.78
$826.04
$930.10
$1,299.82
$1,975.20 		$1,006.16
$1,104.42
$1,208.48
$1,578.20 		$1,284.54
$1,382.80
$1,486.86
$1,856.58 		$1,562.92
$1,661.18
$1,765.24
$2,134.96 		$278.38
Toc - Plan #82 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$355.93
$403.98
$454.87
$635.68
$965.98 		$628.21
$676.26
$727.15
$907.96 		$900.49
$948.54
$999.43
$1,180.24 		$1,172.77
$1,220.82
$1,271.71
$1,452.52 		$272.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.86
$807.96
$909.74
$1,271.36
$1,931.96 		$984.14
$1,080.24
$1,182.02
$1,543.64 		$1,256.42
$1,352.52
$1,454.30
$1,815.92 		$1,528.70
$1,624.80
$1,726.58
$2,088.20 		$272.28
Toc - Plan #83 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value (Virtual Urgent Care + PCP Visits, Rx Copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$7,850 $15,700 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$292.96
$332.51
$374.40
$523.23
$795.10 		$517.07
$556.62
$598.51
$747.34 		$741.18
$780.73
$822.62
$971.45 		$965.29
$1,004.84
$1,046.73
$1,195.56 		$224.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.92
$665.02
$748.80
$1,046.46
$1,590.20 		$810.03
$889.13
$972.91
$1,270.57 		$1,034.14
$1,113.24
$1,197.02
$1,494.68 		$1,258.25
$1,337.35
$1,421.13
$1,718.79 		$224.11
Toc - Plan #84 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$8,050 $16,100 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 		$282.43
$320.56
$360.95
$504.42
$766.52 		$498.49
$536.62
$577.01
$720.48 		$714.55
$752.68
$793.07
$936.54 		$930.61
$968.74
$1,009.13
$1,152.60 		$216.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.86
$641.12
$721.90
$1,008.84
$1,533.04 		$780.92
$857.18
$937.96
$1,224.90 		$996.98
$1,073.24
$1,154.02
$1,440.96 		$1,213.04
$1,289.30
$1,370.08
$1,657.02 		$216.06
Toc - Plan #85 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$294.77
$334.56
$376.71
$526.46
$800.00 		$520.27
$560.06
$602.21
$751.96 		$745.77
$785.56
$827.71
$977.46 		$971.27
$1,011.06
$1,053.21
$1,202.96 		$225.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.54
$669.12
$753.42
$1,052.92
$1,600.00 		$815.04
$894.62
$978.92
$1,278.42 		$1,040.54
$1,120.12
$1,204.42
$1,503.92 		$1,266.04
$1,345.62
$1,429.92
$1,729.42 		$225.50
Toc - Plan #86 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus (Virtual Urgent Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$312.11
$354.25
$398.88
$557.43
$847.07 		$550.88
$593.02
$637.65
$796.20 		$789.65
$831.79
$876.42
$1,034.97 		$1,028.42
$1,070.56
$1,115.19
$1,273.74 		$238.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.22
$708.50
$797.76
$1,114.86
$1,694.14 		$862.99
$947.27
$1,036.53
$1,353.63 		$1,101.76
$1,186.04
$1,275.30
$1,592.40 		$1,340.53
$1,424.81
$1,514.07
$1,831.17 		$238.77
Toc - Plan #87 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited App-based Care, Rx Copay) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$289.09
$328.11
$369.45
$516.31
$784.58 		$510.24
$549.26
$590.60
$737.46 		$731.39
$770.41
$811.75
$958.61 		$952.54
$991.56
$1,032.90
$1,179.76 		$221.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.18
$656.22
$738.90
$1,032.62
$1,569.16 		$799.33
$877.37
$960.05
$1,253.77 		$1,020.48
$1,098.52
$1,181.20
$1,474.92 		$1,241.63
$1,319.67
$1,402.35
$1,696.07 		$221.15
Toc - Plan #88 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage (Virtual Urgent Care + PCP Visits, Rx Copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$355.51
$403.50
$454.34
$634.94
$964.85 		$627.47
$675.46
$726.30
$906.90 		$899.43
$947.42
$998.26
$1,178.86 		$1,171.39
$1,219.38
$1,270.22
$1,450.82 		$271.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.02
$807.00
$908.68
$1,269.88
$1,929.70 		$982.98
$1,078.96
$1,180.64
$1,541.84 		$1,254.94
$1,350.92
$1,452.60
$1,813.80 		$1,526.90
$1,622.88
$1,724.56
$2,085.76 		$271.96
Toc - Plan #89 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage (Virtual Urgent Care + PCP Visits, Rx Copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$419.91
$476.60
$536.65
$749.96
$1,139.64 		$741.14
$797.83
$857.88
$1,071.19 		$1,062.37
$1,119.06
$1,179.11
$1,392.42 		$1,383.60
$1,440.29
$1,500.34
$1,713.65 		$321.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.82
$953.20
$1,073.30
$1,499.92
$2,279.28 		$1,161.05
$1,274.43
$1,394.53
$1,821.15 		$1,482.28
$1,595.66
$1,715.76
$2,142.38 		$1,803.51
$1,916.89
$2,036.99
$2,463.61 		$321.23
Toc - Plan #90 UnitedHealthcare
Gold

(HMO) UHC Gold Copay Focus (Virtual Urgent Care + PCP Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$421.06
$477.90
$538.11
$752.01
$1,142.75 		$743.17
$800.01
$860.22
$1,074.12 		$1,065.28
$1,122.12
$1,182.33
$1,396.23 		$1,387.39
$1,444.23
$1,504.44
$1,718.34 		$322.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.12
$955.80
$1,076.22
$1,504.02
$2,285.50 		$1,164.23
$1,277.91
$1,398.33
$1,826.13 		$1,486.34
$1,600.02
$1,720.44
$2,148.24 		$1,808.45
$1,922.13
$2,042.55
$2,470.35 		$322.11
Toc - Plan #91 UnitedHealthcare
Gold

(HMO) UHC Gold Virtual First (Unlimited App-based Care) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$394.81
$448.11
$504.57
$705.14
$1,071.52 		$696.84
$750.14
$806.60
$1,007.17 		$998.87
$1,052.17
$1,108.63
$1,309.20 		$1,300.90
$1,354.20
$1,410.66
$1,611.23 		$302.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.62
$896.22
$1,009.14
$1,410.28
$2,143.04 		$1,091.65
$1,198.25
$1,311.17
$1,712.31 		$1,393.68
$1,500.28
$1,613.20
$2,014.34 		$1,695.71
$1,802.31
$1,915.23
$2,316.37 		$302.03
Toc - Plan #92 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ (Virtual Urgent Care + PCP Visits, Rx Copay, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.05
$422.28
$475.48
$664.49
$1,009.75 		$656.67
$706.90
$760.10
$949.11 		$941.29
$991.52
$1,044.72
$1,233.73 		$1,225.91
$1,276.14
$1,329.34
$1,518.35 		$284.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.10
$844.56
$950.96
$1,328.98
$2,019.50 		$1,028.72
$1,129.18
$1,235.58
$1,613.60 		$1,313.34
$1,413.80
$1,520.20
$1,898.22 		$1,597.96
$1,698.42
$1,804.82
$2,182.84 		$284.62
Toc - Plan #93 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Virtual Urgent Care + PCP Visits, Rx Copay, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$436.45
$495.37
$557.79
$779.51
$1,184.53 		$770.34
$829.26
$891.68
$1,113.40 		$1,104.23
$1,163.15
$1,225.57
$1,447.29 		$1,438.12
$1,497.04
$1,559.46
$1,781.18 		$333.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$872.90
$990.74
$1,115.58
$1,559.02
$2,369.06 		$1,206.79
$1,324.63
$1,449.47
$1,892.91 		$1,540.68
$1,658.52
$1,783.36
$2,226.80 		$1,874.57
$1,992.41
$2,117.25
$2,560.69 		$333.89

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #94 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 5000 Indiv Med Deductible - Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.28
$358.98
$404.21
$564.88
$858.39 		$558.24
$600.94
$646.17
$806.84 		$800.20
$842.90
$888.13
$1,048.80 		$1,042.16
$1,084.86
$1,130.09
$1,290.76 		$241.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.56
$717.96
$808.42
$1,129.76
$1,716.78 		$874.52
$959.92
$1,050.38
$1,371.72 		$1,116.48
$1,201.88
$1,292.34
$1,613.68 		$1,358.44
$1,443.84
$1,534.30
$1,855.64 		$241.96
Toc - Plan #95 Cigna Healthcare
Silver

(HMO) Connect Silver 3000 Indiv Med Deductible - Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$354.30
$402.13
$452.80
$632.78
$961.57 		$625.34
$673.17
$723.84
$903.82 		$896.38
$944.21
$994.88
$1,174.86 		$1,167.42
$1,215.25
$1,265.92
$1,445.90 		$271.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.60
$804.26
$905.60
$1,265.56
$1,923.14 		$979.64
$1,075.30
$1,176.64
$1,536.60 		$1,250.68
$1,346.34
$1,447.68
$1,807.64 		$1,521.72
$1,617.38
$1,718.72
$2,078.68 		$271.04
Toc - Plan #96 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 0 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$334.17
$379.28
$427.07
$596.82
$906.93 		$589.81
$634.92
$682.71
$852.46 		$845.45
$890.56
$938.35
$1,108.10 		$1,101.09
$1,146.20
$1,193.99
$1,363.74 		$255.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.34
$758.56
$854.14
$1,193.64
$1,813.86 		$923.98
$1,014.20
$1,109.78
$1,449.28 		$1,179.62
$1,269.84
$1,365.42
$1,704.92 		$1,435.26
$1,525.48
$1,621.06
$1,960.56 		$255.64
Toc - Plan #97 Cigna Healthcare
Silver

(HMO) Connect Silver 5000 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$353.13
$400.81
$451.31
$630.70
$958.41 		$623.28
$670.96
$721.46
$900.85 		$893.43
$941.11
$991.61
$1,171.00 		$1,163.58
$1,211.26
$1,261.76
$1,441.15 		$270.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.26
$801.62
$902.62
$1,261.40
$1,916.82 		$976.41
$1,071.77
$1,172.77
$1,531.55 		$1,246.56
$1,341.92
$1,442.92
$1,801.70 		$1,516.71
$1,612.07
$1,713.07
$2,071.85 		$270.15
Toc - Plan #98 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 6500 Indiv Med Deductible Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.50
$351.28
$395.54
$552.77
$839.98 		$546.27
$588.05
$632.31
$789.54 		$783.04
$824.82
$869.08
$1,026.31 		$1,019.81
$1,061.59
$1,105.85
$1,263.08 		$236.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.00
$702.56
$791.08
$1,105.54
$1,679.96 		$855.77
$939.33
$1,027.85
$1,342.31 		$1,092.54
$1,176.10
$1,264.62
$1,579.08 		$1,329.31
$1,412.87
$1,501.39
$1,815.85 		$236.77
Toc - Plan #99 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze CMS Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$308.77
$350.45
$394.60
$551.46
$837.99 		$544.98
$586.66
$630.81
$787.67 		$781.19
$822.87
$867.02
$1,023.88 		$1,017.40
$1,059.08
$1,103.23
$1,260.09 		$236.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.54
$700.90
$789.20
$1,102.92
$1,675.98 		$853.75
$937.11
$1,025.41
$1,339.13 		$1,089.96
$1,173.32
$1,261.62
$1,575.34 		$1,326.17
$1,409.53
$1,497.83
$1,811.55 		$236.21
Toc - Plan #100 Cigna Healthcare
Silver

(HMO) Connect Silver CMS Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.42
$396.59
$446.56
$624.06
$948.32 		$616.73
$663.90
$713.87
$891.37 		$884.04
$931.21
$981.18
$1,158.68 		$1,151.35
$1,198.52
$1,248.49
$1,425.99 		$267.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.84
$793.18
$893.12
$1,248.12
$1,896.64 		$966.15
$1,060.49
$1,160.43
$1,515.43 		$1,233.46
$1,327.80
$1,427.74
$1,782.74 		$1,500.77
$1,595.11
$1,695.05
$2,050.05 		$267.31
Toc - Plan #101 Cigna Healthcare
Gold

(HMO) Connect Gold CMS Standard - Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.73
$465.04
$523.63
$731.78
$1,112.00 		$723.17
$778.48
$837.07
$1,045.22 		$1,036.61
$1,091.92
$1,150.51
$1,358.66 		$1,350.05
$1,405.36
$1,463.95
$1,672.10 		$313.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.46
$930.08
$1,047.26
$1,463.56
$2,224.00 		$1,132.90
$1,243.52
$1,360.70
$1,777.00 		$1,446.34
$1,556.96
$1,674.14
$2,090.44 		$1,759.78
$1,870.40
$1,987.58
$2,403.88 		$313.44

ADVERTISEMENT

Aetna CVS Health

Local: 1-855-586-6962 | Toll Free: 1-855-586-6962 | TTY: 1-855-586-6962
Toc - Plan #102 Aetna CVS Health
Expanded Bronze

(PPO) Bronze 1 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$8,995 $17,990 Annual Deductible
$9,395 $18,790 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.37
$435.13
$489.95
$684.70
$1,040.47 		$676.65
$728.41
$783.23
$977.98 		$969.93
$1,021.69
$1,076.51
$1,271.26 		$1,263.21
$1,314.97
$1,369.79
$1,564.54 		$293.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.74
$870.26
$979.90
$1,369.40
$2,080.94 		$1,060.02
$1,163.54
$1,273.18
$1,662.68 		$1,353.30
$1,456.82
$1,566.46
$1,955.96 		$1,646.58
$1,750.10
$1,859.74
$2,249.24 		$293.28
Toc - Plan #103 Aetna CVS Health
Expanded Bronze

(PPO) Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.35
$473.69
$533.37
$745.38
$1,132.67 		$736.62
$792.96
$852.64
$1,064.65 		$1,055.89
$1,112.23
$1,171.91
$1,383.92 		$1,375.16
$1,431.50
$1,491.18
$1,703.19 		$319.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.70
$947.38
$1,066.74
$1,490.76
$2,265.34 		$1,153.97
$1,266.65
$1,386.01
$1,810.03 		$1,473.24
$1,585.92
$1,705.28
$2,129.30 		$1,792.51
$1,905.19
$2,024.55
$2,448.57 		$319.27
Toc - Plan #104 Aetna CVS Health
Expanded Bronze

(PPO) Bronze S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$377.94
$428.96
$483.01
$675.00
$1,025.72 		$667.06
$718.08
$772.13
$964.12 		$956.18
$1,007.20
$1,061.25
$1,253.24 		$1,245.30
$1,296.32
$1,350.37
$1,542.36 		$289.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.88
$857.92
$966.02
$1,350.00
$2,051.44 		$1,045.00
$1,147.04
$1,255.14
$1,639.12 		$1,334.12
$1,436.16
$1,544.26
$1,928.24 		$1,623.24
$1,725.28
$1,833.38
$2,217.36 		$289.12
Toc - Plan #105 Aetna CVS Health
Gold

(PPO) Gold 3 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$795 $1,590 Annual Deductible
$9,195 $18,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$581.68
$660.20
$743.38
$1,038.87
$1,578.66 		$1,026.66
$1,105.18
$1,188.36
$1,483.85 		$1,471.64
$1,550.16
$1,633.34
$1,928.83 		$1,916.62
$1,995.14
$2,078.32
$2,373.81 		$444.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,163.36
$1,320.40
$1,486.76
$2,077.74
$3,157.32 		$1,608.34
$1,765.38
$1,931.74
$2,522.72 		$2,053.32
$2,210.36
$2,376.72
$2,967.70 		$2,498.30
$2,655.34
$2,821.70
$3,412.68 		$444.98
Toc - Plan #106 Aetna CVS Health
Gold

(PPO) Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$576.99
$654.89
$737.40
$1,030.51
$1,565.95 		$1,018.39
$1,096.29
$1,178.80
$1,471.91 		$1,459.79
$1,537.69
$1,620.20
$1,913.31 		$1,901.19
$1,979.09
$2,061.60
$2,354.71 		$441.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,153.98
$1,309.78
$1,474.80
$2,061.02
$3,131.90 		$1,595.38
$1,751.18
$1,916.20
$2,502.42 		$2,036.78
$2,192.58
$2,357.60
$2,943.82 		$2,478.18
$2,633.98
$2,799.00
$3,385.22 		$441.40
Toc - Plan #107 Aetna CVS Health
Silver

(PPO) Silver 5 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 Annual Deductible
$8,850 $17,700 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 		$499.73
$567.20
$638.66
$892.52
$1,356.27 		$882.03
$949.50
$1,020.96
$1,274.82 		$1,264.33
$1,331.80
$1,403.26
$1,657.12 		$1,646.63
$1,714.10
$1,785.56
$2,039.42 		$382.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$999.46
$1,134.40
$1,277.32
$1,785.04
$2,712.54 		$1,381.76
$1,516.70
$1,659.62
$2,167.34 		$1,764.06
$1,899.00
$2,041.92
$2,549.64 		$2,146.36
$2,281.30
$2,424.22
$2,931.94 		$382.30
Toc - Plan #108 Aetna CVS Health
Silver

(PPO) Silver 7 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,845 $17,690 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$500.70
$568.29
$639.89
$894.25
$1,358.89 		$883.74
$951.33
$1,022.93
$1,277.29 		$1,266.78
$1,334.37
$1,405.97
$1,660.33 		$1,649.82
$1,717.41
$1,789.01
$2,043.37 		$383.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,001.40
$1,136.58
$1,279.78
$1,788.50
$2,717.78 		$1,384.44
$1,519.62
$1,662.82
$2,171.54 		$1,767.48
$1,902.66
$2,045.86
$2,554.58 		$2,150.52
$2,285.70
$2,428.90
$2,937.62 		$383.04
Toc - Plan #109 Aetna CVS Health
Silver

(PPO) Silver S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$488.04
$553.92
$623.71
$871.63
$1,324.53 		$861.39
$927.27
$997.06
$1,244.98 		$1,234.74
$1,300.62
$1,370.41
$1,618.33 		$1,608.09
$1,673.97
$1,743.76
$1,991.68 		$373.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$976.08
$1,107.84
$1,247.42
$1,743.26
$2,649.06 		$1,349.43
$1,481.19
$1,620.77
$2,116.61 		$1,722.78
$1,854.54
$1,994.12
$2,489.96 		$2,096.13
$2,227.89
$2,367.47
$2,863.31 		$373.35
Toc - Plan #110 Aetna CVS Health
Silver

(PPO) Silver 6 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,445 $16,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$500.11
$567.62
$639.14
$893.19
$1,357.29 		$882.70
$950.21
$1,021.73
$1,275.78 		$1,265.29
$1,332.80
$1,404.32
$1,658.37 		$1,647.88
$1,715.39
$1,786.91
$2,040.96 		$382.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,000.22
$1,135.24
$1,278.28
$1,786.38
$2,714.58 		$1,382.81
$1,517.83
$1,660.87
$2,168.97 		$1,765.40
$1,900.42
$2,043.46
$2,551.56 		$2,147.99
$2,283.01
$2,426.05
$2,934.15 		$382.59
Toc - Plan #111 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 1: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$8,995 $17,990 Annual Deductible
$9,395 $18,790 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$265.48
$301.32
$339.28
$474.14
$720.51 		$468.57
$504.41
$542.37
$677.23 		$671.66
$707.50
$745.46
$880.32 		$874.75
$910.59
$948.55
$1,083.41 		$203.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$530.96
$602.64
$678.56
$948.28
$1,441.02 		$734.05
$805.73
$881.65
$1,151.37 		$937.14
$1,008.82
$1,084.74
$1,354.46 		$1,140.23
$1,211.91
$1,287.83
$1,557.55 		$203.09
Toc - Plan #112 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$262.24
$297.64
$335.14
$468.35
$711.70 		$462.85
$498.25
$535.75
$668.96 		$663.46
$698.86
$736.36
$869.57 		$864.07
$899.47
$936.97
$1,070.18 		$200.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524.48
$595.28
$670.28
$936.70
$1,423.40 		$725.09
$795.89
$870.89
$1,137.31 		$925.70
$996.50
$1,071.50
$1,337.92 		$1,126.31
$1,197.11
$1,272.11
$1,538.53 		$200.61
Toc - Plan #113 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.88
$386.89
$435.64
$608.80
$925.13 		$601.65
$647.66
$696.41
$869.57 		$862.42
$908.43
$957.18
$1,130.34 		$1,123.19
$1,169.20
$1,217.95
$1,391.11 		$260.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.76
$773.78
$871.28
$1,217.60
$1,850.26 		$942.53
$1,034.55
$1,132.05
$1,478.37 		$1,203.30
$1,295.32
$1,392.82
$1,739.14 		$1,464.07
$1,556.09
$1,653.59
$1,999.91 		$260.77
Toc - Plan #114 Aetna CVS Health
Silver

(HMO) Silver 5: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$8,395 $16,790 Annual Deductible
$8,885 $17,770 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.84
$356.20
$401.08
$560.51
$851.74 		$553.93
$596.29
$641.17
$800.60 		$794.02
$836.38
$881.26
$1,040.69 		$1,034.11
$1,076.47
$1,121.35
$1,280.78 		$240.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.68
$712.40
$802.16
$1,121.02
$1,703.48 		$867.77
$952.49
$1,042.25
$1,361.11 		$1,107.86
$1,192.58
$1,282.34
$1,601.20 		$1,347.95
$1,432.67
$1,522.43
$1,841.29 		$240.09
Toc - Plan #115 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.44
$355.75
$400.57
$559.80
$850.66 		$553.22
$595.53
$640.35
$799.58 		$793.00
$835.31
$880.13
$1,039.36 		$1,032.78
$1,075.09
$1,119.91
$1,279.14 		$239.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.88
$711.50
$801.14
$1,119.60
$1,701.32 		$866.66
$951.28
$1,040.92
$1,359.38 		$1,106.44
$1,191.06
$1,280.70
$1,599.16 		$1,346.22
$1,430.84
$1,520.48
$1,838.94 		$239.78
Toc - Plan #116 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$289.15
$328.19
$369.54
$516.43
$784.76 		$510.35
$549.39
$590.74
$737.63 		$731.55
$770.59
$811.94
$958.83 		$952.75
$991.79
$1,033.14
$1,180.03 		$221.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.30
$656.38
$739.08
$1,032.86
$1,569.52 		$799.50
$877.58
$960.28
$1,254.06 		$1,020.70
$1,098.78
$1,181.48
$1,475.26 		$1,241.90
$1,319.98
$1,402.68
$1,696.46 		$221.20
Toc - Plan #117 Aetna CVS Health
Gold

(HMO) Gold 3: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$795 $1,590 Annual Deductible
$9,195 $18,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$341.96
$388.13
$437.03
$610.74
$928.08 		$603.56
$649.73
$698.63
$872.34 		$865.16
$911.33
$960.23
$1,133.94 		$1,126.76
$1,172.93
$1,221.83
$1,395.54 		$261.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.92
$776.26
$874.06
$1,221.48
$1,856.16 		$945.52
$1,037.86
$1,135.66
$1,483.08 		$1,207.12
$1,299.46
$1,397.26
$1,744.68 		$1,468.72
$1,561.06
$1,658.86
$2,006.28 		$261.60
Toc - Plan #118 Aetna CVS Health
Silver

(HMO) Silver 6: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,445 $16,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321.09
$364.43
$410.35
$573.46
$871.42 		$566.72
$610.06
$655.98
$819.09 		$812.35
$855.69
$901.61
$1,064.72 		$1,057.98
$1,101.32
$1,147.24
$1,310.35 		$245.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.18
$728.86
$820.70
$1,146.92
$1,742.84 		$887.81
$974.49
$1,066.33
$1,392.55 		$1,133.44
$1,220.12
$1,311.96
$1,638.18 		$1,379.07
$1,465.75
$1,557.59
$1,883.81 		$245.63
Toc - Plan #119 Aetna CVS Health
Silver

(HMO) Silver 7: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,845 $17,690 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321.35
$364.73
$410.69
$573.93
$872.14 		$567.19
$610.57
$656.53
$819.77 		$813.03
$856.41
$902.37
$1,065.61 		$1,058.87
$1,102.25
$1,148.21
$1,311.45 		$245.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.70
$729.46
$821.38
$1,147.86
$1,744.28 		$888.54
$975.30
$1,067.22
$1,393.70 		$1,134.38
$1,221.14
$1,313.06
$1,639.54 		$1,380.22
$1,466.98
$1,558.90
$1,885.38 		$245.84

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Cook County here.

Cook County is in “Rating Area 1” of Illinois.

Currently, there are 119 plans offered in Rating Area 1.

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