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Ohio Obamacare 2023 Rates

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Obamacare Rates and Providers for Other Years

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Anthem Blue Cross and Blue Shield

Local: 1-855-748-1808 | Toll Free: 1-855-748-1808

Toc - Plan #1 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351.28
$398.70
$448.94
$627.39
$953.37
$620.01
$667.43
$717.67
$896.12
$888.74
$936.16
$986.40
$1,164.85
$1,157.47
$1,204.89
$1,255.13
$1,433.58
$268.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.56
$797.40
$897.88
$1,254.78
$1,906.74
$971.29
$1,066.13
$1,166.61
$1,523.51
$1,240.02
$1,334.86
$1,435.34
$1,792.24
$1,508.75
$1,603.59
$1,704.07
$2,060.97
$268.73
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X HMO 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$331.79
$376.58
$424.03
$592.58
$900.48
$585.61
$630.40
$677.85
$846.40
$839.43
$884.22
$931.67
$1,100.22
$1,093.25
$1,138.04
$1,185.49
$1,354.04
$253.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$663.58
$753.16
$848.06
$1,185.16
$1,800.96
$917.40
$1,006.98
$1,101.88
$1,438.98
$1,171.22
$1,260.80
$1,355.70
$1,692.80
$1,425.04
$1,514.62
$1,609.52
$1,946.62
$253.82
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$442.58
$502.33
$565.62
$790.45
$1,201.16
$781.15
$840.90
$904.19
$1,129.02
$1,119.72
$1,179.47
$1,242.76
$1,467.59
$1,458.29
$1,518.04
$1,581.33
$1,806.16
$338.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$885.16
$1,004.66
$1,131.24
$1,580.90
$2,402.32
$1,223.73
$1,343.23
$1,469.81
$1,919.47
$1,562.30
$1,681.80
$1,808.38
$2,258.04
$1,900.87
$2,020.37
$2,146.95
$2,596.61
$338.57
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 7450/0% for HSA (+ Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.38
$404.49
$455.45
$636.49
$967.22
$629.01
$677.12
$728.08
$909.12
$901.64
$949.75
$1,000.71
$1,181.75
$1,174.27
$1,222.38
$1,273.34
$1,454.38
$272.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.76
$808.98
$910.90
$1,272.98
$1,934.44
$985.39
$1,081.61
$1,183.53
$1,545.61
$1,258.02
$1,354.24
$1,456.16
$1,818.24
$1,530.65
$1,626.87
$1,728.79
$2,090.87
$272.63
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3200/10% for HSA (+ Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$445.36
$505.48
$569.17
$795.41
$1,208.71
$786.06
$846.18
$909.87
$1,136.11
$1,126.76
$1,186.88
$1,250.57
$1,476.81
$1,467.46
$1,527.58
$1,591.27
$1,817.51
$340.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$890.72
$1,010.96
$1,138.34
$1,590.82
$2,417.42
$1,231.42
$1,351.66
$1,479.04
$1,931.52
$1,572.12
$1,692.36
$1,819.74
$2,272.22
$1,912.82
$2,033.06
$2,160.44
$2,612.92
$340.70
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000/20% for HSA (+ Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.04
$409.78
$461.41
$644.82
$979.86
$637.24
$685.98
$737.61
$921.02
$913.44
$962.18
$1,013.81
$1,197.22
$1,189.64
$1,238.38
$1,290.01
$1,473.42
$276.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.08
$819.56
$922.82
$1,289.64
$1,959.72
$998.28
$1,095.76
$1,199.02
$1,565.84
$1,274.48
$1,371.96
$1,475.22
$1,842.04
$1,550.68
$1,648.16
$1,751.42
$2,118.24
$276.20
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5400/0% for HSA ( + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$453.13
$514.30
$579.10
$809.29
$1,229.79
$799.77
$860.94
$925.74
$1,155.93
$1,146.41
$1,207.58
$1,272.38
$1,502.57
$1,493.05
$1,554.22
$1,619.02
$1,849.21
$346.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$906.26
$1,028.60
$1,158.20
$1,618.58
$2,459.58
$1,252.90
$1,375.24
$1,504.84
$1,965.22
$1,599.54
$1,721.88
$1,851.48
$2,311.86
$1,946.18
$2,068.52
$2,198.12
$2,658.50
$346.64
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$453.36
$514.56
$579.39
$809.70
$1,230.42
$800.18
$861.38
$926.21
$1,156.52
$1,147.00
$1,208.20
$1,273.03
$1,503.34
$1,493.82
$1,555.02
$1,619.85
$1,850.16
$346.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$906.72
$1,029.12
$1,158.78
$1,619.40
$2,460.84
$1,253.54
$1,375.94
$1,505.60
$1,966.22
$1,600.36
$1,722.76
$1,852.42
$2,313.04
$1,947.18
$2,069.58
$2,199.24
$2,659.86
$346.82
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,950 $15,900 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
$436.58
$495.52
$557.95
$779.73
$1,184.88
$770.56
$829.50
$891.93
$1,113.71
$1,104.54
$1,163.48
$1,225.91
$1,447.69
$1,438.52
$1,497.46
$1,559.89
$1,781.67
$333.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.16
$991.04
$1,115.90
$1,559.46
$2,369.76
$1,207.14
$1,325.02
$1,449.88
$1,893.44
$1,541.12
$1,659.00
$1,783.86
$2,227.42
$1,875.10
$1,992.98
$2,117.84
$2,561.40
$333.98
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Catastrophic

(HMO) Anthem Catastrophic Pathway X HMO 9100 ( + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$262.57
$298.02
$335.56
$468.95
$712.61
$463.44
$498.89
$536.43
$669.82
$664.31
$699.76
$737.30
$870.69
$865.18
$900.63
$938.17
$1,071.56
$200.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$525.14
$596.04
$671.12
$937.90
$1,425.22
$726.01
$796.91
$871.99
$1,138.77
$926.88
$997.78
$1,072.86
$1,339.64
$1,127.75
$1,198.65
$1,273.73
$1,540.51
$200.87
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 6000/25% ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$439.40
$498.72
$561.55
$784.77
$1,192.53
$775.54
$834.86
$897.69
$1,120.91
$1,111.68
$1,171.00
$1,233.83
$1,457.05
$1,447.82
$1,507.14
$1,569.97
$1,793.19
$336.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$878.80
$997.44
$1,123.10
$1,569.54
$2,385.06
$1,214.94
$1,333.58
$1,459.24
$1,905.68
$1,551.08
$1,669.72
$1,795.38
$2,241.82
$1,887.22
$2,005.86
$2,131.52
$2,577.96
$336.14
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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
$356.02
$404.08
$454.99
$635.85
$966.24
$628.38
$676.44
$727.35
$908.21
$900.74
$948.80
$999.71
$1,180.57
$1,173.10
$1,221.16
$1,272.07
$1,452.93
$272.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.04
$808.16
$909.98
$1,271.70
$1,932.48
$984.40
$1,080.52
$1,182.34
$1,544.06
$1,256.76
$1,352.88
$1,454.70
$1,816.42
$1,529.12
$1,625.24
$1,727.06
$2,088.78
$272.36
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$338.30
$383.97
$432.35
$604.20
$918.15
$597.10
$642.77
$691.15
$863.00
$855.90
$901.57
$949.95
$1,121.80
$1,114.70
$1,160.37
$1,208.75
$1,380.60
$258.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$676.60
$767.94
$864.70
$1,208.40
$1,836.30
$935.40
$1,026.74
$1,123.50
$1,467.20
$1,194.20
$1,285.54
$1,382.30
$1,726.00
$1,453.00
$1,544.34
$1,641.10
$1,984.80
$258.80
Toc - Plan #14 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X HMO 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$332.53
$377.42
$424.97
$593.90
$902.49
$586.92
$631.81
$679.36
$848.29
$841.31
$886.20
$933.75
$1,102.68
$1,095.70
$1,140.59
$1,188.14
$1,357.07
$254.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.06
$754.84
$849.94
$1,187.80
$1,804.98
$919.45
$1,009.23
$1,104.33
$1,442.19
$1,173.84
$1,263.62
$1,358.72
$1,696.58
$1,428.23
$1,518.01
$1,613.11
$1,950.97
$254.39
Toc - Plan #15 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$364.06
$413.21
$465.27
$650.21
$988.06
$642.57
$691.72
$743.78
$928.72
$921.08
$970.23
$1,022.29
$1,207.23
$1,199.59
$1,248.74
$1,300.80
$1,485.74
$278.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728.12
$826.42
$930.54
$1,300.42
$1,976.12
$1,006.63
$1,104.93
$1,209.05
$1,578.93
$1,285.14
$1,383.44
$1,487.56
$1,857.44
$1,563.65
$1,661.95
$1,766.07
$2,135.95
$278.51
Toc - Plan #16 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$434.15
$492.76
$554.84
$775.39
$1,178.28
$766.27
$824.88
$886.96
$1,107.51
$1,098.39
$1,157.00
$1,219.08
$1,439.63
$1,430.51
$1,489.12
$1,551.20
$1,771.75
$332.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.30
$985.52
$1,109.68
$1,550.78
$2,356.56
$1,200.42
$1,317.64
$1,441.80
$1,882.90
$1,532.54
$1,649.76
$1,773.92
$2,215.02
$1,864.66
$1,981.88
$2,106.04
$2,547.14
$332.12
Toc - Plan #17 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway X HMO 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$630.20
$715.28
$805.40
$1,125.54
$1,710.36
$1,112.30
$1,197.38
$1,287.50
$1,607.64
$1,594.40
$1,679.48
$1,769.60
$2,089.74
$2,076.50
$2,161.58
$2,251.70
$2,571.84
$482.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,260.40
$1,430.56
$1,610.80
$2,251.08
$3,420.72
$1,742.50
$1,912.66
$2,092.90
$2,733.18
$2,224.60
$2,394.76
$2,575.00
$3,215.28
$2,706.70
$2,876.86
$3,057.10
$3,697.38
$482.10

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-760-3310 | Toll Free: 1-877-760-3310 | TTY: 1-800-331-4680

Toc - Plan #18 UnitedHealthcare
Gold

(HMO) UHC Gold Value (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$2,150 $4,300 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$350.01
$397.26
$447.31
$625.12
$949.93
$617.77
$665.02
$715.07
$892.88
$885.53
$932.78
$982.83
$1,160.64
$1,153.29
$1,200.54
$1,250.59
$1,428.40
$267.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700.02
$794.52
$894.62
$1,250.24
$1,899.86
$967.78
$1,062.28
$1,162.38
$1,518.00
$1,235.54
$1,330.04
$1,430.14
$1,785.76
$1,503.30
$1,597.80
$1,697.90
$2,053.52
$267.76
Toc - Plan #19 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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
$373.36
$423.77
$477.16
$666.83
$1,013.31
$658.98
$709.39
$762.78
$952.45
$944.60
$995.01
$1,048.40
$1,238.07
$1,230.22
$1,280.63
$1,334.02
$1,523.69
$285.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.72
$847.54
$954.32
$1,333.66
$2,026.62
$1,032.34
$1,133.16
$1,239.94
$1,619.28
$1,317.96
$1,418.78
$1,525.56
$1,904.90
$1,603.58
$1,704.40
$1,811.18
$2,190.52
$285.62
Toc - Plan #20 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$358.11
$406.45
$457.66
$639.58
$971.91
$632.06
$680.40
$731.61
$913.53
$906.01
$954.35
$1,005.56
$1,187.48
$1,179.96
$1,228.30
$1,279.51
$1,461.43
$273.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716.22
$812.90
$915.32
$1,279.16
$1,943.82
$990.17
$1,086.85
$1,189.27
$1,553.11
$1,264.12
$1,360.80
$1,463.22
$1,827.06
$1,538.07
$1,634.75
$1,737.17
$2,101.01
$273.95
Toc - Plan #21 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,450 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.44
$358.03
$403.14
$563.38
$856.11
$556.75
$599.34
$644.45
$804.69
$798.06
$840.65
$885.76
$1,046.00
$1,039.37
$1,081.96
$1,127.07
$1,287.31
$241.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.88
$716.06
$806.28
$1,126.76
$1,712.22
$872.19
$957.37
$1,047.59
$1,368.07
$1,113.50
$1,198.68
$1,288.90
$1,609.38
$1,354.81
$1,439.99
$1,530.21
$1,850.69
$241.31
Toc - Plan #22 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$314.26
$356.68
$401.62
$561.27
$852.90
$554.67
$597.09
$642.03
$801.68
$795.08
$837.50
$882.44
$1,042.09
$1,035.49
$1,077.91
$1,122.85
$1,282.50
$240.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$628.52
$713.36
$803.24
$1,122.54
$1,705.80
$868.93
$953.77
$1,043.65
$1,362.95
$1,109.34
$1,194.18
$1,284.06
$1,603.36
$1,349.75
$1,434.59
$1,524.47
$1,843.77
$240.41
Toc - Plan #23 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$313.46
$355.78
$400.60
$559.84
$850.73
$553.26
$595.58
$640.40
$799.64
$793.06
$835.38
$880.20
$1,039.44
$1,032.86
$1,075.18
$1,120.00
$1,279.24
$239.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$626.92
$711.56
$801.20
$1,119.68
$1,701.46
$866.72
$951.36
$1,041.00
$1,359.48
$1,106.52
$1,191.16
$1,280.80
$1,599.28
$1,346.32
$1,430.96
$1,520.60
$1,839.08
$239.80
Toc - Plan #24 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$320.34
$363.58
$409.39
$572.12
$869.40
$565.40
$608.64
$654.45
$817.18
$810.46
$853.70
$899.51
$1,062.24
$1,055.52
$1,098.76
$1,144.57
$1,307.30
$245.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.68
$727.16
$818.78
$1,144.24
$1,738.80
$885.74
$972.22
$1,063.84
$1,389.30
$1,130.80
$1,217.28
$1,308.90
$1,634.36
$1,375.86
$1,462.34
$1,553.96
$1,879.42
$245.06
Toc - Plan #25 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312.98
$355.24
$399.99
$558.99
$849.44
$552.41
$594.67
$639.42
$798.42
$791.84
$834.10
$878.85
$1,037.85
$1,031.27
$1,073.53
$1,118.28
$1,277.28
$239.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625.96
$710.48
$799.98
$1,117.98
$1,698.88
$865.39
$949.91
$1,039.41
$1,357.41
$1,104.82
$1,189.34
$1,278.84
$1,596.84
$1,344.25
$1,428.77
$1,518.27
$1,836.27
$239.43
Toc - Plan #26 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328.28
$372.60
$419.54
$586.31
$890.95
$579.41
$623.73
$670.67
$837.44
$830.54
$874.86
$921.80
$1,088.57
$1,081.67
$1,125.99
$1,172.93
$1,339.70
$251.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.56
$745.20
$839.08
$1,172.62
$1,781.90
$907.69
$996.33
$1,090.21
$1,423.75
$1,158.82
$1,247.46
$1,341.34
$1,674.88
$1,409.95
$1,498.59
$1,592.47
$1,926.01
$251.13
Toc - Plan #27 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$316.98
$359.77
$405.10
$566.12
$860.28
$559.47
$602.26
$647.59
$808.61
$801.96
$844.75
$890.08
$1,051.10
$1,044.45
$1,087.24
$1,132.57
$1,293.59
$242.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$633.96
$719.54
$810.20
$1,132.24
$1,720.56
$876.45
$962.03
$1,052.69
$1,374.73
$1,118.94
$1,204.52
$1,295.18
$1,617.22
$1,361.43
$1,447.01
$1,537.67
$1,859.71
$242.49
Toc - Plan #28 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$268.93
$305.24
$343.70
$480.31
$729.88
$474.66
$510.97
$549.43
$686.04
$680.39
$716.70
$755.16
$891.77
$886.12
$922.43
$960.89
$1,097.50
$205.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$537.86
$610.48
$687.40
$960.62
$1,459.76
$743.59
$816.21
$893.13
$1,166.35
$949.32
$1,021.94
$1,098.86
$1,372.08
$1,155.05
$1,227.67
$1,304.59
$1,577.81
$205.73
Toc - Plan #29 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA $6,700 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$279.32
$317.03
$356.97
$498.86
$758.07
$493.00
$530.71
$570.65
$712.54
$706.68
$744.39
$784.33
$926.22
$920.36
$958.07
$998.01
$1,139.90
$213.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$558.64
$634.06
$713.94
$997.72
$1,516.14
$772.32
$847.74
$927.62
$1,211.40
$986.00
$1,061.42
$1,141.30
$1,425.08
$1,199.68
$1,275.10
$1,354.98
$1,638.76
$213.68
Toc - Plan #30 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $8,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.27
$327.19
$368.41
$514.85
$782.36
$508.80
$547.72
$588.94
$735.38
$729.33
$768.25
$809.47
$955.91
$949.86
$988.78
$1,030.00
$1,176.44
$220.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.54
$654.38
$736.82
$1,029.70
$1,564.72
$797.07
$874.91
$957.35
$1,250.23
$1,017.60
$1,095.44
$1,177.88
$1,470.76
$1,238.13
$1,315.97
$1,398.41
$1,691.29
$220.53
Toc - Plan #31 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$279.18
$316.87
$356.79
$498.61
$757.69
$492.75
$530.44
$570.36
$712.18
$706.32
$744.01
$783.93
$925.75
$919.89
$957.58
$997.50
$1,139.32
$213.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$558.36
$633.74
$713.58
$997.22
$1,515.38
$771.93
$847.31
$927.15
$1,210.79
$985.50
$1,060.88
$1,140.72
$1,424.36
$1,199.07
$1,274.45
$1,354.29
$1,637.93
$213.57
Toc - Plan #32 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$285.54
$324.08
$364.92
$509.97
$774.95
$503.98
$542.52
$583.36
$728.41
$722.42
$760.96
$801.80
$946.85
$940.86
$979.40
$1,020.24
$1,165.29
$218.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$571.08
$648.16
$729.84
$1,019.94
$1,549.90
$789.52
$866.60
$948.28
$1,238.38
$1,007.96
$1,085.04
$1,166.72
$1,456.82
$1,226.40
$1,303.48
$1,385.16
$1,675.26
$218.44
Toc - Plan #33 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$268.96
$305.27
$343.73
$480.36
$729.96
$474.71
$511.02
$549.48
$686.11
$680.46
$716.77
$755.23
$891.86
$886.21
$922.52
$960.98
$1,097.61
$205.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$537.92
$610.54
$687.46
$960.72
$1,459.92
$743.67
$816.29
$893.21
$1,166.47
$949.42
$1,022.04
$1,098.96
$1,372.22
$1,155.17
$1,227.79
$1,304.71
$1,577.97
$205.75

ADVERTISEMENT

Ambetter from Buckeye Health Plan

Local: 1-877-687-1189 | Toll Free: 1-877-687-1189 | TTY: 1-877-941-9236

Toc - Plan #34 Ambetter from Buckeye Health Plan
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$346.94
$393.76
$443.37
$619.61
$941.56
$612.34
$659.16
$708.77
$885.01
$877.74
$924.56
$974.17
$1,150.41
$1,143.14
$1,189.96
$1,239.57
$1,415.81
$265.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.88
$787.52
$886.74
$1,239.22
$1,883.12
$959.28
$1,052.92
$1,152.14
$1,504.62
$1,224.68
$1,318.32
$1,417.54
$1,770.02
$1,490.08
$1,583.72
$1,682.94
$2,035.42
$265.40
Toc - Plan #35 Ambetter from Buckeye Health Plan
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.78
$390.18
$439.34
$613.97
$932.99
$606.76
$653.16
$702.32
$876.95
$869.74
$916.14
$965.30
$1,139.93
$1,132.72
$1,179.12
$1,228.28
$1,402.91
$262.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.56
$780.36
$878.68
$1,227.94
$1,865.98
$950.54
$1,043.34
$1,141.66
$1,490.92
$1,213.52
$1,306.32
$1,404.64
$1,753.90
$1,476.50
$1,569.30
$1,667.62
$2,016.88
$262.98
Toc - Plan #36 Ambetter from Buckeye Health Plan
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$371.22
$421.33
$474.41
$662.98
$1,007.47
$655.20
$705.31
$758.39
$946.96
$939.18
$989.29
$1,042.37
$1,230.94
$1,223.16
$1,273.27
$1,326.35
$1,514.92
$283.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.44
$842.66
$948.82
$1,325.96
$2,014.94
$1,026.42
$1,126.64
$1,232.80
$1,609.94
$1,310.40
$1,410.62
$1,516.78
$1,893.92
$1,594.38
$1,694.60
$1,800.76
$2,177.90
$283.98
Toc - Plan #37 Ambetter from Buckeye Health Plan
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$278.94
$316.58
$356.47
$498.17
$757.01
$492.32
$529.96
$569.85
$711.55
$705.70
$743.34
$783.23
$924.93
$919.08
$956.72
$996.61
$1,138.31
$213.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$557.88
$633.16
$712.94
$996.34
$1,514.02
$771.26
$846.54
$926.32
$1,209.72
$984.64
$1,059.92
$1,139.70
$1,423.10
$1,198.02
$1,273.30
$1,353.08
$1,636.48
$213.38
Toc - Plan #38 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$305.37
$346.59
$390.26
$545.38
$828.76
$538.97
$580.19
$623.86
$778.98
$772.57
$813.79
$857.46
$1,012.58
$1,006.17
$1,047.39
$1,091.06
$1,246.18
$233.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610.74
$693.18
$780.52
$1,090.76
$1,657.52
$844.34
$926.78
$1,014.12
$1,324.36
$1,077.94
$1,160.38
$1,247.72
$1,557.96
$1,311.54
$1,393.98
$1,481.32
$1,791.56
$233.60
Toc - Plan #39 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$297.29
$337.41
$379.93
$530.94
$806.82
$524.71
$564.83
$607.35
$758.36
$752.13
$792.25
$834.77
$985.78
$979.55
$1,019.67
$1,062.19
$1,213.20
$227.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$594.58
$674.82
$759.86
$1,061.88
$1,613.64
$822.00
$902.24
$987.28
$1,289.30
$1,049.42
$1,129.66
$1,214.70
$1,516.72
$1,276.84
$1,357.08
$1,442.12
$1,744.14
$227.42
Toc - Plan #40 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.82
$377.74
$425.33
$594.39
$903.24
$587.42
$632.34
$679.93
$848.99
$842.02
$886.94
$934.53
$1,103.59
$1,096.62
$1,141.54
$1,189.13
$1,358.19
$254.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.64
$755.48
$850.66
$1,188.78
$1,806.48
$920.24
$1,010.08
$1,105.26
$1,443.38
$1,174.84
$1,264.68
$1,359.86
$1,697.98
$1,429.44
$1,519.28
$1,614.46
$1,952.58
$254.60
Toc - Plan #41 Ambetter from Buckeye Health Plan
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$340.17
$386.08
$434.73
$607.53
$923.20
$600.39
$646.30
$694.95
$867.75
$860.61
$906.52
$955.17
$1,127.97
$1,120.83
$1,166.74
$1,215.39
$1,388.19
$260.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.34
$772.16
$869.46
$1,215.06
$1,846.40
$940.56
$1,032.38
$1,129.68
$1,475.28
$1,200.78
$1,292.60
$1,389.90
$1,735.50
$1,461.00
$1,552.82
$1,650.12
$1,995.72
$260.22
Toc - Plan #42 Ambetter from Buckeye Health Plan
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$342.63
$388.88
$437.87
$611.93
$929.88
$604.74
$650.99
$699.98
$874.04
$866.85
$913.10
$962.09
$1,136.15
$1,128.96
$1,175.21
$1,224.20
$1,398.26
$262.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.26
$777.76
$875.74
$1,223.86
$1,859.76
$947.37
$1,039.87
$1,137.85
$1,485.97
$1,209.48
$1,301.98
$1,399.96
$1,748.08
$1,471.59
$1,564.09
$1,662.07
$2,010.19
$262.11
Toc - Plan #43 Ambetter from Buckeye Health Plan
Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.37
$404.47
$455.43
$636.46
$967.17
$628.99
$677.09
$728.05
$909.08
$901.61
$949.71
$1,000.67
$1,181.70
$1,174.23
$1,222.33
$1,273.29
$1,454.32
$272.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.74
$808.94
$910.86
$1,272.92
$1,934.34
$985.36
$1,081.56
$1,183.48
$1,545.54
$1,257.98
$1,354.18
$1,456.10
$1,818.16
$1,530.60
$1,626.80
$1,728.72
$2,090.78
$272.62
Toc - Plan #44 Ambetter from Buckeye Health Plan
Silver

(HMO) Enhanced Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.84
$387.97
$436.85
$610.50
$927.72
$603.34
$649.47
$698.35
$872.00
$864.84
$910.97
$959.85
$1,133.50
$1,126.34
$1,172.47
$1,221.35
$1,395.00
$261.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.68
$775.94
$873.70
$1,221.00
$1,855.44
$945.18
$1,037.44
$1,135.20
$1,482.50
$1,206.68
$1,298.94
$1,396.70
$1,744.00
$1,468.18
$1,560.44
$1,658.20
$2,005.50
$261.50
Toc - Plan #45 Ambetter from Buckeye Health Plan
Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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
$351.76
$399.24
$449.54
$628.22
$954.65
$620.85
$668.33
$718.63
$897.31
$889.94
$937.42
$987.72
$1,166.40
$1,159.03
$1,206.51
$1,256.81
$1,435.49
$269.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$703.52
$798.48
$899.08
$1,256.44
$1,909.30
$972.61
$1,067.57
$1,168.17
$1,525.53
$1,241.70
$1,336.66
$1,437.26
$1,794.62
$1,510.79
$1,605.75
$1,706.35
$2,063.71
$269.09
Toc - Plan #46 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$291.57
$330.92
$372.61
$520.72
$791.29
$514.61
$553.96
$595.65
$743.76
$737.65
$777.00
$818.69
$966.80
$960.69
$1,000.04
$1,041.73
$1,189.84
$223.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$583.14
$661.84
$745.22
$1,041.44
$1,582.58
$806.18
$884.88
$968.26
$1,264.48
$1,029.22
$1,107.92
$1,191.30
$1,487.52
$1,252.26
$1,330.96
$1,414.34
$1,710.56
$223.04
Toc - Plan #47 Ambetter from Buckeye Health Plan
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$339.69
$385.53
$434.11
$606.66
$921.88
$599.54
$645.38
$693.96
$866.51
$859.39
$905.23
$953.81
$1,126.36
$1,119.24
$1,165.08
$1,213.66
$1,386.21
$259.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$679.38
$771.06
$868.22
$1,213.32
$1,843.76
$939.23
$1,030.91
$1,128.07
$1,473.17
$1,199.08
$1,290.76
$1,387.92
$1,733.02
$1,458.93
$1,550.61
$1,647.77
$1,992.87
$259.85
Toc - Plan #48 Ambetter from Buckeye Health Plan
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$353.91
$401.68
$452.28
$632.07
$960.48
$624.64
$672.41
$723.01
$902.80
$895.37
$943.14
$993.74
$1,173.53
$1,166.10
$1,213.87
$1,264.47
$1,444.26
$270.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.82
$803.36
$904.56
$1,264.14
$1,920.96
$978.55
$1,074.09
$1,175.29
$1,534.87
$1,249.28
$1,344.82
$1,446.02
$1,805.60
$1,520.01
$1,615.55
$1,716.75
$2,076.33
$270.73
Toc - Plan #49 Ambetter from Buckeye Health Plan
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.18
$403.11
$453.90
$634.33
$963.92
$626.88
$674.81
$725.60
$906.03
$898.58
$946.51
$997.30
$1,177.73
$1,170.28
$1,218.21
$1,269.00
$1,449.43
$271.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.36
$806.22
$907.80
$1,268.66
$1,927.84
$982.06
$1,077.92
$1,179.50
$1,540.36
$1,253.76
$1,349.62
$1,451.20
$1,812.06
$1,525.46
$1,621.32
$1,722.90
$2,083.76
$271.70
Toc - Plan #50 Ambetter from Buckeye Health Plan
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$358.44
$406.81
$458.07
$640.15
$972.77
$632.64
$681.01
$732.27
$914.35
$906.84
$955.21
$1,006.47
$1,188.55
$1,181.04
$1,229.41
$1,280.67
$1,462.75
$274.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716.88
$813.62
$916.14
$1,280.30
$1,945.54
$991.08
$1,087.82
$1,190.34
$1,554.50
$1,265.28
$1,362.02
$1,464.54
$1,828.70
$1,539.48
$1,636.22
$1,738.74
$2,102.90
$274.20
Toc - Plan #51 Ambetter from Buckeye Health Plan
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$383.53
$435.29
$490.13
$684.96
$1,040.87
$676.92
$728.68
$783.52
$978.35
$970.31
$1,022.07
$1,076.91
$1,271.74
$1,263.70
$1,315.46
$1,370.30
$1,565.13
$293.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.06
$870.58
$980.26
$1,369.92
$2,081.74
$1,060.45
$1,163.97
$1,273.65
$1,663.31
$1,353.84
$1,457.36
$1,567.04
$1,956.70
$1,647.23
$1,750.75
$1,860.43
$2,250.09
$293.39
Toc - Plan #52 Ambetter from Buckeye Health Plan
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.19
$327.08
$368.29
$514.68
$782.11
$508.64
$547.53
$588.74
$735.13
$729.09
$767.98
$809.19
$955.58
$949.54
$988.43
$1,029.64
$1,176.03
$220.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.38
$654.16
$736.58
$1,029.36
$1,564.22
$796.83
$874.61
$957.03
$1,249.81
$1,017.28
$1,095.06
$1,177.48
$1,470.26
$1,237.73
$1,315.51
$1,397.93
$1,690.71
$220.45
Toc - Plan #53 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$315.50
$358.08
$403.19
$563.46
$856.23
$556.85
$599.43
$644.54
$804.81
$798.20
$840.78
$885.89
$1,046.16
$1,039.55
$1,082.13
$1,127.24
$1,287.51
$241.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$631.00
$716.16
$806.38
$1,126.92
$1,712.46
$872.35
$957.51
$1,047.73
$1,368.27
$1,113.70
$1,198.86
$1,289.08
$1,609.62
$1,355.05
$1,440.21
$1,530.43
$1,850.97
$241.35
Toc - Plan #54 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$307.15
$348.60
$392.52
$548.55
$833.57
$542.11
$583.56
$627.48
$783.51
$777.07
$818.52
$862.44
$1,018.47
$1,012.03
$1,053.48
$1,097.40
$1,253.43
$234.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$614.30
$697.20
$785.04
$1,097.10
$1,667.14
$849.26
$932.16
$1,020.00
$1,332.06
$1,084.22
$1,167.12
$1,254.96
$1,567.02
$1,319.18
$1,402.08
$1,489.92
$1,801.98
$234.96
Toc - Plan #55 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.85
$390.26
$439.43
$614.10
$933.18
$606.89
$653.30
$702.47
$877.14
$869.93
$916.34
$965.51
$1,140.18
$1,132.97
$1,179.38
$1,228.55
$1,403.22
$263.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.70
$780.52
$878.86
$1,228.20
$1,866.36
$950.74
$1,043.56
$1,141.90
$1,491.24
$1,213.78
$1,306.60
$1,404.94
$1,754.28
$1,476.82
$1,569.64
$1,667.98
$2,017.32
$263.04
Toc - Plan #56 Ambetter from Buckeye Health Plan
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$351.45
$398.88
$449.14
$627.67
$953.80
$620.30
$667.73
$717.99
$896.52
$889.15
$936.58
$986.84
$1,165.37
$1,158.00
$1,205.43
$1,255.69
$1,434.22
$268.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.90
$797.76
$898.28
$1,255.34
$1,907.60
$971.75
$1,066.61
$1,167.13
$1,524.19
$1,240.60
$1,335.46
$1,435.98
$1,793.04
$1,509.45
$1,604.31
$1,704.83
$2,061.89
$268.85
Toc - Plan #57 Ambetter from Buckeye Health Plan
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.99
$401.77
$452.39
$632.21
$960.71
$624.79
$672.57
$723.19
$903.01
$895.59
$943.37
$993.99
$1,173.81
$1,166.39
$1,214.17
$1,264.79
$1,444.61
$270.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.98
$803.54
$904.78
$1,264.42
$1,921.42
$978.78
$1,074.34
$1,175.58
$1,535.22
$1,249.58
$1,345.14
$1,446.38
$1,806.02
$1,520.38
$1,615.94
$1,717.18
$2,076.82
$270.80
Toc - Plan #58 Ambetter from Buckeye Health Plan
Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$368.19
$417.88
$470.53
$657.56
$999.23
$649.84
$699.53
$752.18
$939.21
$931.49
$981.18
$1,033.83
$1,220.86
$1,213.14
$1,262.83
$1,315.48
$1,502.51
$281.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$736.38
$835.76
$941.06
$1,315.12
$1,998.46
$1,018.03
$1,117.41
$1,222.71
$1,596.77
$1,299.68
$1,399.06
$1,504.36
$1,878.42
$1,581.33
$1,680.71
$1,786.01
$2,160.07
$281.65
Toc - Plan #59 Ambetter from Buckeye Health Plan
Silver

(HMO) Enhanced Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.17
$400.83
$451.34
$630.74
$958.47
$623.34
$671.00
$721.51
$900.91
$893.51
$941.17
$991.68
$1,171.08
$1,163.68
$1,211.34
$1,261.85
$1,441.25
$270.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.34
$801.66
$902.68
$1,261.48
$1,916.94
$976.51
$1,071.83
$1,172.85
$1,531.65
$1,246.68
$1,342.00
$1,443.02
$1,801.82
$1,516.85
$1,612.17
$1,713.19
$2,071.99
$270.17
Toc - Plan #60 Ambetter from Buckeye Health Plan
Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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
$363.42
$412.47
$464.44
$649.05
$986.29
$641.43
$690.48
$742.45
$927.06
$919.44
$968.49
$1,020.46
$1,205.07
$1,197.45
$1,246.50
$1,298.47
$1,483.08
$278.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$726.84
$824.94
$928.88
$1,298.10
$1,972.58
$1,004.85
$1,102.95
$1,206.89
$1,576.11
$1,282.86
$1,380.96
$1,484.90
$1,854.12
$1,560.87
$1,658.97
$1,762.91
$2,132.13
$278.01
Toc - Plan #61 Ambetter from Buckeye Health Plan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$291.15
$330.45
$372.08
$519.98
$790.16
$513.87
$553.17
$594.80
$742.70
$736.59
$775.89
$817.52
$965.42
$959.31
$998.61
$1,040.24
$1,188.14
$222.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.30
$660.90
$744.16
$1,039.96
$1,580.32
$805.02
$883.62
$966.88
$1,262.68
$1,027.74
$1,106.34
$1,189.60
$1,485.40
$1,250.46
$1,329.06
$1,412.32
$1,708.12
$222.72
Toc - Plan #62 Ambetter from Buckeye Health Plan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$336.18
$381.56
$429.63
$600.40
$912.37
$593.35
$638.73
$686.80
$857.57
$850.52
$895.90
$943.97
$1,114.74
$1,107.69
$1,153.07
$1,201.14
$1,371.91
$257.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.36
$763.12
$859.26
$1,200.80
$1,824.74
$929.53
$1,020.29
$1,116.43
$1,457.97
$1,186.70
$1,277.46
$1,373.60
$1,715.14
$1,443.87
$1,534.63
$1,630.77
$1,972.31
$257.17
Toc - Plan #63 Ambetter from Buckeye Health Plan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$356.82
$404.98
$456.01
$637.27
$968.39
$629.78
$677.94
$728.97
$910.23
$902.74
$950.90
$1,001.93
$1,183.19
$1,175.70
$1,223.86
$1,274.89
$1,456.15
$272.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.64
$809.96
$912.02
$1,274.54
$1,936.78
$986.60
$1,082.92
$1,184.98
$1,547.50
$1,259.56
$1,355.88
$1,457.94
$1,820.46
$1,532.52
$1,628.84
$1,730.90
$2,093.42
$272.96

ADVERTISEMENT

Oscar Insurance Corporation of Ohio

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

Toc - Plan #64 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Simple

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$350.60
$397.92
$448.06
$626.16
$951.51
$618.80
$666.12
$716.26
$894.36
$887.00
$934.32
$984.46
$1,162.56
$1,155.20
$1,202.52
$1,252.66
$1,430.76
$268.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$701.20
$795.84
$896.12
$1,252.32
$1,903.02
$969.40
$1,064.04
$1,164.32
$1,520.52
$1,237.60
$1,332.24
$1,432.52
$1,788.72
$1,505.80
$1,600.44
$1,700.72
$2,056.92
$268.20
Toc - Plan #65 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.16
$405.37
$456.44
$637.87
$969.31
$630.38
$678.59
$729.66
$911.09
$903.60
$951.81
$1,002.88
$1,184.31
$1,176.82
$1,225.03
$1,276.10
$1,457.53
$273.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714.32
$810.74
$912.88
$1,275.74
$1,938.62
$987.54
$1,083.96
$1,186.10
$1,548.96
$1,260.76
$1,357.18
$1,459.32
$1,822.18
$1,533.98
$1,630.40
$1,732.54
$2,095.40
$273.22
Toc - Plan #66 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$352.70
$400.30
$450.74
$629.91
$957.20
$622.51
$670.11
$720.55
$899.72
$892.32
$939.92
$990.36
$1,169.53
$1,162.13
$1,209.73
$1,260.17
$1,439.34
$269.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$705.40
$800.60
$901.48
$1,259.82
$1,914.40
$975.21
$1,070.41
$1,171.29
$1,529.63
$1,245.02
$1,340.22
$1,441.10
$1,799.44
$1,514.83
$1,610.03
$1,710.91
$2,069.25
$269.81
Toc - Plan #67 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Elite- Deductible+PCP Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.12
$463.20
$521.56
$728.88
$1,107.60
$720.32
$775.40
$833.76
$1,041.08
$1,032.52
$1,087.60
$1,145.96
$1,353.28
$1,344.72
$1,399.80
$1,458.16
$1,665.48
$312.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$816.24
$926.40
$1,043.12
$1,457.76
$2,215.20
$1,128.44
$1,238.60
$1,355.32
$1,769.96
$1,440.64
$1,550.80
$1,667.52
$2,082.16
$1,752.84
$1,863.00
$1,979.72
$2,394.36
$312.20
Toc - Plan #68 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.69
$487.68
$549.12
$767.40
$1,166.14
$758.39
$816.38
$877.82
$1,096.10
$1,087.09
$1,145.08
$1,206.52
$1,424.80
$1,415.79
$1,473.78
$1,535.22
$1,753.50
$328.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.38
$975.36
$1,098.24
$1,534.80
$2,332.28
$1,188.08
$1,304.06
$1,426.94
$1,863.50
$1,516.78
$1,632.76
$1,755.64
$2,192.20
$1,845.48
$1,961.46
$2,084.34
$2,520.90
$328.70
Toc - Plan #69 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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
$421.38
$478.25
$538.51
$752.57
$1,143.60
$743.73
$800.60
$860.86
$1,074.92
$1,066.08
$1,122.95
$1,183.21
$1,397.27
$1,388.43
$1,445.30
$1,505.56
$1,719.62
$322.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$842.76
$956.50
$1,077.02
$1,505.14
$2,287.20
$1,165.11
$1,278.85
$1,399.37
$1,827.49
$1,487.46
$1,601.20
$1,721.72
$2,149.84
$1,809.81
$1,923.55
$2,044.07
$2,472.19
$322.35
Toc - Plan #70 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.60
$487.59
$549.02
$767.26
$1,165.92
$758.24
$816.23
$877.66
$1,095.90
$1,086.88
$1,144.87
$1,206.30
$1,424.54
$1,415.52
$1,473.51
$1,534.94
$1,753.18
$328.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.20
$975.18
$1,098.04
$1,534.52
$2,331.84
$1,187.84
$1,303.82
$1,426.68
$1,863.16
$1,516.48
$1,632.46
$1,755.32
$2,191.80
$1,845.12
$1,961.10
$2,083.96
$2,520.44
$328.64
Toc - Plan #71 Oscar Insurance Corporation of Ohio
Catastrophic

(HMO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$254.18
$288.48
$324.83
$453.95
$689.82
$448.62
$482.92
$519.27
$648.39
$643.06
$677.36
$713.71
$842.83
$837.50
$871.80
$908.15
$1,037.27
$194.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$508.36
$576.96
$649.66
$907.90
$1,379.64
$702.80
$771.40
$844.10
$1,102.34
$897.24
$965.84
$1,038.54
$1,296.78
$1,091.68
$1,160.28
$1,232.98
$1,491.22
$194.44
Toc - Plan #72 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Elite- Deductible+Specialist Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.57
$463.71
$522.14
$729.68
$1,108.83
$721.12
$776.26
$834.69
$1,042.23
$1,033.67
$1,088.81
$1,147.24
$1,354.78
$1,346.22
$1,401.36
$1,459.79
$1,667.33
$312.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$817.14
$927.42
$1,044.28
$1,459.36
$2,217.66
$1,129.69
$1,239.97
$1,356.83
$1,771.91
$1,442.24
$1,552.52
$1,669.38
$2,084.46
$1,754.79
$1,865.07
$1,981.93
$2,397.01
$312.55
Toc - Plan #73 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic

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

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
$487.94
$553.79
$623.57
$871.43
$1,324.23
$861.20
$927.05
$996.83
$1,244.69
$1,234.46
$1,300.31
$1,370.09
$1,617.95
$1,607.72
$1,673.57
$1,743.35
$1,991.21
$373.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$975.88
$1,107.58
$1,247.14
$1,742.86
$2,648.46
$1,349.14
$1,480.84
$1,620.40
$2,116.12
$1,722.40
$1,854.10
$1,993.66
$2,489.38
$2,095.66
$2,227.36
$2,366.92
$2,862.64
$373.26
Toc - Plan #74 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.95
$435.77
$490.68
$685.72
$1,042.01
$677.66
$729.48
$784.39
$979.43
$971.37
$1,023.19
$1,078.10
$1,273.14
$1,265.08
$1,316.90
$1,371.81
$1,566.85
$293.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.90
$871.54
$981.36
$1,371.44
$2,084.02
$1,061.61
$1,165.25
$1,275.07
$1,665.15
$1,355.32
$1,458.96
$1,568.78
$1,958.86
$1,649.03
$1,752.67
$1,862.49
$2,252.57
$293.71
Toc - Plan #75 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$424.05
$481.28
$541.92
$757.33
$1,150.84
$748.44
$805.67
$866.31
$1,081.72
$1,072.83
$1,130.06
$1,190.70
$1,406.11
$1,397.22
$1,454.45
$1,515.09
$1,730.50
$324.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$848.10
$962.56
$1,083.84
$1,514.66
$2,301.68
$1,172.49
$1,286.95
$1,408.23
$1,839.05
$1,496.88
$1,611.34
$1,732.62
$2,163.44
$1,821.27
$1,935.73
$2,057.01
$2,487.83
$324.39
Toc - Plan #76 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Elite

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$437.37
$496.40
$558.94
$781.12
$1,186.99
$771.95
$830.98
$893.52
$1,115.70
$1,106.53
$1,165.56
$1,228.10
$1,450.28
$1,441.11
$1,500.14
$1,562.68
$1,784.86
$334.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.74
$992.80
$1,117.88
$1,562.24
$2,373.98
$1,209.32
$1,327.38
$1,452.46
$1,896.82
$1,543.90
$1,661.96
$1,787.04
$2,231.40
$1,878.48
$1,996.54
$2,121.62
$2,565.98
$334.58
Toc - Plan #77 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Deductible Saver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $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
$457.71
$519.49
$584.94
$817.46
$1,242.20
$807.85
$869.63
$935.08
$1,167.60
$1,157.99
$1,219.77
$1,285.22
$1,517.74
$1,508.13
$1,569.91
$1,635.36
$1,867.88
$350.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$915.42
$1,038.98
$1,169.88
$1,634.92
$2,484.40
$1,265.56
$1,389.12
$1,520.02
$1,985.06
$1,615.70
$1,739.26
$1,870.16
$2,335.20
$1,965.84
$2,089.40
$2,220.30
$2,685.34
$350.14
Toc - Plan #78 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- PCP Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.78
$416.28
$468.73
$655.04
$995.40
$647.36
$696.86
$749.31
$935.62
$927.94
$977.44
$1,029.89
$1,216.20
$1,208.52
$1,258.02
$1,310.47
$1,496.78
$280.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.56
$832.56
$937.46
$1,310.08
$1,990.80
$1,014.14
$1,113.14
$1,218.04
$1,590.66
$1,294.72
$1,393.72
$1,498.62
$1,871.24
$1,575.30
$1,674.30
$1,779.20
$2,151.82
$280.58
Toc - Plan #79 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- Deductible Saver

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

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.64
$424.07
$477.50
$667.30
$1,014.03
$659.47
$709.90
$763.33
$953.13
$945.30
$995.73
$1,049.16
$1,238.96
$1,231.13
$1,281.56
$1,334.99
$1,524.79
$285.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.28
$848.14
$955.00
$1,334.60
$2,028.06
$1,033.11
$1,133.97
$1,240.83
$1,620.43
$1,318.94
$1,419.80
$1,526.66
$1,906.26
$1,604.77
$1,705.63
$1,812.49
$2,192.09
$285.83
Toc - Plan #80 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415.76
$471.87
$531.32
$742.52
$1,128.33
$733.80
$789.91
$849.36
$1,060.56
$1,051.84
$1,107.95
$1,167.40
$1,378.60
$1,369.88
$1,425.99
$1,485.44
$1,696.64
$318.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$831.52
$943.74
$1,062.64
$1,485.04
$2,256.66
$1,149.56
$1,261.78
$1,380.68
$1,803.08
$1,467.60
$1,579.82
$1,698.72
$2,121.12
$1,785.64
$1,897.86
$2,016.76
$2,439.16
$318.04
Toc - Plan #81 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$4,850 $9,700 Annual Deductible
$4,850 $9,700 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
$452.06
$513.08
$577.72
$807.36
$1,226.87
$797.88
$858.90
$923.54
$1,153.18
$1,143.70
$1,204.72
$1,269.36
$1,499.00
$1,489.52
$1,550.54
$1,615.18
$1,844.82
$345.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$904.12
$1,026.16
$1,155.44
$1,614.72
$2,453.74
$1,249.94
$1,371.98
$1,501.26
$1,960.54
$1,595.76
$1,717.80
$1,847.08
$2,306.36
$1,941.58
$2,063.62
$2,192.90
$2,652.18
$345.82
Toc - Plan #82 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$440.01
$499.40
$562.32
$785.84
$1,194.15
$776.61
$836.00
$898.92
$1,122.44
$1,113.21
$1,172.60
$1,235.52
$1,459.04
$1,449.81
$1,509.20
$1,572.12
$1,795.64
$336.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$880.02
$998.80
$1,124.64
$1,571.68
$2,388.30
$1,216.62
$1,335.40
$1,461.24
$1,908.28
$1,553.22
$1,672.00
$1,797.84
$2,244.88
$1,889.82
$2,008.60
$2,134.44
$2,581.48
$336.60
Toc - Plan #83 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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
$533.60
$605.62
$681.93
$952.99
$1,448.16
$941.79
$1,013.81
$1,090.12
$1,361.18
$1,349.98
$1,422.00
$1,498.31
$1,769.37
$1,758.17
$1,830.19
$1,906.50
$2,177.56
$408.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,067.20
$1,211.24
$1,363.86
$1,905.98
$2,896.32
$1,475.39
$1,619.43
$1,772.05
$2,314.17
$1,883.58
$2,027.62
$2,180.24
$2,722.36
$2,291.77
$2,435.81
$2,588.43
$3,130.55
$408.19
Toc - Plan #84 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$509.78
$578.58
$651.48
$910.44
$1,383.50
$899.75
$968.55
$1,041.45
$1,300.41
$1,289.72
$1,358.52
$1,431.42
$1,690.38
$1,679.69
$1,748.49
$1,821.39
$2,080.35
$389.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,019.56
$1,157.16
$1,302.96
$1,820.88
$2,767.00
$1,409.53
$1,547.13
$1,692.93
$2,210.85
$1,799.50
$1,937.10
$2,082.90
$2,600.82
$2,189.47
$2,327.07
$2,472.87
$2,990.79
$389.97
Toc - Plan #85 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$420.95
$477.77
$537.97
$751.80
$1,142.44
$742.97
$799.79
$859.99
$1,073.82
$1,064.99
$1,121.81
$1,182.01
$1,395.84
$1,387.01
$1,443.83
$1,504.03
$1,717.86
$322.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$841.90
$955.54
$1,075.94
$1,503.60
$2,284.88
$1,163.92
$1,277.56
$1,397.96
$1,825.62
$1,485.94
$1,599.58
$1,719.98
$2,147.64
$1,807.96
$1,921.60
$2,042.00
$2,469.66
$322.02
Toc - Plan #86 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Specialist Saver

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

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
$422.69
$479.74
$540.18
$754.90
$1,147.15
$746.04
$803.09
$863.53
$1,078.25
$1,069.39
$1,126.44
$1,186.88
$1,401.60
$1,392.74
$1,449.79
$1,510.23
$1,724.95
$323.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.38
$959.48
$1,080.36
$1,509.80
$2,294.30
$1,168.73
$1,282.83
$1,403.71
$1,833.15
$1,492.08
$1,606.18
$1,727.06
$2,156.50
$1,815.43
$1,929.53
$2,050.41
$2,479.85
$323.35
Toc - Plan #87 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.46
$417.05
$469.60
$656.26
$997.25
$648.56
$698.15
$750.70
$937.36
$929.66
$979.25
$1,031.80
$1,218.46
$1,210.76
$1,260.35
$1,312.90
$1,499.56
$281.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.92
$834.10
$939.20
$1,312.52
$1,994.50
$1,016.02
$1,115.20
$1,220.30
$1,593.62
$1,297.12
$1,396.30
$1,501.40
$1,874.72
$1,578.22
$1,677.40
$1,782.50
$2,155.82
$281.10
Toc - Plan #88 Oscar Insurance Corporation of Ohio
Bronze

(HMO) Bronze Simple- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$342.68
$388.93
$437.94
$612.01
$930.01
$604.82
$651.07
$700.08
$874.15
$866.96
$913.21
$962.22
$1,136.29
$1,129.10
$1,175.35
$1,224.36
$1,398.43
$262.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.36
$777.86
$875.88
$1,224.02
$1,860.02
$947.50
$1,040.00
$1,138.02
$1,486.16
$1,209.64
$1,302.14
$1,400.16
$1,748.30
$1,471.78
$1,564.28
$1,662.30
$2,010.44
$262.14
Toc - Plan #89 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415.97
$472.11
$531.59
$742.90
$1,128.91
$734.18
$790.32
$849.80
$1,061.11
$1,052.39
$1,108.53
$1,168.01
$1,379.32
$1,370.60
$1,426.74
$1,486.22
$1,697.53
$318.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$831.94
$944.22
$1,063.18
$1,485.80
$2,257.82
$1,150.15
$1,262.43
$1,381.39
$1,804.01
$1,468.36
$1,580.64
$1,699.60
$2,122.22
$1,786.57
$1,898.85
$2,017.81
$2,440.43
$318.21
Toc - Plan #90 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$469.93
$533.36
$600.56
$839.28
$1,275.37
$829.42
$892.85
$960.05
$1,198.77
$1,188.91
$1,252.34
$1,319.54
$1,558.26
$1,548.40
$1,611.83
$1,679.03
$1,917.75
$359.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$939.86
$1,066.72
$1,201.12
$1,678.56
$2,550.74
$1,299.35
$1,426.21
$1,560.61
$2,038.05
$1,658.84
$1,785.70
$1,920.10
$2,397.54
$2,018.33
$2,145.19
$2,279.59
$2,757.03
$359.49

ADVERTISEMENT

Molina Healthcare

Local: 1-888-296-7677 | Toll Free: 1-888-296-7677

Toc - Plan #91 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.34
$377.21
$424.73
$593.57
$901.98
$586.58
$631.45
$678.97
$847.81
$840.82
$885.69
$933.21
$1,102.05
$1,095.06
$1,139.93
$1,187.45
$1,356.29
$254.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.68
$754.42
$849.46
$1,187.14
$1,803.96
$918.92
$1,008.66
$1,103.70
$1,441.38
$1,173.16
$1,262.90
$1,357.94
$1,695.62
$1,427.40
$1,517.14
$1,612.18
$1,949.86
$254.24
Toc - Plan #92 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

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
$297.98
$338.21
$380.82
$532.20
$808.73
$525.94
$566.17
$608.78
$760.16
$753.90
$794.13
$836.74
$988.12
$981.86
$1,022.09
$1,064.70
$1,216.08
$227.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.96
$676.42
$761.64
$1,064.40
$1,617.46
$823.92
$904.38
$989.60
$1,292.36
$1,051.88
$1,132.34
$1,217.56
$1,520.32
$1,279.84
$1,360.30
$1,445.52
$1,748.28
$227.96
Toc - Plan #93 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

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
$342.72
$388.99
$438.00
$612.10
$930.14
$604.90
$651.17
$700.18
$874.28
$867.08
$913.35
$962.36
$1,136.46
$1,129.26
$1,175.53
$1,224.54
$1,398.64
$262.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.44
$777.98
$876.00
$1,224.20
$1,860.28
$947.62
$1,040.16
$1,138.18
$1,486.38
$1,209.80
$1,302.34
$1,400.36
$1,748.56
$1,471.98
$1,564.52
$1,662.54
$2,010.74
$262.18
Toc - Plan #94 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.91
$344.93
$388.39
$542.78
$824.80
$536.40
$577.42
$620.88
$775.27
$768.89
$809.91
$853.37
$1,007.76
$1,001.38
$1,042.40
$1,085.86
$1,240.25
$232.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$607.82
$689.86
$776.78
$1,085.56
$1,649.60
$840.31
$922.35
$1,009.27
$1,318.05
$1,072.80
$1,154.84
$1,241.76
$1,550.54
$1,305.29
$1,387.33
$1,474.25
$1,783.03
$232.49
Toc - Plan #95 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$334.64
$379.82
$427.67
$597.67
$908.21
$590.64
$635.82
$683.67
$853.67
$846.64
$891.82
$939.67
$1,109.67
$1,102.64
$1,147.82
$1,195.67
$1,365.67
$256.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$669.28
$759.64
$855.34
$1,195.34
$1,816.42
$925.28
$1,015.64
$1,111.34
$1,451.34
$1,181.28
$1,271.64
$1,367.34
$1,707.34
$1,437.28
$1,527.64
$1,623.34
$1,963.34
$256.00
Toc - Plan #96 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

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
$300.28
$340.82
$383.76
$536.31
$814.97
$530.00
$570.54
$613.48
$766.03
$759.72
$800.26
$843.20
$995.75
$989.44
$1,029.98
$1,072.92
$1,225.47
$229.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$600.56
$681.64
$767.52
$1,072.62
$1,629.94
$830.28
$911.36
$997.24
$1,302.34
$1,060.00
$1,141.08
$1,226.96
$1,532.06
$1,289.72
$1,370.80
$1,456.68
$1,761.78
$229.72

ADVERTISEMENT

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-750-0750

Toc - Plan #97 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.72
$359.48
$404.77
$565.66
$859.58
$559.01
$601.77
$647.06
$807.95
$801.30
$844.06
$889.35
$1,050.24
$1,043.59
$1,086.35
$1,131.64
$1,292.53
$242.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$633.44
$718.96
$809.54
$1,131.32
$1,719.16
$875.73
$961.25
$1,051.83
$1,373.61
$1,118.02
$1,203.54
$1,294.12
$1,615.90
$1,360.31
$1,445.83
$1,536.41
$1,858.19
$242.29
Toc - Plan #98 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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
$448.03
$508.51
$572.58
$800.18
$1,215.95
$790.77
$851.25
$915.32
$1,142.92
$1,133.51
$1,193.99
$1,258.06
$1,485.66
$1,476.25
$1,536.73
$1,600.80
$1,828.40
$342.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.06
$1,017.02
$1,145.16
$1,600.36
$2,431.90
$1,238.80
$1,359.76
$1,487.90
$1,943.10
$1,581.54
$1,702.50
$1,830.64
$2,285.84
$1,924.28
$2,045.24
$2,173.38
$2,628.58
$342.74
Toc - Plan #99 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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
$323.48
$367.15
$413.41
$577.73
$877.92
$570.94
$614.61
$660.87
$825.19
$818.40
$862.07
$908.33
$1,072.65
$1,065.86
$1,109.53
$1,155.79
$1,320.11
$247.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.96
$734.30
$826.82
$1,155.46
$1,755.84
$894.42
$981.76
$1,074.28
$1,402.92
$1,141.88
$1,229.22
$1,321.74
$1,650.38
$1,389.34
$1,476.68
$1,569.20
$1,897.84
$247.46
Toc - Plan #100 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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
$234.91
$266.62
$300.21
$419.54
$637.54
$414.61
$446.32
$479.91
$599.24
$594.31
$626.02
$659.61
$778.94
$774.01
$805.72
$839.31
$958.64
$179.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$469.82
$533.24
$600.42
$839.08
$1,275.08
$649.52
$712.94
$780.12
$1,018.78
$829.22
$892.64
$959.82
$1,198.48
$1,008.92
$1,072.34
$1,139.52
$1,378.18
$179.70
Toc - Plan #101 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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
$229.78
$260.80
$293.66
$410.39
$623.63
$405.56
$436.58
$469.44
$586.17
$581.34
$612.36
$645.22
$761.95
$757.12
$788.14
$821.00
$937.73
$175.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$459.56
$521.60
$587.32
$820.78
$1,247.26
$635.34
$697.38
$763.10
$996.56
$811.12
$873.16
$938.88
$1,172.34
$986.90
$1,048.94
$1,114.66
$1,348.12
$175.78
Toc - Plan #102 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 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
$362.14
$411.02
$462.81
$646.77
$982.83
$639.17
$688.05
$739.84
$923.80
$916.20
$965.08
$1,016.87
$1,200.83
$1,193.23
$1,242.11
$1,293.90
$1,477.86
$277.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.28
$822.04
$925.62
$1,293.54
$1,965.66
$1,001.31
$1,099.07
$1,202.65
$1,570.57
$1,278.34
$1,376.10
$1,479.68
$1,847.60
$1,555.37
$1,653.13
$1,756.71
$2,124.63
$277.03
Toc - Plan #103 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.82
$365.26
$411.28
$574.76
$873.41
$568.01
$611.45
$657.47
$820.95
$814.20
$857.64
$903.66
$1,067.14
$1,060.39
$1,103.83
$1,149.85
$1,313.33
$246.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.64
$730.52
$822.56
$1,149.52
$1,746.82
$889.83
$976.71
$1,068.75
$1,395.71
$1,136.02
$1,222.90
$1,314.94
$1,641.90
$1,382.21
$1,469.09
$1,561.13
$1,888.09
$246.19
Toc - Plan #104 CareSource
Gold

(HMO) CareSource Marketplace Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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
$454.20
$515.51
$580.46
$811.20
$1,232.69
$801.66
$862.97
$927.92
$1,158.66
$1,149.12
$1,210.43
$1,275.38
$1,506.12
$1,496.58
$1,557.89
$1,622.84
$1,853.58
$347.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$908.40
$1,031.02
$1,160.92
$1,622.40
$2,465.38
$1,255.86
$1,378.48
$1,508.38
$1,969.86
$1,603.32
$1,725.94
$1,855.84
$2,317.32
$1,950.78
$2,073.40
$2,203.30
$2,664.78
$347.46
Toc - Plan #105 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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
$328.57
$372.92
$419.91
$586.82
$891.73
$579.92
$624.27
$671.26
$838.17
$831.27
$875.62
$922.61
$1,089.52
$1,082.62
$1,126.97
$1,173.96
$1,340.87
$251.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$657.14
$745.84
$839.82
$1,173.64
$1,783.46
$908.49
$997.19
$1,091.17
$1,424.99
$1,159.84
$1,248.54
$1,342.52
$1,676.34
$1,411.19
$1,499.89
$1,593.87
$1,927.69
$251.35
Toc - Plan #106 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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
$239.47
$271.80
$306.04
$427.69
$649.92
$422.66
$454.99
$489.23
$610.88
$605.85
$638.18
$672.42
$794.07
$789.04
$821.37
$855.61
$977.26
$183.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$478.94
$543.60
$612.08
$855.38
$1,299.84
$662.13
$726.79
$795.27
$1,038.57
$845.32
$909.98
$978.46
$1,221.76
$1,028.51
$1,093.17
$1,161.65
$1,404.95
$183.19
Toc - Plan #107 CareSource
Bronze

(HMO) CareSource Marketplace Bronze Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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
$234.08
$265.68
$299.15
$418.07
$635.29
$413.15
$444.75
$478.22
$597.14
$592.22
$623.82
$657.29
$776.21
$771.29
$802.89
$836.36
$955.28
$179.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$468.16
$531.36
$598.30
$836.14
$1,270.58
$647.23
$710.43
$777.37
$1,015.21
$826.30
$889.50
$956.44
$1,194.28
$1,005.37
$1,068.57
$1,135.51
$1,373.35
$179.07
Toc - Plan #108 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 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
$367.05
$416.60
$469.09
$655.55
$996.18
$647.84
$697.39
$749.88
$936.34
$928.63
$978.18
$1,030.67
$1,217.13
$1,209.42
$1,258.97
$1,311.46
$1,497.92
$280.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.10
$833.20
$938.18
$1,311.10
$1,992.36
$1,014.89
$1,113.99
$1,218.97
$1,591.89
$1,295.68
$1,394.78
$1,499.76
$1,872.68
$1,576.47
$1,675.57
$1,780.55
$2,153.47
$280.79

ADVERTISEMENT

MedMutual

Local: 1-888-308-0357 | Toll Free: 1-888-308-0357

Toc - Plan #109 MedMutual
Silver

(HMO) Market HMO 3500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$397.29
$450.92
$507.73
$709.55
$1,078.24
$701.21
$754.84
$811.65
$1,013.47
$1,005.13
$1,058.76
$1,115.57
$1,317.39
$1,309.05
$1,362.68
$1,419.49
$1,621.31
$303.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$794.58
$901.84
$1,015.46
$1,419.10
$2,156.48
$1,098.50
$1,205.76
$1,319.38
$1,723.02
$1,402.42
$1,509.68
$1,623.30
$2,026.94
$1,706.34
$1,813.60
$1,927.22
$2,330.86
$303.92
Toc - Plan #110 MedMutual
Silver

(HMO) Market HMO 4000 HSA - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$5,850 $11,700 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
$397.29
$450.92
$507.73
$709.55
$1,078.24
$701.21
$754.84
$811.65
$1,013.47
$1,005.13
$1,058.76
$1,115.57
$1,317.39
$1,309.05
$1,362.68
$1,419.49
$1,621.31
$303.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$794.58
$901.84
$1,015.46
$1,419.10
$2,156.48
$1,098.50
$1,205.76
$1,319.38
$1,723.02
$1,402.42
$1,509.68
$1,623.30
$2,026.94
$1,706.34
$1,813.60
$1,927.22
$2,330.86
$303.92
Toc - Plan #111 MedMutual
Expanded Bronze

(HMO) Market HMO 7000 HSA - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$302.37
$343.19
$386.42
$540.03
$820.62
$533.68
$574.50
$617.73
$771.34
$764.99
$805.81
$849.04
$1,002.65
$996.30
$1,037.12
$1,080.35
$1,233.96
$231.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.74
$686.38
$772.84
$1,080.06
$1,641.24
$836.05
$917.69
$1,004.15
$1,311.37
$1,067.36
$1,149.00
$1,235.46
$1,542.68
$1,298.67
$1,380.31
$1,466.77
$1,773.99
$231.31
Toc - Plan #112 MedMutual
Bronze

(HMO) Market HMO 9100 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$286.02
$324.63
$365.54
$510.83
$776.26
$504.83
$543.44
$584.35
$729.64
$723.64
$762.25
$803.16
$948.45
$942.45
$981.06
$1,021.97
$1,167.26
$218.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$572.04
$649.26
$731.08
$1,021.66
$1,552.52
$790.85
$868.07
$949.89
$1,240.47
$1,009.66
$1,086.88
$1,168.70
$1,459.28
$1,228.47
$1,305.69
$1,387.51
$1,678.09
$218.81
Toc - Plan #113 MedMutual
Catastrophic

(HMO) Market HMO Young Adult Essentials - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$188.90
$214.40
$241.41
$337.38
$512.67
$333.41
$358.91
$385.92
$481.89
$477.92
$503.42
$530.43
$626.40
$622.43
$647.93
$674.94
$770.91
$144.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$377.80
$428.80
$482.82
$674.76
$1,025.34
$522.31
$573.31
$627.33
$819.27
$666.82
$717.82
$771.84
$963.78
$811.33
$862.33
$916.35
$1,108.29
$144.51
Toc - Plan #114 MedMutual
Silver

(HMO) Market HMO 6500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.03
$449.49
$506.13
$707.31
$1,074.82
$698.99
$752.45
$809.09
$1,010.27
$1,001.95
$1,055.41
$1,112.05
$1,313.23
$1,304.91
$1,358.37
$1,415.01
$1,616.19
$302.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.06
$898.98
$1,012.26
$1,414.62
$2,149.64
$1,095.02
$1,201.94
$1,315.22
$1,717.58
$1,397.98
$1,504.90
$1,618.18
$2,020.54
$1,700.94
$1,807.86
$1,921.14
$2,323.50
$302.96
Toc - Plan #115 MedMutual
Expanded Bronze

(HMO) Market HMO Select Bronze - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.34
$387.42
$436.23
$609.63
$926.40
$602.47
$648.55
$697.36
$870.76
$863.60
$909.68
$958.49
$1,131.89
$1,124.73
$1,170.81
$1,219.62
$1,393.02
$261.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.68
$774.84
$872.46
$1,219.26
$1,852.80
$943.81
$1,035.97
$1,133.59
$1,480.39
$1,204.94
$1,297.10
$1,394.72
$1,741.52
$1,466.07
$1,558.23
$1,655.85
$2,002.65
$261.13
Toc - Plan #116 MedMutual
Silver

(HMO) Market HMO Select Silver - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$427.15
$484.81
$545.89
$762.88
$1,159.28
$753.92
$811.58
$872.66
$1,089.65
$1,080.69
$1,138.35
$1,199.43
$1,416.42
$1,407.46
$1,465.12
$1,526.20
$1,743.19
$326.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$854.30
$969.62
$1,091.78
$1,525.76
$2,318.56
$1,181.07
$1,296.39
$1,418.55
$1,852.53
$1,507.84
$1,623.16
$1,745.32
$2,179.30
$1,834.61
$1,949.93
$2,072.09
$2,506.07
$326.77
Toc - Plan #117 MedMutual
Expanded Bronze

(HMO) Market HMO 8000 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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
$289.79
$328.92
$370.36
$517.57
$786.50
$511.48
$550.61
$592.05
$739.26
$733.17
$772.30
$813.74
$960.95
$954.86
$993.99
$1,035.43
$1,182.64
$221.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$579.58
$657.84
$740.72
$1,035.14
$1,573.00
$801.27
$879.53
$962.41
$1,256.83
$1,022.96
$1,101.22
$1,184.10
$1,478.52
$1,244.65
$1,322.91
$1,405.79
$1,700.21
$221.69
Toc - Plan #118 MedMutual
Gold

(HMO) Market HMO 2500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$5,750 $11,500 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
$528.98
$600.40
$676.04
$944.76
$1,435.66
$933.65
$1,005.07
$1,080.71
$1,349.43
$1,338.32
$1,409.74
$1,485.38
$1,754.10
$1,742.99
$1,814.41
$1,890.05
$2,158.77
$404.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,057.96
$1,200.80
$1,352.08
$1,889.52
$2,871.32
$1,462.63
$1,605.47
$1,756.75
$2,294.19
$1,867.30
$2,010.14
$2,161.42
$2,698.86
$2,271.97
$2,414.81
$2,566.09
$3,103.53
$404.67
Toc - Plan #119 MedMutual
Gold

(HMO) Market HMO Standard Gold - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$508.87
$577.56
$650.33
$908.84
$1,381.06
$898.15
$966.84
$1,039.61
$1,298.12
$1,287.43
$1,356.12
$1,428.89
$1,687.40
$1,676.71
$1,745.40
$1,818.17
$2,076.68
$389.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,017.74
$1,155.12
$1,300.66
$1,817.68
$2,762.12
$1,407.02
$1,544.40
$1,689.94
$2,206.96
$1,796.30
$1,933.68
$2,079.22
$2,596.24
$2,185.58
$2,322.96
$2,468.50
$2,985.52
$389.28
Toc - Plan #120 MedMutual
Silver

(HMO) Market HMO Standard Silver - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$394.14
$447.35
$503.72
$703.94
$1,069.71
$695.66
$748.87
$805.24
$1,005.46
$997.18
$1,050.39
$1,106.76
$1,306.98
$1,298.70
$1,351.91
$1,408.28
$1,608.50
$301.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.28
$894.70
$1,007.44
$1,407.88
$2,139.42
$1,089.80
$1,196.22
$1,308.96
$1,709.40
$1,391.32
$1,497.74
$1,610.48
$2,010.92
$1,692.84
$1,799.26
$1,912.00
$2,312.44
$301.52
Toc - Plan #121 MedMutual
Expanded Bronze

(HMO) Market HMO Standard Expanded Bronze - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$309.59
$351.39
$395.66
$552.94
$840.24
$546.43
$588.23
$632.50
$789.78
$783.27
$825.07
$869.34
$1,026.62
$1,020.11
$1,061.91
$1,106.18
$1,263.46
$236.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619.18
$702.78
$791.32
$1,105.88
$1,680.48
$856.02
$939.62
$1,028.16
$1,342.72
$1,092.86
$1,176.46
$1,265.00
$1,579.56
$1,329.70
$1,413.30
$1,501.84
$1,816.40
$236.84
Toc - Plan #122 MedMutual
Bronze

(HMO) Market HMO Standard Bronze - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$289.48
$328.56
$369.95
$517.01
$785.65
$510.93
$550.01
$591.40
$738.46
$732.38
$771.46
$812.85
$959.91
$953.83
$992.91
$1,034.30
$1,181.36
$221.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$578.96
$657.12
$739.90
$1,034.02
$1,571.30
$800.41
$878.57
$961.35
$1,255.47
$1,021.86
$1,100.02
$1,182.80
$1,476.92
$1,243.31
$1,321.47
$1,404.25
$1,698.37
$221.45
Toc - Plan #123 MedMutual
Gold

(HMO) Market HMO 2500 - CLE-Care

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$5,750 $11,500 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
$467.38
$530.47
$597.31
$834.74
$1,268.46
$824.92
$888.01
$954.85
$1,192.28
$1,182.46
$1,245.55
$1,312.39
$1,549.82
$1,540.00
$1,603.09
$1,669.93
$1,907.36
$357.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$934.76
$1,060.94
$1,194.62
$1,669.48
$2,536.92
$1,292.30
$1,418.48
$1,552.16
$2,027.02
$1,649.84
$1,776.02
$1,909.70
$2,384.56
$2,007.38
$2,133.56
$2,267.24
$2,742.10
$357.54
Toc - Plan #124 MedMutual
Silver

(HMO) Market HMO 3500 - CLE-Care

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$350.14
$397.41
$447.48
$625.35
$950.28
$618.00
$665.27
$715.34
$893.21
$885.86
$933.13
$983.20
$1,161.07
$1,153.72
$1,200.99
$1,251.06
$1,428.93
$267.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700.28
$794.82
$894.96
$1,250.70
$1,900.56
$968.14
$1,062.68
$1,162.82
$1,518.56
$1,236.00
$1,330.54
$1,430.68
$1,786.42
$1,503.86
$1,598.40
$1,698.54
$2,054.28
$267.86
Toc - Plan #125 MedMutual
Silver

(HMO) Market HMO 4000 HSA - CLE-Care

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$5,850 $11,700 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
$349.20
$396.34
$446.27
$623.67
$947.72
$616.34
$663.48
$713.41
$890.81
$883.48
$930.62
$980.55
$1,157.95
$1,150.62
$1,197.76
$1,247.69
$1,425.09
$267.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.40
$792.68
$892.54
$1,247.34
$1,895.44
$965.54
$1,059.82
$1,159.68
$1,514.48
$1,232.68
$1,326.96
$1,426.82
$1,781.62
$1,499.82
$1,594.10
$1,693.96
$2,048.76
$267.14
Toc - Plan #126 MedMutual
Silver

(HMO) Market HMO Select Silver - CLE-Care

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$378.11
$429.16
$483.23
$675.31
$1,026.20
$667.37
$718.42
$772.49
$964.57
$956.63
$1,007.68
$1,061.75
$1,253.83
$1,245.89
$1,296.94
$1,351.01
$1,543.09
$289.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.22
$858.32
$966.46
$1,350.62
$2,052.40
$1,045.48
$1,147.58
$1,255.72
$1,639.88
$1,334.74
$1,436.84
$1,544.98
$1,929.14
$1,624.00
$1,726.10
$1,834.24
$2,218.40
$289.26
Toc - Plan #127 MedMutual
Silver

(HMO) Market HMO 6500 - CLE-Care

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$350.14
$397.41
$447.48
$625.35
$950.28
$618.00
$665.27
$715.34
$893.21
$885.86
$933.13
$983.20
$1,161.07
$1,153.72
$1,200.99
$1,251.06
$1,428.93
$267.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700.28
$794.82
$894.96
$1,250.70
$1,900.56
$968.14
$1,062.68
$1,162.82
$1,518.56
$1,236.00
$1,330.54
$1,430.68
$1,786.42
$1,503.86
$1,598.40
$1,698.54
$2,054.28
$267.86
Toc - Plan #128 MedMutual
Expanded Bronze

(HMO) Market HMO 7000 HSA - CLE-Care

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$264.96
$300.73
$338.62
$473.22
$719.11
$467.66
$503.43
$541.32
$675.92
$670.36
$706.13
$744.02
$878.62
$873.06
$908.83
$946.72
$1,081.32
$202.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$529.92
$601.46
$677.24
$946.44
$1,438.22
$732.62
$804.16
$879.94
$1,149.14
$935.32
$1,006.86
$1,082.64
$1,351.84
$1,138.02
$1,209.56
$1,285.34
$1,554.54
$202.70
Toc - Plan #129 MedMutual
Expanded Bronze

(HMO) Market HMO 8000 - CLE-Care

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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
$254.90
$289.32
$325.77
$455.26
$691.81
$449.90
$484.32
$520.77
$650.26
$644.90
$679.32
$715.77
$845.26
$839.90
$874.32
$910.77
$1,040.26
$195.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$509.80
$578.64
$651.54
$910.52
$1,383.62
$704.80
$773.64
$846.54
$1,105.52
$899.80
$968.64
$1,041.54
$1,300.52
$1,094.80
$1,163.64
$1,236.54
$1,495.52
$195.00
Toc - Plan #130 MedMutual
Bronze

(HMO) Market HMO 9100 - CLE-Care

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$250.50
$284.32
$320.14
$447.40
$679.87
$442.14
$475.96
$511.78
$639.04
$633.78
$667.60
$703.42
$830.68
$825.42
$859.24
$895.06
$1,022.32
$191.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$501.00
$568.64
$640.28
$894.80
$1,359.74
$692.64
$760.28
$831.92
$1,086.44
$884.28
$951.92
$1,023.56
$1,278.08
$1,075.92
$1,143.56
$1,215.20
$1,469.72
$191.64
Toc - Plan #131 MedMutual
Expanded Bronze

(HMO) Market HMO Select Bronze - CLE-Care

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$297.97
$338.19
$380.80
$532.17
$808.68
$525.91
$566.13
$608.74
$760.11
$753.85
$794.07
$836.68
$988.05
$981.79
$1,022.01
$1,064.62
$1,215.99
$227.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.94
$676.38
$761.60
$1,064.34
$1,617.36
$823.88
$904.32
$989.54
$1,292.28
$1,051.82
$1,132.26
$1,217.48
$1,520.22
$1,279.76
$1,360.20
$1,445.42
$1,748.16
$227.94

‡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 Cuyahoga County here.

Cuyahoga County is in “Rating Area 11” of Ohio.

Currently, there are 131 plans offered in Rating Area 11.

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2023 Obamacare Plans for Cuyahoga County, OH

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