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North Dakota Obamacare 2023 Rates

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Blue Cross Blue Shield of North Dakota

Local: 1-844-363-8457 | Toll Free: 1-844-363-8457

Toc - Plan #1 Blue Cross Blue Shield of North Dakota
Silver

(PPO) BlueCare 60 Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

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
$422.99
$480.09
$540.58
$755.46
$1,147.99
$746.58
$803.68
$864.17
$1,079.05
$1,070.17
$1,127.27
$1,187.76
$1,402.64
$1,393.76
$1,450.86
$1,511.35
$1,726.23
$323.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.98
$960.18
$1,081.16
$1,510.92
$2,295.98
$1,169.57
$1,283.77
$1,404.75
$1,834.51
$1,493.16
$1,607.36
$1,728.34
$2,158.10
$1,816.75
$1,930.95
$2,051.93
$2,481.69
$323.59
Toc - Plan #2 Blue Cross Blue Shield of North Dakota
Gold

(PPO) BlueCare 70 Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

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
$393.32
$446.42
$502.66
$702.47
$1,067.47
$694.21
$747.31
$803.55
$1,003.36
$995.10
$1,048.20
$1,104.44
$1,304.25
$1,295.99
$1,349.09
$1,405.33
$1,605.14
$300.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.64
$892.84
$1,005.32
$1,404.94
$2,134.94
$1,087.53
$1,193.73
$1,306.21
$1,705.83
$1,388.42
$1,494.62
$1,607.10
$2,006.72
$1,689.31
$1,795.51
$1,907.99
$2,307.61
$300.89
Toc - Plan #3 Blue Cross Blue Shield of North Dakota
Silver

(PPO) BlueDirect 80 Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.18
$487.12
$548.49
$766.52
$1,164.79
$757.50
$815.44
$876.81
$1,094.84
$1,085.82
$1,143.76
$1,205.13
$1,423.16
$1,414.14
$1,472.08
$1,533.45
$1,751.48
$328.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.36
$974.24
$1,096.98
$1,533.04
$2,329.58
$1,186.68
$1,302.56
$1,425.30
$1,861.36
$1,515.00
$1,630.88
$1,753.62
$2,189.68
$1,843.32
$1,959.20
$2,081.94
$2,518.00
$328.32
Toc - Plan #4 Blue Cross Blue Shield of North Dakota
Expanded Bronze

(PPO) BlueDirect 100 Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$6,800 $13,600 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
$277.32
$314.76
$354.41
$495.29
$752.65
$489.47
$526.91
$566.56
$707.44
$701.62
$739.06
$778.71
$919.59
$913.77
$951.21
$990.86
$1,131.74
$212.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$554.64
$629.52
$708.82
$990.58
$1,505.30
$766.79
$841.67
$920.97
$1,202.73
$978.94
$1,053.82
$1,133.12
$1,414.88
$1,191.09
$1,265.97
$1,345.27
$1,627.03
$212.15
Toc - Plan #5 Blue Cross Blue Shield of North Dakota
Catastrophic

(PPO) BlueEssential 100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

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
$152.46
$173.04
$194.84
$272.29
$413.78
$269.09
$289.67
$311.47
$388.92
$385.72
$406.30
$428.10
$505.55
$502.35
$522.93
$544.73
$622.18
$116.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$304.92
$346.08
$389.68
$544.58
$827.56
$421.55
$462.71
$506.31
$661.21
$538.18
$579.34
$622.94
$777.84
$654.81
$695.97
$739.57
$894.47
$116.63
Toc - Plan #6 Blue Cross Blue Shield of North Dakota
Gold

(PPO) BlueDirect 90 Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

Annual Out of Pocket Expenses:

Individual Family
$2,600 $5,200 Annual Deductible
$4,300 $8,600 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
$397.99
$451.72
$508.63
$710.81
$1,080.14
$702.45
$756.18
$813.09
$1,015.27
$1,006.91
$1,060.64
$1,117.55
$1,319.73
$1,311.37
$1,365.10
$1,422.01
$1,624.19
$304.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.98
$903.44
$1,017.26
$1,421.62
$2,160.28
$1,100.44
$1,207.90
$1,321.72
$1,726.08
$1,404.90
$1,512.36
$1,626.18
$2,030.54
$1,709.36
$1,816.82
$1,930.64
$2,335.00
$304.46
Toc - Plan #7 Blue Cross Blue Shield of North Dakota
Expanded Bronze

(PPO) SimplyBlue 50

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

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
$246.30
$279.55
$314.77
$439.89
$668.46
$434.72
$467.97
$503.19
$628.31
$623.14
$656.39
$691.61
$816.73
$811.56
$844.81
$880.03
$1,005.15
$188.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$492.60
$559.10
$629.54
$879.78
$1,336.92
$681.02
$747.52
$817.96
$1,068.20
$869.44
$935.94
$1,006.38
$1,256.62
$1,057.86
$1,124.36
$1,194.80
$1,445.04
$188.42
Toc - Plan #8 Blue Cross Blue Shield of North Dakota
Gold

(PPO) BlueValue Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

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
$400.16
$454.18
$511.40
$714.69
$1,086.03
$706.28
$760.30
$817.52
$1,020.81
$1,012.40
$1,066.42
$1,123.64
$1,326.93
$1,318.52
$1,372.54
$1,429.76
$1,633.05
$306.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$800.32
$908.36
$1,022.80
$1,429.38
$2,172.06
$1,106.44
$1,214.48
$1,328.92
$1,735.50
$1,412.56
$1,520.60
$1,635.04
$2,041.62
$1,718.68
$1,826.72
$1,941.16
$2,347.74
$306.12
Toc - Plan #9 Blue Cross Blue Shield of North Dakota
Silver

(PPO) BlueValue Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

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
$416.67
$472.92
$532.50
$744.17
$1,130.84
$735.42
$791.67
$851.25
$1,062.92
$1,054.17
$1,110.42
$1,170.00
$1,381.67
$1,372.92
$1,429.17
$1,488.75
$1,700.42
$318.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$833.34
$945.84
$1,065.00
$1,488.34
$2,261.68
$1,152.09
$1,264.59
$1,383.75
$1,807.09
$1,470.84
$1,583.34
$1,702.50
$2,125.84
$1,789.59
$1,902.09
$2,021.25
$2,444.59
$318.75
Toc - Plan #10 Blue Cross Blue Shield of North Dakota
Expanded Bronze

(PPO) BlueValue Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

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
$268.85
$305.14
$343.59
$480.17
$729.66
$474.52
$510.81
$549.26
$685.84
$680.19
$716.48
$754.93
$891.51
$885.86
$922.15
$960.60
$1,097.18
$205.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$537.70
$610.28
$687.18
$960.34
$1,459.32
$743.37
$815.95
$892.85
$1,166.01
$949.04
$1,021.62
$1,098.52
$1,371.68
$1,154.71
$1,227.29
$1,304.19
$1,577.35
$205.67
Toc - Plan #11 Blue Cross Blue Shield of North Dakota
Gold

(PPO) BluePrime 70 Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-363-8457

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
$391.69
$444.57
$500.58
$699.56
$1,063.05
$691.33
$744.21
$800.22
$999.20
$990.97
$1,043.85
$1,099.86
$1,298.84
$1,290.61
$1,343.49
$1,399.50
$1,598.48
$299.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.38
$889.14
$1,001.16
$1,399.12
$2,126.10
$1,083.02
$1,188.78
$1,300.80
$1,698.76
$1,382.66
$1,488.42
$1,600.44
$1,998.40
$1,682.30
$1,788.06
$1,900.08
$2,298.04
$299.64

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-269-7477

Toc - Plan #12 Medica
Expanded Bronze

(HMO) Medica Individual Choice 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
$352.67
$400.27
$450.70
$629.86
$957.13
$622.46
$670.06
$720.49
$899.65
$892.25
$939.85
$990.28
$1,169.44
$1,162.04
$1,209.64
$1,260.07
$1,439.23
$269.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$705.34
$800.54
$901.40
$1,259.72
$1,914.26
$975.13
$1,070.33
$1,171.19
$1,529.51
$1,244.92
$1,340.12
$1,440.98
$1,799.30
$1,514.71
$1,609.91
$1,710.77
$2,069.09
$269.79
Toc - Plan #13 Medica
Catastrophic

(HMO) Medica Individual Choice 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
$212.38
$241.04
$271.41
$379.29
$576.37
$374.84
$403.50
$433.87
$541.75
$537.30
$565.96
$596.33
$704.21
$699.76
$728.42
$758.79
$866.67
$162.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$424.76
$482.08
$542.82
$758.58
$1,152.74
$587.22
$644.54
$705.28
$921.04
$749.68
$807.00
$867.74
$1,083.50
$912.14
$969.46
$1,030.20
$1,245.96
$162.46
Toc - Plan #14 Medica
Expanded Bronze

(HMO) Medica Individual Choice 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
$308.54
$350.18
$394.30
$551.03
$837.35
$544.56
$586.20
$630.32
$787.05
$780.58
$822.22
$866.34
$1,023.07
$1,016.60
$1,058.24
$1,102.36
$1,259.09
$236.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$617.08
$700.36
$788.60
$1,102.06
$1,674.70
$853.10
$936.38
$1,024.62
$1,338.08
$1,089.12
$1,172.40
$1,260.64
$1,574.10
$1,325.14
$1,408.42
$1,496.66
$1,810.12
$236.02
Toc - Plan #15 Medica
Expanded Bronze

(HMO) Medica Individual Choice 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
$7,000 $14,000 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
$301.11
$341.74
$384.80
$537.76
$817.17
$531.45
$572.08
$615.14
$768.10
$761.79
$802.42
$845.48
$998.44
$992.13
$1,032.76
$1,075.82
$1,228.78
$230.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$602.22
$683.48
$769.60
$1,075.52
$1,634.34
$832.56
$913.82
$999.94
$1,305.86
$1,062.90
$1,144.16
$1,230.28
$1,536.20
$1,293.24
$1,374.50
$1,460.62
$1,766.54
$230.34
Toc - Plan #16 Medica
Silver

(HMO) Medica Individual Choice 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
$417.12
$473.42
$533.07
$744.96
$1,132.04
$736.21
$792.51
$852.16
$1,064.05
$1,055.30
$1,111.60
$1,171.25
$1,383.14
$1,374.39
$1,430.69
$1,490.34
$1,702.23
$319.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.24
$946.84
$1,066.14
$1,489.92
$2,264.08
$1,153.33
$1,265.93
$1,385.23
$1,809.01
$1,472.42
$1,585.02
$1,704.32
$2,128.10
$1,791.51
$1,904.11
$2,023.41
$2,447.19
$319.09
Toc - Plan #17 Medica
Bronze

(HMO) Medica Individual Choice 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
$282.87
$321.05
$361.49
$505.19
$767.68
$499.26
$537.44
$577.88
$721.58
$715.65
$753.83
$794.27
$937.97
$932.04
$970.22
$1,010.66
$1,154.36
$216.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$565.74
$642.10
$722.98
$1,010.38
$1,535.36
$782.13
$858.49
$939.37
$1,226.77
$998.52
$1,074.88
$1,155.76
$1,443.16
$1,214.91
$1,291.27
$1,372.15
$1,659.55
$216.39
Toc - Plan #18 Medica
Expanded Bronze

(HMO) Essentia Choice Care with 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
$273.66
$310.60
$349.73
$488.74
$742.69
$483.00
$519.94
$559.07
$698.08
$692.34
$729.28
$768.41
$907.42
$901.68
$938.62
$977.75
$1,116.76
$209.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$547.32
$621.20
$699.46
$977.48
$1,485.38
$756.66
$830.54
$908.80
$1,186.82
$966.00
$1,039.88
$1,118.14
$1,396.16
$1,175.34
$1,249.22
$1,327.48
$1,605.50
$209.34
Toc - Plan #19 Medica
Catastrophic

(HMO) Essentia Choice Care with 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
$164.80
$187.04
$210.60
$294.31
$447.24
$290.86
$313.10
$336.66
$420.37
$416.92
$439.16
$462.72
$546.43
$542.98
$565.22
$588.78
$672.49
$126.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$329.60
$374.08
$421.20
$588.62
$894.48
$455.66
$500.14
$547.26
$714.68
$581.72
$626.20
$673.32
$840.74
$707.78
$752.26
$799.38
$966.80
$126.06
Toc - Plan #20 Medica
Expanded Bronze

(HMO) Essentia Choice Care with 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
$239.42
$271.73
$305.96
$427.58
$649.75
$422.57
$454.88
$489.11
$610.73
$605.72
$638.03
$672.26
$793.88
$788.87
$821.18
$855.41
$977.03
$183.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$478.84
$543.46
$611.92
$855.16
$1,299.50
$661.99
$726.61
$795.07
$1,038.31
$845.14
$909.76
$978.22
$1,221.46
$1,028.29
$1,092.91
$1,161.37
$1,404.61
$183.15
Toc - Plan #21 Medica
Expanded Bronze

(HMO) Essentia Choice Care with 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
$7,000 $14,000 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
$233.65
$265.18
$298.59
$417.28
$634.09
$412.38
$443.91
$477.32
$596.01
$591.11
$622.64
$656.05
$774.74
$769.84
$801.37
$834.78
$953.47
$178.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$467.30
$530.36
$597.18
$834.56
$1,268.18
$646.03
$709.09
$775.91
$1,013.29
$824.76
$887.82
$954.64
$1,192.02
$1,003.49
$1,066.55
$1,133.37
$1,370.75
$178.73
Toc - Plan #22 Medica
Gold

(HMO) Essentia Choice Care with 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
$850 $1,700 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
$354.41
$402.24
$452.92
$632.95
$961.84
$625.52
$673.35
$724.03
$904.06
$896.63
$944.46
$995.14
$1,175.17
$1,167.74
$1,215.57
$1,266.25
$1,446.28
$271.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.82
$804.48
$905.84
$1,265.90
$1,923.68
$979.93
$1,075.59
$1,176.95
$1,537.01
$1,251.04
$1,346.70
$1,448.06
$1,808.12
$1,522.15
$1,617.81
$1,719.17
$2,079.23
$271.11
Toc - Plan #23 Medica
Silver

(HMO) Essentia Choice Care with Medica Silver 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
$4,600 $9,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$330.41
$375.00
$422.25
$590.09
$896.70
$583.16
$627.75
$675.00
$842.84
$835.91
$880.50
$927.75
$1,095.59
$1,088.66
$1,133.25
$1,180.50
$1,348.34
$252.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$660.82
$750.00
$844.50
$1,180.18
$1,793.40
$913.57
$1,002.75
$1,097.25
$1,432.93
$1,166.32
$1,255.50
$1,350.00
$1,685.68
$1,419.07
$1,508.25
$1,602.75
$1,938.43
$252.75
Toc - Plan #24 Medica
Gold

(HMO) Essentia Choice Care with 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
$324.14
$367.88
$414.23
$578.89
$879.68
$572.10
$615.84
$662.19
$826.85
$820.06
$863.80
$910.15
$1,074.81
$1,068.02
$1,111.76
$1,158.11
$1,322.77
$247.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.28
$735.76
$828.46
$1,157.78
$1,759.36
$896.24
$983.72
$1,076.42
$1,405.74
$1,144.20
$1,231.68
$1,324.38
$1,653.70
$1,392.16
$1,479.64
$1,572.34
$1,901.66
$247.96
Toc - Plan #25 Medica
Silver

(HMO) Essentia Choice Care with 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
$323.67
$367.36
$413.64
$578.06
$878.42
$571.27
$614.96
$661.24
$825.66
$818.87
$862.56
$908.84
$1,073.26
$1,066.47
$1,110.16
$1,156.44
$1,320.86
$247.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$647.34
$734.72
$827.28
$1,156.12
$1,756.84
$894.94
$982.32
$1,074.88
$1,403.72
$1,142.54
$1,229.92
$1,322.48
$1,651.32
$1,390.14
$1,477.52
$1,570.08
$1,898.92
$247.60
Toc - Plan #26 Medica
Bronze

(HMO) Essentia Choice Care with 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
$219.50
$249.12
$280.51
$392.01
$595.69
$387.41
$417.03
$448.42
$559.92
$555.32
$584.94
$616.33
$727.83
$723.23
$752.85
$784.24
$895.74
$167.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$439.00
$498.24
$561.02
$784.02
$1,191.38
$606.91
$666.15
$728.93
$951.93
$774.82
$834.06
$896.84
$1,119.84
$942.73
$1,001.97
$1,064.75
$1,287.75
$167.91

ADVERTISEMENT

Sanford Health Plan

Local: 1-605-328-6800 | Toll Free: 1-800-752-5863 | TTY: 1-877-652-1844

Toc - Plan #27 Sanford Health Plan
Expanded Bronze

(HMO) Sanford TRUE $6,000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$204.99
$232.67
$261.98
$366.11
$556.34
$361.81
$389.49
$418.80
$522.93
$518.63
$546.31
$575.62
$679.75
$675.45
$703.13
$732.44
$836.57
$156.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$409.98
$465.34
$523.96
$732.22
$1,112.68
$566.80
$622.16
$680.78
$889.04
$723.62
$778.98
$837.60
$1,045.86
$880.44
$935.80
$994.42
$1,202.68
$156.82
Toc - Plan #28 Sanford Health Plan
Silver

(HMO) Sanford TRUE $3,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$355.43
$403.42
$454.24
$634.80
$964.64
$627.34
$675.33
$726.15
$906.71
$899.25
$947.24
$998.06
$1,178.62
$1,171.16
$1,219.15
$1,269.97
$1,450.53
$271.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.86
$806.84
$908.48
$1,269.60
$1,929.28
$982.77
$1,078.75
$1,180.39
$1,541.51
$1,254.68
$1,350.66
$1,452.30
$1,813.42
$1,526.59
$1,622.57
$1,724.21
$2,085.33
$271.91
Toc - Plan #29 Sanford Health Plan
Expanded Bronze

(HMO) Sanford TRUE $6,900 HSA/HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$211.44
$239.99
$270.22
$377.63
$573.85
$373.20
$401.75
$431.98
$539.39
$534.96
$563.51
$593.74
$701.15
$696.72
$725.27
$755.50
$862.91
$161.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$422.88
$479.98
$540.44
$755.26
$1,147.70
$584.64
$641.74
$702.20
$917.02
$746.40
$803.50
$863.96
$1,078.78
$908.16
$965.26
$1,025.72
$1,240.54
$161.76
Toc - Plan #30 Sanford Health Plan
Catastrophic

(HMO) Sanford TRUE $9,100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$128.14
$145.43
$163.76
$228.85
$347.76
$226.17
$243.46
$261.79
$326.88
$324.20
$341.49
$359.82
$424.91
$422.23
$439.52
$457.85
$522.94
$98.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$256.28
$290.86
$327.52
$457.70
$695.52
$354.31
$388.89
$425.55
$555.73
$452.34
$486.92
$523.58
$653.76
$550.37
$584.95
$621.61
$751.79
$98.03
Toc - Plan #31 Sanford Health Plan
Silver

(HMO) Sanford TRUE $4,750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$4,750 $9,500 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
$333.27
$378.26
$425.91
$595.21
$904.47
$588.22
$633.21
$680.86
$850.16
$843.17
$888.16
$935.81
$1,105.11
$1,098.12
$1,143.11
$1,190.76
$1,360.06
$254.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.54
$756.52
$851.82
$1,190.42
$1,808.94
$921.49
$1,011.47
$1,106.77
$1,445.37
$1,176.44
$1,266.42
$1,361.72
$1,700.32
$1,431.39
$1,521.37
$1,616.67
$1,955.27
$254.95
Toc - Plan #32 Sanford Health Plan
Gold

(HMO) Sanford TRUE $1,750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 Annual Deductible
$8,450 $16,900 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
$313.64
$355.99
$400.84
$560.17
$851.22
$553.58
$595.93
$640.78
$800.11
$793.52
$835.87
$880.72
$1,040.05
$1,033.46
$1,075.81
$1,120.66
$1,279.99
$239.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627.28
$711.98
$801.68
$1,120.34
$1,702.44
$867.22
$951.92
$1,041.62
$1,360.28
$1,107.16
$1,191.86
$1,281.56
$1,600.22
$1,347.10
$1,431.80
$1,521.50
$1,840.16
$239.94
Toc - Plan #33 Sanford Health Plan
Expanded Bronze

(HMO) Sanford TRUE $7,000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$203.23
$230.67
$259.73
$362.97
$551.56
$358.70
$386.14
$415.20
$518.44
$514.17
$541.61
$570.67
$673.91
$669.64
$697.08
$726.14
$829.38
$155.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$406.46
$461.34
$519.46
$725.94
$1,103.12
$561.93
$616.81
$674.93
$881.41
$717.40
$772.28
$830.40
$1,036.88
$872.87
$927.75
$985.87
$1,192.35
$155.47
Toc - Plan #34 Sanford Health Plan
Silver

(HMO) Sanford TRUE Enhanced - Diabetes & Asthma/COPD Care Plan $3,700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 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
$324.47
$368.27
$414.67
$579.50
$880.60
$572.69
$616.49
$662.89
$827.72
$820.91
$864.71
$911.11
$1,075.94
$1,069.13
$1,112.93
$1,159.33
$1,324.16
$248.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.94
$736.54
$829.34
$1,159.00
$1,761.20
$897.16
$984.76
$1,077.56
$1,407.22
$1,145.38
$1,232.98
$1,325.78
$1,655.44
$1,393.60
$1,481.20
$1,574.00
$1,903.66
$248.22
Toc - Plan #35 Sanford Health Plan
Gold

(HMO) Sanford TRUE Enhanced - Diabetes & Asthma/COPD Care Plan $1,250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$318.97
$362.03
$407.64
$569.68
$865.68
$562.98
$606.04
$651.65
$813.69
$806.99
$850.05
$895.66
$1,057.70
$1,051.00
$1,094.06
$1,139.67
$1,301.71
$244.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$637.94
$724.06
$815.28
$1,139.36
$1,731.36
$881.95
$968.07
$1,059.29
$1,383.37
$1,125.96
$1,212.08
$1,303.30
$1,627.38
$1,369.97
$1,456.09
$1,547.31
$1,871.39
$244.01
Toc - Plan #36 Sanford Health Plan
Expanded Bronze

(HMO) Sanford TRUE - Standardized $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$223.45
$253.61
$285.56
$399.07
$606.43
$394.39
$424.55
$456.50
$570.01
$565.33
$595.49
$627.44
$740.95
$736.27
$766.43
$798.38
$911.89
$170.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$446.90
$507.22
$571.12
$798.14
$1,212.86
$617.84
$678.16
$742.06
$969.08
$788.78
$849.10
$913.00
$1,140.02
$959.72
$1,020.04
$1,083.94
$1,310.96
$170.94
Toc - Plan #37 Sanford Health Plan
Silver

(HMO) Sanford TRUE - Standardized $5,800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$313.91
$356.28
$401.17
$560.64
$851.94
$554.05
$596.42
$641.31
$800.78
$794.19
$836.56
$881.45
$1,040.92
$1,034.33
$1,076.70
$1,121.59
$1,281.06
$240.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627.82
$712.56
$802.34
$1,121.28
$1,703.88
$867.96
$952.70
$1,042.48
$1,361.42
$1,108.10
$1,192.84
$1,282.62
$1,601.56
$1,348.24
$1,432.98
$1,522.76
$1,841.70
$240.14
Toc - Plan #38 Sanford Health Plan
Gold

(HMO) Sanford TRUE - Standardized $2,000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$309.38
$351.15
$395.39
$552.56
$839.66
$546.06
$587.83
$632.07
$789.24
$782.74
$824.51
$868.75
$1,025.92
$1,019.42
$1,061.19
$1,105.43
$1,262.60
$236.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$618.76
$702.30
$790.78
$1,105.12
$1,679.32
$855.44
$938.98
$1,027.46
$1,341.80
$1,092.12
$1,175.66
$1,264.14
$1,578.48
$1,328.80
$1,412.34
$1,500.82
$1,815.16
$236.68
Toc - Plan #39 Sanford Health Plan
Gold

(PPO) Sanford Simplicity $1,750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 Annual Deductible
$8,450 $16,900 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
$399.29
$453.19
$510.29
$713.12
$1,083.65
$704.74
$758.64
$815.74
$1,018.57
$1,010.19
$1,064.09
$1,121.19
$1,324.02
$1,315.64
$1,369.54
$1,426.64
$1,629.47
$305.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798.58
$906.38
$1,020.58
$1,426.24
$2,167.30
$1,104.03
$1,211.83
$1,326.03
$1,731.69
$1,409.48
$1,517.28
$1,631.48
$2,037.14
$1,714.93
$1,822.73
$1,936.93
$2,342.59
$305.45
Toc - Plan #40 Sanford Health Plan
Silver

(PPO) Sanford Simplicity $3,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$458.56
$520.46
$586.03
$818.98
$1,244.51
$809.36
$871.26
$936.83
$1,169.78
$1,160.16
$1,222.06
$1,287.63
$1,520.58
$1,510.96
$1,572.86
$1,638.43
$1,871.38
$350.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.12
$1,040.92
$1,172.06
$1,637.96
$2,489.02
$1,267.92
$1,391.72
$1,522.86
$1,988.76
$1,618.72
$1,742.52
$1,873.66
$2,339.56
$1,969.52
$2,093.32
$2,224.46
$2,690.36
$350.80
Toc - Plan #41 Sanford Health Plan
Silver

(PPO) Sanford Simplicity $4,750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$4,750 $9,500 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
$396.54
$450.08
$506.78
$708.22
$1,076.21
$699.90
$753.44
$810.14
$1,011.58
$1,003.26
$1,056.80
$1,113.50
$1,314.94
$1,306.62
$1,360.16
$1,416.86
$1,618.30
$303.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793.08
$900.16
$1,013.56
$1,416.44
$2,152.42
$1,096.44
$1,203.52
$1,316.92
$1,719.80
$1,399.80
$1,506.88
$1,620.28
$2,023.16
$1,703.16
$1,810.24
$1,923.64
$2,326.52
$303.36
Toc - Plan #42 Sanford Health Plan
Expanded Bronze

(PPO) Sanford Simplicity $6,900 HSA/HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$268.07
$304.26
$342.60
$478.77
$727.54
$473.15
$509.34
$547.68
$683.85
$678.23
$714.42
$752.76
$888.93
$883.31
$919.50
$957.84
$1,094.01
$205.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$536.14
$608.52
$685.20
$957.54
$1,455.08
$741.22
$813.60
$890.28
$1,162.62
$946.30
$1,018.68
$1,095.36
$1,367.70
$1,151.38
$1,223.76
$1,300.44
$1,572.78
$205.08
Toc - Plan #43 Sanford Health Plan
Expanded Bronze

(PPO) Sanford Simplicity $6,000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$256.42
$291.03
$327.70
$457.96
$695.90
$452.58
$487.19
$523.86
$654.12
$648.74
$683.35
$720.02
$850.28
$844.90
$879.51
$916.18
$1,046.44
$196.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$512.84
$582.06
$655.40
$915.92
$1,391.80
$709.00
$778.22
$851.56
$1,112.08
$905.16
$974.38
$1,047.72
$1,308.24
$1,101.32
$1,170.54
$1,243.88
$1,504.40
$196.16
Toc - Plan #44 Sanford Health Plan
Expanded Bronze

(PPO) Sanford Simplicity $7,000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$254.33
$288.66
$325.03
$454.23
$690.24
$448.89
$483.22
$519.59
$648.79
$643.45
$677.78
$714.15
$843.35
$838.01
$872.34
$908.71
$1,037.91
$194.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$508.66
$577.32
$650.06
$908.46
$1,380.48
$703.22
$771.88
$844.62
$1,103.02
$897.78
$966.44
$1,039.18
$1,297.58
$1,092.34
$1,161.00
$1,233.74
$1,492.14
$194.56
Toc - Plan #45 Sanford Health Plan
Catastrophic

(PPO) Sanford Simplicity $9,100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$160.23
$181.86
$204.77
$286.16
$434.85
$282.81
$304.44
$327.35
$408.74
$405.39
$427.02
$449.93
$531.32
$527.97
$549.60
$572.51
$653.90
$122.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$320.46
$363.72
$409.54
$572.32
$869.70
$443.04
$486.30
$532.12
$694.90
$565.62
$608.88
$654.70
$817.48
$688.20
$731.46
$777.28
$940.06
$122.58
Toc - Plan #46 Sanford Health Plan
Silver

(PPO) Sanford Simplicity Enhanced - Diabetes & Asthma/COPD Care Plan $3,700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 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
$406.64
$461.53
$519.68
$726.25
$1,103.61
$717.72
$772.61
$830.76
$1,037.33
$1,028.80
$1,083.69
$1,141.84
$1,348.41
$1,339.88
$1,394.77
$1,452.92
$1,659.49
$311.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$813.28
$923.06
$1,039.36
$1,452.50
$2,207.22
$1,124.36
$1,234.14
$1,350.44
$1,763.58
$1,435.44
$1,545.22
$1,661.52
$2,074.66
$1,746.52
$1,856.30
$1,972.60
$2,385.74
$311.08
Toc - Plan #47 Sanford Health Plan
Gold

(PPO) Sanford Simplicity Enhanced - Diabetes & Asthma/COPD Care Plan $1,250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.45
$457.92
$515.61
$720.56
$1,094.96
$712.09
$766.56
$824.25
$1,029.20
$1,020.73
$1,075.20
$1,132.89
$1,337.84
$1,329.37
$1,383.84
$1,441.53
$1,646.48
$308.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.90
$915.84
$1,031.22
$1,441.12
$2,189.92
$1,115.54
$1,224.48
$1,339.86
$1,749.76
$1,424.18
$1,533.12
$1,648.50
$2,058.40
$1,732.82
$1,841.76
$1,957.14
$2,367.04
$308.64
Toc - Plan #48 Sanford Health Plan
Expanded Bronze

(PPO) Sanford Simplicity - Standardized $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$280.84
$318.75
$358.91
$501.57
$762.19
$495.68
$533.59
$573.75
$716.41
$710.52
$748.43
$788.59
$931.25
$925.36
$963.27
$1,003.43
$1,146.09
$214.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$561.68
$637.50
$717.82
$1,003.14
$1,524.38
$776.52
$852.34
$932.66
$1,217.98
$991.36
$1,067.18
$1,147.50
$1,432.82
$1,206.20
$1,282.02
$1,362.34
$1,647.66
$214.84
Toc - Plan #49 Sanford Health Plan
Silver

(PPO) Sanford Simplicity - Standardized $5,800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$398.97
$452.83
$509.88
$712.55
$1,082.79
$704.18
$758.04
$815.09
$1,017.76
$1,009.39
$1,063.25
$1,120.30
$1,322.97
$1,314.60
$1,368.46
$1,425.51
$1,628.18
$305.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$797.94
$905.66
$1,019.76
$1,425.10
$2,165.58
$1,103.15
$1,210.87
$1,324.97
$1,730.31
$1,408.36
$1,516.08
$1,630.18
$2,035.52
$1,713.57
$1,821.29
$1,935.39
$2,340.73
$305.21
Toc - Plan #50 Sanford Health Plan
Gold

(PPO) Sanford Simplicity - Standardized $2,000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-752-5863

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
$391.03
$443.82
$499.74
$698.38
$1,061.26
$690.17
$742.96
$798.88
$997.52
$989.31
$1,042.10
$1,098.02
$1,296.66
$1,288.45
$1,341.24
$1,397.16
$1,595.80
$299.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782.06
$887.64
$999.48
$1,396.76
$2,122.52
$1,081.20
$1,186.78
$1,298.62
$1,695.90
$1,380.34
$1,485.92
$1,597.76
$1,995.04
$1,679.48
$1,785.06
$1,896.90
$2,294.18
$299.14

‡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 Cass County here.

Cass County is in “Rating Area 2” of North Dakota.

Currently, there are 50 plans offered in Rating Area 2.

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2023 Obamacare Plans for Cass County, ND

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