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Illinois Obamacare 2023 Rates

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Obamacare Rates and Providers for Other Years

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Oscar Health Plan, Inc.

Local:  | Toll Free: 

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

(HMO) Bronze Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$268.79
$305.07
$343.50
$480.04
$729.47
$474.41
$510.69
$549.12
$685.66
$680.03
$716.31
$754.74
$891.28
$885.65
$921.93
$960.36
$1,096.90
$205.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$537.58
$610.14
$687.00
$960.08
$1,458.94
$743.20
$815.76
$892.62
$1,165.70
$948.82
$1,021.38
$1,098.24
$1,371.32
$1,154.44
$1,227.00
$1,303.86
$1,576.94
$205.62
Toc - Plan #2 Oscar Health Plan, Inc.
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $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
$320.62
$363.89
$409.74
$572.61
$870.14
$565.89
$609.16
$655.01
$817.88
$811.16
$854.43
$900.28
$1,063.15
$1,056.43
$1,099.70
$1,145.55
$1,308.42
$245.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.24
$727.78
$819.48
$1,145.22
$1,740.28
$886.51
$973.05
$1,064.75
$1,390.49
$1,131.78
$1,218.32
$1,310.02
$1,635.76
$1,377.05
$1,463.59
$1,555.29
$1,881.03
$245.27
Toc - Plan #3 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.04
$405.23
$456.29
$637.66
$968.99
$630.17
$678.36
$729.42
$910.79
$903.30
$951.49
$1,002.55
$1,183.92
$1,176.43
$1,224.62
$1,275.68
$1,457.05
$273.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714.08
$810.46
$912.58
$1,275.32
$1,937.98
$987.21
$1,083.59
$1,185.71
$1,548.45
$1,260.34
$1,356.72
$1,458.84
$1,821.58
$1,533.47
$1,629.85
$1,731.97
$2,094.71
$273.13
Toc - Plan #4 Oscar Health Plan, Inc.
Catastrophic

(HMO) Secure (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$244.46
$277.45
$312.40
$436.58
$663.43
$431.46
$464.45
$499.40
$623.58
$618.46
$651.45
$686.40
$810.58
$805.46
$838.45
$873.40
$997.58
$187.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$488.92
$554.90
$624.80
$873.16
$1,326.86
$675.92
$741.90
$811.80
$1,060.16
$862.92
$928.90
$998.80
$1,247.16
$1,049.92
$1,115.90
$1,185.80
$1,434.16
$187.00
Toc - Plan #5 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Simple- $5200 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$281.99
$320.05
$360.37
$503.62
$765.29
$497.70
$535.76
$576.08
$719.33
$713.41
$751.47
$791.79
$935.04
$929.12
$967.18
$1,007.50
$1,150.75
$215.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$563.98
$640.10
$720.74
$1,007.24
$1,530.58
$779.69
$855.81
$936.45
$1,222.95
$995.40
$1,071.52
$1,152.16
$1,438.66
$1,211.11
$1,287.23
$1,367.87
$1,654.37
$215.71
Toc - Plan #6 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- Specialist Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351.55
$398.99
$449.26
$627.84
$954.07
$620.48
$667.92
$718.19
$896.77
$889.41
$936.85
$987.12
$1,165.70
$1,158.34
$1,205.78
$1,256.05
$1,434.63
$268.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$703.10
$797.98
$898.52
$1,255.68
$1,908.14
$972.03
$1,066.91
$1,167.45
$1,524.61
$1,240.96
$1,335.84
$1,436.38
$1,793.54
$1,509.89
$1,604.77
$1,705.31
$2,062.47
$268.93
Toc - Plan #7 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- PCP Saver Plus Rx Copay (Choice)

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
$286.42
$325.08
$366.03
$511.53
$777.32
$505.53
$544.19
$585.14
$730.64
$724.64
$763.30
$804.25
$949.75
$943.75
$982.41
$1,023.36
$1,168.86
$219.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$572.84
$650.16
$732.06
$1,023.06
$1,554.64
$791.95
$869.27
$951.17
$1,242.17
$1,011.06
$1,088.38
$1,170.28
$1,461.28
$1,230.17
$1,307.49
$1,389.39
$1,680.39
$219.11
Toc - Plan #8 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- Deductible Saver (Choice)

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
$289.90
$329.02
$370.47
$517.74
$786.75
$511.66
$550.78
$592.23
$739.50
$733.42
$772.54
$813.99
$961.26
$955.18
$994.30
$1,035.75
$1,183.02
$221.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$579.80
$658.04
$740.94
$1,035.48
$1,573.50
$801.56
$879.80
$962.70
$1,257.24
$1,023.32
$1,101.56
$1,184.46
$1,479.00
$1,245.08
$1,323.32
$1,406.22
$1,700.76
$221.76
Toc - Plan #9 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
$342.58
$388.81
$437.80
$611.82
$929.73
$604.64
$650.87
$699.86
$873.88
$866.70
$912.93
$961.92
$1,135.94
$1,128.76
$1,174.99
$1,223.98
$1,398.00
$262.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.16
$777.62
$875.60
$1,223.64
$1,859.46
$947.22
$1,039.68
$1,137.66
$1,485.70
$1,209.28
$1,301.74
$1,399.72
$1,747.76
$1,471.34
$1,563.80
$1,661.78
$2,009.82
$262.06
Toc - Plan #10 Oscar Health Plan, Inc.
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$362.07
$410.94
$462.72
$646.64
$982.64
$639.05
$687.92
$739.70
$923.62
$916.03
$964.90
$1,016.68
$1,200.60
$1,193.01
$1,241.88
$1,293.66
$1,477.58
$276.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.14
$821.88
$925.44
$1,293.28
$1,965.28
$1,001.12
$1,098.86
$1,202.42
$1,570.26
$1,278.10
$1,375.84
$1,479.40
$1,847.24
$1,555.08
$1,652.82
$1,756.38
$2,124.22
$276.98
Toc - Plan #11 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- For Diabetes (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.62
$401.35
$451.91
$631.55
$959.70
$624.13
$671.86
$722.42
$902.06
$894.64
$942.37
$992.93
$1,172.57
$1,165.15
$1,212.88
$1,263.44
$1,443.08
$270.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.24
$802.70
$903.82
$1,263.10
$1,919.40
$977.75
$1,073.21
$1,174.33
$1,533.61
$1,248.26
$1,343.72
$1,444.84
$1,804.12
$1,518.77
$1,614.23
$1,715.35
$2,074.63
$270.51
Toc - Plan #12 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
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$283.76
$322.06
$362.63
$506.78
$770.10
$500.83
$539.13
$579.70
$723.85
$717.90
$756.20
$796.77
$940.92
$934.97
$973.27
$1,013.84
$1,157.99
$217.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$567.52
$644.12
$725.26
$1,013.56
$1,540.20
$784.59
$861.19
$942.33
$1,230.63
$1,001.66
$1,078.26
$1,159.40
$1,447.70
$1,218.73
$1,295.33
$1,376.47
$1,664.77
$217.07
Toc - Plan #13 Oscar Health Plan, Inc.
Bronze

(HMO) Bronze Simple- Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$255.80
$290.32
$326.89
$456.83
$694.20
$451.48
$486.00
$522.57
$652.51
$647.16
$681.68
$718.25
$848.19
$842.84
$877.36
$913.93
$1,043.87
$195.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$511.60
$580.64
$653.78
$913.66
$1,388.40
$707.28
$776.32
$849.46
$1,109.34
$902.96
$972.00
$1,045.14
$1,305.02
$1,098.64
$1,167.68
$1,240.82
$1,500.70
$195.68
Toc - Plan #14 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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$345.41
$392.03
$441.42
$616.88
$937.41
$609.64
$656.26
$705.65
$881.11
$873.87
$920.49
$969.88
$1,145.34
$1,138.10
$1,184.72
$1,234.11
$1,409.57
$264.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$690.82
$784.06
$882.84
$1,233.76
$1,874.82
$955.05
$1,048.29
$1,147.07
$1,497.99
$1,219.28
$1,312.52
$1,411.30
$1,762.22
$1,483.51
$1,576.75
$1,675.53
$2,026.45
$264.23
Toc - Plan #15 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
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.50
$423.91
$477.31
$667.04
$1,013.64
$659.22
$709.63
$763.03
$952.76
$944.94
$995.35
$1,048.75
$1,238.48
$1,230.66
$1,281.07
$1,334.47
$1,524.20
$285.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.00
$847.82
$954.62
$1,334.08
$2,027.28
$1,032.72
$1,133.54
$1,240.34
$1,619.80
$1,318.44
$1,419.26
$1,526.06
$1,905.52
$1,604.16
$1,704.98
$1,811.78
$2,191.24
$285.72
Toc - Plan #16 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$236.40
$268.30
$302.10
$422.19
$641.56
$417.24
$449.14
$482.94
$603.03
$598.08
$629.98
$663.78
$783.87
$778.92
$810.82
$844.62
$964.71
$180.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$472.80
$536.60
$604.20
$844.38
$1,283.12
$653.64
$717.44
$785.04
$1,025.22
$834.48
$898.28
$965.88
$1,206.06
$1,015.32
$1,079.12
$1,146.72
$1,386.90
$180.84
Toc - Plan #17 Oscar Health Plan, Inc.
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $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
$281.71
$319.73
$360.02
$503.12
$764.55
$497.21
$535.23
$575.52
$718.62
$712.71
$750.73
$791.02
$934.12
$928.21
$966.23
$1,006.52
$1,149.62
$215.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$563.42
$639.46
$720.04
$1,006.24
$1,529.10
$778.92
$854.96
$935.54
$1,221.74
$994.42
$1,070.46
$1,151.04
$1,437.24
$1,209.92
$1,285.96
$1,366.54
$1,652.74
$215.50
Toc - Plan #18 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$313.56
$355.88
$400.72
$560.00
$850.98
$553.43
$595.75
$640.59
$799.87
$793.30
$835.62
$880.46
$1,039.74
$1,033.17
$1,075.49
$1,120.33
$1,279.61
$239.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627.12
$711.76
$801.44
$1,120.00
$1,701.96
$866.99
$951.63
$1,041.31
$1,359.87
$1,106.86
$1,191.50
$1,281.18
$1,599.74
$1,346.73
$1,431.37
$1,521.05
$1,839.61
$239.87
Toc - Plan #19 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Simple- $5200 Ded (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$247.94
$281.40
$316.85
$442.80
$672.87
$437.60
$471.06
$506.51
$632.46
$627.26
$660.72
$696.17
$822.12
$816.92
$850.38
$885.83
$1,011.78
$189.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$495.88
$562.80
$633.70
$885.60
$1,345.74
$685.54
$752.46
$823.36
$1,075.26
$875.20
$942.12
$1,013.02
$1,264.92
$1,064.86
$1,131.78
$1,202.68
$1,454.58
$189.66
Toc - Plan #20 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- Specialist Saver (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$308.76
$350.43
$394.58
$551.42
$837.94
$544.95
$586.62
$630.77
$787.61
$781.14
$822.81
$866.96
$1,023.80
$1,017.33
$1,059.00
$1,103.15
$1,259.99
$236.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$617.52
$700.86
$789.16
$1,102.84
$1,675.88
$853.71
$937.05
$1,025.35
$1,339.03
$1,089.90
$1,173.24
$1,261.54
$1,575.22
$1,326.09
$1,409.43
$1,497.73
$1,811.41
$236.19
Toc - Plan #21 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
$251.81
$285.80
$321.80
$449.72
$683.39
$444.44
$478.43
$514.43
$642.35
$637.07
$671.06
$707.06
$834.98
$829.70
$863.69
$899.69
$1,027.61
$192.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$503.62
$571.60
$643.60
$899.44
$1,366.78
$696.25
$764.23
$836.23
$1,092.07
$888.88
$956.86
$1,028.86
$1,284.70
$1,081.51
$1,149.49
$1,221.49
$1,477.33
$192.63
Toc - Plan #22 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- Deductible Saver (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
$254.85
$289.24
$325.69
$455.14
$691.64
$449.80
$484.19
$520.64
$650.09
$644.75
$679.14
$715.59
$845.04
$839.70
$874.09
$910.54
$1,039.99
$194.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$509.70
$578.48
$651.38
$910.28
$1,383.28
$704.65
$773.43
$846.33
$1,105.23
$899.60
$968.38
$1,041.28
$1,300.18
$1,094.55
$1,163.33
$1,236.23
$1,495.13
$194.95
Toc - Plan #23 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
$300.91
$341.52
$384.55
$537.41
$816.65
$531.10
$571.71
$614.74
$767.60
$761.29
$801.90
$844.93
$997.79
$991.48
$1,032.09
$1,075.12
$1,227.98
$230.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$601.82
$683.04
$769.10
$1,074.82
$1,633.30
$832.01
$913.23
$999.29
$1,305.01
$1,062.20
$1,143.42
$1,229.48
$1,535.20
$1,292.39
$1,373.61
$1,459.67
$1,765.39
$230.19
Toc - Plan #24 Oscar Health Plan, Inc.
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.96
$360.87
$406.34
$567.86
$862.91
$561.19
$604.10
$649.57
$811.09
$804.42
$847.33
$892.80
$1,054.32
$1,047.65
$1,090.56
$1,136.03
$1,297.55
$243.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$635.92
$721.74
$812.68
$1,135.72
$1,725.82
$879.15
$964.97
$1,055.91
$1,378.95
$1,122.38
$1,208.20
$1,299.14
$1,622.18
$1,365.61
$1,451.43
$1,542.37
$1,865.41
$243.23
Toc - Plan #25 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- For Diabetes (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.57
$352.48
$396.89
$554.66
$842.86
$548.15
$590.06
$634.47
$792.24
$785.73
$827.64
$872.05
$1,029.82
$1,023.31
$1,065.22
$1,109.63
$1,267.40
$237.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.14
$704.96
$793.78
$1,109.32
$1,685.72
$858.72
$942.54
$1,031.36
$1,346.90
$1,096.30
$1,180.12
$1,268.94
$1,584.48
$1,333.88
$1,417.70
$1,506.52
$1,822.06
$237.58
Toc - Plan #26 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
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$249.49
$283.16
$318.83
$445.57
$677.08
$440.34
$474.01
$509.68
$636.42
$631.19
$664.86
$700.53
$827.27
$822.04
$855.71
$891.38
$1,018.12
$190.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$498.98
$566.32
$637.66
$891.14
$1,354.16
$689.83
$757.17
$828.51
$1,081.99
$880.68
$948.02
$1,019.36
$1,272.84
$1,071.53
$1,138.87
$1,210.21
$1,463.69
$190.85
Toc - Plan #27 Oscar Health Plan, Inc.
Bronze

(HMO) Bronze Simple- Standard (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$225.03
$255.40
$287.58
$401.89
$610.71
$397.17
$427.54
$459.72
$574.03
$569.31
$599.68
$631.86
$746.17
$741.45
$771.82
$804.00
$918.31
$172.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$450.06
$510.80
$575.16
$803.78
$1,221.42
$622.20
$682.94
$747.30
$975.92
$794.34
$855.08
$919.44
$1,148.06
$966.48
$1,027.22
$1,091.58
$1,320.20
$172.14
Toc - Plan #28 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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.39
$344.33
$387.72
$541.83
$823.37
$535.47
$576.41
$619.80
$773.91
$767.55
$808.49
$851.88
$1,005.99
$999.63
$1,040.57
$1,083.96
$1,238.07
$232.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$606.78
$688.66
$775.44
$1,083.66
$1,646.74
$838.86
$920.74
$1,007.52
$1,315.74
$1,070.94
$1,152.82
$1,239.60
$1,547.82
$1,303.02
$1,384.90
$1,471.68
$1,779.90
$232.08
Toc - Plan #29 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
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$327.95
$372.21
$419.10
$585.70
$890.02
$578.82
$623.08
$669.97
$836.57
$829.69
$873.95
$920.84
$1,087.44
$1,080.56
$1,124.82
$1,171.71
$1,338.31
$250.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$655.90
$744.42
$838.20
$1,171.40
$1,780.04
$906.77
$995.29
$1,089.07
$1,422.27
$1,157.64
$1,246.16
$1,339.94
$1,673.14
$1,408.51
$1,497.03
$1,590.81
$1,924.01
$250.87

ADVERTISEMENT

Ambetter of Illinois

Local: 1-855-745-5507 | Toll Free: 1-855-745-5507 | TTY: 1-844-517-3431

Toc - Plan #30 Ambetter of Illinois
Silver

(HMO) Premier Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.03
$351.87
$396.20
$553.69
$841.39
$547.19
$589.03
$633.36
$790.85
$784.35
$826.19
$870.52
$1,028.01
$1,021.51
$1,063.35
$1,107.68
$1,265.17
$237.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.06
$703.74
$792.40
$1,107.38
$1,682.78
$857.22
$940.90
$1,029.56
$1,344.54
$1,094.38
$1,178.06
$1,266.72
$1,581.70
$1,331.54
$1,415.22
$1,503.88
$1,818.86
$237.16
Toc - Plan #31 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
$362.21
$411.09
$462.89
$646.88
$983.00
$639.29
$688.17
$739.97
$923.96
$916.37
$965.25
$1,017.05
$1,201.04
$1,193.45
$1,242.33
$1,294.13
$1,478.12
$277.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.42
$822.18
$925.78
$1,293.76
$1,966.00
$1,001.50
$1,099.26
$1,202.86
$1,570.84
$1,278.58
$1,376.34
$1,479.94
$1,847.92
$1,555.66
$1,653.42
$1,757.02
$2,125.00
$277.08
Toc - Plan #32 Ambetter of Illinois
Silver

(HMO) Complete Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$309.60
$351.38
$395.65
$552.92
$840.21
$546.43
$588.21
$632.48
$789.75
$783.26
$825.04
$869.31
$1,026.58
$1,020.09
$1,061.87
$1,106.14
$1,263.41
$236.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619.20
$702.76
$791.30
$1,105.84
$1,680.42
$856.03
$939.59
$1,028.13
$1,342.67
$1,092.86
$1,176.42
$1,264.96
$1,579.50
$1,329.69
$1,413.25
$1,501.79
$1,816.33
$236.83
Toc - Plan #33 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
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$257.64
$292.41
$329.25
$460.12
$699.20
$454.72
$489.49
$526.33
$657.20
$651.80
$686.57
$723.41
$854.28
$848.88
$883.65
$920.49
$1,051.36
$197.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$515.28
$584.82
$658.50
$920.24
$1,398.40
$712.36
$781.90
$855.58
$1,117.32
$909.44
$978.98
$1,052.66
$1,314.40
$1,106.52
$1,176.06
$1,249.74
$1,511.48
$197.08
Toc - Plan #34 Ambetter of Illinois
Silver

(HMO) Everyday Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304.79
$345.93
$389.51
$544.34
$827.17
$537.95
$579.09
$622.67
$777.50
$771.11
$812.25
$855.83
$1,010.66
$1,004.27
$1,045.41
$1,088.99
$1,243.82
$233.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$609.58
$691.86
$779.02
$1,088.68
$1,654.34
$842.74
$925.02
$1,012.18
$1,321.84
$1,075.90
$1,158.18
$1,245.34
$1,555.00
$1,309.06
$1,391.34
$1,478.50
$1,788.16
$233.16
Toc - Plan #35 Ambetter of Illinois
Silver

(HMO) Elite Silver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 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
$326.58
$370.66
$417.36
$583.26
$886.32
$576.41
$620.49
$667.19
$833.09
$826.24
$870.32
$917.02
$1,082.92
$1,076.07
$1,120.15
$1,166.85
$1,332.75
$249.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$653.16
$741.32
$834.72
$1,166.52
$1,772.64
$902.99
$991.15
$1,084.55
$1,416.35
$1,152.82
$1,240.98
$1,334.38
$1,666.18
$1,402.65
$1,490.81
$1,584.21
$1,916.01
$249.83
Toc - Plan #36 Ambetter of Illinois
Expanded Bronze

(HMO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$249.92
$283.64
$319.38
$446.33
$678.25
$441.10
$474.82
$510.56
$637.51
$632.28
$666.00
$701.74
$828.69
$823.46
$857.18
$892.92
$1,019.87
$191.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$499.84
$567.28
$638.76
$892.66
$1,356.50
$691.02
$758.46
$829.94
$1,083.84
$882.20
$949.64
$1,021.12
$1,275.02
$1,073.38
$1,140.82
$1,212.30
$1,466.20
$191.18
Toc - Plan #37 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
$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
$299.27
$339.66
$382.46
$534.48
$812.20
$528.21
$568.60
$611.40
$763.42
$757.15
$797.54
$840.34
$992.36
$986.09
$1,026.48
$1,069.28
$1,221.30
$228.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.54
$679.32
$764.92
$1,068.96
$1,624.40
$827.48
$908.26
$993.86
$1,297.90
$1,056.42
$1,137.20
$1,222.80
$1,526.84
$1,285.36
$1,366.14
$1,451.74
$1,755.78
$228.94
Toc - Plan #38 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
$295.55
$335.44
$377.70
$527.84
$802.10
$521.64
$561.53
$603.79
$753.93
$747.73
$787.62
$829.88
$980.02
$973.82
$1,013.71
$1,055.97
$1,206.11
$226.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$591.10
$670.88
$755.40
$1,055.68
$1,604.20
$817.19
$896.97
$981.49
$1,281.77
$1,043.28
$1,123.06
$1,207.58
$1,507.86
$1,269.37
$1,349.15
$1,433.67
$1,733.95
$226.09
Toc - Plan #39 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
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$300.88
$341.49
$384.52
$537.36
$816.57
$531.05
$571.66
$614.69
$767.53
$761.22
$801.83
$844.86
$997.70
$991.39
$1,032.00
$1,075.03
$1,227.87
$230.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$601.76
$682.98
$769.04
$1,074.72
$1,633.14
$831.93
$913.15
$999.21
$1,304.89
$1,062.10
$1,143.32
$1,229.38
$1,535.06
$1,292.27
$1,373.49
$1,459.55
$1,765.23
$230.17
Toc - Plan #40 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
$343.36
$389.70
$438.80
$613.22
$931.84
$606.02
$652.36
$701.46
$875.88
$868.68
$915.02
$964.12
$1,138.54
$1,131.34
$1,177.68
$1,226.78
$1,401.20
$262.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.72
$779.40
$877.60
$1,226.44
$1,863.68
$949.38
$1,042.06
$1,140.26
$1,489.10
$1,212.04
$1,304.72
$1,402.92
$1,751.76
$1,474.70
$1,567.38
$1,665.58
$2,014.42
$262.66
Toc - Plan #41 Ambetter of Illinois
Bronze

(HMO) Clear Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$229.86
$260.88
$293.75
$410.51
$623.81
$405.69
$436.71
$469.58
$586.34
$581.52
$612.54
$645.41
$762.17
$757.35
$788.37
$821.24
$938.00
$175.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$459.72
$521.76
$587.50
$821.02
$1,247.62
$635.55
$697.59
$763.33
$996.85
$811.38
$873.42
$939.16
$1,172.68
$987.21
$1,049.25
$1,114.99
$1,348.51
$175.83
Toc - Plan #42 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
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$406.38
$461.23
$519.34
$725.78
$1,102.90
$717.26
$772.11
$830.22
$1,036.66
$1,028.14
$1,082.99
$1,141.10
$1,347.54
$1,339.02
$1,393.87
$1,451.98
$1,658.42
$310.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$812.76
$922.46
$1,038.68
$1,451.56
$2,205.80
$1,123.64
$1,233.34
$1,349.56
$1,762.44
$1,434.52
$1,544.22
$1,660.44
$2,073.32
$1,745.40
$1,855.10
$1,971.32
$2,384.20
$310.88
Toc - Plan #43 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
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$254.54
$288.89
$325.28
$454.58
$690.78
$449.25
$483.60
$519.99
$649.29
$643.96
$678.31
$714.70
$844.00
$838.67
$873.02
$909.41
$1,038.71
$194.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$509.08
$577.78
$650.56
$909.16
$1,381.56
$703.79
$772.49
$845.27
$1,103.87
$898.50
$967.20
$1,039.98
$1,298.58
$1,093.21
$1,161.91
$1,234.69
$1,493.29
$194.71
Toc - Plan #44 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
$318.12
$361.06
$406.55
$568.15
$863.35
$561.47
$604.41
$649.90
$811.50
$804.82
$847.76
$893.25
$1,054.85
$1,048.17
$1,091.11
$1,136.60
$1,298.20
$243.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636.24
$722.12
$813.10
$1,136.30
$1,726.70
$879.59
$965.47
$1,056.45
$1,379.65
$1,122.94
$1,208.82
$1,299.80
$1,623.00
$1,366.29
$1,452.17
$1,543.15
$1,866.35
$243.35
Toc - Plan #45 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
$350.89
$398.25
$448.42
$626.67
$952.29
$619.31
$666.67
$716.84
$895.09
$887.73
$935.09
$985.26
$1,163.51
$1,156.15
$1,203.51
$1,253.68
$1,431.93
$268.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$701.78
$796.50
$896.84
$1,253.34
$1,904.58
$970.20
$1,064.92
$1,165.26
$1,521.76
$1,238.62
$1,333.34
$1,433.68
$1,790.18
$1,507.04
$1,601.76
$1,702.10
$2,058.60
$268.42
Toc - Plan #46 Ambetter of Illinois
Bronze

(HMO) CMS Standard Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$215.75
$244.87
$275.72
$385.32
$585.52
$380.79
$409.91
$440.76
$550.36
$545.83
$574.95
$605.80
$715.40
$710.87
$739.99
$770.84
$880.44
$165.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$431.50
$489.74
$551.44
$770.64
$1,171.04
$596.54
$654.78
$716.48
$935.68
$761.58
$819.82
$881.52
$1,100.72
$926.62
$984.86
$1,046.56
$1,265.76
$165.04
Toc - Plan #47 Ambetter of Illinois
Expanded Bronze

(HMO) CMS 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
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$250.13
$283.89
$319.66
$446.72
$678.84
$441.47
$475.23
$511.00
$638.06
$632.81
$666.57
$702.34
$829.40
$824.15
$857.91
$893.68
$1,020.74
$191.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$500.26
$567.78
$639.32
$893.44
$1,357.68
$691.60
$759.12
$830.66
$1,084.78
$882.94
$950.46
$1,022.00
$1,276.12
$1,074.28
$1,141.80
$1,213.34
$1,467.46
$191.34
Toc - Plan #48 Ambetter of Illinois
Silver

(HMO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$298.68
$338.99
$381.70
$533.43
$810.60
$527.16
$567.47
$610.18
$761.91
$755.64
$795.95
$838.66
$990.39
$984.12
$1,024.43
$1,067.14
$1,218.87
$228.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$597.36
$677.98
$763.40
$1,066.86
$1,621.20
$825.84
$906.46
$991.88
$1,295.34
$1,054.32
$1,134.94
$1,220.36
$1,523.82
$1,282.80
$1,363.42
$1,448.84
$1,752.30
$228.48
Toc - Plan #49 Ambetter of Illinois
Gold

(HMO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$334.95
$380.16
$428.06
$598.21
$909.04
$591.18
$636.39
$684.29
$854.44
$847.41
$892.62
$940.52
$1,110.67
$1,103.64
$1,148.85
$1,196.75
$1,366.90
$256.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$669.90
$760.32
$856.12
$1,196.42
$1,818.08
$926.13
$1,016.55
$1,112.35
$1,452.65
$1,182.36
$1,272.78
$1,368.58
$1,708.88
$1,438.59
$1,529.01
$1,624.81
$1,965.11
$256.23
Toc - Plan #50 Ambetter of Illinois
Silver

(HMO) Premier Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.96
$365.41
$411.45
$575.00
$873.76
$568.25
$611.70
$657.74
$821.29
$814.54
$857.99
$904.03
$1,067.58
$1,060.83
$1,104.28
$1,150.32
$1,313.87
$246.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.92
$730.82
$822.90
$1,150.00
$1,747.52
$890.21
$977.11
$1,069.19
$1,396.29
$1,136.50
$1,223.40
$1,315.48
$1,642.58
$1,382.79
$1,469.69
$1,561.77
$1,888.87
$246.29
Toc - Plan #51 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
$376.14
$426.91
$480.69
$671.77
$1,020.82
$663.88
$714.65
$768.43
$959.51
$951.62
$1,002.39
$1,056.17
$1,247.25
$1,239.36
$1,290.13
$1,343.91
$1,534.99
$287.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.28
$853.82
$961.38
$1,343.54
$2,041.64
$1,040.02
$1,141.56
$1,249.12
$1,631.28
$1,327.76
$1,429.30
$1,536.86
$1,919.02
$1,615.50
$1,717.04
$1,824.60
$2,206.76
$287.74
Toc - Plan #52 Ambetter of Illinois
Silver

(HMO) Complete Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.51
$364.90
$410.87
$574.19
$872.54
$567.45
$610.84
$656.81
$820.13
$813.39
$856.78
$902.75
$1,066.07
$1,059.33
$1,102.72
$1,148.69
$1,312.01
$245.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.02
$729.80
$821.74
$1,148.38
$1,745.08
$888.96
$975.74
$1,067.68
$1,394.32
$1,134.90
$1,221.68
$1,313.62
$1,640.26
$1,380.84
$1,467.62
$1,559.56
$1,886.20
$245.94
Toc - Plan #53 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
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$267.55
$303.65
$341.91
$477.82
$726.10
$472.22
$508.32
$546.58
$682.49
$676.89
$712.99
$751.25
$887.16
$881.56
$917.66
$955.92
$1,091.83
$204.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$535.10
$607.30
$683.82
$955.64
$1,452.20
$739.77
$811.97
$888.49
$1,160.31
$944.44
$1,016.64
$1,093.16
$1,364.98
$1,149.11
$1,221.31
$1,297.83
$1,569.65
$204.67
Toc - Plan #54 Ambetter of Illinois
Silver

(HMO) Elite Silver + 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
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$339.15
$384.92
$433.42
$605.70
$920.42
$598.59
$644.36
$692.86
$865.14
$858.03
$903.80
$952.30
$1,124.58
$1,117.47
$1,163.24
$1,211.74
$1,384.02
$259.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$678.30
$769.84
$866.84
$1,211.40
$1,840.84
$937.74
$1,029.28
$1,126.28
$1,470.84
$1,197.18
$1,288.72
$1,385.72
$1,730.28
$1,456.62
$1,548.16
$1,645.16
$1,989.72
$259.44
Toc - Plan #55 Ambetter of Illinois
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$259.53
$294.56
$331.67
$463.50
$704.34
$458.06
$493.09
$530.20
$662.03
$656.59
$691.62
$728.73
$860.56
$855.12
$890.15
$927.26
$1,059.09
$198.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$519.06
$589.12
$663.34
$927.00
$1,408.68
$717.59
$787.65
$861.87
$1,125.53
$916.12
$986.18
$1,060.40
$1,324.06
$1,114.65
$1,184.71
$1,258.93
$1,522.59
$198.53
Toc - Plan #56 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
$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
$310.78
$352.73
$397.17
$555.04
$843.44
$548.52
$590.47
$634.91
$792.78
$786.26
$828.21
$872.65
$1,030.52
$1,024.00
$1,065.95
$1,110.39
$1,268.26
$237.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.56
$705.46
$794.34
$1,110.08
$1,686.88
$859.30
$943.20
$1,032.08
$1,347.82
$1,097.04
$1,180.94
$1,269.82
$1,585.56
$1,334.78
$1,418.68
$1,507.56
$1,823.30
$237.74
Toc - Plan #57 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
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312.46
$354.63
$399.31
$558.03
$847.99
$551.48
$593.65
$638.33
$797.05
$790.50
$832.67
$877.35
$1,036.07
$1,029.52
$1,071.69
$1,116.37
$1,275.09
$239.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$624.92
$709.26
$798.62
$1,116.06
$1,695.98
$863.94
$948.28
$1,037.64
$1,355.08
$1,102.96
$1,187.30
$1,276.66
$1,594.10
$1,341.98
$1,426.32
$1,515.68
$1,833.12
$239.02
Toc - Plan #58 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
$356.57
$404.69
$455.68
$636.81
$967.69
$629.34
$677.46
$728.45
$909.58
$902.11
$950.23
$1,001.22
$1,182.35
$1,174.88
$1,223.00
$1,273.99
$1,455.12
$272.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.14
$809.38
$911.36
$1,273.62
$1,935.38
$985.91
$1,082.15
$1,184.13
$1,546.39
$1,258.68
$1,354.92
$1,456.90
$1,819.16
$1,531.45
$1,627.69
$1,729.67
$2,091.93
$272.77
Toc - Plan #59 Ambetter of Illinois
Silver

(HMO) Everyday Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.52
$359.23
$404.49
$565.28
$859.00
$558.65
$601.36
$646.62
$807.41
$800.78
$843.49
$888.75
$1,049.54
$1,042.91
$1,085.62
$1,130.88
$1,291.67
$242.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$633.04
$718.46
$808.98
$1,130.56
$1,718.00
$875.17
$960.59
$1,051.11
$1,372.69
$1,117.30
$1,202.72
$1,293.24
$1,614.82
$1,359.43
$1,444.85
$1,535.37
$1,856.95
$242.13
Toc - Plan #60 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
$306.92
$348.34
$392.23
$548.14
$832.96
$541.71
$583.13
$627.02
$782.93
$776.50
$817.92
$861.81
$1,017.72
$1,011.29
$1,052.71
$1,096.60
$1,252.51
$234.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$613.84
$696.68
$784.46
$1,096.28
$1,665.92
$848.63
$931.47
$1,019.25
$1,331.07
$1,083.42
$1,166.26
$1,254.04
$1,565.86
$1,318.21
$1,401.05
$1,488.83
$1,800.65
$234.79
Toc - Plan #61 Ambetter of Illinois
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$238.70
$270.91
$305.05
$426.30
$647.81
$421.30
$453.51
$487.65
$608.90
$603.90
$636.11
$670.25
$791.50
$786.50
$818.71
$852.85
$974.10
$182.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$477.40
$541.82
$610.10
$852.60
$1,295.62
$660.00
$724.42
$792.70
$1,035.20
$842.60
$907.02
$975.30
$1,217.80
$1,025.20
$1,089.62
$1,157.90
$1,400.40
$182.60
Toc - Plan #62 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
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$422.02
$478.98
$539.33
$753.71
$1,145.33
$744.86
$801.82
$862.17
$1,076.55
$1,067.70
$1,124.66
$1,185.01
$1,399.39
$1,390.54
$1,447.50
$1,507.85
$1,722.23
$322.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$844.04
$957.96
$1,078.66
$1,507.42
$2,290.66
$1,166.88
$1,280.80
$1,401.50
$1,830.26
$1,489.72
$1,603.64
$1,724.34
$2,153.10
$1,812.56
$1,926.48
$2,047.18
$2,475.94
$322.84
Toc - Plan #63 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
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$264.33
$300.00
$337.80
$472.07
$717.36
$466.53
$502.20
$540.00
$674.27
$668.73
$704.40
$742.20
$876.47
$870.93
$906.60
$944.40
$1,078.67
$202.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$528.66
$600.00
$675.60
$944.14
$1,434.72
$730.86
$802.20
$877.80
$1,146.34
$933.06
$1,004.40
$1,080.00
$1,348.54
$1,135.26
$1,206.60
$1,282.20
$1,550.74
$202.20
Toc - Plan #64 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
$330.36
$374.95
$422.19
$590.00
$896.57
$583.08
$627.67
$674.91
$842.72
$835.80
$880.39
$927.63
$1,095.44
$1,088.52
$1,133.11
$1,180.35
$1,348.16
$252.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$660.72
$749.90
$844.38
$1,180.00
$1,793.14
$913.44
$1,002.62
$1,097.10
$1,432.72
$1,166.16
$1,255.34
$1,349.82
$1,685.44
$1,418.88
$1,508.06
$1,602.54
$1,938.16
$252.72
Toc - Plan #65 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
$364.39
$413.57
$465.68
$650.78
$988.92
$643.14
$692.32
$744.43
$929.53
$921.89
$971.07
$1,023.18
$1,208.28
$1,200.64
$1,249.82
$1,301.93
$1,487.03
$278.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728.78
$827.14
$931.36
$1,301.56
$1,977.84
$1,007.53
$1,105.89
$1,210.11
$1,580.31
$1,286.28
$1,384.64
$1,488.86
$1,859.06
$1,565.03
$1,663.39
$1,767.61
$2,137.81
$278.75

ADVERTISEMENT

Molina Healthcare

Local: 1-833-644-1623 | Toll Free: 1-833-644-1623 | TTY: 1-800-877-8339

Toc - Plan #66 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$325.22
$369.13
$415.64
$580.85
$882.66
$574.02
$617.93
$664.44
$829.65
$822.82
$866.73
$913.24
$1,078.45
$1,071.62
$1,115.53
$1,162.04
$1,327.25
$248.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$650.44
$738.26
$831.28
$1,161.70
$1,765.32
$899.24
$987.06
$1,080.08
$1,410.50
$1,148.04
$1,235.86
$1,328.88
$1,659.30
$1,396.84
$1,484.66
$1,577.68
$1,908.10
$248.80
Toc - Plan #67 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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
$313.69
$356.04
$400.90
$560.26
$851.37
$553.67
$596.02
$640.88
$800.24
$793.65
$836.00
$880.86
$1,040.22
$1,033.63
$1,075.98
$1,120.84
$1,280.20
$239.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627.38
$712.08
$801.80
$1,120.52
$1,702.74
$867.36
$952.06
$1,041.78
$1,360.50
$1,107.34
$1,192.04
$1,281.76
$1,600.48
$1,347.32
$1,432.02
$1,521.74
$1,840.46
$239.98
Toc - Plan #68 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$334.94
$380.16
$428.06
$598.21
$909.04
$591.17
$636.39
$684.29
$854.44
$847.40
$892.62
$940.52
$1,110.67
$1,103.63
$1,148.85
$1,196.75
$1,366.90
$256.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$669.88
$760.32
$856.12
$1,196.42
$1,818.08
$926.11
$1,016.55
$1,112.35
$1,452.65
$1,182.34
$1,272.78
$1,368.58
$1,708.88
$1,438.57
$1,529.01
$1,624.81
$1,965.11
$256.23
Toc - Plan #69 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.19
$360.01
$405.37
$566.50
$860.86
$559.84
$602.66
$648.02
$809.15
$802.49
$845.31
$890.67
$1,051.80
$1,045.14
$1,087.96
$1,133.32
$1,294.45
$242.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.38
$720.02
$810.74
$1,133.00
$1,721.72
$877.03
$962.67
$1,053.39
$1,375.65
$1,119.68
$1,205.32
$1,296.04
$1,618.30
$1,362.33
$1,447.97
$1,538.69
$1,860.95
$242.65
Toc - Plan #70 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.38
$367.03
$413.27
$577.55
$877.64
$570.76
$614.41
$660.65
$824.93
$818.14
$861.79
$908.03
$1,072.31
$1,065.52
$1,109.17
$1,155.41
$1,319.69
$247.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.76
$734.06
$826.54
$1,155.10
$1,755.28
$894.14
$981.44
$1,073.92
$1,402.48
$1,141.52
$1,228.82
$1,321.30
$1,649.86
$1,388.90
$1,476.20
$1,568.68
$1,897.24
$247.38
Toc - Plan #71 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 with RX Copay + Vision

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$329.83
$374.36
$421.52
$589.08
$895.16
$582.15
$626.68
$673.84
$841.40
$834.47
$879.00
$926.16
$1,093.72
$1,086.79
$1,131.32
$1,178.48
$1,346.04
$252.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$659.66
$748.72
$843.04
$1,178.16
$1,790.32
$911.98
$1,001.04
$1,095.36
$1,430.48
$1,164.30
$1,253.36
$1,347.68
$1,682.80
$1,416.62
$1,505.68
$1,600.00
$1,935.12
$252.32

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 #72 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 $2,250 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$450.46
$511.28
$575.69
$804.53
$1,222.56
$795.06
$855.88
$920.29
$1,149.13
$1,139.66
$1,200.48
$1,264.89
$1,493.73
$1,484.26
$1,545.08
$1,609.49
$1,838.33
$344.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$900.92
$1,022.56
$1,151.38
$1,609.06
$2,445.12
$1,245.52
$1,367.16
$1,495.98
$1,953.66
$1,590.12
$1,711.76
$1,840.58
$2,298.26
$1,934.72
$2,056.36
$2,185.18
$2,642.86
$344.60
Toc - Plan #73 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
$4,600 $13,800 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
$370.40
$420.41
$473.38
$661.54
$1,005.27
$653.76
$703.77
$756.74
$944.90
$937.12
$987.13
$1,040.10
$1,228.26
$1,220.48
$1,270.49
$1,323.46
$1,511.62
$283.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.80
$840.82
$946.76
$1,323.08
$2,010.54
$1,024.16
$1,124.18
$1,230.12
$1,606.44
$1,307.52
$1,407.54
$1,513.48
$1,889.80
$1,590.88
$1,690.90
$1,796.84
$2,173.16
$283.36
Toc - Plan #74 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 $17,400 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
$322.58
$366.13
$412.26
$576.13
$875.48
$569.35
$612.90
$659.03
$822.90
$816.12
$859.67
$905.80
$1,069.67
$1,062.89
$1,106.44
$1,152.57
$1,316.44
$246.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$645.16
$732.26
$824.52
$1,152.26
$1,750.96
$891.93
$979.03
$1,071.29
$1,399.03
$1,138.70
$1,225.80
$1,318.06
$1,645.80
$1,385.47
$1,472.57
$1,564.83
$1,892.57
$246.77
Toc - Plan #75 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
$950 $2,850 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$480.39
$545.25
$613.94
$857.98
$1,303.79
$847.89
$912.75
$981.44
$1,225.48
$1,215.39
$1,280.25
$1,348.94
$1,592.98
$1,582.89
$1,647.75
$1,716.44
$1,960.48
$367.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$960.78
$1,090.50
$1,227.88
$1,715.96
$2,607.58
$1,328.28
$1,458.00
$1,595.38
$2,083.46
$1,695.78
$1,825.50
$1,962.88
$2,450.96
$2,063.28
$2,193.00
$2,330.38
$2,818.46
$367.50
Toc - Plan #76 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
$9,100 $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
$404.52
$459.13
$516.97
$722.47
$1,097.86
$713.98
$768.59
$826.43
$1,031.93
$1,023.44
$1,078.05
$1,135.89
$1,341.39
$1,332.90
$1,387.51
$1,445.35
$1,650.85
$309.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$809.04
$918.26
$1,033.94
$1,444.94
$2,195.72
$1,118.50
$1,227.72
$1,343.40
$1,754.40
$1,427.96
$1,537.18
$1,652.86
$2,063.86
$1,737.42
$1,846.64
$1,962.32
$2,373.32
$309.46
Toc - Plan #77 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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.30
$360.14
$405.51
$566.70
$861.16
$560.04
$602.88
$648.25
$809.44
$802.78
$845.62
$890.99
$1,052.18
$1,045.52
$1,088.36
$1,133.73
$1,294.92
$242.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.60
$720.28
$811.02
$1,133.40
$1,722.32
$877.34
$963.02
$1,053.76
$1,376.14
$1,120.08
$1,205.76
$1,296.50
$1,618.88
$1,362.82
$1,448.50
$1,539.24
$1,861.62
$242.74
Toc - Plan #78 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
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$485.77
$551.35
$620.81
$867.58
$1,318.37
$857.38
$922.96
$992.42
$1,239.19
$1,228.99
$1,294.57
$1,364.03
$1,610.80
$1,600.60
$1,666.18
$1,735.64
$1,982.41
$371.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$971.54
$1,102.70
$1,241.62
$1,735.16
$2,636.74
$1,343.15
$1,474.31
$1,613.23
$2,106.77
$1,714.76
$1,845.92
$1,984.84
$2,478.38
$2,086.37
$2,217.53
$2,356.45
$2,849.99
$371.61
Toc - Plan #79 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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$442.95
$502.75
$566.09
$791.11
$1,202.17
$781.81
$841.61
$904.95
$1,129.97
$1,120.67
$1,180.47
$1,243.81
$1,468.83
$1,459.53
$1,519.33
$1,582.67
$1,807.69
$338.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$885.90
$1,005.50
$1,132.18
$1,582.22
$2,404.34
$1,224.76
$1,344.36
$1,471.04
$1,921.08
$1,563.62
$1,683.22
$1,809.90
$2,259.94
$1,902.48
$2,022.08
$2,148.76
$2,598.80
$338.86
Toc - Plan #80 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
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.31
$425.98
$479.65
$670.31
$1,018.60
$662.43
$713.10
$766.77
$957.43
$949.55
$1,000.22
$1,053.89
$1,244.55
$1,236.67
$1,287.34
$1,341.01
$1,531.67
$287.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.62
$851.96
$959.30
$1,340.62
$2,037.20
$1,037.74
$1,139.08
$1,246.42
$1,627.74
$1,324.86
$1,426.20
$1,533.54
$1,914.86
$1,611.98
$1,713.32
$1,820.66
$2,201.98
$287.12
Toc - Plan #81 Blue Cross and Blue Shield of Illinois
Silver

(HMO) BlueCare Direct Silver? 212 with Advocate

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

Annual Out of Pocket Expenses:

Individual Family
$4,600 $13,800 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
$327.69
$371.93
$418.79
$585.26
$889.36
$578.37
$622.61
$669.47
$835.94
$829.05
$873.29
$920.15
$1,086.62
$1,079.73
$1,123.97
$1,170.83
$1,337.30
$250.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$655.38
$743.86
$837.58
$1,170.52
$1,778.72
$906.06
$994.54
$1,088.26
$1,421.20
$1,156.74
$1,245.22
$1,338.94
$1,671.88
$1,407.42
$1,495.90
$1,589.62
$1,922.56
$250.68
Toc - Plan #82 Blue Cross and Blue Shield of Illinois
Gold

(HMO) BlueCare Direct Gold? 409 with Advocate

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

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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
$394.45
$447.70
$504.10
$704.48
$1,070.53
$696.20
$749.45
$805.85
$1,006.23
$997.95
$1,051.20
$1,107.60
$1,307.98
$1,299.70
$1,352.95
$1,409.35
$1,609.73
$301.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.90
$895.40
$1,008.20
$1,408.96
$2,141.06
$1,090.65
$1,197.15
$1,309.95
$1,710.71
$1,392.40
$1,498.90
$1,611.70
$2,012.46
$1,694.15
$1,800.65
$1,913.45
$2,314.21
$301.75
Toc - Plan #83 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) BlueCare Direct Bronze? 401 with Advocate

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $17,400 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
$280.54
$318.41
$358.53
$501.04
$761.38
$495.15
$533.02
$573.14
$715.65
$709.76
$747.63
$787.75
$930.26
$924.37
$962.24
$1,002.36
$1,144.87
$214.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$561.08
$636.82
$717.06
$1,002.08
$1,522.76
$775.69
$851.43
$931.67
$1,216.69
$990.30
$1,066.04
$1,146.28
$1,431.30
$1,204.91
$1,280.65
$1,360.89
$1,645.91
$214.61
Toc - Plan #84 Blue Cross and Blue Shield of Illinois
Gold

(PPO) Blue Choice Preferred Gold PPO? 204

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

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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
$573.74
$651.19
$733.24
$1,024.70
$1,557.13
$1,012.65
$1,090.10
$1,172.15
$1,463.61
$1,451.56
$1,529.01
$1,611.06
$1,902.52
$1,890.47
$1,967.92
$2,049.97
$2,341.43
$438.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,147.48
$1,302.38
$1,466.48
$2,049.40
$3,114.26
$1,586.39
$1,741.29
$1,905.39
$2,488.31
$2,025.30
$2,180.20
$2,344.30
$2,927.22
$2,464.21
$2,619.11
$2,783.21
$3,366.13
$438.91
Toc - Plan #85 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 $6,750 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
$476.95
$541.34
$609.55
$851.84
$1,294.45
$841.82
$906.21
$974.42
$1,216.71
$1,206.69
$1,271.08
$1,339.29
$1,581.58
$1,571.56
$1,635.95
$1,704.16
$1,946.45
$364.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$953.90
$1,082.68
$1,219.10
$1,703.68
$2,588.90
$1,318.77
$1,447.55
$1,583.97
$2,068.55
$1,683.64
$1,812.42
$1,948.84
$2,433.42
$2,048.51
$2,177.29
$2,313.71
$2,798.29
$364.87
Toc - Plan #86 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 $13,500 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
$416.63
$472.88
$532.46
$744.11
$1,130.74
$735.35
$791.60
$851.18
$1,062.83
$1,054.07
$1,110.32
$1,169.90
$1,381.55
$1,372.79
$1,429.04
$1,488.62
$1,700.27
$318.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$833.26
$945.76
$1,064.92
$1,488.22
$2,261.48
$1,151.98
$1,264.48
$1,383.64
$1,806.94
$1,470.70
$1,583.20
$1,702.36
$2,125.66
$1,789.42
$1,901.92
$2,021.08
$2,444.38
$318.72
Toc - Plan #87 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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.55
$387.66
$436.50
$610.01
$926.96
$602.83
$648.94
$697.78
$871.29
$864.11
$910.22
$959.06
$1,132.57
$1,125.39
$1,171.50
$1,220.34
$1,393.85
$261.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.10
$775.32
$873.00
$1,220.02
$1,853.92
$944.38
$1,036.60
$1,134.28
$1,481.30
$1,205.66
$1,297.88
$1,395.56
$1,742.58
$1,466.94
$1,559.16
$1,656.84
$2,003.86
$261.28
Toc - Plan #88 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 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$374.06
$424.56
$478.05
$668.07
$1,015.19
$660.21
$710.71
$764.20
$954.22
$946.36
$996.86
$1,050.35
$1,240.37
$1,232.51
$1,283.01
$1,336.50
$1,526.52
$286.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$748.12
$849.12
$956.10
$1,336.14
$2,030.38
$1,034.27
$1,135.27
$1,242.25
$1,622.29
$1,320.42
$1,421.42
$1,528.40
$1,908.44
$1,606.57
$1,707.57
$1,814.55
$2,194.59
$286.15
Toc - Plan #89 Blue Cross and Blue Shield of Illinois
Bronze

(PPO) Blue Choice Preferred Bronze PPO? 601

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $17,400 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
$365.90
$415.29
$467.62
$653.49
$993.05
$645.81
$695.20
$747.53
$933.40
$925.72
$975.11
$1,027.44
$1,213.31
$1,205.63
$1,255.02
$1,307.35
$1,493.22
$279.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.80
$830.58
$935.24
$1,306.98
$1,986.10
$1,011.71
$1,110.49
$1,215.15
$1,586.89
$1,291.62
$1,390.40
$1,495.06
$1,866.80
$1,571.53
$1,670.31
$1,774.97
$2,146.71
$279.91
Toc - Plan #90 Blue Cross and Blue Shield of Illinois
Bronze

(PPO) Blue Choice Preferred Bronze PPO? 701

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

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,400 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
$342.96
$389.26
$438.30
$612.53
$930.79
$605.32
$651.62
$700.66
$874.89
$867.68
$913.98
$963.02
$1,137.25
$1,130.04
$1,176.34
$1,225.38
$1,399.61
$262.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.92
$778.52
$876.60
$1,225.06
$1,861.58
$948.28
$1,040.88
$1,138.96
$1,487.42
$1,210.64
$1,303.24
$1,401.32
$1,749.78
$1,473.00
$1,565.60
$1,663.68
$2,012.14
$262.36
Toc - Plan #91 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
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$560.26
$635.89
$716.01
$1,000.62
$1,520.54
$988.86
$1,064.49
$1,144.61
$1,429.22
$1,417.46
$1,493.09
$1,573.21
$1,857.82
$1,846.06
$1,921.69
$2,001.81
$2,286.42
$428.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,120.52
$1,271.78
$1,432.02
$2,001.24
$3,041.08
$1,549.12
$1,700.38
$1,860.62
$2,429.84
$1,977.72
$2,128.98
$2,289.22
$2,858.44
$2,406.32
$2,557.58
$2,717.82
$3,287.04
$428.60
Toc - Plan #92 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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$484.48
$549.89
$619.17
$865.29
$1,314.88
$855.11
$920.52
$989.80
$1,235.92
$1,225.74
$1,291.15
$1,360.43
$1,606.55
$1,596.37
$1,661.78
$1,731.06
$1,977.18
$370.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$968.96
$1,099.78
$1,238.34
$1,730.58
$2,629.76
$1,339.59
$1,470.41
$1,608.97
$2,101.21
$1,710.22
$1,841.04
$1,979.60
$2,471.84
$2,080.85
$2,211.67
$2,350.23
$2,842.47
$370.63
Toc - Plan #93 Blue Cross and Blue Shield of Illinois
Bronze

(PPO) Blue Choice Preferred Bronze PPO? 705

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.60
$405.87
$457.01
$638.67
$970.52
$631.16
$679.43
$730.57
$912.23
$904.72
$952.99
$1,004.13
$1,185.79
$1,178.28
$1,226.55
$1,277.69
$1,459.35
$273.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.20
$811.74
$914.02
$1,277.34
$1,941.04
$988.76
$1,085.30
$1,187.58
$1,550.90
$1,262.32
$1,358.86
$1,461.14
$1,824.46
$1,535.88
$1,632.42
$1,734.70
$2,098.02
$273.56
Toc - Plan #94 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
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$425.14
$482.54
$543.33
$759.31
$1,153.84
$750.37
$807.77
$868.56
$1,084.54
$1,075.60
$1,133.00
$1,193.79
$1,409.77
$1,400.83
$1,458.23
$1,519.02
$1,735.00
$325.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$850.28
$965.08
$1,086.66
$1,518.62
$2,307.68
$1,175.51
$1,290.31
$1,411.89
$1,843.85
$1,500.74
$1,615.54
$1,737.12
$2,169.08
$1,825.97
$1,940.77
$2,062.35
$2,494.31
$325.23
Toc - Plan #95 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 $2,250 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
$352.39
$399.97
$450.36
$629.37
$956.40
$621.97
$669.55
$719.94
$898.95
$891.55
$939.13
$989.52
$1,168.53
$1,161.13
$1,208.71
$1,259.10
$1,438.11
$269.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704.78
$799.94
$900.72
$1,258.74
$1,912.80
$974.36
$1,069.52
$1,170.30
$1,528.32
$1,243.94
$1,339.10
$1,439.88
$1,797.90
$1,513.52
$1,608.68
$1,709.46
$2,067.48
$269.58
Toc - Plan #96 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
$4,000 $12,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$293.67
$333.32
$375.32
$524.50
$797.03
$518.33
$557.98
$599.98
$749.16
$742.99
$782.64
$824.64
$973.82
$967.65
$1,007.30
$1,049.30
$1,198.48
$224.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$587.34
$666.64
$750.64
$1,049.00
$1,594.06
$812.00
$891.30
$975.30
$1,273.66
$1,036.66
$1,115.96
$1,199.96
$1,498.32
$1,261.32
$1,340.62
$1,424.62
$1,722.98
$224.66
Toc - Plan #97 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 $17,400 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
$230.43
$261.53
$294.48
$411.54
$625.37
$406.71
$437.81
$470.76
$587.82
$582.99
$614.09
$647.04
$764.10
$759.27
$790.37
$823.32
$940.38
$176.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$460.86
$523.06
$588.96
$823.08
$1,250.74
$637.14
$699.34
$765.24
$999.36
$813.42
$875.62
$941.52
$1,175.64
$989.70
$1,051.90
$1,117.80
$1,351.92
$176.28

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0325 | Toll Free: 1-888-200-0325 | TTY: 1-888-200-0325

Toc - Plan #98 UnitedHealthcare
Expanded Bronze

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

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
$9,100 $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
$270.17
$306.65
$345.28
$482.53
$733.25
$476.85
$513.33
$551.96
$689.21
$683.53
$720.01
$758.64
$895.89
$890.21
$926.69
$965.32
$1,102.57
$206.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$540.34
$613.30
$690.56
$965.06
$1,466.50
$747.02
$819.98
$897.24
$1,171.74
$953.70
$1,026.66
$1,103.92
$1,378.42
$1,160.38
$1,233.34
$1,310.60
$1,585.10
$206.68
Toc - Plan #99 UnitedHealthcare
Silver

(HMO) UHC Silver Value 1 (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$3,450 $6,900 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$326.92
$371.05
$417.80
$583.87
$887.25
$577.01
$621.14
$667.89
$833.96
$827.10
$871.23
$917.98
$1,084.05
$1,077.19
$1,121.32
$1,168.07
$1,334.14
$250.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$653.84
$742.10
$835.60
$1,167.74
$1,774.50
$903.93
$992.19
$1,085.69
$1,417.83
$1,154.02
$1,242.28
$1,335.78
$1,667.92
$1,404.11
$1,492.37
$1,585.87
$1,918.01
$250.09
Toc - Plan #100 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322.08
$365.56
$411.62
$575.24
$874.14
$568.47
$611.95
$658.01
$821.63
$814.86
$858.34
$904.40
$1,068.02
$1,061.25
$1,104.73
$1,150.79
$1,314.41
$246.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$644.16
$731.12
$823.24
$1,150.48
$1,748.28
$890.55
$977.51
$1,069.63
$1,396.87
$1,136.94
$1,223.90
$1,316.02
$1,643.26
$1,383.33
$1,470.29
$1,562.41
$1,889.65
$246.39
Toc - Plan #101 UnitedHealthcare
Gold

(HMO) UHC Gold Value (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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
$382.11
$433.69
$488.33
$682.44
$1,037.04
$674.42
$726.00
$780.64
$974.75
$966.73
$1,018.31
$1,072.95
$1,267.06
$1,259.04
$1,310.62
$1,365.26
$1,559.37
$292.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.22
$867.38
$976.66
$1,364.88
$2,074.08
$1,056.53
$1,159.69
$1,268.97
$1,657.19
$1,348.84
$1,452.00
$1,561.28
$1,949.50
$1,641.15
$1,744.31
$1,853.59
$2,241.81
$292.31
Toc - Plan #102 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$399.89
$453.87
$511.06
$714.20
$1,085.29
$705.80
$759.78
$816.97
$1,020.11
$1,011.71
$1,065.69
$1,122.88
$1,326.02
$1,317.62
$1,371.60
$1,428.79
$1,631.93
$305.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$799.78
$907.74
$1,022.12
$1,428.40
$2,170.58
$1,105.69
$1,213.65
$1,328.03
$1,734.31
$1,411.60
$1,519.56
$1,633.94
$2,040.22
$1,717.51
$1,825.47
$1,939.85
$2,346.13
$305.91
Toc - Plan #103 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.77
$474.17
$533.92
$746.15
$1,133.84
$737.37
$793.77
$853.52
$1,065.75
$1,056.97
$1,113.37
$1,173.12
$1,385.35
$1,376.57
$1,432.97
$1,492.72
$1,704.95
$319.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.54
$948.34
$1,067.84
$1,492.30
$2,267.68
$1,155.14
$1,267.94
$1,387.44
$1,811.90
$1,474.74
$1,587.54
$1,707.04
$2,131.50
$1,794.34
$1,907.14
$2,026.64
$2,451.10
$319.60
Toc - Plan #104 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
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.70
$441.18
$496.76
$694.23
$1,054.94
$686.06
$738.54
$794.12
$991.59
$983.42
$1,035.90
$1,091.48
$1,288.95
$1,280.78
$1,333.26
$1,388.84
$1,586.31
$297.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.40
$882.36
$993.52
$1,388.46
$2,109.88
$1,074.76
$1,179.72
$1,290.88
$1,685.82
$1,372.12
$1,477.08
$1,588.24
$1,983.18
$1,669.48
$1,774.44
$1,885.60
$2,280.54
$297.36
Toc - Plan #105 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage 1 (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $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
$332.97
$377.92
$425.53
$594.68
$903.67
$587.69
$632.64
$680.25
$849.40
$842.41
$887.36
$934.97
$1,104.12
$1,097.13
$1,142.08
$1,189.69
$1,358.84
$254.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.94
$755.84
$851.06
$1,189.36
$1,807.34
$920.66
$1,010.56
$1,105.78
$1,444.08
$1,175.38
$1,265.28
$1,360.50
$1,698.80
$1,430.10
$1,520.00
$1,615.22
$1,953.52
$254.72
Toc - Plan #106 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.50
$387.60
$436.44
$609.92
$926.83
$602.75
$648.85
$697.69
$871.17
$864.00
$910.10
$958.94
$1,132.42
$1,125.25
$1,171.35
$1,220.19
$1,393.67
$261.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.00
$775.20
$872.88
$1,219.84
$1,853.66
$944.25
$1,036.45
$1,134.13
$1,481.09
$1,205.50
$1,297.70
$1,395.38
$1,742.34
$1,466.75
$1,558.95
$1,656.63
$2,003.59
$261.25
Toc - Plan #107 UnitedHealthcare
Silver

(HMO) UHC Silver Value (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

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

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
$325.26
$369.17
$415.68
$580.91
$882.75
$574.08
$617.99
$664.50
$829.73
$822.90
$866.81
$913.32
$1,078.55
$1,071.72
$1,115.63
$1,162.14
$1,327.37
$248.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$650.52
$738.34
$831.36
$1,161.82
$1,765.50
$899.34
$987.16
$1,080.18
$1,410.64
$1,148.16
$1,235.98
$1,329.00
$1,659.46
$1,396.98
$1,484.80
$1,577.82
$1,908.28
$248.82
Toc - Plan #108 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328.62
$372.98
$419.98
$586.92
$891.88
$580.02
$624.38
$671.38
$838.32
$831.42
$875.78
$922.78
$1,089.72
$1,082.82
$1,127.18
$1,174.18
$1,341.12
$251.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$657.24
$745.96
$839.96
$1,173.84
$1,783.76
$908.64
$997.36
$1,091.36
$1,425.24
$1,160.04
$1,248.76
$1,342.76
$1,676.64
$1,411.44
$1,500.16
$1,594.16
$1,928.04
$251.40
Toc - Plan #109 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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$329.12
$373.55
$420.62
$587.81
$893.24
$580.90
$625.33
$672.40
$839.59
$832.68
$877.11
$924.18
$1,091.37
$1,084.46
$1,128.89
$1,175.96
$1,343.15
$251.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$658.24
$747.10
$841.24
$1,175.62
$1,786.48
$910.02
$998.88
$1,093.02
$1,427.40
$1,161.80
$1,250.66
$1,344.80
$1,679.18
$1,413.58
$1,502.44
$1,596.58
$1,930.96
$251.78
Toc - Plan #110 UnitedHealthcare
Expanded Bronze

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

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
$9,100 $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
$280.43
$318.28
$358.39
$500.84
$761.08
$494.96
$532.81
$572.92
$715.37
$709.49
$747.34
$787.45
$929.90
$924.02
$961.87
$1,001.98
$1,144.43
$214.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$560.86
$636.56
$716.78
$1,001.68
$1,522.16
$775.39
$851.09
$931.31
$1,216.21
$989.92
$1,065.62
$1,145.84
$1,430.74
$1,204.45
$1,280.15
$1,360.37
$1,645.27
$214.53
Toc - Plan #111 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential (Preferred Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$269.01
$305.32
$343.79
$480.45
$730.08
$474.80
$511.11
$549.58
$686.24
$680.59
$716.90
$755.37
$892.03
$886.38
$922.69
$961.16
$1,097.82
$205.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$538.02
$610.64
$687.58
$960.90
$1,460.16
$743.81
$816.43
$893.37
$1,166.69
$949.60
$1,022.22
$1,099.16
$1,372.48
$1,155.39
$1,228.01
$1,304.95
$1,578.27
$205.79
Toc - Plan #112 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
$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
$277.53
$314.99
$354.68
$495.66
$753.21
$489.84
$527.30
$566.99
$707.97
$702.15
$739.61
$779.30
$920.28
$914.46
$951.92
$991.61
$1,132.59
$212.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$555.06
$629.98
$709.36
$991.32
$1,506.42
$767.37
$842.29
$921.67
$1,203.63
$979.68
$1,054.60
$1,133.98
$1,415.94
$1,191.99
$1,266.91
$1,346.29
$1,628.25
$212.31
Toc - Plan #113 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard 1

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
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$278.59
$316.20
$356.04
$497.57
$756.10
$491.71
$529.32
$569.16
$710.69
$704.83
$742.44
$782.28
$923.81
$917.95
$955.56
$995.40
$1,136.93
$213.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$557.18
$632.40
$712.08
$995.14
$1,512.20
$770.30
$845.52
$925.20
$1,208.26
$983.42
$1,058.64
$1,138.32
$1,421.38
$1,196.54
$1,271.76
$1,351.44
$1,634.50
$213.12
Toc - Plan #114 UnitedHealthcare
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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$261.19
$296.45
$333.81
$466.49
$708.88
$461.00
$496.26
$533.62
$666.30
$660.81
$696.07
$733.43
$866.11
$860.62
$895.88
$933.24
$1,065.92
$199.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$522.38
$592.90
$667.62
$932.98
$1,417.76
$722.19
$792.71
$867.43
$1,132.79
$922.00
$992.52
$1,067.24
$1,332.60
$1,121.81
$1,192.33
$1,267.05
$1,532.41
$199.81

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

Toc - Plan #115 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5000 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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$293.88
$333.56
$375.58
$524.88
$797.60
$518.70
$558.38
$600.40
$749.70
$743.52
$783.20
$825.22
$974.52
$968.34
$1,008.02
$1,050.04
$1,199.34
$224.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$587.76
$667.12
$751.16
$1,049.76
$1,595.20
$812.58
$891.94
$975.98
$1,274.58
$1,037.40
$1,116.76
$1,200.80
$1,499.40
$1,262.22
$1,341.58
$1,425.62
$1,724.22
$224.82
Toc - Plan #116 Cigna Healthcare
Silver

(HMO) Cigna Connect 3000 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
$335.25
$380.51
$428.45
$598.76
$909.87
$591.72
$636.98
$684.92
$855.23
$848.19
$893.45
$941.39
$1,111.70
$1,104.66
$1,149.92
$1,197.86
$1,368.17
$256.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.50
$761.02
$856.90
$1,197.52
$1,819.74
$926.97
$1,017.49
$1,113.37
$1,453.99
$1,183.44
$1,273.96
$1,369.84
$1,710.46
$1,439.91
$1,530.43
$1,626.31
$1,966.93
$256.47
Toc - Plan #117 Cigna Healthcare
Gold

(HMO) Cigna Connect 1000 Rx Copay

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.94
$452.80
$509.84
$712.51
$1,082.72
$704.13
$757.99
$815.03
$1,017.70
$1,009.32
$1,063.18
$1,120.22
$1,322.89
$1,314.51
$1,368.37
$1,425.41
$1,628.08
$305.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$797.88
$905.60
$1,019.68
$1,425.02
$2,165.44
$1,103.07
$1,210.79
$1,324.87
$1,730.21
$1,408.26
$1,515.98
$1,630.06
$2,035.40
$1,713.45
$1,821.17
$1,935.25
$2,340.59
$305.19
Toc - Plan #118 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 0A

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $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
$313.21
$355.49
$400.28
$559.39
$850.05
$552.82
$595.10
$639.89
$799.00
$792.43
$834.71
$879.50
$1,038.61
$1,032.04
$1,074.32
$1,119.11
$1,278.22
$239.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$626.42
$710.98
$800.56
$1,118.78
$1,700.10
$866.03
$950.59
$1,040.17
$1,358.39
$1,105.64
$1,190.20
$1,279.78
$1,598.00
$1,345.25
$1,429.81
$1,519.39
$1,837.61
$239.61
Toc - Plan #119 Cigna Healthcare
Silver

(HMO) Cigna Connect 6000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$337.85
$383.46
$431.77
$603.39
$916.92
$596.30
$641.91
$690.22
$861.84
$854.75
$900.36
$948.67
$1,120.29
$1,113.20
$1,158.81
$1,207.12
$1,378.74
$258.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$675.70
$766.92
$863.54
$1,206.78
$1,833.84
$934.15
$1,025.37
$1,121.99
$1,465.23
$1,192.60
$1,283.82
$1,380.44
$1,723.68
$1,451.05
$1,542.27
$1,638.89
$1,982.13
$258.45
Toc - Plan #120 Cigna Healthcare
Silver

(HMO) Cigna Connect 8000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.96
$386.99
$435.75
$608.96
$925.37
$601.80
$647.83
$696.59
$869.80
$862.64
$908.67
$957.43
$1,130.64
$1,123.48
$1,169.51
$1,218.27
$1,391.48
$260.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$681.92
$773.98
$871.50
$1,217.92
$1,850.74
$942.76
$1,034.82
$1,132.34
$1,478.76
$1,203.60
$1,295.66
$1,393.18
$1,739.60
$1,464.44
$1,556.50
$1,654.02
$2,000.44
$260.84
Toc - Plan #121 Cigna Healthcare
Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

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

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
$341.52
$387.63
$436.46
$609.95
$926.89
$602.78
$648.89
$697.72
$871.21
$864.04
$910.15
$958.98
$1,132.47
$1,125.30
$1,171.41
$1,220.24
$1,393.73
$261.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.04
$775.26
$872.92
$1,219.90
$1,853.78
$944.30
$1,036.52
$1,134.18
$1,481.16
$1,205.56
$1,297.78
$1,395.44
$1,742.42
$1,466.82
$1,559.04
$1,656.70
$2,003.68
$261.26
Toc - Plan #122 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect HSA 7050

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.45
$329.66
$371.19
$518.74
$788.28
$512.64
$551.85
$593.38
$740.93
$734.83
$774.04
$815.57
$963.12
$957.02
$996.23
$1,037.76
$1,185.31
$222.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.90
$659.32
$742.38
$1,037.48
$1,576.56
$803.09
$881.51
$964.57
$1,259.67
$1,025.28
$1,103.70
$1,186.76
$1,481.86
$1,247.47
$1,325.89
$1,408.95
$1,704.05
$222.19
Toc - Plan #123 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$289.13
$328.16
$369.51
$516.39
$784.70
$510.32
$549.35
$590.70
$737.58
$731.51
$770.54
$811.89
$958.77
$952.70
$991.73
$1,033.08
$1,179.96
$221.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$578.26
$656.32
$739.02
$1,032.78
$1,569.40
$799.45
$877.51
$960.21
$1,253.97
$1,020.64
$1,098.70
$1,181.40
$1,475.16
$1,241.83
$1,319.89
$1,402.59
$1,696.35
$221.19
Toc - Plan #124 Cigna Healthcare
Silver

(HMO) Cigna Connect 0B

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $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
$339.16
$384.95
$433.45
$605.75
$920.49
$598.62
$644.41
$692.91
$865.21
$858.08
$903.87
$952.37
$1,124.67
$1,117.54
$1,163.33
$1,211.83
$1,384.13
$259.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$678.32
$769.90
$866.90
$1,211.50
$1,840.98
$937.78
$1,029.36
$1,126.36
$1,470.96
$1,197.24
$1,288.82
$1,385.82
$1,730.42
$1,456.70
$1,548.28
$1,645.28
$1,989.88
$259.46
Toc - Plan #125 Cigna Healthcare
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.16
$386.08
$434.73
$607.53
$923.20
$600.38
$646.30
$694.95
$867.75
$860.60
$906.52
$955.17
$1,127.97
$1,120.82
$1,166.74
$1,215.39
$1,388.19
$260.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.32
$772.16
$869.46
$1,215.06
$1,846.40
$940.54
$1,032.38
$1,129.68
$1,475.28
$1,200.76
$1,292.60
$1,389.90
$1,735.50
$1,460.98
$1,552.82
$1,650.12
$1,995.72
$260.22
Toc - Plan #126 Cigna Healthcare
Bronze

(HMO) Cigna Simple Choice 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$276.19
$313.48
$352.98
$493.28
$749.59
$487.48
$524.77
$564.27
$704.57
$698.77
$736.06
$775.56
$915.86
$910.06
$947.35
$986.85
$1,127.15
$211.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$552.38
$626.96
$705.96
$986.56
$1,499.18
$763.67
$838.25
$917.25
$1,197.85
$974.96
$1,049.54
$1,128.54
$1,409.14
$1,186.25
$1,260.83
$1,339.83
$1,620.43
$211.29
Toc - Plan #127 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Simple Choice 7500

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
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$286.98
$325.72
$366.76
$512.54
$778.85
$506.52
$545.26
$586.30
$732.08
$726.06
$764.80
$805.84
$951.62
$945.60
$984.34
$1,025.38
$1,171.16
$219.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$573.96
$651.44
$733.52
$1,025.08
$1,557.70
$793.50
$870.98
$953.06
$1,244.62
$1,013.04
$1,090.52
$1,172.60
$1,464.16
$1,232.58
$1,310.06
$1,392.14
$1,683.70
$219.54
Toc - Plan #128 Cigna Healthcare
Silver

(HMO) Cigna Simple Choice 5800

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$334.25
$379.38
$427.18
$596.98
$907.16
$589.95
$635.08
$682.88
$852.68
$845.65
$890.78
$938.58
$1,108.38
$1,101.35
$1,146.48
$1,194.28
$1,364.08
$255.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$668.50
$758.76
$854.36
$1,193.96
$1,814.32
$924.20
$1,014.46
$1,110.06
$1,449.66
$1,179.90
$1,270.16
$1,365.76
$1,705.36
$1,435.60
$1,525.86
$1,621.46
$1,961.06
$255.70
Toc - Plan #129 Cigna Healthcare
Gold

(HMO) Cigna Simple Choice 2000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.87
$444.77
$500.81
$699.88
$1,063.54
$691.65
$744.55
$800.59
$999.66
$991.43
$1,044.33
$1,100.37
$1,299.44
$1,291.21
$1,344.11
$1,400.15
$1,599.22
$299.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.74
$889.54
$1,001.62
$1,399.76
$2,127.08
$1,083.52
$1,189.32
$1,301.40
$1,699.54
$1,383.30
$1,489.10
$1,601.18
$1,999.32
$1,683.08
$1,788.88
$1,900.96
$2,299.10
$299.78
Toc - Plan #130 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 7600 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.89
$327.89
$369.20
$515.96
$784.05
$509.89
$548.89
$590.20
$736.96
$730.89
$769.89
$811.20
$957.96
$951.89
$990.89
$1,032.20
$1,178.96
$221.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$577.78
$655.78
$738.40
$1,031.92
$1,568.10
$798.78
$876.78
$959.40
$1,252.92
$1,019.78
$1,097.78
$1,180.40
$1,473.92
$1,240.78
$1,318.78
$1,401.40
$1,694.92
$221.00

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915 | TTY: 1-877-336-3915

Toc - Plan #131 Aetna CVS Health
Expanded Bronze

(HMO) Bronze: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$8,800 $17,600 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
$282.73
$320.90
$361.33
$504.96
$767.34
$499.02
$537.19
$577.62
$721.25
$715.31
$753.48
$793.91
$937.54
$931.60
$969.77
$1,010.20
$1,153.83
$216.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$565.46
$641.80
$722.66
$1,009.92
$1,534.68
$781.75
$858.09
$938.95
$1,226.21
$998.04
$1,074.38
$1,155.24
$1,442.50
$1,214.33
$1,290.67
$1,371.53
$1,658.79
$216.29
Toc - Plan #132 Aetna CVS Health
Expanded Bronze

(HMO) Bronze: Aetna network of doctors & hospitals + Low-cost MinuteClinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,100 $14,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$278.03
$315.57
$355.32
$496.56
$754.58
$490.72
$528.26
$568.01
$709.25
$703.41
$740.95
$780.70
$921.94
$916.10
$953.64
$993.39
$1,134.63
$212.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$556.06
$631.14
$710.64
$993.12
$1,509.16
$768.75
$843.83
$923.33
$1,205.81
$981.44
$1,056.52
$1,136.02
$1,418.50
$1,194.13
$1,269.21
$1,348.71
$1,631.19
$212.69
Toc - Plan #133 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$267.64
$303.77
$342.04
$478.00
$726.36
$472.38
$508.51
$546.78
$682.74
$677.12
$713.25
$751.52
$887.48
$881.86
$917.99
$956.26
$1,092.22
$204.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$535.28
$607.54
$684.08
$956.00
$1,452.72
$740.02
$812.28
$888.82
$1,160.74
$944.76
$1,017.02
$1,093.56
$1,365.48
$1,149.50
$1,221.76
$1,298.30
$1,570.22
$204.74
Toc - Plan #134 Aetna CVS Health
Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

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
$422.51
$479.55
$539.97
$754.61
$1,146.70
$745.73
$802.77
$863.19
$1,077.83
$1,068.95
$1,125.99
$1,186.41
$1,401.05
$1,392.17
$1,449.21
$1,509.63
$1,724.27
$323.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.02
$959.10
$1,079.94
$1,509.22
$2,293.40
$1,168.24
$1,282.32
$1,403.16
$1,832.44
$1,491.46
$1,605.54
$1,726.38
$2,155.66
$1,814.68
$1,928.76
$2,049.60
$2,478.88
$323.22
Toc - Plan #135 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.43
$423.85
$477.25
$666.95
$1,013.50
$659.11
$709.53
$762.93
$952.63
$944.79
$995.21
$1,048.61
$1,238.31
$1,230.47
$1,280.89
$1,334.29
$1,523.99
$285.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.86
$847.70
$954.50
$1,333.90
$2,027.00
$1,032.54
$1,133.38
$1,240.18
$1,619.58
$1,318.22
$1,419.06
$1,525.86
$1,905.26
$1,603.90
$1,704.74
$1,811.54
$2,190.94
$285.68
Toc - Plan #136 Aetna CVS Health
Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$4,550 $9,100 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$350.27
$397.56
$447.65
$625.59
$950.64
$618.23
$665.52
$715.61
$893.55
$886.19
$933.48
$983.57
$1,161.51
$1,154.15
$1,201.44
$1,251.53
$1,429.47
$267.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700.54
$795.12
$895.30
$1,251.18
$1,901.28
$968.50
$1,063.08
$1,163.26
$1,519.14
$1,236.46
$1,331.04
$1,431.22
$1,787.10
$1,504.42
$1,599.00
$1,699.18
$2,055.06
$267.96
Toc - Plan #137 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$347.42
$394.32
$444.00
$620.49
$942.89
$613.19
$660.09
$709.77
$886.26
$878.96
$925.86
$975.54
$1,152.03
$1,144.73
$1,191.63
$1,241.31
$1,417.80
$265.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$694.84
$788.64
$888.00
$1,240.98
$1,885.78
$960.61
$1,054.41
$1,153.77
$1,506.75
$1,226.38
$1,320.18
$1,419.54
$1,772.52
$1,492.15
$1,585.95
$1,685.31
$2,038.29
$265.77
Toc - Plan #138 Aetna CVS Health
Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$354.02
$401.82
$452.44
$632.29
$960.82
$624.85
$672.65
$723.27
$903.12
$895.68
$943.48
$994.10
$1,173.95
$1,166.51
$1,214.31
$1,264.93
$1,444.78
$270.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.04
$803.64
$904.88
$1,264.58
$1,921.64
$978.87
$1,074.47
$1,175.71
$1,535.41
$1,249.70
$1,345.30
$1,446.54
$1,806.24
$1,520.53
$1,616.13
$1,717.37
$2,077.07
$270.83
Toc - Plan #139 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.71
$362.87
$408.59
$571.00
$867.70
$564.29
$607.45
$653.17
$815.58
$808.87
$852.03
$897.75
$1,060.16
$1,053.45
$1,096.61
$1,142.33
$1,304.74
$244.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$639.42
$725.74
$817.18
$1,142.00
$1,735.40
$884.00
$970.32
$1,061.76
$1,386.58
$1,128.58
$1,214.90
$1,306.34
$1,631.16
$1,373.16
$1,459.48
$1,550.92
$1,875.74
$244.58

‡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 139 plans offered in Rating Area 1.

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2023 Obamacare Plans for Cook County, IL

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