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BlueCross BlueShield of South Carolina

Local: 1-855-404-6752 | Toll Free: 1-855-404-6752 | TTY: 1-855-889-4325

Toc - Plan #1 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$4,900 $9,800 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
$454.17
$515.48
$580.43
$811.14
$1,232.61
$801.61
$862.92
$927.87
$1,158.58
$1,149.05
$1,210.36
$1,275.31
$1,506.02
$1,496.49
$1,557.80
$1,622.75
$1,853.46
$347.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$908.34
$1,030.96
$1,160.86
$1,622.28
$2,465.22
$1,255.78
$1,378.40
$1,508.30
$1,969.72
$1,603.22
$1,725.84
$1,855.74
$2,317.16
$1,950.66
$2,073.28
$2,203.18
$2,664.60
$347.44
Toc - Plan #2 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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
$450.01
$510.77
$575.12
$803.72
$1,221.34
$794.27
$855.03
$919.38
$1,147.98
$1,138.53
$1,199.29
$1,263.64
$1,492.24
$1,482.79
$1,543.55
$1,607.90
$1,836.50
$344.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$900.02
$1,021.54
$1,150.24
$1,607.44
$2,442.68
$1,244.28
$1,365.80
$1,494.50
$1,951.70
$1,588.54
$1,710.06
$1,838.76
$2,295.96
$1,932.80
$2,054.32
$2,183.02
$2,640.22
$344.26
Toc - Plan #3 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials HD Gold 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 Annual Deductible
$3,400 $6,800 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
$450.90
$511.78
$576.26
$805.32
$1,223.75
$795.84
$856.72
$921.20
$1,150.26
$1,140.78
$1,201.66
$1,266.14
$1,495.20
$1,485.72
$1,546.60
$1,611.08
$1,840.14
$344.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$901.80
$1,023.56
$1,152.52
$1,610.64
$2,447.50
$1,246.74
$1,368.50
$1,497.46
$1,955.58
$1,591.68
$1,713.44
$1,842.40
$2,300.52
$1,936.62
$2,058.38
$2,187.34
$2,645.46
$344.94
Toc - Plan #4 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials HD Silver 6

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$456.14
$517.72
$582.95
$814.67
$1,237.98
$805.09
$866.67
$931.90
$1,163.62
$1,154.04
$1,215.62
$1,280.85
$1,512.57
$1,502.99
$1,564.57
$1,629.80
$1,861.52
$348.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$912.28
$1,035.44
$1,165.90
$1,629.34
$2,475.96
$1,261.23
$1,384.39
$1,514.85
$1,978.29
$1,610.18
$1,733.34
$1,863.80
$2,327.24
$1,959.13
$2,082.29
$2,212.75
$2,676.19
$348.95
Toc - Plan #5 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials HD Bronze 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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
$302.08
$342.87
$386.06
$539.52
$819.86
$533.17
$573.96
$617.15
$770.61
$764.26
$805.05
$848.24
$1,001.70
$995.35
$1,036.14
$1,079.33
$1,232.79
$231.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.16
$685.74
$772.12
$1,079.04
$1,639.72
$835.25
$916.83
$1,003.21
$1,310.13
$1,066.34
$1,147.92
$1,234.30
$1,541.22
$1,297.43
$1,379.01
$1,465.39
$1,772.31
$231.09
Toc - Plan #6 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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
$291.42
$330.76
$372.44
$520.48
$790.92
$514.36
$553.70
$595.38
$743.42
$737.30
$776.64
$818.32
$966.36
$960.24
$999.58
$1,041.26
$1,189.30
$222.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.84
$661.52
$744.88
$1,040.96
$1,581.84
$805.78
$884.46
$967.82
$1,263.90
$1,028.72
$1,107.40
$1,190.76
$1,486.84
$1,251.66
$1,330.34
$1,413.70
$1,709.78
$222.94
Toc - Plan #7 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials HD Bronze 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$297.34
$337.48
$380.00
$531.05
$806.98
$524.80
$564.94
$607.46
$758.51
$752.26
$792.40
$834.92
$985.97
$979.72
$1,019.86
$1,062.38
$1,213.43
$227.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$594.68
$674.96
$760.00
$1,062.10
$1,613.96
$822.14
$902.42
$987.46
$1,289.56
$1,049.60
$1,129.88
$1,214.92
$1,517.02
$1,277.06
$1,357.34
$1,442.38
$1,744.48
$227.46
Toc - Plan #8 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 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
$437.54
$496.61
$559.18
$781.45
$1,187.48
$772.26
$831.33
$893.90
$1,116.17
$1,106.98
$1,166.05
$1,228.62
$1,450.89
$1,441.70
$1,500.77
$1,563.34
$1,785.61
$334.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$875.08
$993.22
$1,118.36
$1,562.90
$2,374.96
$1,209.80
$1,327.94
$1,453.08
$1,897.62
$1,544.52
$1,662.66
$1,787.80
$2,232.34
$1,879.24
$1,997.38
$2,122.52
$2,567.06
$334.72
Toc - Plan #9 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.79
$493.49
$555.66
$776.53
$1,180.02
$767.40
$826.10
$888.27
$1,109.14
$1,100.01
$1,158.71
$1,220.88
$1,441.75
$1,432.62
$1,491.32
$1,553.49
$1,774.36
$332.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869.58
$986.98
$1,111.32
$1,553.06
$2,360.04
$1,202.19
$1,319.59
$1,443.93
$1,885.67
$1,534.80
$1,652.20
$1,776.54
$2,218.28
$1,867.41
$1,984.81
$2,109.15
$2,550.89
$332.61
Toc - Plan #10 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 14

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$8,800 $17,600 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
$424.07
$481.32
$541.96
$757.38
$1,150.92
$748.48
$805.73
$866.37
$1,081.79
$1,072.89
$1,130.14
$1,190.78
$1,406.20
$1,397.30
$1,454.55
$1,515.19
$1,730.61
$324.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$848.14
$962.64
$1,083.92
$1,514.76
$2,301.84
$1,172.55
$1,287.05
$1,408.33
$1,839.17
$1,496.96
$1,611.46
$1,732.74
$2,163.58
$1,821.37
$1,935.87
$2,057.15
$2,487.99
$324.41
Toc - Plan #11 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials Bronze 6

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.56
$387.67
$436.51
$610.03
$927.00
$602.85
$648.96
$697.80
$871.32
$864.14
$910.25
$959.09
$1,132.61
$1,125.43
$1,171.54
$1,220.38
$1,393.90
$261.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.12
$775.34
$873.02
$1,220.06
$1,854.00
$944.41
$1,036.63
$1,134.31
$1,481.35
$1,205.70
$1,297.92
$1,395.60
$1,742.64
$1,466.99
$1,559.21
$1,656.89
$2,003.93
$261.29
Toc - Plan #12 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$426.56
$484.14
$545.14
$761.83
$1,157.67
$752.88
$810.46
$871.46
$1,088.15
$1,079.20
$1,136.78
$1,197.78
$1,414.47
$1,405.52
$1,463.10
$1,524.10
$1,740.79
$326.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.12
$968.28
$1,090.28
$1,523.66
$2,315.34
$1,179.44
$1,294.60
$1,416.60
$1,849.98
$1,505.76
$1,620.92
$1,742.92
$2,176.30
$1,832.08
$1,947.24
$2,069.24
$2,502.62
$326.32
Toc - Plan #13 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 38

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$418.30
$474.78
$534.59
$747.09
$1,135.28
$738.30
$794.78
$854.59
$1,067.09
$1,058.30
$1,114.78
$1,174.59
$1,387.09
$1,378.30
$1,434.78
$1,494.59
$1,707.09
$320.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.60
$949.56
$1,069.18
$1,494.18
$2,270.56
$1,156.60
$1,269.56
$1,389.18
$1,814.18
$1,476.60
$1,589.56
$1,709.18
$2,134.18
$1,796.60
$1,909.56
$2,029.18
$2,454.18
$320.00
Toc - Plan #14 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 39

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$433.03
$491.48
$553.41
$773.38
$1,175.23
$764.29
$822.74
$884.67
$1,104.64
$1,095.55
$1,154.00
$1,215.93
$1,435.90
$1,426.81
$1,485.26
$1,547.19
$1,767.16
$331.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$866.06
$982.96
$1,106.82
$1,546.76
$2,350.46
$1,197.32
$1,314.22
$1,438.08
$1,878.02
$1,528.58
$1,645.48
$1,769.34
$2,209.28
$1,859.84
$1,976.74
$2,100.60
$2,540.54
$331.26
Toc - Plan #15 BlueCross BlueShield of South Carolina
Catastrophic

(EPO) BlueEssentials Catastrophic 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$193.94
$220.12
$247.86
$346.38
$526.36
$342.31
$368.49
$396.23
$494.75
$490.68
$516.86
$544.60
$643.12
$639.05
$665.23
$692.97
$791.49
$148.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$387.88
$440.24
$495.72
$692.76
$1,052.72
$536.25
$588.61
$644.09
$841.13
$684.62
$736.98
$792.46
$989.50
$832.99
$885.35
$940.83
$1,137.87
$148.37
Toc - Plan #16 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueExclusive Reedy Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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
$415.57
$471.68
$531.10
$742.21
$1,127.87
$733.48
$789.59
$849.01
$1,060.12
$1,051.39
$1,107.50
$1,166.92
$1,378.03
$1,369.30
$1,425.41
$1,484.83
$1,695.94
$317.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$831.14
$943.36
$1,062.20
$1,484.42
$2,255.74
$1,149.05
$1,261.27
$1,380.11
$1,802.33
$1,466.96
$1,579.18
$1,698.02
$2,120.24
$1,784.87
$1,897.09
$2,015.93
$2,438.15
$317.91
Toc - Plan #17 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueExclusive Reedy Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 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
$412.47
$468.16
$527.14
$736.68
$1,119.46
$728.01
$783.70
$842.68
$1,052.22
$1,043.55
$1,099.24
$1,158.22
$1,367.76
$1,359.09
$1,414.78
$1,473.76
$1,683.30
$315.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$824.94
$936.32
$1,054.28
$1,473.36
$2,238.92
$1,140.48
$1,251.86
$1,369.82
$1,788.90
$1,456.02
$1,567.40
$1,685.36
$2,104.44
$1,771.56
$1,882.94
$2,000.90
$2,419.98
$315.54
Toc - Plan #18 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueExclusive Reedy Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 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
$281.11
$319.06
$359.25
$502.06
$762.92
$496.16
$534.11
$574.30
$717.11
$711.21
$749.16
$789.35
$932.16
$926.26
$964.21
$1,004.40
$1,147.21
$215.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$562.22
$638.12
$718.50
$1,004.12
$1,525.84
$777.27
$853.17
$933.55
$1,219.17
$992.32
$1,068.22
$1,148.60
$1,434.22
$1,207.37
$1,283.27
$1,363.65
$1,649.27
$215.05
Toc - Plan #19 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueExclusive Reedy Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$409.22
$464.47
$522.98
$730.87
$1,110.62
$722.27
$777.52
$836.03
$1,043.92
$1,035.32
$1,090.57
$1,149.08
$1,356.97
$1,348.37
$1,403.62
$1,462.13
$1,670.02
$313.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.44
$928.94
$1,045.96
$1,461.74
$2,221.24
$1,131.49
$1,241.99
$1,359.01
$1,774.79
$1,444.54
$1,555.04
$1,672.06
$2,087.84
$1,757.59
$1,868.09
$1,985.11
$2,400.89
$313.05
Toc - Plan #20 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$448.15
$508.65
$572.74
$800.40
$1,216.29
$790.99
$851.49
$915.58
$1,143.24
$1,133.83
$1,194.33
$1,258.42
$1,486.08
$1,476.67
$1,537.17
$1,601.26
$1,828.92
$342.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.30
$1,017.30
$1,145.48
$1,600.80
$2,432.58
$1,239.14
$1,360.14
$1,488.32
$1,943.64
$1,581.98
$1,702.98
$1,831.16
$2,286.48
$1,924.82
$2,045.82
$2,174.00
$2,629.32
$342.84
Toc - Plan #21 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$426.60
$484.20
$545.20
$761.92
$1,157.81
$752.95
$810.55
$871.55
$1,088.27
$1,079.30
$1,136.90
$1,197.90
$1,414.62
$1,405.65
$1,463.25
$1,524.25
$1,740.97
$326.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.20
$968.40
$1,090.40
$1,523.84
$2,315.62
$1,179.55
$1,294.75
$1,416.75
$1,850.19
$1,505.90
$1,621.10
$1,743.10
$2,176.54
$1,832.25
$1,947.45
$2,069.45
$2,502.89
$326.35
Toc - Plan #22 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$291.34
$330.68
$372.34
$520.34
$790.71
$514.22
$553.56
$595.22
$743.22
$737.10
$776.44
$818.10
$966.10
$959.98
$999.32
$1,040.98
$1,188.98
$222.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.68
$661.36
$744.68
$1,040.68
$1,581.42
$805.56
$884.24
$967.56
$1,263.56
$1,028.44
$1,107.12
$1,190.44
$1,486.44
$1,251.32
$1,330.00
$1,413.32
$1,709.32
$222.88
Toc - Plan #23 BlueCross BlueShield of South Carolina
Bronze

(EPO) BlueEssentials Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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
$284.61
$323.04
$363.74
$508.32
$772.44
$502.34
$540.77
$581.47
$726.05
$720.07
$758.50
$799.20
$943.78
$937.80
$976.23
$1,016.93
$1,161.51
$217.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$569.22
$646.08
$727.48
$1,016.64
$1,544.88
$786.95
$863.81
$945.21
$1,234.37
$1,004.68
$1,081.54
$1,162.94
$1,452.10
$1,222.41
$1,299.27
$1,380.67
$1,669.83
$217.73

ADVERTISEMENT

Molina Healthcare

Local: 1-855-885-3176 | Toll Free: 1-855-885-3176 | TTY: 1-855-885-3176

Toc - Plan #24 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-885-3176

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
$478.50
$543.10
$611.52
$854.60
$1,298.65
$844.55
$909.15
$977.57
$1,220.65
$1,210.60
$1,275.20
$1,343.62
$1,586.70
$1,576.65
$1,641.25
$1,709.67
$1,952.75
$366.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$957.00
$1,086.20
$1,223.04
$1,709.20
$2,597.30
$1,323.05
$1,452.25
$1,589.09
$2,075.25
$1,689.10
$1,818.30
$1,955.14
$2,441.30
$2,055.15
$2,184.35
$2,321.19
$2,807.35
$366.05
Toc - Plan #25 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-885-3176

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
$458.82
$520.76
$586.37
$819.46
$1,245.24
$809.82
$871.76
$937.37
$1,170.46
$1,160.82
$1,222.76
$1,288.37
$1,521.46
$1,511.82
$1,573.76
$1,639.37
$1,872.46
$351.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.64
$1,041.52
$1,172.74
$1,638.92
$2,490.48
$1,268.64
$1,392.52
$1,523.74
$1,989.92
$1,619.64
$1,743.52
$1,874.74
$2,340.92
$1,970.64
$2,094.52
$2,225.74
$2,691.92
$351.00
Toc - Plan #26 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-885-3176

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
$478.45
$543.04
$611.45
$854.50
$1,298.50
$844.46
$909.05
$977.46
$1,220.51
$1,210.47
$1,275.06
$1,343.47
$1,586.52
$1,576.48
$1,641.07
$1,709.48
$1,952.53
$366.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$956.90
$1,086.08
$1,222.90
$1,709.00
$2,597.00
$1,322.91
$1,452.09
$1,588.91
$2,075.01
$1,688.92
$1,818.10
$1,954.92
$2,441.02
$2,054.93
$2,184.11
$2,320.93
$2,807.03
$366.01
Toc - Plan #27 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-885-3176

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
$451.02
$511.91
$576.41
$805.53
$1,224.08
$796.05
$856.94
$921.44
$1,150.56
$1,141.08
$1,201.97
$1,266.47
$1,495.59
$1,486.11
$1,547.00
$1,611.50
$1,840.62
$345.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$902.04
$1,023.82
$1,152.82
$1,611.06
$2,448.16
$1,247.07
$1,368.85
$1,497.85
$1,956.09
$1,592.10
$1,713.88
$1,842.88
$2,301.12
$1,937.13
$2,058.91
$2,187.91
$2,646.15
$345.03
Toc - Plan #28 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-885-3176

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
$481.85
$546.90
$615.81
$860.59
$1,307.75
$850.47
$915.52
$984.43
$1,229.21
$1,219.09
$1,284.14
$1,353.05
$1,597.83
$1,587.71
$1,652.76
$1,721.67
$1,966.45
$368.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$963.70
$1,093.80
$1,231.62
$1,721.18
$2,615.50
$1,332.32
$1,462.42
$1,600.24
$2,089.80
$1,700.94
$1,831.04
$1,968.86
$2,458.42
$2,069.56
$2,199.66
$2,337.48
$2,827.04
$368.62
Toc - Plan #29 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-885-3176

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
$462.64
$525.10
$591.26
$826.28
$1,255.61
$816.56
$879.02
$945.18
$1,180.20
$1,170.48
$1,232.94
$1,299.10
$1,534.12
$1,524.40
$1,586.86
$1,653.02
$1,888.04
$353.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$925.28
$1,050.20
$1,182.52
$1,652.56
$2,511.22
$1,279.20
$1,404.12
$1,536.44
$2,006.48
$1,633.12
$1,758.04
$1,890.36
$2,360.40
$1,987.04
$2,111.96
$2,244.28
$2,714.32
$353.92

ADVERTISEMENT

First Choice Next

Local: 1-833-983-7272 | Toll Free: 1-833-983-7272

Toc - Plan #30 First Choice Next
Bronze

(HMO) First Choice Next Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-983-7272

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$275.99
$313.25
$352.71
$492.91
$749.02
$487.12
$524.38
$563.84
$704.04
$698.25
$735.51
$774.97
$915.17
$909.38
$946.64
$986.10
$1,126.30
$211.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$551.98
$626.50
$705.42
$985.82
$1,498.04
$763.11
$837.63
$916.55
$1,196.95
$974.24
$1,048.76
$1,127.68
$1,408.08
$1,185.37
$1,259.89
$1,338.81
$1,619.21
$211.13
Toc - Plan #31 First Choice Next
Expanded Bronze

(HMO) First Choice Next Expanded Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-983-7272

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
$310.16
$352.03
$396.39
$553.94
$841.77
$547.43
$589.30
$633.66
$791.21
$784.70
$826.57
$870.93
$1,028.48
$1,021.97
$1,063.84
$1,108.20
$1,265.75
$237.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.32
$704.06
$792.78
$1,107.88
$1,683.54
$857.59
$941.33
$1,030.05
$1,345.15
$1,094.86
$1,178.60
$1,267.32
$1,582.42
$1,332.13
$1,415.87
$1,504.59
$1,819.69
$237.27
Toc - Plan #32 First Choice Next
Silver

(HMO) First Choice Next Silver 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-983-7272

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
$411.72
$467.31
$526.18
$735.34
$1,117.41
$726.69
$782.28
$841.15
$1,050.31
$1,041.66
$1,097.25
$1,156.12
$1,365.28
$1,356.63
$1,412.22
$1,471.09
$1,680.25
$314.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$823.44
$934.62
$1,052.36
$1,470.68
$2,234.82
$1,138.41
$1,249.59
$1,367.33
$1,785.65
$1,453.38
$1,564.56
$1,682.30
$2,100.62
$1,768.35
$1,879.53
$1,997.27
$2,415.59
$314.97
Toc - Plan #33 First Choice Next
Gold

(HMO) First Choice Next Gold 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-983-7272

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
$437.59
$496.67
$559.24
$781.54
$1,187.62
$772.35
$831.43
$894.00
$1,116.30
$1,107.11
$1,166.19
$1,228.76
$1,451.06
$1,441.87
$1,500.95
$1,563.52
$1,785.82
$334.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$875.18
$993.34
$1,118.48
$1,563.08
$2,375.24
$1,209.94
$1,328.10
$1,453.24
$1,897.84
$1,544.70
$1,662.86
$1,788.00
$2,232.60
$1,879.46
$1,997.62
$2,122.76
$2,567.36
$334.76

ADVERTISEMENT

Ambetter from Absolute Total Care

Local: 1-833-270-5443 | Toll Free: 1-833-270-5443

Toc - Plan #34 Ambetter from Absolute Total Care
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$332.40
$377.27
$424.80
$593.65
$902.11
$586.68
$631.55
$679.08
$847.93
$840.96
$885.83
$933.36
$1,102.21
$1,095.24
$1,140.11
$1,187.64
$1,356.49
$254.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.80
$754.54
$849.60
$1,187.30
$1,804.22
$919.08
$1,008.82
$1,103.88
$1,441.58
$1,173.36
$1,263.10
$1,358.16
$1,695.86
$1,427.64
$1,517.38
$1,612.44
$1,950.14
$254.28
Toc - Plan #35 Ambetter from Absolute Total Care
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$475.07
$539.19
$607.12
$848.45
$1,289.30
$838.49
$902.61
$970.54
$1,211.87
$1,201.91
$1,266.03
$1,333.96
$1,575.29
$1,565.33
$1,629.45
$1,697.38
$1,938.71
$363.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$950.14
$1,078.38
$1,214.24
$1,696.90
$2,578.60
$1,313.56
$1,441.80
$1,577.66
$2,060.32
$1,676.98
$1,805.22
$1,941.08
$2,423.74
$2,040.40
$2,168.64
$2,304.50
$2,787.16
$363.42
Toc - Plan #36 Ambetter from Absolute Total Care
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$429.85
$487.86
$549.33
$767.69
$1,166.58
$758.68
$816.69
$878.16
$1,096.52
$1,087.51
$1,145.52
$1,206.99
$1,425.35
$1,416.34
$1,474.35
$1,535.82
$1,754.18
$328.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.70
$975.72
$1,098.66
$1,535.38
$2,333.16
$1,188.53
$1,304.55
$1,427.49
$1,864.21
$1,517.36
$1,633.38
$1,756.32
$2,193.04
$1,846.19
$1,962.21
$2,085.15
$2,521.87
$328.83
Toc - Plan #37 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$356.99
$405.17
$456.22
$637.57
$968.84
$630.08
$678.26
$729.31
$910.66
$903.17
$951.35
$1,002.40
$1,183.75
$1,176.26
$1,224.44
$1,275.49
$1,456.84
$273.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.98
$810.34
$912.44
$1,275.14
$1,937.68
$987.07
$1,083.43
$1,185.53
$1,548.23
$1,260.16
$1,356.52
$1,458.62
$1,821.32
$1,533.25
$1,629.61
$1,731.71
$2,094.41
$273.09
Toc - Plan #38 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$401.78
$456.01
$513.46
$717.56
$1,090.40
$709.13
$763.36
$820.81
$1,024.91
$1,016.48
$1,070.71
$1,128.16
$1,332.26
$1,323.83
$1,378.06
$1,435.51
$1,639.61
$307.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.56
$912.02
$1,026.92
$1,435.12
$2,180.80
$1,110.91
$1,219.37
$1,334.27
$1,742.47
$1,418.26
$1,526.72
$1,641.62
$2,049.82
$1,725.61
$1,834.07
$1,948.97
$2,357.17
$307.35
Toc - Plan #39 Ambetter from Absolute Total Care
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$424.09
$481.33
$541.97
$757.40
$1,150.95
$748.51
$805.75
$866.39
$1,081.82
$1,072.93
$1,130.17
$1,190.81
$1,406.24
$1,397.35
$1,454.59
$1,515.23
$1,730.66
$324.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$848.18
$962.66
$1,083.94
$1,514.80
$2,301.90
$1,172.60
$1,287.08
$1,408.36
$1,839.22
$1,497.02
$1,611.50
$1,732.78
$2,163.64
$1,821.44
$1,935.92
$2,057.20
$2,488.06
$324.42
Toc - Plan #40 Ambetter from Absolute Total Care
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$428.13
$485.91
$547.13
$764.62
$1,161.91
$755.64
$813.42
$874.64
$1,092.13
$1,083.15
$1,140.93
$1,202.15
$1,419.64
$1,410.66
$1,468.44
$1,529.66
$1,747.15
$327.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.26
$971.82
$1,094.26
$1,529.24
$2,323.82
$1,183.77
$1,299.33
$1,421.77
$1,856.75
$1,511.28
$1,626.84
$1,749.28
$2,184.26
$1,838.79
$1,954.35
$2,076.79
$2,511.77
$327.51
Toc - Plan #41 Ambetter from Absolute Total Care
Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$454.52
$515.87
$580.86
$811.75
$1,233.54
$802.22
$863.57
$928.56
$1,159.45
$1,149.92
$1,211.27
$1,276.26
$1,507.15
$1,497.62
$1,558.97
$1,623.96
$1,854.85
$347.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$909.04
$1,031.74
$1,161.72
$1,623.50
$2,467.08
$1,256.74
$1,379.44
$1,509.42
$1,971.20
$1,604.44
$1,727.14
$1,857.12
$2,318.90
$1,952.14
$2,074.84
$2,204.82
$2,666.60
$347.70
Toc - Plan #42 Ambetter from Absolute Total Care
Silver

(HMO) Enhanced Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$429.37
$487.33
$548.73
$766.84
$1,165.29
$757.83
$815.79
$877.19
$1,095.30
$1,086.29
$1,144.25
$1,205.65
$1,423.76
$1,414.75
$1,472.71
$1,534.11
$1,752.22
$328.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.74
$974.66
$1,097.46
$1,533.68
$2,330.58
$1,187.20
$1,303.12
$1,425.92
$1,862.14
$1,515.66
$1,631.58
$1,754.38
$2,190.60
$1,844.12
$1,960.04
$2,082.84
$2,519.06
$328.46
Toc - Plan #43 Ambetter from Absolute Total Care
Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$524.02
$594.76
$669.69
$935.89
$1,422.17
$924.89
$995.63
$1,070.56
$1,336.76
$1,325.76
$1,396.50
$1,471.43
$1,737.63
$1,726.63
$1,797.37
$1,872.30
$2,138.50
$400.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,048.04
$1,189.52
$1,339.38
$1,871.78
$2,844.34
$1,448.91
$1,590.39
$1,740.25
$2,272.65
$1,849.78
$1,991.26
$2,141.12
$2,673.52
$2,250.65
$2,392.13
$2,541.99
$3,074.39
$400.87
Toc - Plan #44 Ambetter from Absolute Total Care
Bronze

(HMO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$317.06
$359.85
$405.19
$566.25
$860.47
$559.60
$602.39
$647.73
$808.79
$802.14
$844.93
$890.27
$1,051.33
$1,044.68
$1,087.47
$1,132.81
$1,293.87
$242.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.12
$719.70
$810.38
$1,132.50
$1,720.94
$876.66
$962.24
$1,052.92
$1,375.04
$1,119.20
$1,204.78
$1,295.46
$1,617.58
$1,361.74
$1,447.32
$1,538.00
$1,860.12
$242.54
Toc - Plan #45 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$349.51
$396.68
$446.66
$624.21
$948.54
$616.88
$664.05
$714.03
$891.58
$884.25
$931.42
$981.40
$1,158.95
$1,151.62
$1,198.79
$1,248.77
$1,426.32
$267.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$699.02
$793.36
$893.32
$1,248.42
$1,897.08
$966.39
$1,060.73
$1,160.69
$1,515.79
$1,233.76
$1,328.10
$1,428.06
$1,783.16
$1,501.13
$1,595.47
$1,695.43
$2,050.53
$267.37
Toc - Plan #46 Ambetter from Absolute Total Care
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$423.70
$480.89
$541.48
$756.71
$1,149.90
$747.82
$805.01
$865.60
$1,080.83
$1,071.94
$1,129.13
$1,189.72
$1,404.95
$1,396.06
$1,453.25
$1,513.84
$1,729.07
$324.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$847.40
$961.78
$1,082.96
$1,513.42
$2,299.80
$1,171.52
$1,285.90
$1,407.08
$1,837.54
$1,495.64
$1,610.02
$1,731.20
$2,161.66
$1,819.76
$1,934.14
$2,055.32
$2,485.78
$324.12
Toc - Plan #47 Ambetter from Absolute Total Care
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$448.29
$508.79
$572.90
$800.62
$1,216.62
$791.22
$851.72
$915.83
$1,143.55
$1,134.15
$1,194.65
$1,258.76
$1,486.48
$1,477.08
$1,537.58
$1,601.69
$1,829.41
$342.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.58
$1,017.58
$1,145.80
$1,601.24
$2,433.24
$1,239.51
$1,360.51
$1,488.73
$1,944.17
$1,582.44
$1,703.44
$1,831.66
$2,287.10
$1,925.37
$2,046.37
$2,174.59
$2,630.03
$342.93
Toc - Plan #48 Ambetter from Absolute Total Care
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$494.08
$560.77
$631.42
$882.40
$1,340.90
$872.04
$938.73
$1,009.38
$1,260.36
$1,250.00
$1,316.69
$1,387.34
$1,638.32
$1,627.96
$1,694.65
$1,765.30
$2,016.28
$377.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$988.16
$1,121.54
$1,262.84
$1,764.80
$2,681.80
$1,366.12
$1,499.50
$1,640.80
$2,142.76
$1,744.08
$1,877.46
$2,018.76
$2,520.72
$2,122.04
$2,255.42
$2,396.72
$2,898.68
$377.96
Toc - Plan #49 Ambetter from Absolute Total Care
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$345.70
$392.36
$441.80
$617.41
$938.21
$610.16
$656.82
$706.26
$881.87
$874.62
$921.28
$970.72
$1,146.33
$1,139.08
$1,185.74
$1,235.18
$1,410.79
$264.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$691.40
$784.72
$883.60
$1,234.82
$1,876.42
$955.86
$1,049.18
$1,148.06
$1,499.28
$1,220.32
$1,313.64
$1,412.52
$1,763.74
$1,484.78
$1,578.10
$1,676.98
$2,028.20
$264.46
Toc - Plan #50 Ambetter from Absolute Total Care
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$447.05
$507.39
$571.31
$798.41
$1,213.26
$789.03
$849.37
$913.29
$1,140.39
$1,131.01
$1,191.35
$1,255.27
$1,482.37
$1,472.99
$1,533.33
$1,597.25
$1,824.35
$341.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$894.10
$1,014.78
$1,142.62
$1,596.82
$2,426.52
$1,236.08
$1,356.76
$1,484.60
$1,938.80
$1,578.06
$1,698.74
$1,826.58
$2,280.78
$1,920.04
$2,040.72
$2,168.56
$2,622.76
$341.98
Toc - Plan #51 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$371.27
$421.39
$474.48
$663.08
$1,007.61
$655.29
$705.41
$758.50
$947.10
$939.31
$989.43
$1,042.52
$1,231.12
$1,223.33
$1,273.45
$1,326.54
$1,515.14
$284.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.54
$842.78
$948.96
$1,326.16
$2,015.22
$1,026.56
$1,126.80
$1,232.98
$1,610.18
$1,310.58
$1,410.82
$1,517.00
$1,894.20
$1,594.60
$1,694.84
$1,801.02
$2,178.22
$284.02
Toc - Plan #52 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$417.86
$474.26
$534.01
$746.27
$1,134.03
$737.51
$793.91
$853.66
$1,065.92
$1,057.16
$1,113.56
$1,173.31
$1,385.57
$1,376.81
$1,433.21
$1,492.96
$1,705.22
$319.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.72
$948.52
$1,068.02
$1,492.54
$2,268.06
$1,155.37
$1,268.17
$1,387.67
$1,812.19
$1,475.02
$1,587.82
$1,707.32
$2,131.84
$1,794.67
$1,907.47
$2,026.97
$2,451.49
$319.65
Toc - Plan #53 Ambetter from Absolute Total Care
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$441.06
$500.59
$563.66
$787.71
$1,197.00
$778.46
$837.99
$901.06
$1,125.11
$1,115.86
$1,175.39
$1,238.46
$1,462.51
$1,453.26
$1,512.79
$1,575.86
$1,799.91
$337.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.12
$1,001.18
$1,127.32
$1,575.42
$2,394.00
$1,219.52
$1,338.58
$1,464.72
$1,912.82
$1,556.92
$1,675.98
$1,802.12
$2,250.22
$1,894.32
$2,013.38
$2,139.52
$2,587.62
$337.40
Toc - Plan #54 Ambetter from Absolute Total Care
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$445.26
$505.36
$569.03
$795.22
$1,208.41
$785.88
$845.98
$909.65
$1,135.84
$1,126.50
$1,186.60
$1,250.27
$1,476.46
$1,467.12
$1,527.22
$1,590.89
$1,817.08
$340.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$890.52
$1,010.72
$1,138.06
$1,590.44
$2,416.82
$1,231.14
$1,351.34
$1,478.68
$1,931.06
$1,571.76
$1,691.96
$1,819.30
$2,271.68
$1,912.38
$2,032.58
$2,159.92
$2,612.30
$340.62
Toc - Plan #55 Ambetter from Absolute Total Care
Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$472.71
$536.51
$604.11
$844.24
$1,282.90
$834.32
$898.12
$965.72
$1,205.85
$1,195.93
$1,259.73
$1,327.33
$1,567.46
$1,557.54
$1,621.34
$1,688.94
$1,929.07
$361.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$945.42
$1,073.02
$1,208.22
$1,688.48
$2,565.80
$1,307.03
$1,434.63
$1,569.83
$2,050.09
$1,668.64
$1,796.24
$1,931.44
$2,411.70
$2,030.25
$2,157.85
$2,293.05
$2,773.31
$361.61
Toc - Plan #56 Ambetter from Absolute Total Care
Silver

(HMO) Enhanced Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$446.56
$506.83
$570.69
$797.53
$1,211.93
$788.17
$848.44
$912.30
$1,139.14
$1,129.78
$1,190.05
$1,253.91
$1,480.75
$1,471.39
$1,531.66
$1,595.52
$1,822.36
$341.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$893.12
$1,013.66
$1,141.38
$1,595.06
$2,423.86
$1,234.73
$1,355.27
$1,482.99
$1,936.67
$1,576.34
$1,696.88
$1,824.60
$2,278.28
$1,917.95
$2,038.49
$2,166.21
$2,619.89
$341.61
Toc - Plan #57 Ambetter from Absolute Total Care
Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$544.99
$618.56
$696.49
$973.34
$1,479.09
$961.90
$1,035.47
$1,113.40
$1,390.25
$1,378.81
$1,452.38
$1,530.31
$1,807.16
$1,795.72
$1,869.29
$1,947.22
$2,224.07
$416.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,089.98
$1,237.12
$1,392.98
$1,946.68
$2,958.18
$1,506.89
$1,654.03
$1,809.89
$2,363.59
$1,923.80
$2,070.94
$2,226.80
$2,780.50
$2,340.71
$2,487.85
$2,643.71
$3,197.41
$416.91
Toc - Plan #58 Ambetter from Absolute Total Care
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$347.53
$394.44
$444.13
$620.68
$943.18
$613.39
$660.30
$709.99
$886.54
$879.25
$926.16
$975.85
$1,152.40
$1,145.11
$1,192.02
$1,241.71
$1,418.26
$265.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$695.06
$788.88
$888.26
$1,241.36
$1,886.36
$960.92
$1,054.74
$1,154.12
$1,507.22
$1,226.78
$1,320.60
$1,419.98
$1,773.08
$1,492.64
$1,586.46
$1,685.84
$2,038.94
$265.86
Toc - Plan #59 Ambetter from Absolute Total Care
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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
$418.84
$475.38
$535.27
$748.04
$1,136.71
$739.25
$795.79
$855.68
$1,068.45
$1,059.66
$1,116.20
$1,176.09
$1,388.86
$1,380.07
$1,436.61
$1,496.50
$1,709.27
$320.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$837.68
$950.76
$1,070.54
$1,496.08
$2,273.42
$1,158.09
$1,271.17
$1,390.95
$1,816.49
$1,478.50
$1,591.58
$1,711.36
$2,136.90
$1,798.91
$1,911.99
$2,031.77
$2,457.31
$320.41

‡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 Greenville County here.

Greenville County is in “Rating Area 23” of South Carolina.

Currently, there are 59 plans offered in Rating Area 23.

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2023 Obamacare Plans for Greenville County, SC

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