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Ambetter from Sunflower Health Plan

Local: 1-844-518-9505 | Toll Free: 1-844-518-9505 | TTY: 1-844-546-9713

Toc - Plan #1 Ambetter from Sunflower Health Plan
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$365.05
$414.32
$466.52
$651.96
$990.72
$644.31
$693.58
$745.78
$931.22
$923.57
$972.84
$1,025.04
$1,210.48
$1,202.83
$1,252.10
$1,304.30
$1,489.74
$279.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.10
$828.64
$933.04
$1,303.92
$1,981.44
$1,009.36
$1,107.90
$1,212.30
$1,583.18
$1,288.62
$1,387.16
$1,491.56
$1,862.44
$1,567.88
$1,666.42
$1,770.82
$2,141.70
$279.26
Toc - Plan #2 Ambetter from Sunflower Health Plan
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$384.10
$435.95
$490.87
$685.99
$1,042.43
$677.93
$729.78
$784.70
$979.82
$971.76
$1,023.61
$1,078.53
$1,273.65
$1,265.59
$1,317.44
$1,372.36
$1,567.48
$293.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.20
$871.90
$981.74
$1,371.98
$2,084.86
$1,062.03
$1,165.73
$1,275.57
$1,665.81
$1,355.86
$1,459.56
$1,569.40
$1,959.64
$1,649.69
$1,753.39
$1,863.23
$2,253.47
$293.83
Toc - Plan #3 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$281.75
$319.77
$360.06
$503.18
$764.64
$497.28
$535.30
$575.59
$718.71
$712.81
$750.83
$791.12
$934.24
$928.34
$966.36
$1,006.65
$1,149.77
$215.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$563.50
$639.54
$720.12
$1,006.36
$1,529.28
$779.03
$855.07
$935.65
$1,221.89
$994.56
$1,070.60
$1,151.18
$1,437.42
$1,210.09
$1,286.13
$1,366.71
$1,652.95
$215.53
Toc - Plan #4 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$309.27
$351.01
$395.24
$552.34
$839.34
$545.85
$587.59
$631.82
$788.92
$782.43
$824.17
$868.40
$1,025.50
$1,019.01
$1,060.75
$1,104.98
$1,262.08
$236.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$618.54
$702.02
$790.48
$1,104.68
$1,678.68
$855.12
$938.60
$1,027.06
$1,341.26
$1,091.70
$1,175.18
$1,263.64
$1,577.84
$1,328.28
$1,411.76
$1,500.22
$1,814.42
$236.58
Toc - Plan #5 Ambetter from Sunflower Health Plan
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$367.57
$417.18
$469.74
$656.46
$997.55
$648.75
$698.36
$750.92
$937.64
$929.93
$979.54
$1,032.10
$1,218.82
$1,211.11
$1,260.72
$1,313.28
$1,500.00
$281.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.14
$834.36
$939.48
$1,312.92
$1,995.10
$1,016.32
$1,115.54
$1,220.66
$1,594.10
$1,297.50
$1,396.72
$1,501.84
$1,875.28
$1,578.68
$1,677.90
$1,783.02
$2,156.46
$281.18
Toc - Plan #6 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$302.12
$342.89
$386.09
$539.56
$819.92
$533.23
$574.00
$617.20
$770.67
$764.34
$805.11
$848.31
$1,001.78
$995.45
$1,036.22
$1,079.42
$1,232.89
$231.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.24
$685.78
$772.18
$1,079.12
$1,639.84
$835.35
$916.89
$1,003.29
$1,310.23
$1,066.46
$1,148.00
$1,234.40
$1,541.34
$1,297.57
$1,379.11
$1,465.51
$1,772.45
$231.11
Toc - Plan #7 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$341.03
$387.06
$435.82
$609.06
$925.53
$601.91
$647.94
$696.70
$869.94
$862.79
$908.82
$957.58
$1,130.82
$1,123.67
$1,169.70
$1,218.46
$1,391.70
$260.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.06
$774.12
$871.64
$1,218.12
$1,851.06
$942.94
$1,035.00
$1,132.52
$1,479.00
$1,203.82
$1,295.88
$1,393.40
$1,739.88
$1,464.70
$1,556.76
$1,654.28
$2,000.76
$260.88
Toc - Plan #8 Ambetter from Sunflower Health Plan
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$356.58
$404.71
$455.70
$636.83
$967.73
$629.36
$677.49
$728.48
$909.61
$902.14
$950.27
$1,001.26
$1,182.39
$1,174.92
$1,223.05
$1,274.04
$1,455.17
$272.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.16
$809.42
$911.40
$1,273.66
$1,935.46
$985.94
$1,082.20
$1,184.18
$1,546.44
$1,258.72
$1,354.98
$1,456.96
$1,819.22
$1,531.50
$1,627.76
$1,729.74
$2,092.00
$272.78
Toc - Plan #9 Ambetter from Sunflower Health Plan
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$360.12
$408.73
$460.22
$643.16
$977.34
$635.61
$684.22
$735.71
$918.65
$911.10
$959.71
$1,011.20
$1,194.14
$1,186.59
$1,235.20
$1,286.69
$1,469.63
$275.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.24
$817.46
$920.44
$1,286.32
$1,954.68
$995.73
$1,092.95
$1,195.93
$1,561.81
$1,271.22
$1,368.44
$1,471.42
$1,837.30
$1,546.71
$1,643.93
$1,746.91
$2,112.79
$275.49
Toc - Plan #10 Ambetter from Sunflower Health Plan
Silver

(EPO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$369.32
$419.17
$471.98
$659.59
$1,002.31
$651.84
$701.69
$754.50
$942.11
$934.36
$984.21
$1,037.02
$1,224.63
$1,216.88
$1,266.73
$1,319.54
$1,507.15
$282.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.64
$838.34
$943.96
$1,319.18
$2,004.62
$1,021.16
$1,120.86
$1,226.48
$1,601.70
$1,303.68
$1,403.38
$1,509.00
$1,884.22
$1,586.20
$1,685.90
$1,791.52
$2,166.74
$282.52
Toc - Plan #11 Ambetter from Sunflower Health Plan
Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$422.84
$479.91
$540.37
$755.17
$1,147.55
$746.30
$803.37
$863.83
$1,078.63
$1,069.76
$1,126.83
$1,187.29
$1,402.09
$1,393.22
$1,450.29
$1,510.75
$1,725.55
$323.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.68
$959.82
$1,080.74
$1,510.34
$2,295.10
$1,169.14
$1,283.28
$1,404.20
$1,833.80
$1,492.60
$1,606.74
$1,727.66
$2,157.26
$1,816.06
$1,930.20
$2,051.12
$2,480.72
$323.46
Toc - Plan #12 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$296.17
$336.14
$378.49
$528.94
$803.77
$522.73
$562.70
$605.05
$755.50
$749.29
$789.26
$831.61
$982.06
$975.85
$1,015.82
$1,058.17
$1,208.62
$226.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$592.34
$672.28
$756.98
$1,057.88
$1,607.54
$818.90
$898.84
$983.54
$1,284.44
$1,045.46
$1,125.40
$1,210.10
$1,511.00
$1,272.02
$1,351.96
$1,436.66
$1,737.56
$226.56
Toc - Plan #13 Ambetter from Sunflower Health Plan
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$357.05
$405.25
$456.30
$637.68
$969.02
$630.19
$678.39
$729.44
$910.82
$903.33
$951.53
$1,002.58
$1,183.96
$1,176.47
$1,224.67
$1,275.72
$1,457.10
$273.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714.10
$810.50
$912.60
$1,275.36
$1,938.04
$987.24
$1,083.64
$1,185.74
$1,548.50
$1,260.38
$1,356.78
$1,458.88
$1,821.64
$1,533.52
$1,629.92
$1,732.02
$2,094.78
$273.14
Toc - Plan #14 Ambetter from Sunflower Health Plan
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$364.36
$413.53
$465.63
$650.72
$988.83
$643.08
$692.25
$744.35
$929.44
$921.80
$970.97
$1,023.07
$1,208.16
$1,200.52
$1,249.69
$1,301.79
$1,486.88
$278.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728.72
$827.06
$931.26
$1,301.44
$1,977.66
$1,007.44
$1,105.78
$1,209.98
$1,580.16
$1,286.16
$1,384.50
$1,488.70
$1,858.88
$1,564.88
$1,663.22
$1,767.42
$2,137.60
$278.72
Toc - Plan #15 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$292.10
$331.52
$373.29
$521.67
$792.72
$515.55
$554.97
$596.74
$745.12
$739.00
$778.42
$820.19
$968.57
$962.45
$1,001.87
$1,043.64
$1,192.02
$223.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$584.20
$663.04
$746.58
$1,043.34
$1,585.44
$807.65
$886.49
$970.03
$1,266.79
$1,031.10
$1,109.94
$1,193.48
$1,490.24
$1,254.55
$1,333.39
$1,416.93
$1,713.69
$223.45
Toc - Plan #16 Ambetter from Sunflower Health Plan
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$398.21
$451.96
$508.91
$711.19
$1,080.73
$702.84
$756.59
$813.54
$1,015.82
$1,007.47
$1,061.22
$1,118.17
$1,320.45
$1,312.10
$1,365.85
$1,422.80
$1,625.08
$304.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.42
$903.92
$1,017.82
$1,422.38
$2,161.46
$1,101.05
$1,208.55
$1,322.45
$1,727.01
$1,405.68
$1,513.18
$1,627.08
$2,031.64
$1,710.31
$1,817.81
$1,931.71
$2,336.27
$304.63
Toc - Plan #17 Ambetter from Sunflower Health Plan
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$378.46
$429.54
$483.66
$675.91
$1,027.11
$667.97
$719.05
$773.17
$965.42
$957.48
$1,008.56
$1,062.68
$1,254.93
$1,246.99
$1,298.07
$1,352.19
$1,544.44
$289.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.92
$859.08
$967.32
$1,351.82
$2,054.22
$1,046.43
$1,148.59
$1,256.83
$1,641.33
$1,335.94
$1,438.10
$1,546.34
$1,930.84
$1,625.45
$1,727.61
$1,835.85
$2,220.35
$289.51
Toc - Plan #18 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$320.63
$363.91
$409.76
$572.63
$870.17
$565.91
$609.19
$655.04
$817.91
$811.19
$854.47
$900.32
$1,063.19
$1,056.47
$1,099.75
$1,145.60
$1,308.47
$245.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.26
$727.82
$819.52
$1,145.26
$1,740.34
$886.54
$973.10
$1,064.80
$1,390.54
$1,131.82
$1,218.38
$1,310.08
$1,635.82
$1,377.10
$1,463.66
$1,555.36
$1,881.10
$245.28
Toc - Plan #19 Ambetter from Sunflower Health Plan
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$381.07
$432.50
$487.00
$680.57
$1,034.20
$672.58
$724.01
$778.51
$972.08
$964.09
$1,015.52
$1,070.02
$1,263.59
$1,255.60
$1,307.03
$1,361.53
$1,555.10
$291.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.14
$865.00
$974.00
$1,361.14
$2,068.40
$1,053.65
$1,156.51
$1,265.51
$1,652.65
$1,345.16
$1,448.02
$1,557.02
$1,944.16
$1,636.67
$1,739.53
$1,848.53
$2,235.67
$291.51
Toc - Plan #20 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$313.21
$355.49
$400.28
$559.38
$850.04
$552.81
$595.09
$639.88
$798.98
$792.41
$834.69
$879.48
$1,038.58
$1,032.01
$1,074.29
$1,119.08
$1,278.18
$239.60
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
$1,118.76
$1,700.08
$866.02
$950.58
$1,040.16
$1,358.36
$1,105.62
$1,190.18
$1,279.76
$1,597.96
$1,345.22
$1,429.78
$1,519.36
$1,837.56
$239.60
Toc - Plan #21 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$353.56
$401.28
$451.83
$631.44
$959.53
$624.02
$671.74
$722.29
$901.90
$894.48
$942.20
$992.75
$1,172.36
$1,164.94
$1,212.66
$1,263.21
$1,442.82
$270.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.12
$802.56
$903.66
$1,262.88
$1,919.06
$977.58
$1,073.02
$1,174.12
$1,533.34
$1,248.04
$1,343.48
$1,444.58
$1,803.80
$1,518.50
$1,613.94
$1,715.04
$2,074.26
$270.46
Toc - Plan #22 Ambetter from Sunflower Health Plan
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$373.35
$423.74
$477.13
$666.79
$1,013.25
$658.96
$709.35
$762.74
$952.40
$944.57
$994.96
$1,048.35
$1,238.01
$1,230.18
$1,280.57
$1,333.96
$1,523.62
$285.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.70
$847.48
$954.26
$1,333.58
$2,026.50
$1,032.31
$1,133.09
$1,239.87
$1,619.19
$1,317.92
$1,418.70
$1,525.48
$1,904.80
$1,603.53
$1,704.31
$1,811.09
$2,190.41
$285.61
Toc - Plan #23 Ambetter from Sunflower Health Plan
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$369.68
$419.57
$472.44
$660.23
$1,003.28
$652.48
$702.37
$755.24
$943.03
$935.28
$985.17
$1,038.04
$1,225.83
$1,218.08
$1,267.97
$1,320.84
$1,508.63
$282.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$739.36
$839.14
$944.88
$1,320.46
$2,006.56
$1,022.16
$1,121.94
$1,227.68
$1,603.26
$1,304.96
$1,404.74
$1,510.48
$1,886.06
$1,587.76
$1,687.54
$1,793.28
$2,168.86
$282.80
Toc - Plan #24 Ambetter from Sunflower Health Plan
Silver

(EPO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$382.89
$434.57
$489.32
$683.82
$1,039.13
$675.79
$727.47
$782.22
$976.72
$968.69
$1,020.37
$1,075.12
$1,269.62
$1,261.59
$1,313.27
$1,368.02
$1,562.52
$292.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.78
$869.14
$978.64
$1,367.64
$2,078.26
$1,058.68
$1,162.04
$1,271.54
$1,660.54
$1,351.58
$1,454.94
$1,564.44
$1,953.44
$1,644.48
$1,747.84
$1,857.34
$2,246.34
$292.90
Toc - Plan #25 Ambetter from Sunflower Health Plan
Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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
$438.37
$497.54
$560.22
$782.91
$1,189.70
$773.71
$832.88
$895.56
$1,118.25
$1,109.05
$1,168.22
$1,230.90
$1,453.59
$1,444.39
$1,503.56
$1,566.24
$1,788.93
$335.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$876.74
$995.08
$1,120.44
$1,565.82
$2,379.40
$1,212.08
$1,330.42
$1,455.78
$1,901.16
$1,547.42
$1,665.76
$1,791.12
$2,236.50
$1,882.76
$2,001.10
$2,126.46
$2,571.84
$335.34
Toc - Plan #26 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Ambetter Virtual Access Bronze - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$294.41
$334.15
$376.25
$525.81
$799.01
$519.63
$559.37
$601.47
$751.03
$744.85
$784.59
$826.69
$976.25
$970.07
$1,009.81
$1,051.91
$1,201.47
$225.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$588.82
$668.30
$752.50
$1,051.62
$1,598.02
$814.04
$893.52
$977.72
$1,276.84
$1,039.26
$1,118.74
$1,202.94
$1,502.06
$1,264.48
$1,343.96
$1,428.16
$1,727.28
$225.22
Toc - Plan #27 Ambetter from Sunflower Health Plan
Silver

(EPO) Ambetter Virtual Access Silver - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$7,400 $14,800 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
$352.31
$399.86
$450.24
$629.21
$956.14
$621.82
$669.37
$719.75
$898.72
$891.33
$938.88
$989.26
$1,168.23
$1,160.84
$1,208.39
$1,258.77
$1,437.74
$269.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704.62
$799.72
$900.48
$1,258.42
$1,912.28
$974.13
$1,069.23
$1,169.99
$1,527.93
$1,243.64
$1,338.74
$1,439.50
$1,797.44
$1,513.15
$1,608.25
$1,709.01
$2,066.95
$269.51
Toc - Plan #28 Ambetter from Sunflower Health Plan
Gold

(EPO) Ambetter Virtual Access Gold - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 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
$373.04
$423.39
$476.74
$666.24
$1,012.41
$658.41
$708.76
$762.11
$951.61
$943.78
$994.13
$1,047.48
$1,236.98
$1,229.15
$1,279.50
$1,332.85
$1,522.35
$285.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.08
$846.78
$953.48
$1,332.48
$2,024.82
$1,031.45
$1,132.15
$1,238.85
$1,617.85
$1,316.82
$1,417.52
$1,524.22
$1,903.22
$1,602.19
$1,702.89
$1,809.59
$2,188.59
$285.37

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-866-735-2957

Toc - Plan #29 Medica
Expanded Bronze

(EPO) Select by Medica Bronze HSA ($0 Virtual Care after deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.04
$472.19
$531.69
$743.03
$1,129.10
$734.30
$790.45
$849.95
$1,061.29
$1,052.56
$1,108.71
$1,168.21
$1,379.55
$1,370.82
$1,426.97
$1,486.47
$1,697.81
$318.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.08
$944.38
$1,063.38
$1,486.06
$2,258.20
$1,150.34
$1,262.64
$1,381.64
$1,804.32
$1,468.60
$1,580.90
$1,699.90
$2,122.58
$1,786.86
$1,899.16
$2,018.16
$2,440.84
$318.26
Toc - Plan #30 Medica
Catastrophic

(EPO) Select by Medica Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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
$247.06
$280.40
$315.72
$441.22
$670.48
$436.05
$469.39
$504.71
$630.21
$625.04
$658.38
$693.70
$819.20
$814.03
$847.37
$882.69
$1,008.19
$188.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$494.12
$560.80
$631.44
$882.44
$1,340.96
$683.11
$749.79
$820.43
$1,071.43
$872.10
$938.78
$1,009.42
$1,260.42
$1,061.09
$1,127.77
$1,198.41
$1,449.41
$188.99
Toc - Plan #31 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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
$354.80
$402.68
$453.42
$633.65
$962.89
$626.21
$674.09
$724.83
$905.06
$897.62
$945.50
$996.24
$1,176.47
$1,169.03
$1,216.91
$1,267.65
$1,447.88
$271.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.60
$805.36
$906.84
$1,267.30
$1,925.78
$981.01
$1,076.77
$1,178.25
$1,538.71
$1,252.42
$1,348.18
$1,449.66
$1,810.12
$1,523.83
$1,619.59
$1,721.07
$2,081.53
$271.41
Toc - Plan #32 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 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
$344.30
$390.77
$440.01
$614.91
$934.41
$607.68
$654.15
$703.39
$878.29
$871.06
$917.53
$966.77
$1,141.67
$1,134.44
$1,180.91
$1,230.15
$1,405.05
$263.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.60
$781.54
$880.02
$1,229.82
$1,868.82
$951.98
$1,044.92
$1,143.40
$1,493.20
$1,215.36
$1,308.30
$1,406.78
$1,756.58
$1,478.74
$1,571.68
$1,670.16
$2,019.96
$263.38
Toc - Plan #33 Medica
Gold

(EPO) Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$510.57
$579.49
$652.50
$911.86
$1,385.66
$901.15
$970.07
$1,043.08
$1,302.44
$1,291.73
$1,360.65
$1,433.66
$1,693.02
$1,682.31
$1,751.23
$1,824.24
$2,083.60
$390.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,021.14
$1,158.98
$1,305.00
$1,823.72
$2,771.32
$1,411.72
$1,549.56
$1,695.58
$2,214.30
$1,802.30
$1,940.14
$2,086.16
$2,604.88
$2,192.88
$2,330.72
$2,476.74
$2,995.46
$390.58
Toc - Plan #34 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Premier ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$345.66
$392.31
$441.74
$617.33
$938.10
$610.08
$656.73
$706.16
$881.75
$874.50
$921.15
$970.58
$1,146.17
$1,138.92
$1,185.57
$1,235.00
$1,410.59
$264.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$691.32
$784.62
$883.48
$1,234.66
$1,876.20
$955.74
$1,049.04
$1,147.90
$1,499.08
$1,220.16
$1,313.46
$1,412.32
$1,763.50
$1,484.58
$1,577.88
$1,676.74
$2,027.92
$264.42
Toc - Plan #35 Medica
Gold

(EPO) Select by Medica Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$484.43
$549.81
$619.09
$865.17
$1,314.71
$855.01
$920.39
$989.67
$1,235.75
$1,225.59
$1,290.97
$1,360.25
$1,606.33
$1,596.17
$1,661.55
$1,730.83
$1,976.91
$370.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$968.86
$1,099.62
$1,238.18
$1,730.34
$2,629.42
$1,339.44
$1,470.20
$1,608.76
$2,100.92
$1,710.02
$1,840.78
$1,979.34
$2,471.50
$2,080.60
$2,211.36
$2,349.92
$2,842.08
$370.58
Toc - Plan #36 Medica
Silver

(EPO) Select by Medica Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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
$527.58
$598.79
$674.23
$942.24
$1,431.82
$931.17
$1,002.38
$1,077.82
$1,345.83
$1,334.76
$1,405.97
$1,481.41
$1,749.42
$1,738.35
$1,809.56
$1,885.00
$2,153.01
$403.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,055.16
$1,197.58
$1,348.46
$1,884.48
$2,863.64
$1,458.75
$1,601.17
$1,752.05
$2,288.07
$1,862.34
$2,004.76
$2,155.64
$2,691.66
$2,265.93
$2,408.35
$2,559.23
$3,095.25
$403.59
Toc - Plan #37 Medica
Bronze

(EPO) Select by Medica Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.04
$377.99
$425.61
$594.79
$903.85
$587.81
$632.76
$680.38
$849.56
$842.58
$887.53
$935.15
$1,104.33
$1,097.35
$1,142.30
$1,189.92
$1,359.10
$254.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.08
$755.98
$851.22
$1,189.58
$1,807.70
$920.85
$1,010.75
$1,105.99
$1,444.35
$1,175.62
$1,265.52
$1,360.76
$1,699.12
$1,430.39
$1,520.29
$1,615.53
$1,953.89
$254.77

ADVERTISEMENT

Oscar Insurance Company

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755

Toc - Plan #38 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$285.26
$323.76
$364.56
$509.46
$774.18
$503.48
$541.98
$582.78
$727.68
$721.70
$760.20
$801.00
$945.90
$939.92
$978.42
$1,019.22
$1,164.12
$218.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$570.52
$647.52
$729.12
$1,018.92
$1,548.36
$788.74
$865.74
$947.34
$1,237.14
$1,006.96
$1,083.96
$1,165.56
$1,455.36
$1,225.18
$1,302.18
$1,383.78
$1,673.58
$218.22
Toc - Plan #39 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- Deductible+PCP Saver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$344.70
$391.23
$440.52
$615.62
$935.50
$608.39
$654.92
$704.21
$879.31
$872.08
$918.61
$967.90
$1,143.00
$1,135.77
$1,182.30
$1,231.59
$1,406.69
$263.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$689.40
$782.46
$881.04
$1,231.24
$1,871.00
$953.09
$1,046.15
$1,144.73
$1,494.93
$1,216.78
$1,309.84
$1,408.42
$1,758.62
$1,480.47
$1,573.53
$1,672.11
$2,022.31
$263.69
Toc - Plan #40 Oscar Insurance Company
Silver

(EPO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$382.19
$433.78
$488.43
$682.57
$1,037.24
$674.56
$726.15
$780.80
$974.94
$966.93
$1,018.52
$1,073.17
$1,267.31
$1,259.30
$1,310.89
$1,365.54
$1,559.68
$292.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.38
$867.56
$976.86
$1,365.14
$2,074.48
$1,056.75
$1,159.93
$1,269.23
$1,657.51
$1,349.12
$1,452.30
$1,561.60
$1,949.88
$1,641.49
$1,744.67
$1,853.97
$2,242.25
$292.37
Toc - Plan #41 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$377.10
$428.00
$481.92
$673.48
$1,023.42
$665.57
$716.47
$770.39
$961.95
$954.04
$1,004.94
$1,058.86
$1,250.42
$1,242.51
$1,293.41
$1,347.33
$1,538.89
$288.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$754.20
$856.00
$963.84
$1,346.96
$2,046.84
$1,042.67
$1,144.47
$1,252.31
$1,635.43
$1,331.14
$1,432.94
$1,540.78
$1,923.90
$1,619.61
$1,721.41
$1,829.25
$2,212.37
$288.47
Toc - Plan #42 Oscar Insurance Company
Catastrophic

(EPO) Secure

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$240.59
$273.06
$307.46
$429.68
$652.93
$424.63
$457.10
$491.50
$613.72
$608.67
$641.14
$675.54
$797.76
$792.71
$825.18
$859.58
$981.80
$184.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$481.18
$546.12
$614.92
$859.36
$1,305.86
$665.22
$730.16
$798.96
$1,043.40
$849.26
$914.20
$983.00
$1,227.44
$1,033.30
$1,098.24
$1,167.04
$1,411.48
$184.04
Toc - Plan #43 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$306.18
$347.50
$391.28
$546.82
$830.94
$540.40
$581.72
$625.50
$781.04
$774.62
$815.94
$859.72
$1,015.26
$1,008.84
$1,050.16
$1,093.94
$1,249.48
$234.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.36
$695.00
$782.56
$1,093.64
$1,661.88
$846.58
$929.22
$1,016.78
$1,327.86
$1,080.80
$1,163.44
$1,251.00
$1,562.08
$1,315.02
$1,397.66
$1,485.22
$1,796.30
$234.22
Toc - Plan #44 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- PCP Saver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$305.88
$347.17
$390.91
$546.29
$830.14
$539.87
$581.16
$624.90
$780.28
$773.86
$815.15
$858.89
$1,014.27
$1,007.85
$1,049.14
$1,092.88
$1,248.26
$233.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$611.76
$694.34
$781.82
$1,092.58
$1,660.28
$845.75
$928.33
$1,015.81
$1,326.57
$1,079.74
$1,162.32
$1,249.80
$1,560.56
$1,313.73
$1,396.31
$1,483.79
$1,794.55
$233.99
Toc - Plan #45 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Deductible Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$310.44
$352.34
$396.73
$554.43
$842.51
$547.92
$589.82
$634.21
$791.91
$785.40
$827.30
$871.69
$1,029.39
$1,022.88
$1,064.78
$1,109.17
$1,266.87
$237.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.88
$704.68
$793.46
$1,108.86
$1,685.02
$858.36
$942.16
$1,030.94
$1,346.34
$1,095.84
$1,179.64
$1,268.42
$1,583.82
$1,333.32
$1,417.12
$1,505.90
$1,821.30
$237.48
Toc - Plan #46 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$365.41
$414.73
$466.98
$652.60
$991.69
$644.94
$694.26
$746.51
$932.13
$924.47
$973.79
$1,026.04
$1,211.66
$1,204.00
$1,253.32
$1,305.57
$1,491.19
$279.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.82
$829.46
$933.96
$1,305.20
$1,983.38
$1,010.35
$1,108.99
$1,213.49
$1,584.73
$1,289.88
$1,388.52
$1,493.02
$1,864.26
$1,569.41
$1,668.05
$1,772.55
$2,143.79
$279.53
Toc - Plan #47 Oscar Insurance Company
Silver

(EPO) Silver Elite- Deductible Saver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$387.06
$439.30
$494.65
$691.27
$1,050.45
$683.15
$735.39
$790.74
$987.36
$979.24
$1,031.48
$1,086.83
$1,283.45
$1,275.33
$1,327.57
$1,382.92
$1,579.54
$296.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774.12
$878.60
$989.30
$1,382.54
$2,100.90
$1,070.21
$1,174.69
$1,285.39
$1,678.63
$1,366.30
$1,470.78
$1,581.48
$1,974.72
$1,662.39
$1,766.87
$1,877.57
$2,270.81
$296.09
Toc - Plan #48 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$378.78
$429.90
$484.07
$676.48
$1,027.98
$668.54
$719.66
$773.83
$966.24
$958.30
$1,009.42
$1,063.59
$1,256.00
$1,248.06
$1,299.18
$1,353.35
$1,545.76
$289.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.56
$859.80
$968.14
$1,352.96
$2,055.96
$1,047.32
$1,149.56
$1,257.90
$1,642.72
$1,337.08
$1,439.32
$1,547.66
$1,932.48
$1,626.84
$1,729.08
$1,837.42
$2,222.24
$289.76
Toc - Plan #49 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$303.45
$344.41
$387.80
$541.95
$823.55
$535.58
$576.54
$619.93
$774.08
$767.71
$808.67
$852.06
$1,006.21
$999.84
$1,040.80
$1,084.19
$1,238.34
$232.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$606.90
$688.82
$775.60
$1,083.90
$1,647.10
$839.03
$920.95
$1,007.73
$1,316.03
$1,071.16
$1,153.08
$1,239.86
$1,548.16
$1,303.29
$1,385.21
$1,471.99
$1,780.29
$232.13
Toc - Plan #50 Oscar Insurance Company
Bronze

(EPO) Bronze Simple- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$275.90
$313.14
$352.59
$492.74
$748.77
$486.96
$524.20
$563.65
$703.80
$698.02
$735.26
$774.71
$914.86
$909.08
$946.32
$985.77
$1,125.92
$211.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$551.80
$626.28
$705.18
$985.48
$1,497.54
$762.86
$837.34
$916.24
$1,196.54
$973.92
$1,048.40
$1,127.30
$1,407.60
$1,184.98
$1,259.46
$1,338.36
$1,618.66
$211.06
Toc - Plan #51 Oscar Insurance Company
Silver

(EPO) Silver Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$370.95
$421.02
$474.06
$662.50
$1,006.73
$654.72
$704.79
$757.83
$946.27
$938.49
$988.56
$1,041.60
$1,230.04
$1,222.26
$1,272.33
$1,325.37
$1,513.81
$283.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$741.90
$842.04
$948.12
$1,325.00
$2,013.46
$1,025.67
$1,125.81
$1,231.89
$1,608.77
$1,309.44
$1,409.58
$1,515.66
$1,892.54
$1,593.21
$1,693.35
$1,799.43
$2,176.31
$283.77
Toc - Plan #52 Oscar Insurance Company
Gold

(EPO) Gold Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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
$391.78
$444.66
$500.69
$699.71
$1,063.27
$691.49
$744.37
$800.40
$999.42
$991.20
$1,044.08
$1,100.11
$1,299.13
$1,290.91
$1,343.79
$1,399.82
$1,598.84
$299.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.56
$889.32
$1,001.38
$1,399.42
$2,126.54
$1,083.27
$1,189.03
$1,301.09
$1,699.13
$1,382.98
$1,488.74
$1,600.80
$1,998.84
$1,682.69
$1,788.45
$1,900.51
$2,298.55
$299.71

ADVERTISEMENT

Cigna Healthcare

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

Toc - Plan #53 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 5900

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$404.53
$459.14
$516.99
$722.49
$1,097.90
$714.00
$768.61
$826.46
$1,031.96
$1,023.47
$1,078.08
$1,135.93
$1,341.43
$1,332.94
$1,387.55
$1,445.40
$1,650.90
$309.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$809.06
$918.28
$1,033.98
$1,444.98
$2,195.80
$1,118.53
$1,227.75
$1,343.45
$1,754.45
$1,428.00
$1,537.22
$1,652.92
$2,063.92
$1,737.47
$1,846.69
$1,962.39
$2,373.39
$309.47
Toc - Plan #54 Cigna Healthcare
Silver

(EPO) Cigna Connect 5000

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
$431.46
$489.71
$551.41
$770.60
$1,170.99
$761.53
$819.78
$881.48
$1,100.67
$1,091.60
$1,149.85
$1,211.55
$1,430.74
$1,421.67
$1,479.92
$1,541.62
$1,760.81
$330.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$862.92
$979.42
$1,102.82
$1,541.20
$2,341.98
$1,192.99
$1,309.49
$1,432.89
$1,871.27
$1,523.06
$1,639.56
$1,762.96
$2,201.34
$1,853.13
$1,969.63
$2,093.03
$2,531.41
$330.07
Toc - Plan #55 Cigna Healthcare
Gold

(EPO) Cigna Connect 800

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

Annual Out of Pocket Expenses:

Individual Family
$800 $1,600 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
$519.39
$589.51
$663.78
$927.63
$1,409.63
$916.72
$986.84
$1,061.11
$1,324.96
$1,314.05
$1,384.17
$1,458.44
$1,722.29
$1,711.38
$1,781.50
$1,855.77
$2,119.62
$397.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,038.78
$1,179.02
$1,327.56
$1,855.26
$2,819.26
$1,436.11
$1,576.35
$1,724.89
$2,252.59
$1,833.44
$1,973.68
$2,122.22
$2,649.92
$2,230.77
$2,371.01
$2,519.55
$3,047.25
$397.33
Toc - Plan #56 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$436.07
$494.94
$557.30
$778.82
$1,183.50
$769.67
$828.54
$890.90
$1,112.42
$1,103.27
$1,162.14
$1,224.50
$1,446.02
$1,436.87
$1,495.74
$1,558.10
$1,779.62
$333.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$872.14
$989.88
$1,114.60
$1,557.64
$2,367.00
$1,205.74
$1,323.48
$1,448.20
$1,891.24
$1,539.34
$1,657.08
$1,781.80
$2,224.84
$1,872.94
$1,990.68
$2,115.40
$2,558.44
$333.60
Toc - Plan #57 Cigna Healthcare
Silver

(EPO) 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
$434.87
$493.57
$555.76
$776.67
$1,180.22
$767.54
$826.24
$888.43
$1,109.34
$1,100.21
$1,158.91
$1,221.10
$1,442.01
$1,432.88
$1,491.58
$1,553.77
$1,774.68
$332.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869.74
$987.14
$1,111.52
$1,553.34
$2,360.44
$1,202.41
$1,319.81
$1,444.19
$1,886.01
$1,535.08
$1,652.48
$1,776.86
$2,218.68
$1,867.75
$1,985.15
$2,109.53
$2,551.35
$332.67
Toc - Plan #58 Cigna Healthcare
Expanded Bronze

(EPO) 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
$403.27
$457.71
$515.38
$720.24
$1,094.48
$711.77
$766.21
$823.88
$1,028.74
$1,020.27
$1,074.71
$1,132.38
$1,337.24
$1,328.77
$1,383.21
$1,440.88
$1,645.74
$308.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.54
$915.42
$1,030.76
$1,440.48
$2,188.96
$1,115.04
$1,223.92
$1,339.26
$1,748.98
$1,423.54
$1,532.42
$1,647.76
$2,057.48
$1,732.04
$1,840.92
$1,956.26
$2,365.98
$308.50
Toc - Plan #59 Cigna Healthcare
Expanded Bronze

(EPO) 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
$404.37
$458.96
$516.78
$722.20
$1,097.45
$713.71
$768.30
$826.12
$1,031.54
$1,023.05
$1,077.64
$1,135.46
$1,340.88
$1,332.39
$1,386.98
$1,444.80
$1,650.22
$309.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.74
$917.92
$1,033.56
$1,444.40
$2,194.90
$1,118.08
$1,227.26
$1,342.90
$1,753.74
$1,427.42
$1,536.60
$1,652.24
$2,063.08
$1,736.76
$1,845.94
$1,961.58
$2,372.42
$309.34
Toc - Plan #60 Cigna Healthcare
Silver

(EPO) 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
$433.27
$491.77
$553.72
$773.83
$1,175.91
$764.72
$823.22
$885.17
$1,105.28
$1,096.17
$1,154.67
$1,216.62
$1,436.73
$1,427.62
$1,486.12
$1,548.07
$1,768.18
$331.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$866.54
$983.54
$1,107.44
$1,547.66
$2,351.82
$1,197.99
$1,314.99
$1,438.89
$1,879.11
$1,529.44
$1,646.44
$1,770.34
$2,210.56
$1,860.89
$1,977.89
$2,101.79
$2,542.01
$331.45
Toc - Plan #61 Cigna Healthcare
Gold

(EPO) Cigna Connect 1900 Enhanced Diabetes Care

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

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
$524.11
$594.86
$669.81
$936.06
$1,422.43
$925.05
$995.80
$1,070.75
$1,337.00
$1,325.99
$1,396.74
$1,471.69
$1,737.94
$1,726.93
$1,797.68
$1,872.63
$2,138.88
$400.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,048.22
$1,189.72
$1,339.62
$1,872.12
$2,844.86
$1,449.16
$1,590.66
$1,740.56
$2,273.06
$1,850.10
$1,991.60
$2,141.50
$2,674.00
$2,251.04
$2,392.54
$2,542.44
$3,074.94
$400.94
Toc - Plan #62 Cigna Healthcare
Bronze

(EPO) 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
$385.06
$437.04
$492.11
$687.72
$1,045.05
$679.63
$731.61
$786.68
$982.29
$974.20
$1,026.18
$1,081.25
$1,276.86
$1,268.77
$1,320.75
$1,375.82
$1,571.43
$294.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.12
$874.08
$984.22
$1,375.44
$2,090.10
$1,064.69
$1,168.65
$1,278.79
$1,670.01
$1,359.26
$1,463.22
$1,573.36
$1,964.58
$1,653.83
$1,757.79
$1,867.93
$2,259.15
$294.57
Toc - Plan #63 Cigna Healthcare
Expanded Bronze

(EPO) 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
$400.75
$454.85
$512.16
$715.73
$1,087.63
$707.32
$761.42
$818.73
$1,022.30
$1,013.89
$1,067.99
$1,125.30
$1,328.87
$1,320.46
$1,374.56
$1,431.87
$1,635.44
$306.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$801.50
$909.70
$1,024.32
$1,431.46
$2,175.26
$1,108.07
$1,216.27
$1,330.89
$1,738.03
$1,414.64
$1,522.84
$1,637.46
$2,044.60
$1,721.21
$1,829.41
$1,944.03
$2,351.17
$306.57
Toc - Plan #64 Cigna Healthcare
Silver

(EPO) 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
$431.74
$490.02
$551.76
$771.09
$1,171.74
$762.02
$820.30
$882.04
$1,101.37
$1,092.30
$1,150.58
$1,212.32
$1,431.65
$1,422.58
$1,480.86
$1,542.60
$1,761.93
$330.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$863.48
$980.04
$1,103.52
$1,542.18
$2,343.48
$1,193.76
$1,310.32
$1,433.80
$1,872.46
$1,524.04
$1,640.60
$1,764.08
$2,202.74
$1,854.32
$1,970.88
$2,094.36
$2,533.02
$330.28
Toc - Plan #65 Cigna Healthcare
Gold

(EPO) 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
$520.76
$591.07
$665.54
$930.08
$1,413.35
$919.14
$989.45
$1,063.92
$1,328.46
$1,317.52
$1,387.83
$1,462.30
$1,726.84
$1,715.90
$1,786.21
$1,860.68
$2,125.22
$398.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,041.52
$1,182.14
$1,331.08
$1,860.16
$2,826.70
$1,439.90
$1,580.52
$1,729.46
$2,258.54
$1,838.28
$1,978.90
$2,127.84
$2,656.92
$2,236.66
$2,377.28
$2,526.22
$3,055.30
$398.38

ADVERTISEMENT

Blue Cross and Blue Shield of Kansas City

Local: 1-816-395-3558 | Toll Free: 1-888-800-4478

Toc - Plan #66 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$443.48
$503.35
$566.77
$792.06
$1,203.61
$782.74
$842.61
$906.03
$1,131.32
$1,122.00
$1,181.87
$1,245.29
$1,470.58
$1,461.26
$1,521.13
$1,584.55
$1,809.84
$339.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.96
$1,006.70
$1,133.54
$1,584.12
$2,407.22
$1,226.22
$1,345.96
$1,472.80
$1,923.38
$1,565.48
$1,685.22
$1,812.06
$2,262.64
$1,904.74
$2,024.48
$2,151.32
$2,601.90
$339.26
Toc - Plan #67 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$588.49
$667.93
$752.08
$1,051.04
$1,597.15
$1,038.68
$1,118.12
$1,202.27
$1,501.23
$1,488.87
$1,568.31
$1,652.46
$1,951.42
$1,939.06
$2,018.50
$2,102.65
$2,401.61
$450.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,176.98
$1,335.86
$1,504.16
$2,102.08
$3,194.30
$1,627.17
$1,786.05
$1,954.35
$2,552.27
$2,077.36
$2,236.24
$2,404.54
$3,002.46
$2,527.55
$2,686.43
$2,854.73
$3,452.65
$450.19
Toc - Plan #68 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$511.27
$580.29
$653.40
$913.12
$1,387.57
$902.39
$971.41
$1,044.52
$1,304.24
$1,293.51
$1,362.53
$1,435.64
$1,695.36
$1,684.63
$1,753.65
$1,826.76
$2,086.48
$391.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,022.54
$1,160.58
$1,306.80
$1,826.24
$2,775.14
$1,413.66
$1,551.70
$1,697.92
$2,217.36
$1,804.78
$1,942.82
$2,089.04
$2,608.48
$2,195.90
$2,333.94
$2,480.16
$2,999.60
$391.12
Toc - Plan #69 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 Blue Select EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$386.19
$438.33
$493.55
$689.74
$1,048.13
$681.63
$733.77
$788.99
$985.18
$977.07
$1,029.21
$1,084.43
$1,280.62
$1,272.51
$1,324.65
$1,379.87
$1,576.06
$295.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$772.38
$876.66
$987.10
$1,379.48
$2,096.26
$1,067.82
$1,172.10
$1,282.54
$1,674.92
$1,363.26
$1,467.54
$1,577.98
$1,970.36
$1,658.70
$1,762.98
$1,873.42
$2,265.80
$295.44
Toc - Plan #70 Blue Cross and Blue Shield of Kansas City
Gold

(EPO) Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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
$697.50
$791.66
$891.40
$1,245.73
$1,893.01
$1,231.09
$1,325.25
$1,424.99
$1,779.32
$1,764.68
$1,858.84
$1,958.58
$2,312.91
$2,298.27
$2,392.43
$2,492.17
$2,846.50
$533.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,395.00
$1,583.32
$1,782.80
$2,491.46
$3,786.02
$1,928.59
$2,116.91
$2,316.39
$3,025.05
$2,462.18
$2,650.50
$2,849.98
$3,558.64
$2,995.77
$3,184.09
$3,383.57
$4,092.23
$533.59
Toc - Plan #71 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 8700 Blue Select EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$8,700 $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
$378.42
$429.50
$483.61
$675.85
$1,027.02
$667.91
$718.99
$773.10
$965.34
$957.40
$1,008.48
$1,062.59
$1,254.83
$1,246.89
$1,297.97
$1,352.08
$1,544.32
$289.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.84
$859.00
$967.22
$1,351.70
$2,054.04
$1,046.33
$1,148.49
$1,256.71
$1,641.19
$1,335.82
$1,437.98
$1,546.20
$1,930.68
$1,625.31
$1,727.47
$1,835.69
$2,220.17
$289.49
Toc - Plan #72 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$475.15
$539.30
$607.24
$848.62
$1,289.56
$838.64
$902.79
$970.73
$1,212.11
$1,202.13
$1,266.28
$1,334.22
$1,575.60
$1,565.62
$1,629.77
$1,697.71
$1,939.09
$363.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$950.30
$1,078.60
$1,214.48
$1,697.24
$2,579.12
$1,313.79
$1,442.09
$1,577.97
$2,060.73
$1,677.28
$1,805.58
$1,941.46
$2,424.22
$2,040.77
$2,169.07
$2,304.95
$2,787.71
$363.49
Toc - Plan #73 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with BlueSelectEPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.35
$462.35
$520.60
$727.53
$1,105.56
$718.98
$773.98
$832.23
$1,039.16
$1,030.61
$1,085.61
$1,143.86
$1,350.79
$1,342.24
$1,397.24
$1,455.49
$1,662.42
$311.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.70
$924.70
$1,041.20
$1,455.06
$2,211.12
$1,126.33
$1,236.33
$1,352.83
$1,766.69
$1,437.96
$1,547.96
$1,664.46
$2,078.32
$1,749.59
$1,859.59
$1,976.09
$2,389.95
$311.63
Toc - Plan #74 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$509.40
$578.17
$651.01
$909.79
$1,382.51
$899.09
$967.86
$1,040.70
$1,299.48
$1,288.78
$1,357.55
$1,430.39
$1,689.17
$1,678.47
$1,747.24
$1,820.08
$2,078.86
$389.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,018.80
$1,156.34
$1,302.02
$1,819.58
$2,765.02
$1,408.49
$1,546.03
$1,691.71
$2,209.27
$1,798.18
$1,935.72
$2,081.40
$2,598.96
$2,187.87
$2,325.41
$2,471.09
$2,988.65
$389.69
Toc - Plan #75 Blue Cross and Blue Shield of Kansas City
Catastrophic

(EPO) Blue KC Catastrophic BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312.83
$355.06
$399.80
$558.72
$849.02
$552.15
$594.38
$639.12
$798.04
$791.47
$833.70
$878.44
$1,037.36
$1,030.79
$1,073.02
$1,117.76
$1,276.68
$239.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625.66
$710.12
$799.60
$1,117.44
$1,698.04
$864.98
$949.44
$1,038.92
$1,356.76
$1,104.30
$1,188.76
$1,278.24
$1,596.08
$1,343.62
$1,428.08
$1,517.56
$1,835.40
$239.32
Toc - Plan #76 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Standard Silver 5800 BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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
$520.84
$591.15
$665.63
$930.22
$1,413.56
$919.28
$989.59
$1,064.07
$1,328.66
$1,317.72
$1,388.03
$1,462.51
$1,727.10
$1,716.16
$1,786.47
$1,860.95
$2,125.54
$398.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,041.68
$1,182.30
$1,331.26
$1,860.44
$2,827.12
$1,440.12
$1,580.74
$1,729.70
$2,258.88
$1,838.56
$1,979.18
$2,128.14
$2,657.32
$2,237.00
$2,377.62
$2,526.58
$3,055.76
$398.44
Toc - Plan #77 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Standard Bronze 7500 BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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
$378.60
$429.72
$483.86
$676.19
$1,027.53
$668.23
$719.35
$773.49
$965.82
$957.86
$1,008.98
$1,063.12
$1,255.45
$1,247.49
$1,298.61
$1,352.75
$1,545.08
$289.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.20
$859.44
$967.72
$1,352.38
$2,055.06
$1,046.83
$1,149.07
$1,257.35
$1,642.01
$1,336.46
$1,438.70
$1,546.98
$1,931.64
$1,626.09
$1,728.33
$1,836.61
$2,221.27
$289.63

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-632-4195 | Toll Free: 1-877-632-4195 | TTY: 1-866-761-7748

Toc - Plan #78 UnitedHealthcare
Gold

(EPO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$378.24
$429.30
$483.39
$675.54
$1,026.55
$667.59
$718.65
$772.74
$964.89
$956.94
$1,008.00
$1,062.09
$1,254.24
$1,246.29
$1,297.35
$1,351.44
$1,543.59
$289.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.48
$858.60
$966.78
$1,351.08
$2,053.10
$1,045.83
$1,147.95
$1,256.13
$1,640.43
$1,335.18
$1,437.30
$1,545.48
$1,929.78
$1,624.53
$1,726.65
$1,834.83
$2,219.13
$289.35
Toc - Plan #79 UnitedHealthcare
Gold

(EPO) UHC Gold Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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
$390.94
$443.72
$499.62
$698.22
$1,061.01
$690.01
$742.79
$798.69
$997.29
$989.08
$1,041.86
$1,097.76
$1,296.36
$1,288.15
$1,340.93
$1,396.83
$1,595.43
$299.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.88
$887.44
$999.24
$1,396.44
$2,122.02
$1,080.95
$1,186.51
$1,298.31
$1,695.51
$1,380.02
$1,485.58
$1,597.38
$1,994.58
$1,679.09
$1,784.65
$1,896.45
$2,293.65
$299.07
Toc - Plan #80 UnitedHealthcare
Gold

(EPO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$382.80
$434.48
$489.22
$683.68
$1,038.92
$675.64
$727.32
$782.06
$976.52
$968.48
$1,020.16
$1,074.90
$1,269.36
$1,261.32
$1,313.00
$1,367.74
$1,562.20
$292.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.60
$868.96
$978.44
$1,367.36
$2,077.84
$1,058.44
$1,161.80
$1,271.28
$1,660.20
$1,351.28
$1,454.64
$1,564.12
$1,953.04
$1,644.12
$1,747.48
$1,856.96
$2,245.88
$292.84
Toc - Plan #81 UnitedHealthcare
Silver

(EPO) UHC Silver Value $4,000 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$368.72
$418.50
$471.22
$658.53
$1,000.71
$650.79
$700.57
$753.29
$940.60
$932.86
$982.64
$1,035.36
$1,222.67
$1,214.93
$1,264.71
$1,317.43
$1,504.74
$282.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737.44
$837.00
$942.44
$1,317.06
$2,001.42
$1,019.51
$1,119.07
$1,224.51
$1,599.13
$1,301.58
$1,401.14
$1,506.58
$1,881.20
$1,583.65
$1,683.21
$1,788.65
$2,163.27
$282.07
Toc - Plan #82 UnitedHealthcare
Silver

(EPO) UHC Silver Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$364.92
$414.18
$466.37
$651.75
$990.39
$644.08
$693.34
$745.53
$930.91
$923.24
$972.50
$1,024.69
$1,210.07
$1,202.40
$1,251.66
$1,303.85
$1,489.23
$279.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.84
$828.36
$932.74
$1,303.50
$1,980.78
$1,009.00
$1,107.52
$1,211.90
$1,582.66
$1,288.16
$1,386.68
$1,491.06
$1,861.82
$1,567.32
$1,665.84
$1,770.22
$2,140.98
$279.16
Toc - Plan #83 UnitedHealthcare
Silver

(EPO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$378.24
$429.30
$483.39
$675.53
$1,026.53
$667.59
$718.65
$772.74
$964.88
$956.94
$1,008.00
$1,062.09
$1,254.23
$1,246.29
$1,297.35
$1,351.44
$1,543.58
$289.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.48
$858.60
$966.78
$1,351.06
$2,053.06
$1,045.83
$1,147.95
$1,256.13
$1,640.41
$1,335.18
$1,437.30
$1,545.48
$1,929.76
$1,624.53
$1,726.65
$1,834.83
$2,219.11
$289.35
Toc - Plan #84 UnitedHealthcare
Silver

(EPO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$368.84
$418.64
$471.38
$658.76
$1,001.04
$651.01
$700.81
$753.55
$940.93
$933.18
$982.98
$1,035.72
$1,223.10
$1,215.35
$1,265.15
$1,317.89
$1,505.27
$282.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737.68
$837.28
$942.76
$1,317.52
$2,002.08
$1,019.85
$1,119.45
$1,224.93
$1,599.69
$1,302.02
$1,401.62
$1,507.10
$1,881.86
$1,584.19
$1,683.79
$1,789.27
$2,164.03
$282.17
Toc - Plan #85 UnitedHealthcare
Silver

(EPO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$371.14
$421.24
$474.31
$662.85
$1,007.26
$655.06
$705.16
$758.23
$946.77
$938.98
$989.08
$1,042.15
$1,230.69
$1,222.90
$1,273.00
$1,326.07
$1,514.61
$283.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.28
$842.48
$948.62
$1,325.70
$2,014.52
$1,026.20
$1,126.40
$1,232.54
$1,609.62
$1,310.12
$1,410.32
$1,516.46
$1,893.54
$1,594.04
$1,694.24
$1,800.38
$2,177.46
$283.92
Toc - Plan #86 UnitedHealthcare
Silver

(EPO) UHC Silver Value HSA $5,400 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$372.47
$422.75
$476.02
$665.23
$1,010.88
$657.41
$707.69
$760.96
$950.17
$942.35
$992.63
$1,045.90
$1,235.11
$1,227.29
$1,277.57
$1,330.84
$1,520.05
$284.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.94
$845.50
$952.04
$1,330.46
$2,021.76
$1,029.88
$1,130.44
$1,236.98
$1,615.40
$1,314.82
$1,415.38
$1,521.92
$1,900.34
$1,599.76
$1,700.32
$1,806.86
$2,185.28
$284.94
Toc - Plan #87 UnitedHealthcare
Bronze

(EPO) UHC Bronze Essential ($3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$267.51
$303.62
$341.87
$477.77
$726.01
$472.15
$508.26
$546.51
$682.41
$676.79
$712.90
$751.15
$887.05
$881.43
$917.54
$955.79
$1,091.69
$204.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$535.02
$607.24
$683.74
$955.54
$1,452.02
$739.66
$811.88
$888.38
$1,160.18
$944.30
$1,016.52
$1,093.02
$1,364.82
$1,148.94
$1,221.16
$1,297.66
$1,569.46
$204.64
Toc - Plan #88 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value $6,500 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$273.83
$310.79
$349.95
$489.05
$743.16
$483.31
$520.27
$559.43
$698.53
$692.79
$729.75
$768.91
$908.01
$902.27
$939.23
$978.39
$1,117.49
$209.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$547.66
$621.58
$699.90
$978.10
$1,486.32
$757.14
$831.06
$909.38
$1,187.58
$966.62
$1,040.54
$1,118.86
$1,397.06
$1,176.10
$1,250.02
$1,328.34
$1,606.54
$209.48
Toc - Plan #89 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value HSA $6,700 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$272.41
$309.18
$348.14
$486.52
$739.32
$480.80
$517.57
$556.53
$694.91
$689.19
$725.96
$764.92
$903.30
$897.58
$934.35
$973.31
$1,111.69
$208.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$544.82
$618.36
$696.28
$973.04
$1,478.64
$753.21
$826.75
$904.67
$1,181.43
$961.60
$1,035.14
$1,113.06
$1,389.82
$1,169.99
$1,243.53
$1,321.45
$1,598.21
$208.39
Toc - Plan #90 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Standard $7,500 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$269.44
$305.82
$344.35
$481.23
$731.27
$475.56
$511.94
$550.47
$687.35
$681.68
$718.06
$756.59
$893.47
$887.80
$924.18
$962.71
$1,099.59
$206.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$538.88
$611.64
$688.70
$962.46
$1,462.54
$745.00
$817.76
$894.82
$1,168.58
$951.12
$1,023.88
$1,100.94
$1,374.70
$1,157.24
$1,230.00
$1,307.06
$1,580.82
$206.12
Toc - Plan #91 UnitedHealthcare
Bronze

(EPO) UHC Bronze Standard $9,100 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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
$260.17
$295.29
$332.49
$464.66
$706.09
$459.20
$494.32
$531.52
$663.69
$658.23
$693.35
$730.55
$862.72
$857.26
$892.38
$929.58
$1,061.75
$199.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$520.34
$590.58
$664.98
$929.32
$1,412.18
$719.37
$789.61
$864.01
$1,128.35
$918.40
$988.64
$1,063.04
$1,327.38
$1,117.43
$1,187.67
$1,262.07
$1,526.41
$199.03

‡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 Johnson County here.

Johnson County is in “Rating Area 1” of Kansas.

Currently, there are 91 plans offered in Rating Area 1.

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2023 Obamacare Plans for Johnson County, KS

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