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Jackson, Mississippi 39212

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Vantage Health Plan of Mississippi

Local: 1-318-361-0900 | Toll Free: 1-888-823-1910 | TTY: 1-866-524-5144

Toc - Plan #1 Vantage Health Plan of Mississippi
Expanded Bronze

(POS) Essential Bronze 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$346.63
$393.43
$442.99
$619.08
$940.75
$566.74
$613.54
$663.10
$839.19
$786.85
$833.65
$883.21
$1,059.30
$1,006.96
$1,053.76
$1,103.32
$1,279.41
$220.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.26
$786.86
$885.98
$1,238.16
$1,881.50
$913.37
$1,006.97
$1,106.09
$1,458.27
$1,133.48
$1,227.08
$1,326.20
$1,678.38
$1,353.59
$1,447.19
$1,546.31
$1,898.49
$220.11
Toc - Plan #2 Vantage Health Plan of Mississippi
Gold

(POS) Essential Gold 1500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,500 Annual Deductible
$7,800 $15,600 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
$520.19
$590.41
$664.80
$929.05
$1,411.79
$850.51
$920.73
$995.12
$1,259.37
$1,180.83
$1,251.05
$1,325.44
$1,589.69
$1,511.15
$1,581.37
$1,655.76
$1,920.01
$330.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,040.38
$1,180.82
$1,329.60
$1,858.10
$2,823.58
$1,370.70
$1,511.14
$1,659.92
$2,188.42
$1,701.02
$1,841.46
$1,990.24
$2,518.74
$2,031.34
$2,171.78
$2,320.56
$2,849.06
$330.32
Toc - Plan #3 Vantage Health Plan of Mississippi
Silver

(POS) Freedom Silver 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

Individual Family
$4,000 $12,000 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
$400.05
$454.06
$511.27
$714.49
$1,085.74
$654.08
$708.09
$765.30
$968.52
$908.11
$962.12
$1,019.33
$1,222.55
$1,162.14
$1,216.15
$1,273.36
$1,476.58
$254.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$800.10
$908.12
$1,022.54
$1,428.98
$2,171.48
$1,054.13
$1,162.15
$1,276.57
$1,683.01
$1,308.16
$1,416.18
$1,530.60
$1,937.04
$1,562.19
$1,670.21
$1,784.63
$2,191.07
$254.03
Toc - Plan #4 Vantage Health Plan of Mississippi
Expanded Bronze

(POS) Savings Bronze 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,700 $15,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.30
$387.38
$436.19
$609.57
$926.30
$558.03
$604.11
$652.92
$826.30
$774.76
$820.84
$869.65
$1,043.03
$991.49
$1,037.57
$1,086.38
$1,259.76
$216.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.60
$774.76
$872.38
$1,219.14
$1,852.60
$899.33
$991.49
$1,089.11
$1,435.87
$1,116.06
$1,208.22
$1,305.84
$1,652.60
$1,332.79
$1,424.95
$1,522.57
$1,869.33
$216.73
Toc - Plan #5 Vantage Health Plan of Mississippi
Expanded Bronze

(POS) Savings Bronze 7400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.02
$387.06
$435.82
$609.06
$925.53
$557.57
$603.61
$652.37
$825.61
$774.12
$820.16
$868.92
$1,042.16
$990.67
$1,036.71
$1,085.47
$1,258.71
$216.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.04
$774.12
$871.64
$1,218.12
$1,851.06
$898.59
$990.67
$1,088.19
$1,434.67
$1,115.14
$1,207.22
$1,304.74
$1,651.22
$1,331.69
$1,423.77
$1,521.29
$1,867.77
$216.55
Toc - Plan #6 Vantage Health Plan of Mississippi
Gold

(POS) Standard Gold 1500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$538.70
$611.43
$688.46
$962.13
$1,462.04
$880.78
$953.51
$1,030.54
$1,304.21
$1,222.86
$1,295.59
$1,372.62
$1,646.29
$1,564.94
$1,637.67
$1,714.70
$1,988.37
$342.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,077.40
$1,222.86
$1,376.92
$1,924.26
$2,924.08
$1,419.48
$1,564.94
$1,719.00
$2,266.34
$1,761.56
$1,907.02
$2,061.08
$2,608.42
$2,103.64
$2,249.10
$2,403.16
$2,950.50
$342.08
Toc - Plan #7 Vantage Health Plan of Mississippi
Silver

(POS) Standard Silver 5900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393.89
$447.07
$503.40
$703.49
$1,069.03
$644.01
$697.19
$753.52
$953.61
$894.13
$947.31
$1,003.64
$1,203.73
$1,144.25
$1,197.43
$1,253.76
$1,453.85
$250.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.78
$894.14
$1,006.80
$1,406.98
$2,138.06
$1,037.90
$1,144.26
$1,256.92
$1,657.10
$1,288.02
$1,394.38
$1,507.04
$1,907.22
$1,538.14
$1,644.50
$1,757.16
$2,157.34
$250.12
Toc - Plan #8 Vantage Health Plan of Mississippi
Expanded Bronze

(POS) Standard Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370.18
$420.15
$473.09
$661.14
$1,004.67
$605.24
$655.21
$708.15
$896.20
$840.30
$890.27
$943.21
$1,131.26
$1,075.36
$1,125.33
$1,178.27
$1,366.32
$235.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.36
$840.30
$946.18
$1,322.28
$2,009.34
$975.42
$1,075.36
$1,181.24
$1,557.34
$1,210.48
$1,310.42
$1,416.30
$1,792.40
$1,445.54
$1,545.48
$1,651.36
$2,027.46
$235.06

ADVERTISEMENT

Molina Healthcare

Local: 1-866-472-9484 | Toll Free: 1-866-472-9484 | TTY: 1-800-659-8331

Toc - Plan #9 Molina Healthcare
Gold

(HMO) Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.92
$501.58
$564.78
$789.27
$1,199.38
$722.54
$782.20
$845.40
$1,069.89
$1,003.16
$1,062.82
$1,126.02
$1,350.51
$1,283.78
$1,343.44
$1,406.64
$1,631.13
$280.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$883.84
$1,003.16
$1,129.56
$1,578.54
$2,398.76
$1,164.46
$1,283.78
$1,410.18
$1,859.16
$1,445.08
$1,564.40
$1,690.80
$2,139.78
$1,725.70
$1,845.02
$1,971.42
$2,420.40
$280.62
Toc - Plan #10 Molina Healthcare
Silver

(HMO) Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$387.51
$439.82
$495.24
$692.09
$1,051.70
$633.58
$685.89
$741.31
$938.16
$879.65
$931.96
$987.38
$1,184.23
$1,125.72
$1,178.03
$1,233.45
$1,430.30
$246.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.02
$879.64
$990.48
$1,384.18
$2,103.40
$1,021.09
$1,125.71
$1,236.55
$1,630.25
$1,267.16
$1,371.78
$1,482.62
$1,876.32
$1,513.23
$1,617.85
$1,728.69
$2,122.39
$246.07
Toc - Plan #11 Molina Healthcare
Expanded Bronze

(HMO) Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414.32
$470.25
$529.50
$739.97
$1,124.46
$677.41
$733.34
$792.59
$1,003.06
$940.50
$996.43
$1,055.68
$1,266.15
$1,203.59
$1,259.52
$1,318.77
$1,529.24
$263.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$828.64
$940.50
$1,059.00
$1,479.94
$2,248.92
$1,091.73
$1,203.59
$1,322.09
$1,743.03
$1,354.82
$1,466.68
$1,585.18
$2,006.12
$1,617.91
$1,729.77
$1,848.27
$2,269.21
$263.09
Toc - Plan #12 Molina Healthcare
Gold

(HMO) Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$471.49
$535.14
$602.56
$842.08
$1,279.63
$770.89
$834.54
$901.96
$1,141.48
$1,070.29
$1,133.94
$1,201.36
$1,440.88
$1,369.69
$1,433.34
$1,500.76
$1,740.28
$299.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$942.98
$1,070.28
$1,205.12
$1,684.16
$2,559.26
$1,242.38
$1,369.68
$1,504.52
$1,983.56
$1,541.78
$1,669.08
$1,803.92
$2,282.96
$1,841.18
$1,968.48
$2,103.32
$2,582.36
$299.40
Toc - Plan #13 Molina Healthcare
Silver

(HMO) Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

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
$391.61
$444.48
$500.48
$699.42
$1,062.83
$640.28
$693.15
$749.15
$948.09
$888.95
$941.82
$997.82
$1,196.76
$1,137.62
$1,190.49
$1,246.49
$1,445.43
$248.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.22
$888.96
$1,000.96
$1,398.84
$2,125.66
$1,031.89
$1,137.63
$1,249.63
$1,647.51
$1,280.56
$1,386.30
$1,498.30
$1,896.18
$1,529.23
$1,634.97
$1,746.97
$2,144.85
$248.67
Toc - Plan #14 Molina Healthcare
Expanded Bronze

(HMO) Bronze 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.58
$412.66
$464.66
$649.36
$986.76
$594.45
$643.53
$695.53
$880.23
$825.32
$874.40
$926.40
$1,111.10
$1,056.19
$1,105.27
$1,157.27
$1,341.97
$230.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.16
$825.32
$929.32
$1,298.72
$1,973.52
$958.03
$1,056.19
$1,160.19
$1,529.59
$1,188.90
$1,287.06
$1,391.06
$1,760.46
$1,419.77
$1,517.93
$1,621.93
$1,991.33
$230.87
Toc - Plan #15 Molina Healthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393.75
$446.91
$503.22
$703.25
$1,068.65
$643.78
$696.94
$753.25
$953.28
$893.81
$946.97
$1,003.28
$1,203.31
$1,143.84
$1,197.00
$1,253.31
$1,453.34
$250.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.50
$893.82
$1,006.44
$1,406.50
$2,137.30
$1,037.53
$1,143.85
$1,256.47
$1,656.53
$1,287.56
$1,393.88
$1,506.50
$1,906.56
$1,537.59
$1,643.91
$1,756.53
$2,156.59
$250.03
Toc - Plan #16 Molina Healthcare
Gold

(HMO) Gold 1 with Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.84
$504.90
$568.51
$794.49
$1,207.30
$727.31
$787.37
$850.98
$1,076.96
$1,009.78
$1,069.84
$1,133.45
$1,359.43
$1,292.25
$1,352.31
$1,415.92
$1,641.90
$282.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$889.68
$1,009.80
$1,137.02
$1,588.98
$2,414.60
$1,172.15
$1,292.27
$1,419.49
$1,871.45
$1,454.62
$1,574.74
$1,701.96
$2,153.92
$1,737.09
$1,857.21
$1,984.43
$2,436.39
$282.47
Toc - Plan #17 Molina Healthcare
Silver

(HMO) Silver 1 with Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.43
$443.14
$498.97
$697.31
$1,059.62
$638.35
$691.06
$746.89
$945.23
$886.27
$938.98
$994.81
$1,193.15
$1,134.19
$1,186.90
$1,242.73
$1,441.07
$247.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.86
$886.28
$997.94
$1,394.62
$2,119.24
$1,028.78
$1,134.20
$1,245.86
$1,642.54
$1,276.70
$1,382.12
$1,493.78
$1,890.46
$1,524.62
$1,630.04
$1,741.70
$2,138.38
$247.92

ADVERTISEMENT

Ambetter from Magnolia Health

Local: 1-877-687-1187 | Toll Free: 1-877-687-1187 | TTY: 1-877-687-1187

Toc - Plan #18 Ambetter from Magnolia Health
Silver

(HMO) Complete Silver with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$409.91
$465.24
$523.85
$732.08
$1,112.47
$670.20
$725.53
$784.14
$992.37
$930.49
$985.82
$1,044.43
$1,252.66
$1,190.78
$1,246.11
$1,304.72
$1,512.95
$260.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$819.82
$930.48
$1,047.70
$1,464.16
$2,224.94
$1,080.11
$1,190.77
$1,307.99
$1,724.45
$1,340.40
$1,451.06
$1,568.28
$1,984.74
$1,600.69
$1,711.35
$1,828.57
$2,245.03
$260.29
Toc - Plan #19 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Everyday Bronze with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.68
$432.06
$486.49
$679.87
$1,033.13
$622.40
$673.78
$728.21
$921.59
$864.12
$915.50
$969.93
$1,163.31
$1,105.84
$1,157.22
$1,211.65
$1,405.03
$241.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$761.36
$864.12
$972.98
$1,359.74
$2,066.26
$1,003.08
$1,105.84
$1,214.70
$1,601.46
$1,244.80
$1,347.56
$1,456.42
$1,843.18
$1,486.52
$1,589.28
$1,698.14
$2,084.90
$241.72
Toc - Plan #20 Ambetter from Magnolia Health
Gold

(HMO) Complete Gold with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$508.63
$577.29
$650.02
$908.40
$1,380.40
$831.61
$900.27
$973.00
$1,231.38
$1,154.59
$1,223.25
$1,295.98
$1,554.36
$1,477.57
$1,546.23
$1,618.96
$1,877.34
$322.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,017.26
$1,154.58
$1,300.04
$1,816.80
$2,760.80
$1,340.24
$1,477.56
$1,623.02
$2,139.78
$1,663.22
$1,800.54
$1,946.00
$2,462.76
$1,986.20
$2,123.52
$2,268.98
$2,785.74
$322.98
Toc - Plan #21 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Choice Bronze HSA with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$387.55
$439.86
$495.28
$692.15
$1,051.79
$633.64
$685.95
$741.37
$938.24
$879.73
$932.04
$987.46
$1,184.33
$1,125.82
$1,178.13
$1,233.55
$1,430.42
$246.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.10
$879.72
$990.56
$1,384.30
$2,103.58
$1,021.19
$1,125.81
$1,236.65
$1,630.39
$1,267.28
$1,371.90
$1,482.74
$1,876.48
$1,513.37
$1,617.99
$1,728.83
$2,122.57
$246.09
Toc - Plan #22 Ambetter from Magnolia Health
Silver

(HMO) Clear Silver with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$397.35
$450.98
$507.80
$709.65
$1,078.38
$649.66
$703.29
$760.11
$961.96
$901.97
$955.60
$1,012.42
$1,214.27
$1,154.28
$1,207.91
$1,264.73
$1,466.58
$252.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$794.70
$901.96
$1,015.60
$1,419.30
$2,156.76
$1,047.01
$1,154.27
$1,267.91
$1,671.61
$1,299.32
$1,406.58
$1,520.22
$1,923.92
$1,551.63
$1,658.89
$1,772.53
$2,176.23
$252.31
Toc - Plan #23 Ambetter from Magnolia Health
Silver

(HMO) Focused Silver with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.31
$457.75
$515.42
$720.30
$1,094.57
$659.41
$713.85
$771.52
$976.40
$915.51
$969.95
$1,027.62
$1,232.50
$1,171.61
$1,226.05
$1,283.72
$1,488.60
$256.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.62
$915.50
$1,030.84
$1,440.60
$2,189.14
$1,062.72
$1,171.60
$1,286.94
$1,696.70
$1,318.82
$1,427.70
$1,543.04
$1,952.80
$1,574.92
$1,683.80
$1,799.14
$2,208.90
$256.10
Toc - Plan #24 Ambetter from Magnolia Health
Gold

(HMO) Everyday Gold with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$486.47
$552.13
$621.70
$868.82
$1,320.26
$795.37
$861.03
$930.60
$1,177.72
$1,104.27
$1,169.93
$1,239.50
$1,486.62
$1,413.17
$1,478.83
$1,548.40
$1,795.52
$308.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$972.94
$1,104.26
$1,243.40
$1,737.64
$2,640.52
$1,281.84
$1,413.16
$1,552.30
$2,046.54
$1,590.74
$1,722.06
$1,861.20
$2,355.44
$1,899.64
$2,030.96
$2,170.10
$2,664.34
$308.90
Toc - Plan #25 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Standard Expanded Bronze with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.80
$424.26
$477.71
$667.60
$1,014.48
$611.16
$661.62
$715.07
$904.96
$848.52
$898.98
$952.43
$1,142.32
$1,085.88
$1,136.34
$1,189.79
$1,379.68
$237.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.60
$848.52
$955.42
$1,335.20
$2,028.96
$984.96
$1,085.88
$1,192.78
$1,572.56
$1,222.32
$1,323.24
$1,430.14
$1,809.92
$1,459.68
$1,560.60
$1,667.50
$2,047.28
$237.36
Toc - Plan #26 Ambetter from Magnolia Health
Silver

(HMO) Standard Silver with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$395.06
$448.38
$504.87
$705.55
$1,072.16
$645.92
$699.24
$755.73
$956.41
$896.78
$950.10
$1,006.59
$1,207.27
$1,147.64
$1,200.96
$1,257.45
$1,458.13
$250.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$790.12
$896.76
$1,009.74
$1,411.10
$2,144.32
$1,040.98
$1,147.62
$1,260.60
$1,661.96
$1,291.84
$1,398.48
$1,511.46
$1,912.82
$1,542.70
$1,649.34
$1,762.32
$2,163.68
$250.86
Toc - Plan #27 Ambetter from Magnolia Health
Gold

(HMO) Standard Gold with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$486.75
$552.45
$622.05
$869.31
$1,321.01
$795.83
$861.53
$931.13
$1,178.39
$1,104.91
$1,170.61
$1,240.21
$1,487.47
$1,413.99
$1,479.69
$1,549.29
$1,796.55
$309.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$973.50
$1,104.90
$1,244.10
$1,738.62
$2,642.02
$1,282.58
$1,413.98
$1,553.18
$2,047.70
$1,591.66
$1,723.06
$1,862.26
$2,356.78
$1,900.74
$2,032.14
$2,171.34
$2,665.86
$309.08
Toc - Plan #28 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Everyday Bronze with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.01
$449.46
$506.09
$707.26
$1,074.75
$647.47
$700.92
$757.55
$958.72
$898.93
$952.38
$1,009.01
$1,210.18
$1,150.39
$1,203.84
$1,260.47
$1,461.64
$251.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.02
$898.92
$1,012.18
$1,414.52
$2,149.50
$1,043.48
$1,150.38
$1,263.64
$1,665.98
$1,294.94
$1,401.84
$1,515.10
$1,917.44
$1,546.40
$1,653.30
$1,766.56
$2,168.90
$251.46
Toc - Plan #29 Ambetter from Magnolia Health
Gold

(HMO) Complete Gold with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$529.12
$600.54
$676.21
$945.00
$1,436.02
$865.11
$936.53
$1,012.20
$1,280.99
$1,201.10
$1,272.52
$1,348.19
$1,616.98
$1,537.09
$1,608.51
$1,684.18
$1,952.97
$335.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,058.24
$1,201.08
$1,352.42
$1,890.00
$2,872.04
$1,394.23
$1,537.07
$1,688.41
$2,225.99
$1,730.22
$1,873.06
$2,024.40
$2,561.98
$2,066.21
$2,209.05
$2,360.39
$2,897.97
$335.99
Toc - Plan #30 Ambetter from Magnolia Health
Silver

(HMO) Complete Silver with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$426.42
$483.98
$544.96
$761.58
$1,157.29
$697.19
$754.75
$815.73
$1,032.35
$967.96
$1,025.52
$1,086.50
$1,303.12
$1,238.73
$1,296.29
$1,357.27
$1,573.89
$270.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.84
$967.96
$1,089.92
$1,523.16
$2,314.58
$1,123.61
$1,238.73
$1,360.69
$1,793.93
$1,394.38
$1,509.50
$1,631.46
$2,064.70
$1,665.15
$1,780.27
$1,902.23
$2,335.47
$270.77
Toc - Plan #31 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Choice Bronze HSA with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.16
$457.58
$515.23
$720.03
$1,094.16
$659.16
$713.58
$771.23
$976.03
$915.16
$969.58
$1,027.23
$1,232.03
$1,171.16
$1,225.58
$1,283.23
$1,488.03
$256.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.32
$915.16
$1,030.46
$1,440.06
$2,188.32
$1,062.32
$1,171.16
$1,286.46
$1,696.06
$1,318.32
$1,427.16
$1,542.46
$1,952.06
$1,574.32
$1,683.16
$1,798.46
$2,208.06
$256.00
Toc - Plan #32 Ambetter from Magnolia Health
Silver

(HMO) Focused Silver with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419.56
$476.19
$536.19
$749.32
$1,138.66
$685.98
$742.61
$802.61
$1,015.74
$952.40
$1,009.03
$1,069.03
$1,282.16
$1,218.82
$1,275.45
$1,335.45
$1,548.58
$266.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839.12
$952.38
$1,072.38
$1,498.64
$2,277.32
$1,105.54
$1,218.80
$1,338.80
$1,765.06
$1,371.96
$1,485.22
$1,605.22
$2,031.48
$1,638.38
$1,751.64
$1,871.64
$2,297.90
$266.42
Toc - Plan #33 Ambetter from Magnolia Health
Gold

(HMO) Everyday Gold with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$506.07
$574.38
$646.74
$903.82
$1,373.44
$827.42
$895.73
$968.09
$1,225.17
$1,148.77
$1,217.08
$1,289.44
$1,546.52
$1,470.12
$1,538.43
$1,610.79
$1,867.87
$321.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,012.14
$1,148.76
$1,293.48
$1,807.64
$2,746.88
$1,333.49
$1,470.11
$1,614.83
$2,128.99
$1,654.84
$1,791.46
$1,936.18
$2,450.34
$1,976.19
$2,112.81
$2,257.53
$2,771.69
$321.35
Toc - Plan #34 Ambetter from Magnolia Health
Silver

(HMO) Clear Silver with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413.36
$469.15
$528.26
$738.24
$1,121.82
$675.83
$731.62
$790.73
$1,000.71
$938.30
$994.09
$1,053.20
$1,263.18
$1,200.77
$1,256.56
$1,315.67
$1,525.65
$262.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.72
$938.30
$1,056.52
$1,476.48
$2,243.64
$1,089.19
$1,200.77
$1,318.99
$1,738.95
$1,351.66
$1,463.24
$1,581.46
$2,001.42
$1,614.13
$1,725.71
$1,843.93
$2,263.89
$262.47
Toc - Plan #35 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Standard Expanded Bronze with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.86
$441.35
$496.95
$694.49
$1,055.35
$635.78
$688.27
$743.87
$941.41
$882.70
$935.19
$990.79
$1,188.33
$1,129.62
$1,182.11
$1,237.71
$1,435.25
$246.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.72
$882.70
$993.90
$1,388.98
$2,110.70
$1,024.64
$1,129.62
$1,240.82
$1,635.90
$1,271.56
$1,376.54
$1,487.74
$1,882.82
$1,518.48
$1,623.46
$1,734.66
$2,129.74
$246.92
Toc - Plan #36 Ambetter from Magnolia Health
Silver

(HMO) Standard Silver with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$410.97
$466.44
$525.21
$733.98
$1,115.35
$671.93
$727.40
$786.17
$994.94
$932.89
$988.36
$1,047.13
$1,255.90
$1,193.85
$1,249.32
$1,308.09
$1,516.86
$260.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.94
$932.88
$1,050.42
$1,467.96
$2,230.70
$1,082.90
$1,193.84
$1,311.38
$1,728.92
$1,343.86
$1,454.80
$1,572.34
$1,989.88
$1,604.82
$1,715.76
$1,833.30
$2,250.84
$260.96
Toc - Plan #37 Ambetter from Magnolia Health
Gold

(HMO) Standard Gold with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$506.36
$574.70
$647.11
$904.34
$1,374.23
$827.89
$896.23
$968.64
$1,225.87
$1,149.42
$1,217.76
$1,290.17
$1,547.40
$1,470.95
$1,539.29
$1,611.70
$1,868.93
$321.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,012.72
$1,149.40
$1,294.22
$1,808.68
$2,748.46
$1,334.25
$1,470.93
$1,615.75
$2,130.21
$1,655.78
$1,792.46
$1,937.28
$2,451.74
$1,977.31
$2,113.99
$2,258.81
$2,773.27
$321.53
Toc - Plan #38 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze (Virtual PCP selection required)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$378.23
$429.28
$483.36
$675.50
$1,026.48
$618.40
$669.45
$723.53
$915.67
$858.57
$909.62
$963.70
$1,155.84
$1,098.74
$1,149.79
$1,203.87
$1,396.01
$240.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.46
$858.56
$966.72
$1,351.00
$2,052.96
$996.63
$1,098.73
$1,206.89
$1,591.17
$1,236.80
$1,338.90
$1,447.06
$1,831.34
$1,476.97
$1,579.07
$1,687.23
$2,071.51
$240.17
Toc - Plan #39 Ambetter from Magnolia Health
Silver

(HMO) Ambetter Virtual Access Silver (Virtual PCP selection required)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$395.33
$448.69
$505.22
$706.05
$1,072.91
$646.36
$699.72
$756.25
$957.08
$897.39
$950.75
$1,007.28
$1,208.11
$1,148.42
$1,201.78
$1,258.31
$1,459.14
$251.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$790.66
$897.38
$1,010.44
$1,412.10
$2,145.82
$1,041.69
$1,148.41
$1,261.47
$1,663.13
$1,292.72
$1,399.44
$1,512.50
$1,914.16
$1,543.75
$1,650.47
$1,763.53
$2,165.19
$251.03
Toc - Plan #40 Ambetter from Magnolia Health
Gold

(HMO) Ambetter Virtual Access Gold (Virtual PCP selection required)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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
$490.90
$557.16
$627.35
$876.72
$1,332.26
$802.61
$868.87
$939.06
$1,188.43
$1,114.32
$1,180.58
$1,250.77
$1,500.14
$1,426.03
$1,492.29
$1,562.48
$1,811.85
$311.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$981.80
$1,114.32
$1,254.70
$1,753.44
$2,664.52
$1,293.51
$1,426.03
$1,566.41
$2,065.15
$1,605.22
$1,737.74
$1,878.12
$2,376.86
$1,916.93
$2,049.45
$2,189.83
$2,688.57
$311.71

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-239-1451 | Toll Free: 1-888-239-1451 | TTY: 1-888-239-1451

Toc - Plan #41 UnitedHealthcare
Gold

(HMO) UHC Gold Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$571.11
$648.20
$729.87
$1,019.99
$1,549.97
$933.76
$1,010.85
$1,092.52
$1,382.64
$1,296.41
$1,373.50
$1,455.17
$1,745.29
$1,659.06
$1,736.15
$1,817.82
$2,107.94
$362.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,142.22
$1,296.40
$1,459.74
$2,039.98
$3,099.94
$1,504.87
$1,659.05
$1,822.39
$2,402.63
$1,867.52
$2,021.70
$2,185.04
$2,765.28
$2,230.17
$2,384.35
$2,547.69
$3,127.93
$362.65
Toc - Plan #42 UnitedHealthcare
Silver

(HMO) UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.21
$493.97
$556.20
$777.29
$1,181.16
$711.57
$770.33
$832.56
$1,053.65
$987.93
$1,046.69
$1,108.92
$1,330.01
$1,264.29
$1,323.05
$1,385.28
$1,606.37
$276.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$870.42
$987.94
$1,112.40
$1,554.58
$2,362.32
$1,146.78
$1,264.30
$1,388.76
$1,830.94
$1,423.14
$1,540.66
$1,665.12
$2,107.30
$1,699.50
$1,817.02
$1,941.48
$2,383.66
$276.36
Toc - Plan #43 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$459.74
$521.80
$587.55
$821.09
$1,247.73
$751.68
$813.74
$879.49
$1,113.03
$1,043.62
$1,105.68
$1,171.43
$1,404.97
$1,335.56
$1,397.62
$1,463.37
$1,696.91
$291.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$919.48
$1,043.60
$1,175.10
$1,642.18
$2,495.46
$1,211.42
$1,335.54
$1,467.04
$1,934.12
$1,503.36
$1,627.48
$1,758.98
$2,226.06
$1,795.30
$1,919.42
$2,050.92
$2,518.00
$291.94
Toc - Plan #44 UnitedHealthcare
Silver

(HMO) UHC Silver Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

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
$448.37
$508.90
$573.01
$800.78
$1,216.86
$733.09
$793.62
$857.73
$1,085.50
$1,017.81
$1,078.34
$1,142.45
$1,370.22
$1,302.53
$1,363.06
$1,427.17
$1,654.94
$284.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.74
$1,017.80
$1,146.02
$1,601.56
$2,433.72
$1,181.46
$1,302.52
$1,430.74
$1,886.28
$1,466.18
$1,587.24
$1,715.46
$2,171.00
$1,750.90
$1,871.96
$2,000.18
$2,455.72
$284.72
Toc - Plan #45 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$397.94
$451.66
$508.56
$710.72
$1,080.00
$650.63
$704.35
$761.25
$963.41
$903.32
$957.04
$1,013.94
$1,216.10
$1,156.01
$1,209.73
$1,266.63
$1,468.79
$252.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.88
$903.32
$1,017.12
$1,421.44
$2,160.00
$1,048.57
$1,156.01
$1,269.81
$1,674.13
$1,301.26
$1,408.70
$1,522.50
$1,926.82
$1,553.95
$1,661.39
$1,775.19
$2,179.51
$252.69
Toc - Plan #46 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.88
$452.73
$509.77
$712.40
$1,082.55
$652.17
$706.02
$763.06
$965.69
$905.46
$959.31
$1,016.35
$1,218.98
$1,158.75
$1,212.60
$1,269.64
$1,472.27
$253.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$797.76
$905.46
$1,019.54
$1,424.80
$2,165.10
$1,051.05
$1,158.75
$1,272.83
$1,678.09
$1,304.34
$1,412.04
$1,526.12
$1,931.38
$1,557.63
$1,665.33
$1,779.41
$2,184.67
$253.29
Toc - Plan #47 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.25
$448.61
$505.13
$705.91
$1,072.70
$646.24
$699.60
$756.12
$956.90
$897.23
$950.59
$1,007.11
$1,207.89
$1,148.22
$1,201.58
$1,258.10
$1,458.88
$250.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$790.50
$897.22
$1,010.26
$1,411.82
$2,145.40
$1,041.49
$1,148.21
$1,261.25
$1,662.81
$1,292.48
$1,399.20
$1,512.24
$1,913.80
$1,543.47
$1,650.19
$1,763.23
$2,164.79
$250.99
Toc - Plan #48 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus $0 Indiv Med Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414.62
$470.59
$529.88
$740.51
$1,125.27
$677.91
$733.88
$793.17
$1,003.80
$941.20
$997.17
$1,056.46
$1,267.09
$1,204.49
$1,260.46
$1,319.75
$1,530.38
$263.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$829.24
$941.18
$1,059.76
$1,481.02
$2,250.54
$1,092.53
$1,204.47
$1,323.05
$1,744.31
$1,355.82
$1,467.76
$1,586.34
$2,007.60
$1,619.11
$1,731.05
$1,849.63
$2,270.89
$263.29
Toc - Plan #49 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$445.09
$505.17
$568.82
$794.92
$1,207.95
$727.72
$787.80
$851.45
$1,077.55
$1,010.35
$1,070.43
$1,134.08
$1,360.18
$1,292.98
$1,353.06
$1,416.71
$1,642.81
$282.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$890.18
$1,010.34
$1,137.64
$1,589.84
$2,415.90
$1,172.81
$1,292.97
$1,420.27
$1,872.47
$1,455.44
$1,575.60
$1,702.90
$2,155.10
$1,738.07
$1,858.23
$1,985.53
$2,437.73
$282.63
Toc - Plan #50 UnitedHealthcare
Gold

(HMO) UHC Gold Value $1,500 Indiv Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$547.63
$621.56
$699.87
$978.06
$1,486.26
$895.38
$969.31
$1,047.62
$1,325.81
$1,243.13
$1,317.06
$1,395.37
$1,673.56
$1,590.88
$1,664.81
$1,743.12
$2,021.31
$347.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,095.26
$1,243.12
$1,399.74
$1,956.12
$2,972.52
$1,443.01
$1,590.87
$1,747.49
$2,303.87
$1,790.76
$1,938.62
$2,095.24
$2,651.62
$2,138.51
$2,286.37
$2,442.99
$2,999.37
$347.75
Toc - Plan #51 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $1 Tier 2 Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$540.07
$612.98
$690.21
$964.56
$1,465.74
$883.02
$955.93
$1,033.16
$1,307.51
$1,225.97
$1,298.88
$1,376.11
$1,650.46
$1,568.92
$1,641.83
$1,719.06
$1,993.41
$342.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,080.14
$1,225.96
$1,380.42
$1,929.12
$2,931.48
$1,423.09
$1,568.91
$1,723.37
$2,272.07
$1,766.04
$1,911.86
$2,066.32
$2,615.02
$2,108.99
$2,254.81
$2,409.27
$2,957.97
$342.95
Toc - Plan #52 UnitedHealthcare
Gold

(HMO) UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$559.18
$634.67
$714.63
$998.70
$1,517.61
$914.26
$989.75
$1,069.71
$1,353.78
$1,269.34
$1,344.83
$1,424.79
$1,708.86
$1,624.42
$1,699.91
$1,779.87
$2,063.94
$355.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,118.36
$1,269.34
$1,429.26
$1,997.40
$3,035.22
$1,473.44
$1,624.42
$1,784.34
$2,352.48
$1,828.52
$1,979.50
$2,139.42
$2,707.56
$2,183.60
$2,334.58
$2,494.50
$3,062.64
$355.08
Toc - Plan #53 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-239-1451

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$458.68
$520.60
$586.19
$819.19
$1,244.84
$749.94
$811.86
$877.45
$1,110.45
$1,041.20
$1,103.12
$1,168.71
$1,401.71
$1,332.46
$1,394.38
$1,459.97
$1,692.97
$291.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.36
$1,041.20
$1,172.38
$1,638.38
$2,489.68
$1,208.62
$1,332.46
$1,463.64
$1,929.64
$1,499.88
$1,623.72
$1,754.90
$2,220.90
$1,791.14
$1,914.98
$2,046.16
$2,512.16
$291.26

‡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 Hinds County here.

Hinds County is in “Rating Area 3” of Mississippi.

Currently, there are 53 plans offered in Rating Area 3.

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