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PacificSource Health Plans

Local: 1-541-684-5582 | Toll Free: 1-888-977-9299 | TTY: 1-800-735-2900

Toc - Plan #1 PacificSource Health Plans
Expanded Bronze

(PPO) Navigator Bronze HSA 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$308.00
$350.00
$394.00
$550.00
$836.00
$504.00
$546.00
$590.00
$746.00
$700.00
$742.00
$786.00
$942.00
$896.00
$938.00
$982.00
$1,138.00
$196.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$616.00
$700.00
$788.00
$1,100.00
$1,672.00
$812.00
$896.00
$984.00
$1,296.00
$1,008.00
$1,092.00
$1,180.00
$1,492.00
$1,204.00
$1,288.00
$1,376.00
$1,688.00
$196.00
Toc - Plan #2 PacificSource Health Plans
Silver

(PPO) Navigator Silver 4000 Exchange

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

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
$403.00
$458.00
$516.00
$720.00
$1,095.00
$659.00
$714.00
$772.00
$976.00
$915.00
$970.00
$1,028.00
$1,232.00
$1,171.00
$1,226.00
$1,284.00
$1,488.00
$256.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.00
$916.00
$1,032.00
$1,440.00
$2,190.00
$1,062.00
$1,172.00
$1,288.00
$1,696.00
$1,318.00
$1,428.00
$1,544.00
$1,952.00
$1,574.00
$1,684.00
$1,800.00
$2,208.00
$256.00
Toc - Plan #3 PacificSource Health Plans
Silver

(PPO) Navigator Silver 3500 Exchange

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.00
$462.00
$521.00
$728.00
$1,106.00
$666.00
$721.00
$780.00
$987.00
$925.00
$980.00
$1,039.00
$1,246.00
$1,184.00
$1,239.00
$1,298.00
$1,505.00
$259.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.00
$924.00
$1,042.00
$1,456.00
$2,212.00
$1,073.00
$1,183.00
$1,301.00
$1,715.00
$1,332.00
$1,442.00
$1,560.00
$1,974.00
$1,591.00
$1,701.00
$1,819.00
$2,233.00
$259.00
Toc - Plan #4 PacificSource Health Plans
Expanded Bronze

(PPO) PacificSource Oregon Standard Bronze Plan NAV

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.00
$364.00
$410.00
$573.00
$870.00
$525.00
$568.00
$614.00
$777.00
$729.00
$772.00
$818.00
$981.00
$933.00
$976.00
$1,022.00
$1,185.00
$204.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$642.00
$728.00
$820.00
$1,146.00
$1,740.00
$846.00
$932.00
$1,024.00
$1,350.00
$1,050.00
$1,136.00
$1,228.00
$1,554.00
$1,254.00
$1,340.00
$1,432.00
$1,758.00
$204.00
Toc - Plan #5 PacificSource Health Plans
Silver

(PPO) PacificSource Oregon Standard Silver Plan NAV

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$406.00
$461.00
$519.00
$725.00
$1,102.00
$664.00
$719.00
$777.00
$983.00
$922.00
$977.00
$1,035.00
$1,241.00
$1,180.00
$1,235.00
$1,293.00
$1,499.00
$258.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$812.00
$922.00
$1,038.00
$1,450.00
$2,204.00
$1,070.00
$1,180.00
$1,296.00
$1,708.00
$1,328.00
$1,438.00
$1,554.00
$1,966.00
$1,586.00
$1,696.00
$1,812.00
$2,224.00
$258.00
Toc - Plan #6 PacificSource Health Plans
Gold

(PPO) PacificSource Oregon Standard Gold Plan NAV

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$449.00
$509.00
$573.00
$801.00
$1,217.00
$734.00
$794.00
$858.00
$1,086.00
$1,019.00
$1,079.00
$1,143.00
$1,371.00
$1,304.00
$1,364.00
$1,428.00
$1,656.00
$285.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$898.00
$1,018.00
$1,146.00
$1,602.00
$2,434.00
$1,183.00
$1,303.00
$1,431.00
$1,887.00
$1,468.00
$1,588.00
$1,716.00
$2,172.00
$1,753.00
$1,873.00
$2,001.00
$2,457.00
$285.00
Toc - Plan #7 PacificSource Health Plans
Expanded Bronze

(PPO) Navigator Bronze 9400 Exchange

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.00
$327.00
$368.00
$515.00
$782.00
$471.00
$510.00
$551.00
$698.00
$654.00
$693.00
$734.00
$881.00
$837.00
$876.00
$917.00
$1,064.00
$183.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.00
$654.00
$736.00
$1,030.00
$1,564.00
$759.00
$837.00
$919.00
$1,213.00
$942.00
$1,020.00
$1,102.00
$1,396.00
$1,125.00
$1,203.00
$1,285.00
$1,579.00
$183.00
Toc - Plan #8 PacificSource Health Plans
Expanded Bronze

(PPO) Navigator Bronze 7000 Exchange

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312.00
$355.00
$399.00
$558.00
$848.00
$510.00
$553.00
$597.00
$756.00
$708.00
$751.00
$795.00
$954.00
$906.00
$949.00
$993.00
$1,152.00
$198.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$624.00
$710.00
$798.00
$1,116.00
$1,696.00
$822.00
$908.00
$996.00
$1,314.00
$1,020.00
$1,106.00
$1,194.00
$1,512.00
$1,218.00
$1,304.00
$1,392.00
$1,710.00
$198.00
Toc - Plan #9 PacificSource Health Plans
Gold

(PPO) Navigator Gold 1500 Exchange

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.00
$504.00
$568.00
$794.00
$1,206.00
$726.00
$786.00
$850.00
$1,076.00
$1,008.00
$1,068.00
$1,132.00
$1,358.00
$1,290.00
$1,350.00
$1,414.00
$1,640.00
$282.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.00
$1,008.00
$1,136.00
$1,588.00
$2,412.00
$1,170.00
$1,290.00
$1,418.00
$1,870.00
$1,452.00
$1,572.00
$1,700.00
$2,152.00
$1,734.00
$1,854.00
$1,982.00
$2,434.00
$282.00
Toc - Plan #10 PacificSource Health Plans
Gold

(PPO) Navigator Gold 500 Exchange

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-977-9299

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$463.00
$526.00
$592.00
$828.00
$1,258.00
$757.00
$820.00
$886.00
$1,122.00
$1,051.00
$1,114.00
$1,180.00
$1,416.00
$1,345.00
$1,408.00
$1,474.00
$1,710.00
$294.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$926.00
$1,052.00
$1,184.00
$1,656.00
$2,516.00
$1,220.00
$1,346.00
$1,478.00
$1,950.00
$1,514.00
$1,640.00
$1,772.00
$2,244.00
$1,808.00
$1,934.00
$2,066.00
$2,538.00
$294.00

ADVERTISEMENT

Moda Health Plan, Inc.

Local: 1-888-393-2940 | Toll Free: 1-888-393-2940 | TTY: 1-888-393-2940

Toc - Plan #11 Moda Health Plan, Inc.
Gold

(EPO) Moda Health Beacon Gold 1000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$429.00
$487.00
$549.00
$767.00
$1,165.00
$702.00
$760.00
$822.00
$1,040.00
$975.00
$1,033.00
$1,095.00
$1,313.00
$1,248.00
$1,306.00
$1,368.00
$1,586.00
$273.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.00
$974.00
$1,098.00
$1,534.00
$2,330.00
$1,131.00
$1,247.00
$1,371.00
$1,807.00
$1,404.00
$1,520.00
$1,644.00
$2,080.00
$1,677.00
$1,793.00
$1,917.00
$2,353.00
$273.00
Toc - Plan #12 Moda Health Plan, Inc.
Silver

(EPO) Moda Health Beacon Silver 3000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393.00
$447.00
$503.00
$703.00
$1,068.00
$643.00
$697.00
$753.00
$953.00
$893.00
$947.00
$1,003.00
$1,203.00
$1,143.00
$1,197.00
$1,253.00
$1,453.00
$250.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.00
$894.00
$1,006.00
$1,406.00
$2,136.00
$1,036.00
$1,144.00
$1,256.00
$1,656.00
$1,286.00
$1,394.00
$1,506.00
$1,906.00
$1,536.00
$1,644.00
$1,756.00
$2,156.00
$250.00
Toc - Plan #13 Moda Health Plan, Inc.
Gold

(EPO) Moda Health Oregon Standard Gold (Beacon)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.00
$480.00
$541.00
$756.00
$1,149.00
$692.00
$749.00
$810.00
$1,025.00
$961.00
$1,018.00
$1,079.00
$1,294.00
$1,230.00
$1,287.00
$1,348.00
$1,563.00
$269.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$846.00
$960.00
$1,082.00
$1,512.00
$2,298.00
$1,115.00
$1,229.00
$1,351.00
$1,781.00
$1,384.00
$1,498.00
$1,620.00
$2,050.00
$1,653.00
$1,767.00
$1,889.00
$2,319.00
$269.00
Toc - Plan #14 Moda Health Plan, Inc.
Silver

(EPO) Moda Health Oregon Standard Silver (Beacon)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.00
$431.00
$486.00
$679.00
$1,031.00
$621.00
$672.00
$727.00
$920.00
$862.00
$913.00
$968.00
$1,161.00
$1,103.00
$1,154.00
$1,209.00
$1,402.00
$241.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.00
$862.00
$972.00
$1,358.00
$2,062.00
$1,001.00
$1,103.00
$1,213.00
$1,599.00
$1,242.00
$1,344.00
$1,454.00
$1,840.00
$1,483.00
$1,585.00
$1,695.00
$2,081.00
$241.00
Toc - Plan #15 Moda Health Plan, Inc.
Expanded Bronze

(EPO) Moda Health Oregon Standard Bronze Plan (Beacon)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$285.00
$323.00
$364.00
$508.00
$772.00
$466.00
$504.00
$545.00
$689.00
$647.00
$685.00
$726.00
$870.00
$828.00
$866.00
$907.00
$1,051.00
$181.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$570.00
$646.00
$728.00
$1,016.00
$1,544.00
$751.00
$827.00
$909.00
$1,197.00
$932.00
$1,008.00
$1,090.00
$1,378.00
$1,113.00
$1,189.00
$1,271.00
$1,559.00
$181.00
Toc - Plan #16 Moda Health Plan, Inc.
Gold

(EPO) Moda Health Beacon Gold 1500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.00
$467.00
$526.00
$735.00
$1,117.00
$672.00
$728.00
$787.00
$996.00
$933.00
$989.00
$1,048.00
$1,257.00
$1,194.00
$1,250.00
$1,309.00
$1,518.00
$261.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.00
$934.00
$1,052.00
$1,470.00
$2,234.00
$1,083.00
$1,195.00
$1,313.00
$1,731.00
$1,344.00
$1,456.00
$1,574.00
$1,992.00
$1,605.00
$1,717.00
$1,835.00
$2,253.00
$261.00
Toc - Plan #17 Moda Health Plan, Inc.
Silver

(EPO) Moda Health Beacon Silver 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$384.00
$436.00
$491.00
$687.00
$1,043.00
$628.00
$680.00
$735.00
$931.00
$872.00
$924.00
$979.00
$1,175.00
$1,116.00
$1,168.00
$1,223.00
$1,419.00
$244.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.00
$872.00
$982.00
$1,374.00
$2,086.00
$1,012.00
$1,116.00
$1,226.00
$1,618.00
$1,256.00
$1,360.00
$1,470.00
$1,862.00
$1,500.00
$1,604.00
$1,714.00
$2,106.00
$244.00
Toc - Plan #18 Moda Health Plan, Inc.
Expanded Bronze

(EPO) Moda Health Beacon Bronze HSA 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$283.00
$322.00
$362.00
$506.00
$769.00
$463.00
$502.00
$542.00
$686.00
$643.00
$682.00
$722.00
$866.00
$823.00
$862.00
$902.00
$1,046.00
$180.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$566.00
$644.00
$724.00
$1,012.00
$1,538.00
$746.00
$824.00
$904.00
$1,192.00
$926.00
$1,004.00
$1,084.00
$1,372.00
$1,106.00
$1,184.00
$1,264.00
$1,552.00
$180.00
Toc - Plan #19 Moda Health Plan, Inc.
Expanded Bronze

(EPO) Moda Health Beacon Bronze 7750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$293.00
$333.00
$375.00
$524.00
$796.00
$479.00
$519.00
$561.00
$710.00
$665.00
$705.00
$747.00
$896.00
$851.00
$891.00
$933.00
$1,082.00
$186.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$586.00
$666.00
$750.00
$1,048.00
$1,592.00
$772.00
$852.00
$936.00
$1,234.00
$958.00
$1,038.00
$1,122.00
$1,420.00
$1,144.00
$1,224.00
$1,308.00
$1,606.00
$186.00
Toc - Plan #20 Moda Health Plan, Inc.
Gold

(EPO) Moda Health Beacon Gold 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$250 $500 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
$437.00
$496.00
$559.00
$781.00
$1,187.00
$715.00
$774.00
$837.00
$1,059.00
$993.00
$1,052.00
$1,115.00
$1,337.00
$1,271.00
$1,330.00
$1,393.00
$1,615.00
$278.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.00
$992.00
$1,118.00
$1,562.00
$2,374.00
$1,152.00
$1,270.00
$1,396.00
$1,840.00
$1,430.00
$1,548.00
$1,674.00
$2,118.00
$1,708.00
$1,826.00
$1,952.00
$2,396.00
$278.00
Toc - Plan #21 Moda Health Plan, Inc.
Silver

(EPO) Moda Health Beacon Silver 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,050 $16,100 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
$375.00
$425.00
$479.00
$669.00
$1,017.00
$613.00
$663.00
$717.00
$907.00
$851.00
$901.00
$955.00
$1,145.00
$1,089.00
$1,139.00
$1,193.00
$1,383.00
$238.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.00
$850.00
$958.00
$1,338.00
$2,034.00
$988.00
$1,088.00
$1,196.00
$1,576.00
$1,226.00
$1,326.00
$1,434.00
$1,814.00
$1,464.00
$1,564.00
$1,672.00
$2,052.00
$238.00
Toc - Plan #22 Moda Health Plan, Inc.
Expanded Bronze

(EPO) Moda Health Beacon Bronze 9000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$9,000 $18,000 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
$290.00
$329.00
$370.00
$518.00
$787.00
$474.00
$513.00
$554.00
$702.00
$658.00
$697.00
$738.00
$886.00
$842.00
$881.00
$922.00
$1,070.00
$184.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.00
$658.00
$740.00
$1,036.00
$1,574.00
$764.00
$842.00
$924.00
$1,220.00
$948.00
$1,026.00
$1,108.00
$1,404.00
$1,132.00
$1,210.00
$1,292.00
$1,588.00
$184.00
Toc - Plan #23 Moda Health Plan, Inc.
Silver

(EPO) Moda Health Beacon Silver 6400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-393-2940

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.00
$416.00
$469.00
$655.00
$996.00
$600.00
$649.00
$702.00
$888.00
$833.00
$882.00
$935.00
$1,121.00
$1,066.00
$1,115.00
$1,168.00
$1,354.00
$233.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.00
$832.00
$938.00
$1,310.00
$1,992.00
$967.00
$1,065.00
$1,171.00
$1,543.00
$1,200.00
$1,298.00
$1,404.00
$1,776.00
$1,433.00
$1,531.00
$1,637.00
$2,009.00
$233.00

ADVERTISEMENT

Providence Health Plan

Local: 1-503-574-5000 | Toll Free: 1-800-878-4445 | TTY: 1-888-244-6642

Toc - Plan #24 Providence Health Plan
Gold

(EPO) Providence Oregon Standard Gold Plan - Choice Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$461.00
$523.00
$589.00
$824.00
$1,252.00
$754.00
$816.00
$882.00
$1,117.00
$1,047.00
$1,109.00
$1,175.00
$1,410.00
$1,340.00
$1,402.00
$1,468.00
$1,703.00
$293.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$922.00
$1,046.00
$1,178.00
$1,648.00
$2,504.00
$1,215.00
$1,339.00
$1,471.00
$1,941.00
$1,508.00
$1,632.00
$1,764.00
$2,234.00
$1,801.00
$1,925.00
$2,057.00
$2,527.00
$293.00
Toc - Plan #25 Providence Health Plan
Silver

(EPO) Providence Oregon Standard Silver Plan - Choice Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.00
$465.00
$523.00
$731.00
$1,111.00
$670.00
$725.00
$783.00
$991.00
$930.00
$985.00
$1,043.00
$1,251.00
$1,190.00
$1,245.00
$1,303.00
$1,511.00
$260.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$820.00
$930.00
$1,046.00
$1,462.00
$2,222.00
$1,080.00
$1,190.00
$1,306.00
$1,722.00
$1,340.00
$1,450.00
$1,566.00
$1,982.00
$1,600.00
$1,710.00
$1,826.00
$2,242.00
$260.00
Toc - Plan #26 Providence Health Plan
Gold

(EPO) Providence Oregon Standard Gold Plan - Signature Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$493.00
$560.00
$630.00
$881.00
$1,339.00
$806.00
$873.00
$943.00
$1,194.00
$1,119.00
$1,186.00
$1,256.00
$1,507.00
$1,432.00
$1,499.00
$1,569.00
$1,820.00
$313.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$986.00
$1,120.00
$1,260.00
$1,762.00
$2,678.00
$1,299.00
$1,433.00
$1,573.00
$2,075.00
$1,612.00
$1,746.00
$1,886.00
$2,388.00
$1,925.00
$2,059.00
$2,199.00
$2,701.00
$313.00
Toc - Plan #27 Providence Health Plan
Silver

(EPO) Providence Oregon Standard Silver Plan - Signature Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$438.00
$497.00
$560.00
$782.00
$1,189.00
$716.00
$775.00
$838.00
$1,060.00
$994.00
$1,053.00
$1,116.00
$1,338.00
$1,272.00
$1,331.00
$1,394.00
$1,616.00
$278.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$876.00
$994.00
$1,120.00
$1,564.00
$2,378.00
$1,154.00
$1,272.00
$1,398.00
$1,842.00
$1,432.00
$1,550.00
$1,676.00
$2,120.00
$1,710.00
$1,828.00
$1,954.00
$2,398.00
$278.00
Toc - Plan #28 Providence Health Plan
Gold

(EPO) Connect 1500 Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.00
$463.00
$521.00
$728.00
$1,107.00
$667.00
$722.00
$780.00
$987.00
$926.00
$981.00
$1,039.00
$1,246.00
$1,185.00
$1,240.00
$1,298.00
$1,505.00
$259.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$816.00
$926.00
$1,042.00
$1,456.00
$2,214.00
$1,075.00
$1,185.00
$1,301.00
$1,715.00
$1,334.00
$1,444.00
$1,560.00
$1,974.00
$1,593.00
$1,703.00
$1,819.00
$2,233.00
$259.00
Toc - Plan #29 Providence Health Plan
Silver

(EPO) Connect 5000 Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$349.00
$397.00
$447.00
$624.00
$949.00
$571.00
$619.00
$669.00
$846.00
$793.00
$841.00
$891.00
$1,068.00
$1,015.00
$1,063.00
$1,113.00
$1,290.00
$222.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.00
$794.00
$894.00
$1,248.00
$1,898.00
$920.00
$1,016.00
$1,116.00
$1,470.00
$1,142.00
$1,238.00
$1,338.00
$1,692.00
$1,364.00
$1,460.00
$1,560.00
$1,914.00
$222.00
Toc - Plan #30 Providence Health Plan
Expanded Bronze

(EPO) Connect 9450 Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$270.00
$307.00
$346.00
$483.00
$734.00
$442.00
$479.00
$518.00
$655.00
$614.00
$651.00
$690.00
$827.00
$786.00
$823.00
$862.00
$999.00
$172.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$540.00
$614.00
$692.00
$966.00
$1,468.00
$712.00
$786.00
$864.00
$1,138.00
$884.00
$958.00
$1,036.00
$1,310.00
$1,056.00
$1,130.00
$1,208.00
$1,482.00
$172.00
Toc - Plan #31 Providence Health Plan
Expanded Bronze

(EPO) Providence Oregon Standard Bronze Plan - Choice Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.00
$359.00
$405.00
$565.00
$859.00
$518.00
$560.00
$606.00
$766.00
$719.00
$761.00
$807.00
$967.00
$920.00
$962.00
$1,008.00
$1,168.00
$201.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.00
$718.00
$810.00
$1,130.00
$1,718.00
$835.00
$919.00
$1,011.00
$1,331.00
$1,036.00
$1,120.00
$1,212.00
$1,532.00
$1,237.00
$1,321.00
$1,413.00
$1,733.00
$201.00
Toc - Plan #32 Providence Health Plan
Expanded Bronze

(EPO) Providence Oregon Standard Bronze Plan - Signature Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$339.00
$384.00
$433.00
$605.00
$919.00
$554.00
$599.00
$648.00
$820.00
$769.00
$814.00
$863.00
$1,035.00
$984.00
$1,029.00
$1,078.00
$1,250.00
$215.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$678.00
$768.00
$866.00
$1,210.00
$1,838.00
$893.00
$983.00
$1,081.00
$1,425.00
$1,108.00
$1,198.00
$1,296.00
$1,640.00
$1,323.00
$1,413.00
$1,511.00
$1,855.00
$215.00
Toc - Plan #33 Providence Health Plan
Expanded Bronze

(EPO) HSA Qualified 7100 Bronze - Choice Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.00
$364.00
$410.00
$572.00
$870.00
$525.00
$568.00
$614.00
$776.00
$729.00
$772.00
$818.00
$980.00
$933.00
$976.00
$1,022.00
$1,184.00
$204.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$642.00
$728.00
$820.00
$1,144.00
$1,740.00
$846.00
$932.00
$1,024.00
$1,348.00
$1,050.00
$1,136.00
$1,228.00
$1,552.00
$1,254.00
$1,340.00
$1,432.00
$1,756.00
$204.00
Toc - Plan #34 Providence Health Plan
Expanded Bronze

(EPO) HSA Qualified 7100 Bronze - Signature Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-878-4445

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.00
$389.00
$438.00
$612.00
$930.00
$561.00
$607.00
$656.00
$830.00
$779.00
$825.00
$874.00
$1,048.00
$997.00
$1,043.00
$1,092.00
$1,266.00
$218.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.00
$778.00
$876.00
$1,224.00
$1,860.00
$904.00
$996.00
$1,094.00
$1,442.00
$1,122.00
$1,214.00
$1,312.00
$1,660.00
$1,340.00
$1,432.00
$1,530.00
$1,878.00
$218.00

ADVERTISEMENT

BridgeSpan Health Company

Local: 1-855-857-9944 | Toll Free: 1-855-857-9944 | TTY: 1-800-735-2900

Toc - Plan #35 BridgeSpan Health Company
Gold

(EPO) BridgeSpan Standard Gold Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9944

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$490.19
$556.37
$626.46
$875.48
$1,330.37
$801.46
$867.64
$937.73
$1,186.75
$1,112.73
$1,178.91
$1,249.00
$1,498.02
$1,424.00
$1,490.18
$1,560.27
$1,809.29
$311.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$980.38
$1,112.74
$1,252.92
$1,750.96
$2,660.74
$1,291.65
$1,424.01
$1,564.19
$2,062.23
$1,602.92
$1,735.28
$1,875.46
$2,373.50
$1,914.19
$2,046.55
$2,186.73
$2,684.77
$311.27
Toc - Plan #36 BridgeSpan Health Company
Expanded Bronze

(EPO) BridgeSpan Standard Bronze Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9944

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.14
$366.76
$412.97
$577.13
$877.00
$528.34
$571.96
$618.17
$782.33
$733.54
$777.16
$823.37
$987.53
$938.74
$982.36
$1,028.57
$1,192.73
$205.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.28
$733.52
$825.94
$1,154.26
$1,754.00
$851.48
$938.72
$1,031.14
$1,359.46
$1,056.68
$1,143.92
$1,236.34
$1,564.66
$1,261.88
$1,349.12
$1,441.54
$1,769.86
$205.20
Toc - Plan #37 BridgeSpan Health Company
Silver

(EPO) BridgeSpan Standard Silver Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9944

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$420.49
$477.26
$537.39
$751.01
$1,141.22
$687.50
$744.27
$804.40
$1,018.02
$954.51
$1,011.28
$1,071.41
$1,285.03
$1,221.52
$1,278.29
$1,338.42
$1,552.04
$267.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$840.98
$954.52
$1,074.78
$1,502.02
$2,282.44
$1,107.99
$1,221.53
$1,341.79
$1,769.03
$1,375.00
$1,488.54
$1,608.80
$2,036.04
$1,642.01
$1,755.55
$1,875.81
$2,303.05
$267.01

ADVERTISEMENT

Kaiser Permanente

Local: 1-800-801-1270 | Toll Free: 1-800-801-1270 | TTY: 1-800-735-2900

Toc - Plan #38 Kaiser Permanente
Gold

(EPO) KP OR Gold 0/15

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.00
$473.00
$533.00
$745.00
$1,132.00
$682.00
$738.00
$798.00
$1,010.00
$947.00
$1,003.00
$1,063.00
$1,275.00
$1,212.00
$1,268.00
$1,328.00
$1,540.00
$265.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.00
$946.00
$1,066.00
$1,490.00
$2,264.00
$1,099.00
$1,211.00
$1,331.00
$1,755.00
$1,364.00
$1,476.00
$1,596.00
$2,020.00
$1,629.00
$1,741.00
$1,861.00
$2,285.00
$265.00
Toc - Plan #39 Kaiser Permanente
Gold

(EPO) KP Oregon Standard Gold Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.00
$459.00
$517.00
$723.00
$1,098.00
$662.00
$716.00
$774.00
$980.00
$919.00
$973.00
$1,031.00
$1,237.00
$1,176.00
$1,230.00
$1,288.00
$1,494.00
$257.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.00
$918.00
$1,034.00
$1,446.00
$2,196.00
$1,067.00
$1,175.00
$1,291.00
$1,703.00
$1,324.00
$1,432.00
$1,548.00
$1,960.00
$1,581.00
$1,689.00
$1,805.00
$2,217.00
$257.00
Toc - Plan #40 Kaiser Permanente
Silver

(EPO) KP Oregon Standard Silver Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.00
$432.00
$487.00
$680.00
$1,034.00
$623.00
$674.00
$729.00
$922.00
$865.00
$916.00
$971.00
$1,164.00
$1,107.00
$1,158.00
$1,213.00
$1,406.00
$242.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.00
$864.00
$974.00
$1,360.00
$2,068.00
$1,004.00
$1,106.00
$1,216.00
$1,602.00
$1,246.00
$1,348.00
$1,458.00
$1,844.00
$1,488.00
$1,590.00
$1,700.00
$2,086.00
$242.00
Toc - Plan #41 Kaiser Permanente
Expanded Bronze

(EPO) KP Oregon Standard Bronze Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$281.00
$319.00
$359.00
$502.00
$763.00
$460.00
$498.00
$538.00
$681.00
$639.00
$677.00
$717.00
$860.00
$818.00
$856.00
$896.00
$1,039.00
$179.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$562.00
$638.00
$718.00
$1,004.00
$1,526.00
$741.00
$817.00
$897.00
$1,183.00
$920.00
$996.00
$1,076.00
$1,362.00
$1,099.00
$1,175.00
$1,255.00
$1,541.00
$179.00
Toc - Plan #42 Kaiser Permanente
Gold

(EPO) KP OR Gold 1750/20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 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
$382.00
$434.00
$489.00
$683.00
$1,038.00
$625.00
$677.00
$732.00
$926.00
$868.00
$920.00
$975.00
$1,169.00
$1,111.00
$1,163.00
$1,218.00
$1,412.00
$243.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.00
$868.00
$978.00
$1,366.00
$2,076.00
$1,007.00
$1,111.00
$1,221.00
$1,609.00
$1,250.00
$1,354.00
$1,464.00
$1,852.00
$1,493.00
$1,597.00
$1,707.00
$2,095.00
$243.00
Toc - Plan #43 Kaiser Permanente
Silver

(EPO) KP OR Silver 3000/40

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$392.00
$445.00
$501.00
$700.00
$1,064.00
$641.00
$694.00
$750.00
$949.00
$890.00
$943.00
$999.00
$1,198.00
$1,139.00
$1,192.00
$1,248.00
$1,447.00
$249.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.00
$890.00
$1,002.00
$1,400.00
$2,128.00
$1,033.00
$1,139.00
$1,251.00
$1,649.00
$1,282.00
$1,388.00
$1,500.00
$1,898.00
$1,531.00
$1,637.00
$1,749.00
$2,147.00
$249.00
Toc - Plan #44 Kaiser Permanente
Silver

(EPO) KP OR Silver 4000/40

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.00
$410.00
$462.00
$645.00
$981.00
$590.00
$639.00
$691.00
$874.00
$819.00
$868.00
$920.00
$1,103.00
$1,048.00
$1,097.00
$1,149.00
$1,332.00
$229.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.00
$820.00
$924.00
$1,290.00
$1,962.00
$951.00
$1,049.00
$1,153.00
$1,519.00
$1,180.00
$1,278.00
$1,382.00
$1,748.00
$1,409.00
$1,507.00
$1,611.00
$1,977.00
$229.00
Toc - Plan #45 Kaiser Permanente
Expanded Bronze

(EPO) KP OR Bronze 5500/50

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$293.00
$333.00
$375.00
$524.00
$796.00
$479.00
$519.00
$561.00
$710.00
$665.00
$705.00
$747.00
$896.00
$851.00
$891.00
$933.00
$1,082.00
$186.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$586.00
$666.00
$750.00
$1,048.00
$1,592.00
$772.00
$852.00
$936.00
$1,234.00
$958.00
$1,038.00
$1,122.00
$1,420.00
$1,144.00
$1,224.00
$1,308.00
$1,606.00
$186.00
Toc - Plan #46 Kaiser Permanente
Expanded Bronze

(EPO) KP OR Bronze 7100/0% HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.00
$330.00
$372.00
$519.00
$789.00
$476.00
$515.00
$557.00
$704.00
$661.00
$700.00
$742.00
$889.00
$846.00
$885.00
$927.00
$1,074.00
$185.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.00
$660.00
$744.00
$1,038.00
$1,578.00
$767.00
$845.00
$929.00
$1,223.00
$952.00
$1,030.00
$1,114.00
$1,408.00
$1,137.00
$1,215.00
$1,299.00
$1,593.00
$185.00
Toc - Plan #47 Kaiser Permanente
Expanded Bronze

(EPO) KP OR Bronze 9100/75

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

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
$278.00
$315.00
$355.00
$496.00
$754.00
$454.00
$491.00
$531.00
$672.00
$630.00
$667.00
$707.00
$848.00
$806.00
$843.00
$883.00
$1,024.00
$176.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$556.00
$630.00
$710.00
$992.00
$1,508.00
$732.00
$806.00
$886.00
$1,168.00
$908.00
$982.00
$1,062.00
$1,344.00
$1,084.00
$1,158.00
$1,238.00
$1,520.00
$176.00
Toc - Plan #48 Kaiser Permanente
Silver

(EPO) KP OR Silver 750/35

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-801-1270

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$9,300 $18,600 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
$406.00
$461.00
$519.00
$725.00
$1,101.00
$664.00
$719.00
$777.00
$983.00
$922.00
$977.00
$1,035.00
$1,241.00
$1,180.00
$1,235.00
$1,293.00
$1,499.00
$258.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$812.00
$922.00
$1,038.00
$1,450.00
$2,202.00
$1,070.00
$1,180.00
$1,296.00
$1,708.00
$1,328.00
$1,438.00
$1,554.00
$1,966.00
$1,586.00
$1,696.00
$1,812.00
$2,224.00
$258.00

ADVERTISEMENT

Regence BlueCross BlueShield of Oregon

Local: 1-888-675-6570 | Toll Free: 1-888-675-6570

Toc - Plan #49 Regence BlueCross BlueShield of Oregon
Expanded Bronze

(EPO) Bronze HSA 7000 Individual and Family Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$320.34
$363.58
$409.39
$572.12
$869.40
$523.75
$566.99
$612.80
$775.53
$727.16
$770.40
$816.21
$978.94
$930.57
$973.81
$1,019.62
$1,182.35
$203.41
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
$844.09
$930.57
$1,022.19
$1,347.65
$1,047.50
$1,133.98
$1,225.60
$1,551.06
$1,250.91
$1,337.39
$1,429.01
$1,754.47
$203.41
Toc - Plan #50 Regence BlueCross BlueShield of Oregon
Expanded Bronze

(EPO) Bronze Essential 8500 With 4 Copay No Deductible Office Visits Individual and Family Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

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
$303.27
$344.21
$387.57
$541.64
$823.07
$495.85
$536.79
$580.15
$734.22
$688.43
$729.37
$772.73
$926.80
$881.01
$921.95
$965.31
$1,119.38
$192.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$606.54
$688.42
$775.14
$1,083.28
$1,646.14
$799.12
$881.00
$967.72
$1,275.86
$991.70
$1,073.58
$1,160.30
$1,468.44
$1,184.28
$1,266.16
$1,352.88
$1,661.02
$192.58
Toc - Plan #51 Regence BlueCross BlueShield of Oregon
Bronze

(EPO) Bronze Virtual Value 8500 Individual and Family Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.45
$330.79
$372.48
$520.54
$791.01
$476.52
$515.86
$557.55
$705.61
$661.59
$700.93
$742.62
$890.68
$846.66
$886.00
$927.69
$1,075.75
$185.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.90
$661.58
$744.96
$1,041.08
$1,582.02
$767.97
$846.65
$930.03
$1,226.15
$953.04
$1,031.72
$1,115.10
$1,411.22
$1,138.11
$1,216.79
$1,300.17
$1,596.29
$185.07
Toc - Plan #52 Regence BlueCross BlueShield of Oregon
Silver

(EPO) Silver 4500 Individual and Family Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$400.94
$455.07
$512.41
$716.09
$1,088.17
$655.54
$709.67
$767.01
$970.69
$910.14
$964.27
$1,021.61
$1,225.29
$1,164.74
$1,218.87
$1,276.21
$1,479.89
$254.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$801.88
$910.14
$1,024.82
$1,432.18
$2,176.34
$1,056.48
$1,164.74
$1,279.42
$1,686.78
$1,311.08
$1,419.34
$1,534.02
$1,941.38
$1,565.68
$1,673.94
$1,788.62
$2,195.98
$254.60
Toc - Plan #53 Regence BlueCross BlueShield of Oregon
Silver

(EPO) Silver 4500 Legacy

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.66
$412.75
$464.76
$649.49
$986.97
$594.58
$643.67
$695.68
$880.41
$825.50
$874.59
$926.60
$1,111.33
$1,056.42
$1,105.51
$1,157.52
$1,342.25
$230.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.32
$825.50
$929.52
$1,298.98
$1,973.94
$958.24
$1,056.42
$1,160.44
$1,529.90
$1,189.16
$1,287.34
$1,391.36
$1,760.82
$1,420.08
$1,518.26
$1,622.28
$1,991.74
$230.92
Toc - Plan #54 Regence BlueCross BlueShield of Oregon
Expanded Bronze

(EPO) Bronze HSA 7000 Legacy

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.54
$329.76
$371.31
$518.90
$788.52
$475.03
$514.25
$555.80
$703.39
$659.52
$698.74
$740.29
$887.88
$844.01
$883.23
$924.78
$1,072.37
$184.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$581.08
$659.52
$742.62
$1,037.80
$1,577.04
$765.57
$844.01
$927.11
$1,222.29
$950.06
$1,028.50
$1,111.60
$1,406.78
$1,134.55
$1,212.99
$1,296.09
$1,591.27
$184.49
Toc - Plan #55 Regence BlueCross BlueShield of Oregon
Bronze

(EPO) Bronze Virtual Value 8500 Legacy

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$264.34
$300.02
$337.83
$472.11
$717.42
$432.19
$467.87
$505.68
$639.96
$600.04
$635.72
$673.53
$807.81
$767.89
$803.57
$841.38
$975.66
$167.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$528.68
$600.04
$675.66
$944.22
$1,434.84
$696.53
$767.89
$843.51
$1,112.07
$864.38
$935.74
$1,011.36
$1,279.92
$1,032.23
$1,103.59
$1,179.21
$1,447.77
$167.85
Toc - Plan #56 Regence BlueCross BlueShield of Oregon
Silver

(EPO) Silver 6500 Individual and Family Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.92
$432.35
$486.82
$680.33
$1,033.83
$622.81
$674.24
$728.71
$922.22
$864.70
$916.13
$970.60
$1,164.11
$1,106.59
$1,158.02
$1,212.49
$1,406.00
$241.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$761.84
$864.70
$973.64
$1,360.66
$2,067.66
$1,003.73
$1,106.59
$1,215.53
$1,602.55
$1,245.62
$1,348.48
$1,457.42
$1,844.44
$1,487.51
$1,590.37
$1,699.31
$2,086.33
$241.89
Toc - Plan #57 Regence BlueCross BlueShield of Oregon
Silver

(EPO) Silver 6500 Legacy

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$345.48
$392.12
$441.52
$617.02
$937.62
$564.86
$611.50
$660.90
$836.40
$784.24
$830.88
$880.28
$1,055.78
$1,003.62
$1,050.26
$1,099.66
$1,275.16
$219.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$690.96
$784.24
$883.04
$1,234.04
$1,875.24
$910.34
$1,003.62
$1,102.42
$1,453.42
$1,129.72
$1,223.00
$1,321.80
$1,672.80
$1,349.10
$1,442.38
$1,541.18
$1,892.18
$219.38
Toc - Plan #58 Regence BlueCross BlueShield of Oregon
Gold

(EPO) Gold 2500 Individual and Family Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$424.71
$482.04
$542.78
$758.53
$1,152.66
$694.40
$751.73
$812.47
$1,028.22
$964.09
$1,021.42
$1,082.16
$1,297.91
$1,233.78
$1,291.11
$1,351.85
$1,567.60
$269.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.42
$964.08
$1,085.56
$1,517.06
$2,305.32
$1,119.11
$1,233.77
$1,355.25
$1,786.75
$1,388.80
$1,503.46
$1,624.94
$2,056.44
$1,658.49
$1,773.15
$1,894.63
$2,326.13
$269.69
Toc - Plan #59 Regence BlueCross BlueShield of Oregon
Gold

(EPO) Gold 2500 Legacy

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.20
$437.19
$492.28
$687.97
$1,045.42
$629.80
$681.79
$736.88
$932.57
$874.40
$926.39
$981.48
$1,177.17
$1,119.00
$1,170.99
$1,226.08
$1,421.77
$244.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.40
$874.38
$984.56
$1,375.94
$2,090.84
$1,015.00
$1,118.98
$1,229.16
$1,620.54
$1,259.60
$1,363.58
$1,473.76
$1,865.14
$1,504.20
$1,608.18
$1,718.36
$2,109.74
$244.60
Toc - Plan #60 Regence BlueCross BlueShield of Oregon
Silver

(EPO) Regence Standard Silver Plan Individual and Family Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.18
$457.61
$515.26
$720.07
$1,094.23
$659.20
$713.63
$771.28
$976.09
$915.22
$969.65
$1,027.30
$1,232.11
$1,171.24
$1,225.67
$1,283.32
$1,488.13
$256.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.36
$915.22
$1,030.52
$1,440.14
$2,188.46
$1,062.38
$1,171.24
$1,286.54
$1,696.16
$1,318.40
$1,427.26
$1,542.56
$1,952.18
$1,574.42
$1,683.28
$1,798.58
$2,208.20
$256.02
Toc - Plan #61 Regence BlueCross BlueShield of Oregon
Expanded Bronze

(EPO) Regence Standard Bronze Plan Individual and Family Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$309.83
$351.66
$395.97
$553.36
$840.88
$506.58
$548.41
$592.72
$750.11
$703.33
$745.16
$789.47
$946.86
$900.08
$941.91
$986.22
$1,143.61
$196.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619.66
$703.32
$791.94
$1,106.72
$1,681.76
$816.41
$900.07
$988.69
$1,303.47
$1,013.16
$1,096.82
$1,185.44
$1,500.22
$1,209.91
$1,293.57
$1,382.19
$1,696.97
$196.75
Toc - Plan #62 Regence BlueCross BlueShield of Oregon
Gold

(EPO) Regence Standard Gold Plan Individual and Family Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$470.00
$533.46
$600.66
$839.42
$1,275.58
$768.45
$831.91
$899.11
$1,137.87
$1,066.90
$1,130.36
$1,197.56
$1,436.32
$1,365.35
$1,428.81
$1,496.01
$1,734.77
$298.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$940.00
$1,066.92
$1,201.32
$1,678.84
$2,551.16
$1,238.45
$1,365.37
$1,499.77
$1,977.29
$1,536.90
$1,663.82
$1,798.22
$2,275.74
$1,835.35
$1,962.27
$2,096.67
$2,574.19
$298.45
Toc - Plan #63 Regence BlueCross BlueShield of Oregon
Gold

(EPO) Regence Standard Gold Plan Legacy

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.28
$483.83
$544.79
$761.34
$1,156.93
$696.97
$754.52
$815.48
$1,032.03
$967.66
$1,025.21
$1,086.17
$1,302.72
$1,238.35
$1,295.90
$1,356.86
$1,573.41
$270.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.56
$967.66
$1,089.58
$1,522.68
$2,313.86
$1,123.25
$1,238.35
$1,360.27
$1,793.37
$1,393.94
$1,509.04
$1,630.96
$2,064.06
$1,664.63
$1,779.73
$1,901.65
$2,334.75
$270.69
Toc - Plan #64 Regence BlueCross BlueShield of Oregon
Silver

(EPO) Regence Standard Silver Plan Legacy

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$365.70
$415.06
$467.36
$653.13
$992.50
$597.91
$647.27
$699.57
$885.34
$830.12
$879.48
$931.78
$1,117.55
$1,062.33
$1,111.69
$1,163.99
$1,349.76
$232.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.40
$830.12
$934.72
$1,306.26
$1,985.00
$963.61
$1,062.33
$1,166.93
$1,538.47
$1,195.82
$1,294.54
$1,399.14
$1,770.68
$1,428.03
$1,526.75
$1,631.35
$2,002.89
$232.21
Toc - Plan #65 Regence BlueCross BlueShield of Oregon
Expanded Bronze

(EPO) Regence Standard Bronze Plan Legacy

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-675-6570

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$281.01
$318.95
$359.13
$501.89
$762.67
$459.45
$497.39
$537.57
$680.33
$637.89
$675.83
$716.01
$858.77
$816.33
$854.27
$894.45
$1,037.21
$178.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$562.02
$637.90
$718.26
$1,003.78
$1,525.34
$740.46
$816.34
$896.70
$1,182.22
$918.90
$994.78
$1,075.14
$1,360.66
$1,097.34
$1,173.22
$1,253.58
$1,539.10
$178.44

‡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 Multnomah County here.

Multnomah County is in “Rating Area 1” of Oregon.

Currently, there are 65 plans offered in Rating Area 1.

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2024 Obamacare Plans for Multnomah County, OR

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