Tennessee Obamacare 2023 Rates

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BlueCross BlueShield of Tennessee

Local: 1-423-535-5600 | Toll Free: 1-800-565-9140

Toc - Plan #1 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B07S HSA + Free Preventive Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$5,950 $11,900 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$369.67
$419.58
$472.44
$660.23
$1,003.28

$652.47
$702.38
$755.24
$943.03

$935.27
$985.18
$1,038.04
$1,225.83

$1,218.07
$1,267.98
$1,320.84
$1,508.63

$282.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$739.34
$839.16
$944.88
$1,320.46
$2,006.56

$1,022.14
$1,121.96
$1,227.68
$1,603.26

$1,304.94
$1,404.76
$1,510.48
$1,886.06

$1,587.74
$1,687.56
$1,793.28
$2,168.86

$282.80

Toc - Plan #2 BlueCross BlueShield of Tennessee

Bronze

(EPO) Bronze B08S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$332.43
$377.31
$424.85
$593.72
$902.22

$586.74
$631.62
$679.16
$848.03

$841.05
$885.93
$933.47
$1,102.34

$1,095.36
$1,140.24
$1,187.78
$1,356.65

$254.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$664.86
$754.62
$849.70
$1,187.44
$1,804.44

$919.17
$1,008.93
$1,104.01
$1,441.75

$1,173.48
$1,263.24
$1,358.32
$1,696.06

$1,427.79
$1,517.55
$1,612.63
$1,950.37

$254.31

Toc - Plan #3 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B11S $25 PCP Copay at Blue of TN + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$6,400 $12,800 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

$367.89
$417.56
$470.16
$657.05
$998.45

$649.33
$699.00
$751.60
$938.49

$930.77
$980.44
$1,033.04
$1,219.93

$1,212.21
$1,261.88
$1,314.48
$1,501.37

$281.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$735.78
$835.12
$940.32
$1,314.10
$1,996.90

$1,017.22
$1,116.56
$1,221.76
$1,595.54

$1,298.66
$1,398.00
$1,503.20
$1,876.98

$1,580.10
$1,679.44
$1,784.64
$2,158.42

$281.44

Toc - Plan #4 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B13S 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$386.91
$439.14
$494.47
$691.02
$1,050.07

$682.90
$735.13
$790.46
$987.01

$978.89
$1,031.12
$1,086.45
$1,283.00

$1,274.88
$1,327.11
$1,382.44
$1,578.99

$295.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$773.82
$878.28
$988.94
$1,382.04
$2,100.14

$1,069.81
$1,174.27
$1,284.93
$1,678.03

$1,365.80
$1,470.26
$1,580.92
$1,974.02

$1,661.79
$1,766.25
$1,876.91
$2,270.01

$295.99

Toc - Plan #5 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B07E HSA + Free Preventive Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$5,950 $11,900 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$297.29
$337.42
$379.94
$530.96
$806.85

$524.72
$564.85
$607.37
$758.39

$752.15
$792.28
$834.80
$985.82

$979.58
$1,019.71
$1,062.23
$1,213.25

$227.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.58
$674.84
$759.88
$1,061.92
$1,613.70

$822.01
$902.27
$987.31
$1,289.35

$1,049.44
$1,129.70
$1,214.74
$1,516.78

$1,276.87
$1,357.13
$1,442.17
$1,744.21

$227.43

Toc - Plan #6 BlueCross BlueShield of Tennessee

Bronze

(EPO) Bronze B08E Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 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

$267.35
$303.44
$341.67
$477.49
$725.59

$471.87
$507.96
$546.19
$682.01

$676.39
$712.48
$750.71
$886.53

$880.91
$917.00
$955.23
$1,091.05

$204.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$534.70
$606.88
$683.34
$954.98
$1,451.18

$739.22
$811.40
$887.86
$1,159.50

$943.74
$1,015.92
$1,092.38
$1,364.02

$1,148.26
$1,220.44
$1,296.90
$1,568.54

$204.52

Toc - Plan #7 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B10S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$6,600 $13,200 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$363.94
$413.07
$465.12
$650.00
$987.73

$642.35
$691.48
$743.53
$928.41

$920.76
$969.89
$1,021.94
$1,206.82

$1,199.17
$1,248.30
$1,300.35
$1,485.23

$278.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$727.88
$826.14
$930.24
$1,300.00
$1,975.46

$1,006.29
$1,104.55
$1,208.65
$1,578.41

$1,284.70
$1,382.96
$1,487.06
$1,856.82

$1,563.11
$1,661.37
$1,765.47
$2,135.23

$278.41

Toc - Plan #8 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B10E Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$6,600 $13,200 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$292.68
$332.19
$374.05
$522.73
$794.33

$516.58
$556.09
$597.95
$746.63

$740.48
$779.99
$821.85
$970.53

$964.38
$1,003.89
$1,045.75
$1,194.43

$223.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$585.36
$664.38
$748.10
$1,045.46
$1,588.66

$809.26
$888.28
$972.00
$1,269.36

$1,033.16
$1,112.18
$1,195.90
$1,493.26

$1,257.06
$1,336.08
$1,419.80
$1,717.16

$223.90

Toc - Plan #9 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B11E $25 PCP Copay at Blue of TN + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$6,400 $12,800 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

$307.64
$349.17
$393.16
$549.45
$834.93

$542.98
$584.51
$628.50
$784.79

$778.32
$819.85
$863.84
$1,020.13

$1,013.66
$1,055.19
$1,099.18
$1,255.47

$235.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$615.28
$698.34
$786.32
$1,098.90
$1,669.86

$850.62
$933.68
$1,021.66
$1,334.24

$1,085.96
$1,169.02
$1,257.00
$1,569.58

$1,321.30
$1,404.36
$1,492.34
$1,804.92

$235.34

Toc - Plan #10 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B13E 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$311.16
$353.17
$397.66
$555.73
$844.49

$549.20
$591.21
$635.70
$793.77

$787.24
$829.25
$873.74
$1,031.81

$1,025.28
$1,067.29
$1,111.78
$1,269.85

$238.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$622.32
$706.34
$795.32
$1,111.46
$1,688.98

$860.36
$944.38
$1,033.36
$1,349.50

$1,098.40
$1,182.42
$1,271.40
$1,587.54

$1,336.44
$1,420.46
$1,509.44
$1,825.58

$238.04

Toc - Plan #11 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B14S $70 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$338.26
$383.93
$432.30
$604.13
$918.04

$597.03
$642.70
$691.07
$862.90

$855.80
$901.47
$949.84
$1,121.67

$1,114.57
$1,160.24
$1,208.61
$1,380.44

$258.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$676.52
$767.86
$864.60
$1,208.26
$1,836.08

$935.29
$1,026.63
$1,123.37
$1,467.03

$1,194.06
$1,285.40
$1,382.14
$1,725.80

$1,452.83
$1,544.17
$1,640.91
$1,984.57

$258.77

Toc - Plan #12 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B14E $70 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$272.03
$308.75
$347.65
$485.85
$738.29

$480.13
$516.85
$555.75
$693.95

$688.23
$724.95
$763.85
$902.05

$896.33
$933.05
$971.95
$1,110.15

$208.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$544.06
$617.50
$695.30
$971.70
$1,476.58

$752.16
$825.60
$903.40
$1,179.80

$960.26
$1,033.70
$1,111.50
$1,387.90

$1,168.36
$1,241.80
$1,319.60
$1,596.00

$208.10

Toc - Plan #13 BlueCross BlueShield of Tennessee

Bronze

(EPO) Bronze B15S + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$329.10
$373.53
$420.59
$587.77
$893.18

$580.86
$625.29
$672.35
$839.53

$832.62
$877.05
$924.11
$1,091.29

$1,084.38
$1,128.81
$1,175.87
$1,343.05

$251.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$658.20
$747.06
$841.18
$1,175.54
$1,786.36

$909.96
$998.82
$1,092.94
$1,427.30

$1,161.72
$1,250.58
$1,344.70
$1,679.06

$1,413.48
$1,502.34
$1,596.46
$1,930.82

$251.76

Toc - Plan #14 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S01S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$474.33
$538.36
$606.19
$847.15
$1,287.33

$837.19
$901.22
$969.05
$1,210.01

$1,200.05
$1,264.08
$1,331.91
$1,572.87

$1,562.91
$1,626.94
$1,694.77
$1,935.73

$362.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$948.66
$1,076.72
$1,212.38
$1,694.30
$2,574.66

$1,311.52
$1,439.58
$1,575.24
$2,057.16

$1,674.38
$1,802.44
$1,938.10
$2,420.02

$2,037.24
$2,165.30
$2,300.96
$2,782.88

$362.86

Toc - Plan #15 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S04S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$6,200 $12,400 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

$467.96
$531.13
$598.05
$835.78
$1,270.04

$825.95
$889.12
$956.04
$1,193.77

$1,183.94
$1,247.11
$1,314.03
$1,551.76

$1,541.93
$1,605.10
$1,672.02
$1,909.75

$357.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$935.92
$1,062.26
$1,196.10
$1,671.56
$2,540.08

$1,293.91
$1,420.25
$1,554.09
$2,029.55

$1,651.90
$1,778.24
$1,912.08
$2,387.54

$2,009.89
$2,136.23
$2,270.07
$2,745.53

$357.99

Toc - Plan #16 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S21S $10 PCP Copay at Blue of TN + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$470.52
$534.04
$601.32
$840.35
$1,276.99

$830.47
$893.99
$961.27
$1,200.30

$1,190.42
$1,253.94
$1,321.22
$1,560.25

$1,550.37
$1,613.89
$1,681.17
$1,920.20

$359.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$941.04
$1,068.08
$1,202.64
$1,680.70
$2,553.98

$1,300.99
$1,428.03
$1,562.59
$2,040.65

$1,660.94
$1,787.98
$1,922.54
$2,400.60

$2,020.89
$2,147.93
$2,282.49
$2,760.55

$359.95

Toc - Plan #17 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S23S 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$2,200 $4,400 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$464.81
$527.56
$594.03
$830.15
$1,261.49

$820.39
$883.14
$949.61
$1,185.73

$1,175.97
$1,238.72
$1,305.19
$1,541.31

$1,531.55
$1,594.30
$1,660.77
$1,896.89

$355.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$929.62
$1,055.12
$1,188.06
$1,660.30
$2,522.98

$1,285.20
$1,410.70
$1,543.64
$2,015.88

$1,640.78
$1,766.28
$1,899.22
$2,371.46

$1,996.36
$2,121.86
$2,254.80
$2,727.04

$355.58

Toc - Plan #18 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S01E Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$381.46
$432.96
$487.51
$681.29
$1,035.28

$673.28
$724.78
$779.33
$973.11

$965.10
$1,016.60
$1,071.15
$1,264.93

$1,256.92
$1,308.42
$1,362.97
$1,556.75

$291.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$762.92
$865.92
$975.02
$1,362.58
$2,070.56

$1,054.74
$1,157.74
$1,266.84
$1,654.40

$1,346.56
$1,449.56
$1,558.66
$1,946.22

$1,638.38
$1,741.38
$1,850.48
$2,238.04

$291.82

Toc - Plan #19 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S04E Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$6,200 $12,400 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

$376.34
$427.15
$480.96
$672.14
$1,021.39

$664.24
$715.05
$768.86
$960.04

$952.14
$1,002.95
$1,056.76
$1,247.94

$1,240.04
$1,290.85
$1,344.66
$1,535.84

$287.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$752.68
$854.30
$961.92
$1,344.28
$2,042.78

$1,040.58
$1,142.20
$1,249.82
$1,632.18

$1,328.48
$1,430.10
$1,537.72
$1,920.08

$1,616.38
$1,718.00
$1,825.62
$2,207.98

$287.90

Toc - Plan #20 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S21E $10 PCP Copay at Blue of TN + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$389.31
$441.87
$497.54
$695.31
$1,056.59

$687.13
$739.69
$795.36
$993.13

$984.95
$1,037.51
$1,093.18
$1,290.95

$1,282.77
$1,335.33
$1,391.00
$1,588.77

$297.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$778.62
$883.74
$995.08
$1,390.62
$2,113.18

$1,076.44
$1,181.56
$1,292.90
$1,688.44

$1,374.26
$1,479.38
$1,590.72
$1,986.26

$1,672.08
$1,777.20
$1,888.54
$2,284.08

$297.82

Toc - Plan #21 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S23E 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$2,200 $4,400 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$373.81
$424.27
$477.73
$667.62
$1,014.52

$659.77
$710.23
$763.69
$953.58

$945.73
$996.19
$1,049.65
$1,239.54

$1,231.69
$1,282.15
$1,335.61
$1,525.50

$285.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$747.62
$848.54
$955.46
$1,335.24
$2,029.04

$1,033.58
$1,134.50
$1,241.42
$1,621.20

$1,319.54
$1,420.46
$1,527.38
$1,907.16

$1,605.50
$1,706.42
$1,813.34
$2,193.12

$285.96

Toc - Plan #22 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S24S $35 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$5,150 $10,300 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$434.87
$493.58
$555.76
$776.68
$1,180.24

$767.55
$826.26
$888.44
$1,109.36

$1,100.23
$1,158.94
$1,221.12
$1,442.04

$1,432.91
$1,491.62
$1,553.80
$1,774.72

$332.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$869.74
$987.16
$1,111.52
$1,553.36
$2,360.48

$1,202.42
$1,319.84
$1,444.20
$1,886.04

$1,535.10
$1,652.52
$1,776.88
$2,218.72

$1,867.78
$1,985.20
$2,109.56
$2,551.40

$332.68

Toc - Plan #23 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S24E $35 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$5,150 $10,300 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$349.73
$396.94
$446.95
$624.62
$949.17

$617.27
$664.48
$714.49
$892.16

$884.81
$932.02
$982.03
$1,159.70

$1,152.35
$1,199.56
$1,249.57
$1,427.24

$267.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$699.46
$793.88
$893.90
$1,249.24
$1,898.34

$967.00
$1,061.42
$1,161.44
$1,516.78

$1,234.54
$1,328.96
$1,428.98
$1,784.32

$1,502.08
$1,596.50
$1,696.52
$2,051.86

$267.54

Toc - Plan #24 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S25S $45 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$0 $0 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

$446.60
$506.89
$570.75
$797.63
$1,212.07

$788.25
$848.54
$912.40
$1,139.28

$1,129.90
$1,190.19
$1,254.05
$1,480.93

$1,471.55
$1,531.84
$1,595.70
$1,822.58

$341.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$893.20
$1,013.78
$1,141.50
$1,595.26
$2,424.14

$1,234.85
$1,355.43
$1,483.15
$1,936.91

$1,576.50
$1,697.08
$1,824.80
$2,278.56

$1,918.15
$2,038.73
$2,166.45
$2,620.21

$341.65

Toc - Plan #25 BlueCross BlueShield of Tennessee

Gold

(EPO) Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$2,750 $5,500 Annual Deductible

$6,350 $12,700 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

$567.54
$644.16
$725.32
$1,013.63
$1,540.30

$1,001.71
$1,078.33
$1,159.49
$1,447.80

$1,435.88
$1,512.50
$1,593.66
$1,881.97

$1,870.05
$1,946.67
$2,027.83
$2,316.14

$434.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,135.08
$1,288.32
$1,450.64
$2,027.26
$3,080.60

$1,569.25
$1,722.49
$1,884.81
$2,461.43

$2,003.42
$2,156.66
$2,318.98
$2,895.60

$2,437.59
$2,590.83
$2,753.15
$3,329.77

$434.17

Toc - Plan #26 BlueCross BlueShield of Tennessee

Gold

(EPO) Gold G07S $10 PCP Copay at Blue of TN + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$500 $1,000 Annual Deductible

$4,200 $8,400 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

$537.74
$610.33
$687.23
$960.40
$1,459.43

$949.11
$1,021.70
$1,098.60
$1,371.77

$1,360.48
$1,433.07
$1,509.97
$1,783.14

$1,771.85
$1,844.44
$1,921.34
$2,194.51

$411.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,075.48
$1,220.66
$1,374.46
$1,920.80
$2,918.86

$1,486.85
$1,632.03
$1,785.83
$2,332.17

$1,898.22
$2,043.40
$2,197.20
$2,743.54

$2,309.59
$2,454.77
$2,608.57
$3,154.91

$411.37

Toc - Plan #27 BlueCross BlueShield of Tennessee

Gold

(EPO) Gold G06E $35 PCP Copay + Free Telehealth + Rx Copays

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$2,750 $5,500 Annual Deductible

$6,350 $12,700 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

$456.43
$518.05
$583.32
$815.18
$1,238.75

$805.60
$867.22
$932.49
$1,164.35

$1,154.77
$1,216.39
$1,281.66
$1,513.52

$1,503.94
$1,565.56
$1,630.83
$1,862.69

$349.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$912.86
$1,036.10
$1,166.64
$1,630.36
$2,477.50

$1,262.03
$1,385.27
$1,515.81
$1,979.53

$1,611.20
$1,734.44
$1,864.98
$2,328.70

$1,960.37
$2,083.61
$2,214.15
$2,677.87

$349.17

Toc - Plan #28 BlueCross BlueShield of Tennessee

Gold

(EPO) Gold G07E $10 PCP Copay at Blue of TN + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$423.21
$480.34
$540.86
$755.85
$1,148.59

$746.97
$804.10
$864.62
$1,079.61

$1,070.73
$1,127.86
$1,188.38
$1,403.37

$1,394.49
$1,451.62
$1,512.14
$1,727.13

$323.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$846.42
$960.68
$1,081.72
$1,511.70
$2,297.18

$1,170.18
$1,284.44
$1,405.48
$1,835.46

$1,493.94
$1,608.20
$1,729.24
$2,159.22

$1,817.70
$1,931.96
$2,053.00
$2,482.98

$323.76

Toc - Plan #29 BlueCross BlueShield of Tennessee

Gold

(EPO) Gold G08S $30 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$560.95
$636.68
$716.89
$1,001.86
$1,522.42

$990.08
$1,065.81
$1,146.02
$1,430.99

$1,419.21
$1,494.94
$1,575.15
$1,860.12

$1,848.34
$1,924.07
$2,004.28
$2,289.25

$429.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,121.90
$1,273.36
$1,433.78
$2,003.72
$3,044.84

$1,551.03
$1,702.49
$1,862.91
$2,432.85

$1,980.16
$2,131.62
$2,292.04
$2,861.98

$2,409.29
$2,560.75
$2,721.17
$3,291.11

$429.13

Toc - Plan #30 BlueCross BlueShield of Tennessee

Gold

(EPO) Gold G08E $30 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$451.12
$512.02
$576.53
$805.70
$1,224.34

$796.23
$857.13
$921.64
$1,150.81

$1,141.34
$1,202.24
$1,266.75
$1,495.92

$1,486.45
$1,547.35
$1,611.86
$1,841.03

$345.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$902.24
$1,024.04
$1,153.06
$1,611.40
$2,448.68

$1,247.35
$1,369.15
$1,498.17
$1,956.51

$1,592.46
$1,714.26
$1,843.28
$2,301.62

$1,937.57
$2,059.37
$2,188.39
$2,646.73

$345.11

Toc - Plan #31 BlueCross BlueShield of Tennessee

Bronze

(EPO) Bronze B15E + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$264.67
$300.40
$338.25
$472.70
$718.31

$467.14
$502.87
$540.72
$675.17

$669.61
$705.34
$743.19
$877.64

$872.08
$907.81
$945.66
$1,080.11

$202.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$529.34
$600.80
$676.50
$945.40
$1,436.62

$731.81
$803.27
$878.97
$1,147.87

$934.28
$1,005.74
$1,081.44
$1,350.34

$1,136.75
$1,208.21
$1,283.91
$1,552.81

$202.47

Toc - Plan #32 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B16S $50 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$361.25
$410.02
$461.68
$645.19
$980.43

$637.61
$686.38
$738.04
$921.55

$913.97
$962.74
$1,014.40
$1,197.91

$1,190.33
$1,239.10
$1,290.76
$1,474.27

$276.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$722.50
$820.04
$923.36
$1,290.38
$1,960.86

$998.86
$1,096.40
$1,199.72
$1,566.74

$1,275.22
$1,372.76
$1,476.08
$1,843.10

$1,551.58
$1,649.12
$1,752.44
$2,119.46

$276.36

Toc - Plan #33 BlueCross BlueShield of Tennessee

Expanded Bronze

(EPO) Bronze B16E $50 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$290.52
$329.74
$371.28
$518.87
$788.47

$512.77
$551.99
$593.53
$741.12

$735.02
$774.24
$815.78
$963.37

$957.27
$996.49
$1,038.03
$1,185.62

$222.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$581.04
$659.48
$742.56
$1,037.74
$1,576.94

$803.29
$881.73
$964.81
$1,259.99

$1,025.54
$1,103.98
$1,187.06
$1,482.24

$1,247.79
$1,326.23
$1,409.31
$1,704.49

$222.25

Toc - Plan #34 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S25E $45 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$0 $0 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

$359.16
$407.65
$459.01
$641.46
$974.76

$633.92
$682.41
$733.77
$916.22

$908.68
$957.17
$1,008.53
$1,190.98

$1,183.44
$1,231.93
$1,283.29
$1,465.74

$274.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$718.32
$815.30
$918.02
$1,282.92
$1,949.52

$993.08
$1,090.06
$1,192.78
$1,557.68

$1,267.84
$1,364.82
$1,467.54
$1,832.44

$1,542.60
$1,639.58
$1,742.30
$2,107.20

$274.76

Toc - Plan #35 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S26S $40 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$444.02
$503.96
$567.46
$793.02
$1,205.07

$783.70
$843.64
$907.14
$1,132.70

$1,123.38
$1,183.32
$1,246.82
$1,472.38

$1,463.06
$1,523.00
$1,586.50
$1,812.06

$339.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$888.04
$1,007.92
$1,134.92
$1,586.04
$2,410.14

$1,227.72
$1,347.60
$1,474.60
$1,925.72

$1,567.40
$1,687.28
$1,814.28
$2,265.40

$1,907.08
$2,026.96
$2,153.96
$2,605.08

$339.68

Toc - Plan #36 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S26E $40 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

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

$357.09
$405.30
$456.36
$637.76
$969.14

$630.26
$678.47
$729.53
$910.93

$903.43
$951.64
$1,002.70
$1,184.10

$1,176.60
$1,224.81
$1,275.87
$1,457.27

$273.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$714.18
$810.60
$912.72
$1,275.52
$1,938.28

$987.35
$1,083.77
$1,185.89
$1,548.69

$1,260.52
$1,356.94
$1,459.06
$1,821.86

$1,533.69
$1,630.11
$1,732.23
$2,095.03

$273.17

Toc - Plan #37 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S27S $60 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$5,300 $10,600 Annual Deductible

$6,300 $12,600 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

$429.24
$487.19
$548.57
$766.62
$1,164.96

$757.61
$815.56
$876.94
$1,094.99

$1,085.98
$1,143.93
$1,205.31
$1,423.36

$1,414.35
$1,472.30
$1,533.68
$1,751.73

$328.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$858.48
$974.38
$1,097.14
$1,533.24
$2,329.92

$1,186.85
$1,302.75
$1,425.51
$1,861.61

$1,515.22
$1,631.12
$1,753.88
$2,189.98

$1,843.59
$1,959.49
$2,082.25
$2,518.35

$328.37

Toc - Plan #38 BlueCross BlueShield of Tennessee

Silver

(EPO) Silver S28E $30 PCP Copay at Blue of TN + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 Annual Deductible

$6,500 $13,000 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

$343.56
$389.94
$439.07
$613.60
$932.42

$606.38
$652.76
$701.89
$876.42

$869.20
$915.58
$964.71
$1,139.24

$1,132.02
$1,178.40
$1,227.53
$1,402.06

$262.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$687.12
$779.88
$878.14
$1,227.20
$1,864.84

$949.94
$1,042.70
$1,140.96
$1,490.02

$1,212.76
$1,305.52
$1,403.78
$1,752.84

$1,475.58
$1,568.34
$1,666.60
$2,015.66

$262.82

Oscar Insurance Company

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

Toc - Plan #39 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Simple

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$307.49
$348.99
$392.96
$549.16
$834.51

$542.71
$584.21
$628.18
$784.38

$777.93
$819.43
$863.40
$1,019.60

$1,013.15
$1,054.65
$1,098.62
$1,254.82

$235.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$614.98
$697.98
$785.92
$1,098.32
$1,669.02

$850.20
$933.20
$1,021.14
$1,333.54

$1,085.42
$1,168.42
$1,256.36
$1,568.76

$1,320.64
$1,403.64
$1,491.58
$1,803.98

$235.22

Toc - Plan #40 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Classic- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$7,750 $15,500 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$317.92
$360.83
$406.29
$567.79
$862.82

$561.12
$604.03
$649.49
$810.99

$804.32
$847.23
$892.69
$1,054.19

$1,047.52
$1,090.43
$1,135.89
$1,297.39

$243.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$635.84
$721.66
$812.58
$1,135.58
$1,725.64

$879.04
$964.86
$1,055.78
$1,378.78

$1,122.24
$1,208.06
$1,298.98
$1,621.98

$1,365.44
$1,451.26
$1,542.18
$1,865.18

$243.20

Toc - Plan #41 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$7,750 $15,500 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$310.27
$352.14
$396.51
$554.12
$842.04

$547.62
$589.49
$633.86
$791.47

$784.97
$826.84
$871.21
$1,028.82

$1,022.32
$1,064.19
$1,108.56
$1,266.17

$237.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$620.54
$704.28
$793.02
$1,108.24
$1,684.08

$857.89
$941.63
$1,030.37
$1,345.59

$1,095.24
$1,178.98
$1,267.72
$1,582.94

$1,332.59
$1,416.33
$1,505.07
$1,820.29

$237.35

Toc - Plan #42 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$371.49
$421.63
$474.75
$663.46
$1,008.19

$655.67
$705.81
$758.93
$947.64

$939.85
$989.99
$1,043.11
$1,231.82

$1,224.03
$1,274.17
$1,327.29
$1,516.00

$284.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$742.98
$843.26
$949.50
$1,326.92
$2,016.38

$1,027.16
$1,127.44
$1,233.68
$1,611.10

$1,311.34
$1,411.62
$1,517.86
$1,895.28

$1,595.52
$1,695.80
$1,802.04
$2,179.46

$284.18

Toc - Plan #43 Oscar Insurance Company

Silver

(EPO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,400 $10,800 Annual Deductible

$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$403.67
$458.15
$515.87
$720.93
$1,095.53

$712.47
$766.95
$824.67
$1,029.73

$1,021.27
$1,075.75
$1,133.47
$1,338.53

$1,330.07
$1,384.55
$1,442.27
$1,647.33

$308.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$807.34
$916.30
$1,031.74
$1,441.86
$2,191.06

$1,116.14
$1,225.10
$1,340.54
$1,750.66

$1,424.94
$1,533.90
$1,649.34
$2,059.46

$1,733.74
$1,842.70
$1,958.14
$2,368.26

$308.80

Toc - Plan #44 Oscar Insurance Company

Silver

(EPO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$398.69
$452.50
$509.51
$712.04
$1,082.02

$703.68
$757.49
$814.50
$1,017.03

$1,008.67
$1,062.48
$1,119.49
$1,322.02

$1,313.66
$1,367.47
$1,424.48
$1,627.01

$304.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$797.38
$905.00
$1,019.02
$1,424.08
$2,164.04

$1,102.37
$1,209.99
$1,324.01
$1,729.07

$1,407.36
$1,514.98
$1,629.00
$2,034.06

$1,712.35
$1,819.97
$1,933.99
$2,339.05

$304.99

Toc - Plan #45 Oscar Insurance Company

Catastrophic

(EPO) Secure

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$241.50
$274.09
$308.62
$431.29
$655.39

$426.24
$458.83
$493.36
$616.03

$610.98
$643.57
$678.10
$800.77

$795.72
$828.31
$862.84
$985.51

$184.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$483.00
$548.18
$617.24
$862.58
$1,310.78

$667.74
$732.92
$801.98
$1,047.32

$852.48
$917.66
$986.72
$1,232.06

$1,037.22
$1,102.40
$1,171.46
$1,416.80

$184.74

Toc - Plan #46 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Elite- $0 Ded+Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$370.03
$419.97
$472.89
$660.86
$1,004.24

$653.10
$703.04
$755.96
$943.93

$936.17
$986.11
$1,039.03
$1,227.00

$1,219.24
$1,269.18
$1,322.10
$1,510.07

$283.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$740.06
$839.94
$945.78
$1,321.72
$2,008.48

$1,023.13
$1,123.01
$1,228.85
$1,604.79

$1,306.20
$1,406.08
$1,511.92
$1,887.86

$1,589.27
$1,689.15
$1,794.99
$2,170.93

$283.07

Toc - Plan #47 Oscar Insurance Company

Gold

(EPO) Gold Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$473.31
$537.20
$604.88
$845.32
$1,284.55

$835.39
$899.28
$966.96
$1,207.40

$1,197.47
$1,261.36
$1,329.04
$1,569.48

$1,559.55
$1,623.44
$1,691.12
$1,931.56

$362.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$946.62
$1,074.40
$1,209.76
$1,690.64
$2,569.10

$1,308.70
$1,436.48
$1,571.84
$2,052.72

$1,670.78
$1,798.56
$1,933.92
$2,414.80

$2,032.86
$2,160.64
$2,296.00
$2,776.88

$362.08

Toc - Plan #48 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,200 $10,400 Annual Deductible

$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$333.11
$378.07
$425.70
$594.92
$904.04

$587.93
$632.89
$680.52
$849.74

$842.75
$887.71
$935.34
$1,104.56

$1,097.57
$1,142.53
$1,190.16
$1,359.38

$254.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$666.22
$756.14
$851.40
$1,189.84
$1,808.08

$921.04
$1,010.96
$1,106.22
$1,444.66

$1,175.86
$1,265.78
$1,361.04
$1,699.48

$1,430.68
$1,520.60
$1,615.86
$1,954.30

$254.82

Toc - Plan #49 Oscar Insurance Company

Silver

(EPO) Silver Elite

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$411.86
$467.45
$526.35
$735.57
$1,117.76

$726.93
$782.52
$841.42
$1,050.64

$1,042.00
$1,097.59
$1,156.49
$1,365.71

$1,357.07
$1,412.66
$1,471.56
$1,680.78

$315.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$823.72
$934.90
$1,052.70
$1,471.14
$2,235.52

$1,138.79
$1,249.97
$1,367.77
$1,786.21

$1,453.86
$1,565.04
$1,682.84
$2,101.28

$1,768.93
$1,880.11
$1,997.91
$2,416.35

$315.07

Toc - Plan #50 Oscar Insurance Company

Silver

(EPO) Silver Classic- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$426.13
$483.65
$544.58
$761.05
$1,156.49

$752.11
$809.63
$870.56
$1,087.03

$1,078.09
$1,135.61
$1,196.54
$1,413.01

$1,404.07
$1,461.59
$1,522.52
$1,738.99

$325.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$852.26
$967.30
$1,089.16
$1,522.10
$2,312.98

$1,178.24
$1,293.28
$1,415.14
$1,848.08

$1,504.22
$1,619.26
$1,741.12
$2,174.06

$1,830.20
$1,945.24
$2,067.10
$2,500.04

$325.98

Toc - Plan #51 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$331.57
$376.32
$423.74
$592.17
$899.86

$585.22
$629.97
$677.39
$845.82

$838.87
$883.62
$931.04
$1,099.47

$1,092.52
$1,137.27
$1,184.69
$1,353.12

$253.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$663.14
$752.64
$847.48
$1,184.34
$1,799.72

$916.79
$1,006.29
$1,101.13
$1,437.99

$1,170.44
$1,259.94
$1,354.78
$1,691.64

$1,424.09
$1,513.59
$1,608.43
$1,945.29

$253.65

Toc - Plan #52 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$4,700 $9,400 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$334.34
$379.46
$427.27
$597.11
$907.37

$590.10
$635.22
$683.03
$852.87

$845.86
$890.98
$938.79
$1,108.63

$1,101.62
$1,146.74
$1,194.55
$1,364.39

$255.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$668.68
$758.92
$854.54
$1,194.22
$1,814.74

$924.44
$1,014.68
$1,110.30
$1,449.98

$1,180.20
$1,270.44
$1,366.06
$1,705.74

$1,435.96
$1,526.20
$1,621.82
$1,961.50

$255.76

Toc - Plan #53 Oscar Insurance Company

Silver

(EPO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,500 $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

$388.48
$440.92
$496.47
$693.82
$1,054.32

$685.66
$738.10
$793.65
$991.00

$982.84
$1,035.28
$1,090.83
$1,288.18

$1,280.02
$1,332.46
$1,388.01
$1,585.36

$297.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$776.96
$881.84
$992.94
$1,387.64
$2,108.64

$1,074.14
$1,179.02
$1,290.12
$1,684.82

$1,371.32
$1,476.20
$1,587.30
$1,982.00

$1,668.50
$1,773.38
$1,884.48
$2,279.18

$297.18

Toc - Plan #54 Oscar Insurance Company

Gold

(EPO) Gold Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$524.62
$595.43
$670.45
$936.95
$1,423.79

$925.95
$996.76
$1,071.78
$1,338.28

$1,327.28
$1,398.09
$1,473.11
$1,739.61

$1,728.61
$1,799.42
$1,874.44
$2,140.94

$401.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,049.24
$1,190.86
$1,340.90
$1,873.90
$2,847.58

$1,450.57
$1,592.19
$1,742.23
$2,275.23

$1,851.90
$1,993.52
$2,143.56
$2,676.56

$2,253.23
$2,394.85
$2,544.89
$3,077.89

$401.33

Toc - Plan #55 Oscar Insurance Company

Gold

(EPO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$500 $1,000 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$492.19
$558.62
$629.00
$879.03
$1,335.77

$868.70
$935.13
$1,005.51
$1,255.54

$1,245.21
$1,311.64
$1,382.02
$1,632.05

$1,621.72
$1,688.15
$1,758.53
$2,008.56

$376.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$984.38
$1,117.24
$1,258.00
$1,758.06
$2,671.54

$1,360.89
$1,493.75
$1,634.51
$2,134.57

$1,737.40
$1,870.26
$2,011.02
$2,511.08

$2,113.91
$2,246.77
$2,387.53
$2,887.59

$376.51

Toc - Plan #56 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$327.61
$371.83
$418.68
$585.10
$889.12

$578.23
$622.45
$669.30
$835.72

$828.85
$873.07
$919.92
$1,086.34

$1,079.47
$1,123.69
$1,170.54
$1,336.96

$250.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$655.22
$743.66
$837.36
$1,170.20
$1,778.24

$905.84
$994.28
$1,087.98
$1,420.82

$1,156.46
$1,244.90
$1,338.60
$1,671.44

$1,407.08
$1,495.52
$1,589.22
$1,922.06

$250.62

Toc - Plan #57 Oscar Insurance Company

Bronze

(EPO) Bronze Simple- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$294.99
$334.81
$376.99
$526.84
$800.59

$520.65
$560.47
$602.65
$752.50

$746.31
$786.13
$828.31
$978.16

$971.97
$1,011.79
$1,053.97
$1,203.82

$225.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$589.98
$669.62
$753.98
$1,053.68
$1,601.18

$815.64
$895.28
$979.64
$1,279.34

$1,041.30
$1,120.94
$1,205.30
$1,505.00

$1,266.96
$1,346.60
$1,430.96
$1,730.66

$225.66

Toc - Plan #58 Oscar Insurance Company

Silver

(EPO) Silver Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$391.67
$444.53
$500.54
$699.51
$1,062.97

$691.29
$744.15
$800.16
$999.13

$990.91
$1,043.77
$1,099.78
$1,298.75

$1,290.53
$1,343.39
$1,399.40
$1,598.37

$299.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$783.34
$889.06
$1,001.08
$1,399.02
$2,125.94

$1,082.96
$1,188.68
$1,300.70
$1,698.64

$1,382.58
$1,488.30
$1,600.32
$1,998.26

$1,682.20
$1,787.92
$1,899.94
$2,297.88

$299.62

Toc - Plan #59 Oscar Insurance Company

Gold

(EPO) Gold Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$449.47
$510.13
$574.41
$802.73
$1,219.83

$793.31
$853.97
$918.25
$1,146.57

$1,137.15
$1,197.81
$1,262.09
$1,490.41

$1,480.99
$1,541.65
$1,605.93
$1,834.25

$343.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$898.94
$1,020.26
$1,148.82
$1,605.46
$2,439.66

$1,242.78
$1,364.10
$1,492.66
$1,949.30

$1,586.62
$1,707.94
$1,836.50
$2,293.14

$1,930.46
$2,051.78
$2,180.34
$2,636.98

$343.84

UnitedHealthcare

Local: 1-877-250-8188 | Toll Free: 1-877-250-8188 | TTY: 1-877-250-8188

Toc - Plan #60 UnitedHealthcare

Silver

(EPO) UHC Silver Value $3,350 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family

$3,350 $6,700 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

$441.36
$500.95
$564.06
$788.27
$1,197.86

$779.00
$838.59
$901.70
$1,125.91

$1,116.64
$1,176.23
$1,239.34
$1,463.55

$1,454.28
$1,513.87
$1,576.98
$1,801.19

$337.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$882.72
$1,001.90
$1,128.12
$1,576.54
$2,395.72

$1,220.36
$1,339.54
$1,465.76
$1,914.18

$1,558.00
$1,677.18
$1,803.40
$2,251.82

$1,895.64
$2,014.82
$2,141.04
$2,589.46

$337.64

Toc - Plan #61 UnitedHealthcare

Expanded Bronze

(EPO) UHC Bronze Value $7,500 Deductible 1 (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$339.54
$385.38
$433.94
$606.42
$921.52

$599.29
$645.13
$693.69
$866.17

$859.04
$904.88
$953.44
$1,125.92

$1,118.79
$1,164.63
$1,213.19
$1,385.67

$259.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$679.08
$770.76
$867.88
$1,212.84
$1,843.04

$938.83
$1,030.51
$1,127.63
$1,472.59

$1,198.58
$1,290.26
$1,387.38
$1,732.34

$1,458.33
$1,550.01
$1,647.13
$1,992.09

$259.75

Toc - Plan #62 UnitedHealthcare

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family

$1,850 $3,700 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

$586.35
$665.50
$749.35
$1,047.22
$1,591.35

$1,034.91
$1,114.06
$1,197.91
$1,495.78

$1,483.47
$1,562.62
$1,646.47
$1,944.34

$1,932.03
$2,011.18
$2,095.03
$2,392.90

$448.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,172.70
$1,331.00
$1,498.70
$2,094.44
$3,182.70

$1,621.26
$1,779.56
$1,947.26
$2,543.00

$2,069.82
$2,228.12
$2,395.82
$2,991.56

$2,518.38
$2,676.68
$2,844.38
$3,440.12

$448.56

Toc - Plan #63 UnitedHealthcare

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

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

$643.54
$730.42
$822.45
$1,149.37
$1,746.58

$1,135.85
$1,222.73
$1,314.76
$1,641.68

$1,628.16
$1,715.04
$1,807.07
$2,133.99

$2,120.47
$2,207.35
$2,299.38
$2,626.30

$492.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,287.08
$1,460.84
$1,644.90
$2,298.74
$3,493.16

$1,779.39
$1,953.15
$2,137.21
$2,791.05

$2,271.70
$2,445.46
$2,629.52
$3,283.36

$2,764.01
$2,937.77
$3,121.83
$3,775.67

$492.31

Toc - Plan #64 UnitedHealthcare

Gold

(EPO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

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

$625.23
$709.64
$799.05
$1,116.67
$1,696.88

$1,103.53
$1,187.94
$1,277.35
$1,594.97

$1,581.83
$1,666.24
$1,755.65
$2,073.27

$2,060.13
$2,144.54
$2,233.95
$2,551.57

$478.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,250.46
$1,419.28
$1,598.10
$2,233.34
$3,393.76

$1,728.76
$1,897.58
$2,076.40
$2,711.64

$2,207.06
$2,375.88
$2,554.70
$3,189.94

$2,685.36
$2,854.18
$3,033.00
$3,668.24

$478.30

Toc - Plan #65 UnitedHealthcare

Silver

(EPO) UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

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

$442.13
$501.82
$565.04
$789.65
$1,199.94

$780.36
$840.05
$903.27
$1,127.88

$1,118.59
$1,178.28
$1,241.50
$1,466.11

$1,456.82
$1,516.51
$1,579.73
$1,804.34

$338.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$884.26
$1,003.64
$1,130.08
$1,579.30
$2,399.88

$1,222.49
$1,341.87
$1,468.31
$1,917.53

$1,560.72
$1,680.10
$1,806.54
$2,255.76

$1,898.95
$2,018.33
$2,144.77
$2,593.99

$338.23

Toc - Plan #66 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$441.20
$500.76
$563.85
$787.98
$1,197.41

$778.72
$838.28
$901.37
$1,125.50

$1,116.24
$1,175.80
$1,238.89
$1,463.02

$1,453.76
$1,513.32
$1,576.41
$1,800.54

$337.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$882.40
$1,001.52
$1,127.70
$1,575.96
$2,394.82

$1,219.92
$1,339.04
$1,465.22
$1,913.48

$1,557.44
$1,676.56
$1,802.74
$2,251.00

$1,894.96
$2,014.08
$2,140.26
$2,588.52

$337.52

Toc - Plan #67 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$455.54
$517.04
$582.18
$813.59
$1,236.34

$804.03
$865.53
$930.67
$1,162.08

$1,152.52
$1,214.02
$1,279.16
$1,510.57

$1,501.01
$1,562.51
$1,627.65
$1,859.06

$348.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$911.08
$1,034.08
$1,164.36
$1,627.18
$2,472.68

$1,259.57
$1,382.57
$1,512.85
$1,975.67

$1,608.06
$1,731.06
$1,861.34
$2,324.16

$1,956.55
$2,079.55
$2,209.83
$2,672.65

$348.49

Toc - Plan #68 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

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

$448.20
$508.71
$572.80
$800.48
$1,216.41

$791.07
$851.58
$915.67
$1,143.35

$1,133.94
$1,194.45
$1,258.54
$1,486.22

$1,476.81
$1,537.32
$1,601.41
$1,829.09

$342.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$896.40
$1,017.42
$1,145.60
$1,600.96
$2,432.82

$1,239.27
$1,360.29
$1,488.47
$1,943.83

$1,582.14
$1,703.16
$1,831.34
$2,286.70

$1,925.01
$2,046.03
$2,174.21
$2,629.57

$342.87

Toc - Plan #69 UnitedHealthcare

Silver

(EPO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

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

$442.82
$502.60
$565.93
$790.88
$1,201.82

$781.58
$841.36
$904.69
$1,129.64

$1,120.34
$1,180.12
$1,243.45
$1,468.40

$1,459.10
$1,518.88
$1,582.21
$1,807.16

$338.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$885.64
$1,005.20
$1,131.86
$1,581.76
$2,403.64

$1,224.40
$1,343.96
$1,470.62
$1,920.52

$1,563.16
$1,682.72
$1,809.38
$2,259.28

$1,901.92
$2,021.48
$2,148.14
$2,598.04

$338.76

Toc - Plan #70 UnitedHealthcare

Expanded Bronze

(EPO) UHC Bronze Value $7,500 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$345.34
$391.96
$441.34
$616.77
$937.25

$609.52
$656.14
$705.52
$880.95

$873.70
$920.32
$969.70
$1,145.13

$1,137.88
$1,184.50
$1,233.88
$1,409.31

$264.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$690.68
$783.92
$882.68
$1,233.54
$1,874.50

$954.86
$1,048.10
$1,146.86
$1,497.72

$1,219.04
$1,312.28
$1,411.04
$1,761.90

$1,483.22
$1,576.46
$1,675.22
$2,026.08

$264.18

Toc - Plan #71 UnitedHealthcare

Expanded Bronze

(EPO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family

$6,700 $13,400 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$352.47
$400.05
$450.45
$629.50
$956.59

$622.11
$669.69
$720.09
$899.14

$891.75
$939.33
$989.73
$1,168.78

$1,161.39
$1,208.97
$1,259.37
$1,438.42

$269.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$704.94
$800.10
$900.90
$1,259.00
$1,913.18

$974.58
$1,069.74
$1,170.54
$1,528.64

$1,244.22
$1,339.38
$1,440.18
$1,798.28

$1,513.86
$1,609.02
$1,709.82
$2,067.92

$269.64

Toc - Plan #72 UnitedHealthcare

Bronze

(EPO) UHC Bronze Essential $9,100 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

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

$322.66
$366.22
$412.36
$576.27
$875.70

$569.50
$613.06
$659.20
$823.11

$816.34
$859.90
$906.04
$1,069.95

$1,063.18
$1,106.74
$1,152.88
$1,316.79

$246.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$645.32
$732.44
$824.72
$1,152.54
$1,751.40

$892.16
$979.28
$1,071.56
$1,399.38

$1,139.00
$1,226.12
$1,318.40
$1,646.22

$1,385.84
$1,472.96
$1,565.24
$1,893.06

$246.84

Toc - Plan #73 UnitedHealthcare

Expanded Bronze

(EPO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

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

$342.54
$388.78
$437.76
$611.77
$929.65

$604.58
$650.82
$699.80
$873.81

$866.62
$912.86
$961.84
$1,135.85

$1,128.66
$1,174.90
$1,223.88
$1,397.89

$262.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$685.08
$777.56
$875.52
$1,223.54
$1,859.30

$947.12
$1,039.60
$1,137.56
$1,485.58

$1,209.16
$1,301.64
$1,399.60
$1,747.62

$1,471.20
$1,563.68
$1,661.64
$2,009.66

$262.04

Toc - Plan #74 UnitedHealthcare

Bronze

(EPO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

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

$322.70
$366.27
$412.41
$576.34
$875.81

$569.57
$613.14
$659.28
$823.21

$816.44
$860.01
$906.15
$1,070.08

$1,063.31
$1,106.88
$1,153.02
$1,316.95

$246.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$645.40
$732.54
$824.82
$1,152.68
$1,751.62

$892.27
$979.41
$1,071.69
$1,399.55

$1,139.14
$1,226.28
$1,318.56
$1,646.42

$1,386.01
$1,473.15
$1,565.43
$1,893.29

$246.87

Toc - Plan #75 UnitedHealthcare

Bronze

(EPO) UHC Bronze Essential $6,350 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family

$6,350 $12,700 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$334.10
$379.20
$426.98
$596.70
$906.74

$589.68
$634.78
$682.56
$852.28

$845.26
$890.36
$938.14
$1,107.86

$1,100.84
$1,145.94
$1,193.72
$1,363.44

$255.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$668.20
$758.40
$853.96
$1,193.40
$1,813.48

$923.78
$1,013.98
$1,109.54
$1,448.98

$1,179.36
$1,269.56
$1,365.12
$1,704.56

$1,434.94
$1,525.14
$1,620.70
$1,960.14

$255.58

Ambetter of Tennessee

Local: 1-833-709-4735 | Toll Free: 1-833-709-4735

Toc - Plan #76 Ambetter of Tennessee

Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$265.68
$301.54
$339.53
$474.49
$721.03

$468.92
$504.78
$542.77
$677.73

$672.16
$708.02
$746.01
$880.97

$875.40
$911.26
$949.25
$1,084.21

$203.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$531.36
$603.08
$679.06
$948.98
$1,442.06

$734.60
$806.32
$882.30
$1,152.22

$937.84
$1,009.56
$1,085.54
$1,355.46

$1,141.08
$1,212.80
$1,288.78
$1,558.70

$203.24

Toc - Plan #77 Ambetter of Tennessee

Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$366.30
$415.74
$468.12
$654.19
$994.11

$646.51
$695.95
$748.33
$934.40

$926.72
$976.16
$1,028.54
$1,214.61

$1,206.93
$1,256.37
$1,308.75
$1,494.82

$280.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$732.60
$831.48
$936.24
$1,308.38
$1,988.22

$1,012.81
$1,111.69
$1,216.45
$1,588.59

$1,293.02
$1,391.90
$1,496.66
$1,868.80

$1,573.23
$1,672.11
$1,776.87
$2,149.01

$280.21

Toc - Plan #78 Ambetter of Tennessee

Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$378.95
$430.10
$484.29
$676.79
$1,028.45

$668.84
$719.99
$774.18
$966.68

$958.73
$1,009.88
$1,064.07
$1,256.57

$1,248.62
$1,299.77
$1,353.96
$1,546.46

$289.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$757.90
$860.20
$968.58
$1,353.58
$2,056.90

$1,047.79
$1,150.09
$1,258.47
$1,643.47

$1,337.68
$1,439.98
$1,548.36
$1,933.36

$1,627.57
$1,729.87
$1,838.25
$2,223.25

$289.89

Toc - Plan #79 Ambetter of Tennessee

Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$291.21
$330.51
$372.15
$520.08
$790.31

$513.98
$553.28
$594.92
$742.85

$736.75
$776.05
$817.69
$965.62

$959.52
$998.82
$1,040.46
$1,188.39

$222.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$582.42
$661.02
$744.30
$1,040.16
$1,580.62

$805.19
$883.79
$967.07
$1,262.93

$1,027.96
$1,106.56
$1,189.84
$1,485.70

$1,250.73
$1,329.33
$1,412.61
$1,708.47

$222.77

Toc - Plan #80 Ambetter of Tennessee

Silver

(EPO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$362.60
$411.54
$463.39
$647.59
$984.07

$639.98
$688.92
$740.77
$924.97

$917.36
$966.30
$1,018.15
$1,202.35

$1,194.74
$1,243.68
$1,295.53
$1,479.73

$277.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$725.20
$823.08
$926.78
$1,295.18
$1,968.14

$1,002.58
$1,100.46
$1,204.16
$1,572.56

$1,279.96
$1,377.84
$1,481.54
$1,849.94

$1,557.34
$1,655.22
$1,758.92
$2,127.32

$277.38

Toc - Plan #81 Ambetter of Tennessee

Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$285.04
$323.51
$364.27
$509.07
$773.58

$503.09
$541.56
$582.32
$727.12

$721.14
$759.61
$800.37
$945.17

$939.19
$977.66
$1,018.42
$1,163.22

$218.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$570.08
$647.02
$728.54
$1,018.14
$1,547.16

$788.13
$865.07
$946.59
$1,236.19

$1,006.18
$1,083.12
$1,164.64
$1,454.24

$1,224.23
$1,301.17
$1,382.69
$1,672.29

$218.05

Toc - Plan #82 Ambetter of Tennessee

Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$320.97
$364.30
$410.19
$573.24
$871.10

$566.51
$609.84
$655.73
$818.78

$812.05
$855.38
$901.27
$1,064.32

$1,057.59
$1,100.92
$1,146.81
$1,309.86

$245.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$641.94
$728.60
$820.38
$1,146.48
$1,742.20

$887.48
$974.14
$1,065.92
$1,392.02

$1,133.02
$1,219.68
$1,311.46
$1,637.56

$1,378.56
$1,465.22
$1,557.00
$1,883.10

$245.54

Toc - Plan #83 Ambetter of Tennessee

Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$357.16
$405.37
$456.44
$637.87
$969.31

$630.38
$678.59
$729.66
$911.09

$903.60
$951.81
$1,002.88
$1,184.31

$1,176.82
$1,225.03
$1,276.10
$1,457.53

$273.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$714.32
$810.74
$912.88
$1,275.74
$1,938.62

$987.54
$1,083.96
$1,186.10
$1,548.96

$1,260.76
$1,357.18
$1,459.32
$1,822.18

$1,533.98
$1,630.40
$1,732.54
$2,095.40

$273.22

Toc - Plan #84 Ambetter of Tennessee

Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$361.11
$409.85
$461.49
$644.93
$980.03

$637.35
$686.09
$737.73
$921.17

$913.59
$962.33
$1,013.97
$1,197.41

$1,189.83
$1,238.57
$1,290.21
$1,473.65

$276.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$722.22
$819.70
$922.98
$1,289.86
$1,960.06

$998.46
$1,095.94
$1,199.22
$1,566.10

$1,274.70
$1,372.18
$1,475.46
$1,842.34

$1,550.94
$1,648.42
$1,751.70
$2,118.58

$276.24

Toc - Plan #85 Ambetter of Tennessee

Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$362.67
$411.62
$463.48
$647.72
$984.27

$640.11
$689.06
$740.92
$925.16

$917.55
$966.50
$1,018.36
$1,202.60

$1,194.99
$1,243.94
$1,295.80
$1,480.04

$277.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$725.34
$823.24
$926.96
$1,295.44
$1,968.54

$1,002.78
$1,100.68
$1,204.40
$1,572.88

$1,280.22
$1,378.12
$1,481.84
$1,850.32

$1,557.66
$1,655.56
$1,759.28
$2,127.76

$277.44

Toc - Plan #86 Ambetter of Tennessee

Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$417.13
$473.44
$533.08
$744.98
$1,132.07

$736.23
$792.54
$852.18
$1,064.08

$1,055.33
$1,111.64
$1,171.28
$1,383.18

$1,374.43
$1,430.74
$1,490.38
$1,702.28

$319.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$834.26
$946.88
$1,066.16
$1,489.96
$2,264.14

$1,153.36
$1,265.98
$1,385.26
$1,809.06

$1,472.46
$1,585.08
$1,704.36
$2,128.16

$1,791.56
$1,904.18
$2,023.46
$2,447.26

$319.10

Toc - Plan #87 Ambetter of Tennessee

Bronze

(EPO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$253.35
$287.54
$323.77
$452.47
$687.57

$447.16
$481.35
$517.58
$646.28

$640.97
$675.16
$711.39
$840.09

$834.78
$868.97
$905.20
$1,033.90

$193.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$506.70
$575.08
$647.54
$904.94
$1,375.14

$700.51
$768.89
$841.35
$1,098.75

$894.32
$962.70
$1,035.16
$1,292.56

$1,088.13
$1,156.51
$1,228.97
$1,486.37

$193.81

Toc - Plan #88 Ambetter of Tennessee

Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$279.13
$316.80
$356.72
$498.51
$757.54

$492.66
$530.33
$570.25
$712.04

$706.19
$743.86
$783.78
$925.57

$919.72
$957.39
$997.31
$1,139.10

$213.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$558.26
$633.60
$713.44
$997.02
$1,515.08

$771.79
$847.13
$926.97
$1,210.55

$985.32
$1,060.66
$1,140.50
$1,424.08

$1,198.85
$1,274.19
$1,354.03
$1,637.61

$213.53

Toc - Plan #89 Ambetter of Tennessee

Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$357.74
$406.03
$457.18
$638.91
$970.88

$631.40
$679.69
$730.84
$912.57

$905.06
$953.35
$1,004.50
$1,186.23

$1,178.72
$1,227.01
$1,278.16
$1,459.89

$273.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.48
$812.06
$914.36
$1,277.82
$1,941.76

$989.14
$1,085.72
$1,188.02
$1,551.48

$1,262.80
$1,359.38
$1,461.68
$1,825.14

$1,536.46
$1,633.04
$1,735.34
$2,098.80

$273.66

Toc - Plan #90 Ambetter of Tennessee

Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$358.50
$406.89
$458.15
$640.27
$972.95

$632.75
$681.14
$732.40
$914.52

$907.00
$955.39
$1,006.65
$1,188.77

$1,181.25
$1,229.64
$1,280.90
$1,463.02

$274.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$717.00
$813.78
$916.30
$1,280.54
$1,945.90

$991.25
$1,088.03
$1,190.55
$1,554.79

$1,265.50
$1,362.28
$1,464.80
$1,829.04

$1,539.75
$1,636.53
$1,739.05
$2,103.29

$274.25

Toc - Plan #91 Ambetter of Tennessee

Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$275.90
$313.13
$352.59
$492.74
$748.76

$486.96
$524.19
$563.65
$703.80

$698.02
$735.25
$774.71
$914.86

$909.08
$946.31
$985.77
$1,125.92

$211.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$551.80
$626.26
$705.18
$985.48
$1,497.52

$762.86
$837.32
$916.24
$1,196.54

$973.92
$1,048.38
$1,127.30
$1,407.60

$1,184.98
$1,259.44
$1,338.36
$1,618.66

$211.06

Toc - Plan #92 Ambetter of Tennessee

Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$380.39
$431.73
$486.12
$679.36
$1,032.35

$671.38
$722.72
$777.11
$970.35

$962.37
$1,013.71
$1,068.10
$1,261.34

$1,253.36
$1,304.70
$1,359.09
$1,552.33

$290.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$760.78
$863.46
$972.24
$1,358.72
$2,064.70

$1,051.77
$1,154.45
$1,263.23
$1,649.71

$1,342.76
$1,445.44
$1,554.22
$1,940.70

$1,633.75
$1,736.43
$1,845.21
$2,231.69

$290.99

Toc - Plan #93 Ambetter of Tennessee

Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$393.53
$446.64
$502.92
$702.83
$1,068.01

$694.57
$747.68
$803.96
$1,003.87

$995.61
$1,048.72
$1,105.00
$1,304.91

$1,296.65
$1,349.76
$1,406.04
$1,605.95

$301.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$787.06
$893.28
$1,005.84
$1,405.66
$2,136.02

$1,088.10
$1,194.32
$1,306.88
$1,706.70

$1,389.14
$1,495.36
$1,607.92
$2,007.74

$1,690.18
$1,796.40
$1,908.96
$2,308.78

$301.04

Toc - Plan #94 Ambetter of Tennessee

Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$302.41
$343.22
$386.46
$540.08
$820.71

$533.74
$574.55
$617.79
$771.41

$765.07
$805.88
$849.12
$1,002.74

$996.40
$1,037.21
$1,080.45
$1,234.07

$231.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$604.82
$686.44
$772.92
$1,080.16
$1,641.42

$836.15
$917.77
$1,004.25
$1,311.49

$1,067.48
$1,149.10
$1,235.58
$1,542.82

$1,298.81
$1,380.43
$1,466.91
$1,774.15

$231.33

Toc - Plan #95 Ambetter of Tennessee

Silver

(EPO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$376.55
$427.37
$481.21
$672.50
$1,021.92

$664.60
$715.42
$769.26
$960.55

$952.65
$1,003.47
$1,057.31
$1,248.60

$1,240.70
$1,291.52
$1,345.36
$1,536.65

$288.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$753.10
$854.74
$962.42
$1,345.00
$2,043.84

$1,041.15
$1,142.79
$1,250.47
$1,633.05

$1,329.20
$1,430.84
$1,538.52
$1,921.10

$1,617.25
$1,718.89
$1,826.57
$2,209.15

$288.05

Toc - Plan #96 Ambetter of Tennessee

Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$296.01
$335.96
$378.28
$528.65
$803.33

$522.45
$562.40
$604.72
$755.09

$748.89
$788.84
$831.16
$981.53

$975.33
$1,015.28
$1,057.60
$1,207.97

$226.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$592.02
$671.92
$756.56
$1,057.30
$1,606.66

$818.46
$898.36
$983.00
$1,283.74

$1,044.90
$1,124.80
$1,209.44
$1,510.18

$1,271.34
$1,351.24
$1,435.88
$1,736.62

$226.44

Toc - Plan #97 Ambetter of Tennessee

Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family

$3,800 $7,600 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

$333.32
$378.31
$425.97
$595.29
$904.61

$588.30
$633.29
$680.95
$850.27

$843.28
$888.27
$935.93
$1,105.25

$1,098.26
$1,143.25
$1,190.91
$1,360.23

$254.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$666.64
$756.62
$851.94
$1,190.58
$1,809.22

$921.62
$1,011.60
$1,106.92
$1,445.56

$1,176.60
$1,266.58
$1,361.90
$1,700.54

$1,431.58
$1,521.56
$1,616.88
$1,955.52

$254.98

Toc - Plan #98 Ambetter of Tennessee

Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$375.00
$425.62
$479.24
$669.74
$1,017.73

$661.87
$712.49
$766.11
$956.61

$948.74
$999.36
$1,052.98
$1,243.48

$1,235.61
$1,286.23
$1,339.85
$1,530.35

$286.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$750.00
$851.24
$958.48
$1,339.48
$2,035.46

$1,036.87
$1,138.11
$1,245.35
$1,626.35

$1,323.74
$1,424.98
$1,532.22
$1,913.22

$1,610.61
$1,711.85
$1,819.09
$2,200.09

$286.87

Toc - Plan #99 Ambetter of Tennessee

Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$376.62
$427.46
$481.31
$672.63
$1,022.13

$664.73
$715.57
$769.42
$960.74

$952.84
$1,003.68
$1,057.53
$1,248.85

$1,240.95
$1,291.79
$1,345.64
$1,536.96

$288.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$753.24
$854.92
$962.62
$1,345.26
$2,044.26

$1,041.35
$1,143.03
$1,250.73
$1,633.37

$1,329.46
$1,431.14
$1,538.84
$1,921.48

$1,617.57
$1,719.25
$1,826.95
$2,209.59

$288.11

Toc - Plan #100 Ambetter of Tennessee

Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$370.90
$420.96
$474.00
$662.41
$1,006.59

$654.63
$704.69
$757.73
$946.14

$938.36
$988.42
$1,041.46
$1,229.87

$1,222.09
$1,272.15
$1,325.19
$1,513.60

$283.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$741.80
$841.92
$948.00
$1,324.82
$2,013.18

$1,025.53
$1,125.65
$1,231.73
$1,608.55

$1,309.26
$1,409.38
$1,515.46
$1,892.28

$1,592.99
$1,693.11
$1,799.19
$2,176.01

$283.73

Toc - Plan #101 Ambetter of Tennessee

Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-709-4735

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

$433.18
$491.65
$553.59
$773.64
$1,175.62

$764.55
$823.02
$884.96
$1,105.01

$1,095.92
$1,154.39
$1,216.33
$1,436.38

$1,427.29
$1,485.76
$1,547.70
$1,767.75

$331.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$866.36
$983.30
$1,107.18
$1,547.28
$2,351.24

$1,197.73
$1,314.67
$1,438.55
$1,878.65

$1,529.10
$1,646.04
$1,769.92
$2,210.02

$1,860.47
$1,977.41
$2,101.29
$2,541.39

$331.37

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

Toc - Plan #102 Cigna Healthcare

Silver

(EPO) Cigna Connect 4100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$4,100 $8,200 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

$384.37
$436.26
$491.23
$686.49
$1,043.19

$678.41
$730.30
$785.27
$980.53

$972.45
$1,024.34
$1,079.31
$1,274.57

$1,266.49
$1,318.38
$1,373.35
$1,568.61

$294.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$768.74
$872.52
$982.46
$1,372.98
$2,086.38

$1,062.78
$1,166.56
$1,276.50
$1,667.02

$1,356.82
$1,460.60
$1,570.54
$1,961.06

$1,650.86
$1,754.64
$1,864.58
$2,255.10

$294.04

Toc - Plan #103 Cigna Healthcare

Gold

(EPO) Cigna Connect 1000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$6,500 $13,000 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

$584.14
$662.99
$746.53
$1,043.27
$1,585.34

$1,031.00
$1,109.85
$1,193.39
$1,490.13

$1,477.86
$1,556.71
$1,640.25
$1,936.99

$1,924.72
$2,003.57
$2,087.11
$2,383.85

$446.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,168.28
$1,325.98
$1,493.06
$2,086.54
$3,170.68

$1,615.14
$1,772.84
$1,939.92
$2,533.40

$2,062.00
$2,219.70
$2,386.78
$2,980.26

$2,508.86
$2,666.56
$2,833.64
$3,427.12

$446.86

Toc - Plan #104 Cigna Healthcare

Bronze

(EPO) Cigna Connect 6500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$327.07
$371.22
$418.00
$584.15
$887.67

$577.28
$621.43
$668.21
$834.36

$827.49
$871.64
$918.42
$1,084.57

$1,077.70
$1,121.85
$1,168.63
$1,334.78

$250.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$654.14
$742.44
$836.00
$1,168.30
$1,775.34

$904.35
$992.65
$1,086.21
$1,418.51

$1,154.56
$1,242.86
$1,336.42
$1,668.72

$1,404.77
$1,493.07
$1,586.63
$1,918.93

$250.21

Toc - Plan #105 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 5900

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$5,900 $11,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$340.00
$385.90
$434.52
$607.24
$922.76

$600.10
$646.00
$694.62
$867.34

$860.20
$906.10
$954.72
$1,127.44

$1,120.30
$1,166.20
$1,214.82
$1,387.54

$260.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$680.00
$771.80
$869.04
$1,214.48
$1,845.52

$940.10
$1,031.90
$1,129.14
$1,474.58

$1,200.20
$1,292.00
$1,389.24
$1,734.68

$1,460.30
$1,552.10
$1,649.34
$1,994.78

$260.10

Toc - Plan #106 Cigna Healthcare

Silver

(EPO) Cigna Connect 3200

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$3,200 $6,400 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

$388.00
$440.38
$495.87
$692.97
$1,053.04

$684.82
$737.20
$792.69
$989.79

$981.64
$1,034.02
$1,089.51
$1,286.61

$1,278.46
$1,330.84
$1,386.33
$1,583.43

$296.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$776.00
$880.76
$991.74
$1,385.94
$2,106.08

$1,072.82
$1,177.58
$1,288.56
$1,682.76

$1,369.64
$1,474.40
$1,585.38
$1,979.58

$1,666.46
$1,771.22
$1,882.20
$2,276.40

$296.82

Toc - Plan #107 Cigna Healthcare

Bronze

(EPO) Cigna Connect 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$325.07
$368.96
$415.44
$580.58
$882.25

$573.75
$617.64
$664.12
$829.26

$822.43
$866.32
$912.80
$1,077.94

$1,071.11
$1,115.00
$1,161.48
$1,326.62

$248.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$650.14
$737.92
$830.88
$1,161.16
$1,764.50

$898.82
$986.60
$1,079.56
$1,409.84

$1,147.50
$1,235.28
$1,328.24
$1,658.52

$1,396.18
$1,483.96
$1,576.92
$1,907.20

$248.68

Toc - Plan #108 Cigna Healthcare

Silver

(EPO) Cigna Connect 5450

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$5,450 $10,900 Annual Deductible

$8,950 $17,900 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

$386.01
$438.12
$493.32
$689.41
$1,047.62

$681.30
$733.41
$788.61
$984.70

$976.59
$1,028.70
$1,083.90
$1,279.99

$1,271.88
$1,323.99
$1,379.19
$1,575.28

$295.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$772.02
$876.24
$986.64
$1,378.82
$2,095.24

$1,067.31
$1,171.53
$1,281.93
$1,674.11

$1,362.60
$1,466.82
$1,577.22
$1,969.40

$1,657.89
$1,762.11
$1,872.51
$2,264.69

$295.29

Toc - Plan #109 Cigna Healthcare

Silver

(EPO) Cigna Connect 3800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$3,800 $7,600 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$386.69
$438.89
$494.19
$690.62
$1,049.47

$682.51
$734.71
$790.01
$986.44

$978.33
$1,030.53
$1,085.83
$1,282.26

$1,274.15
$1,326.35
$1,381.65
$1,578.08

$295.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$773.38
$877.78
$988.38
$1,381.24
$2,098.94

$1,069.20
$1,173.60
$1,284.20
$1,677.06

$1,365.02
$1,469.42
$1,580.02
$1,972.88

$1,660.84
$1,765.24
$1,875.84
$2,268.70

$295.82

Toc - Plan #110 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 6800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$6,800 $13,600 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$339.96
$385.85
$434.46
$607.16
$922.64

$600.03
$645.92
$694.53
$867.23

$860.10
$905.99
$954.60
$1,127.30

$1,120.17
$1,166.06
$1,214.67
$1,387.37

$260.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$679.92
$771.70
$868.92
$1,214.32
$1,845.28

$939.99
$1,031.77
$1,128.99
$1,474.39

$1,200.06
$1,291.84
$1,389.06
$1,734.46

$1,460.13
$1,551.91
$1,649.13
$1,994.53

$260.07

Toc - Plan #111 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 7800

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,800 $15,600 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$340.27
$386.21
$434.87
$607.73
$923.50

$600.58
$646.52
$695.18
$868.04

$860.89
$906.83
$955.49
$1,128.35

$1,121.20
$1,167.14
$1,215.80
$1,388.66

$260.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$680.54
$772.42
$869.74
$1,215.46
$1,847.00

$940.85
$1,032.73
$1,130.05
$1,475.77

$1,201.16
$1,293.04
$1,390.36
$1,736.08

$1,461.47
$1,553.35
$1,650.67
$1,996.39

$260.31

Toc - Plan #112 Cigna Healthcare

Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$4,200 $8,400 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

$386.05
$438.17
$493.37
$689.49
$1,047.74

$681.38
$733.50
$788.70
$984.82

$976.71
$1,028.83
$1,084.03
$1,280.15

$1,272.04
$1,324.16
$1,379.36
$1,575.48

$295.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$772.10
$876.34
$986.74
$1,378.98
$2,095.48

$1,067.43
$1,171.67
$1,282.07
$1,674.31

$1,362.76
$1,467.00
$1,577.40
$1,969.64

$1,658.09
$1,762.33
$1,872.73
$2,264.97

$295.33

Toc - Plan #113 Cigna Healthcare

Silver

(EPO) Cigna Connect 0B

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$390.13
$442.80
$498.59
$696.78
$1,058.82

$688.58
$741.25
$797.04
$995.23

$987.03
$1,039.70
$1,095.49
$1,293.68

$1,285.48
$1,338.15
$1,393.94
$1,592.13

$298.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$780.26
$885.60
$997.18
$1,393.56
$2,117.64

$1,078.71
$1,184.05
$1,295.63
$1,692.01

$1,377.16
$1,482.50
$1,594.08
$1,990.46

$1,675.61
$1,780.95
$1,892.53
$2,288.91

$298.45

Toc - Plan #114 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect HSA 6000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$341.91
$388.06
$436.96
$610.64
$927.93

$603.47
$649.62
$698.52
$872.20

$865.03
$911.18
$960.08
$1,133.76

$1,126.59
$1,172.74
$1,221.64
$1,395.32

$261.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$683.82
$776.12
$873.92
$1,221.28
$1,855.86

$945.38
$1,037.68
$1,135.48
$1,482.84

$1,206.94
$1,299.24
$1,397.04
$1,744.40

$1,468.50
$1,560.80
$1,658.60
$2,005.96

$261.56

Toc - Plan #115 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 0A

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$363.46
$412.52
$464.50
$649.13
$986.42

$641.50
$690.56
$742.54
$927.17

$919.54
$968.60
$1,020.58
$1,205.21

$1,197.58
$1,246.64
$1,298.62
$1,483.25

$278.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$726.92
$825.04
$929.00
$1,298.26
$1,972.84

$1,004.96
$1,103.08
$1,207.04
$1,576.30

$1,283.00
$1,381.12
$1,485.08
$1,854.34

$1,561.04
$1,659.16
$1,763.12
$2,132.38

$278.04

Toc - Plan #116 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 7600 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,600 $15,200 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

$340.18
$386.11
$434.75
$607.57
$923.25

$600.42
$646.35
$694.99
$867.81

$860.66
$906.59
$955.23
$1,128.05

$1,120.90
$1,166.83
$1,215.47
$1,388.29

$260.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$680.36
$772.22
$869.50
$1,215.14
$1,846.50

$940.60
$1,032.46
$1,129.74
$1,475.38

$1,200.84
$1,292.70
$1,389.98
$1,735.62

$1,461.08
$1,552.94
$1,650.22
$1,995.86

$260.24

Toc - Plan #117 Cigna Healthcare

Bronze

(EPO) Cigna Simple Choice 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$325.07
$368.96
$415.44
$580.58
$882.25

$573.75
$617.64
$664.12
$829.26

$822.43
$866.32
$912.80
$1,077.94

$1,071.11
$1,115.00
$1,161.48
$1,326.62

$248.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$650.14
$737.92
$830.88
$1,161.16
$1,764.50

$898.82
$986.60
$1,079.56
$1,409.84

$1,147.50
$1,235.28
$1,328.24
$1,658.52

$1,396.18
$1,483.96
$1,576.92
$1,907.20

$248.68

Toc - Plan #118 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Simple Choice 7500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$338.78
$384.51
$432.96
$605.05
$919.44

$597.94
$643.67
$692.12
$864.21

$857.10
$902.83
$951.28
$1,123.37

$1,116.26
$1,161.99
$1,210.44
$1,382.53

$259.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$677.56
$769.02
$865.92
$1,210.10
$1,838.88

$936.72
$1,028.18
$1,125.08
$1,469.26

$1,195.88
$1,287.34
$1,384.24
$1,728.42

$1,455.04
$1,546.50
$1,643.40
$1,987.58

$259.16

Toc - Plan #119 Cigna Healthcare

Silver

(EPO) Cigna Simple Choice 5800

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$385.42
$437.45
$492.56
$688.35
$1,046.02

$680.26
$732.29
$787.40
$983.19

$975.10
$1,027.13
$1,082.24
$1,278.03

$1,269.94
$1,321.97
$1,377.08
$1,572.87

$294.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$770.84
$874.90
$985.12
$1,376.70
$2,092.04

$1,065.68
$1,169.74
$1,279.96
$1,671.54

$1,360.52
$1,464.58
$1,574.80
$1,966.38

$1,655.36
$1,759.42
$1,869.64
$2,261.22

$294.84

Toc - Plan #120 Cigna Healthcare

Gold

(EPO) Cigna Simple Choice 2000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$563.17
$639.20
$719.74
$1,005.83
$1,528.46

$994.00
$1,070.03
$1,150.57
$1,436.66

$1,424.83
$1,500.86
$1,581.40
$1,867.49

$1,855.66
$1,931.69
$2,012.23
$2,298.32

$430.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,126.34
$1,278.40
$1,439.48
$2,011.66
$3,056.92

$1,557.17
$1,709.23
$1,870.31
$2,442.49

$1,988.00
$2,140.06
$2,301.14
$2,873.32

$2,418.83
$2,570.89
$2,731.97
$3,304.15

$430.83

‡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 Shelby County here.

Shelby County is in “Rating Area 6” of Tennessee.

Currently, there are 120 plans offered in Rating Area 6.

Top

2023 Obamacare Plans for Shelby County, TN

Plan Browser: 120 Plans

BlueCross BlueShield of Tennessee

Local: 1-423-535-5600 | Toll Free: 1-800-565-9140

1. Expanded Bronze Bronze B07S HSA + Free Preventive Care

2. Bronze Bronze B08S Free Telehealth

3. Expanded Bronze Bronze B11S $25 PCP Copay at Blue of TN + Free Telehealth

4. Expanded Bronze Bronze B13S 2 Free PCP Visits + Free Telehealth

5. Expanded Bronze Bronze B07E HSA + Free Preventive Care

6. Bronze Bronze B08E Free Telehealth

7. Expanded Bronze Bronze B10S Free Telehealth

8. Expanded Bronze Bronze B10E Free Telehealth

9. Expanded Bronze Bronze B11E $25 PCP Copay at Blue of TN + Free Telehealth

10. Expanded Bronze Bronze B13E 2 Free PCP Visits + Free Telehealth

11. Expanded Bronze Bronze B14S $70 PCP Copay + Free Telehealth

12. Expanded Bronze Bronze B14E $70 PCP Copay + Free Telehealth

13. Bronze Bronze B15S + Free Telehealth

14. Silver Silver S01S Free Telehealth

15. Silver Silver S04S Free Telehealth

16. Silver Silver S21S $10 PCP Copay at Blue of TN + Free Telehealth

17. Silver Silver S23S 2 Free PCP Visits + Free Telehealth

18. Silver Silver S01E Free Telehealth

19. Silver Silver S04E Free Telehealth

20. Silver Silver S21E $10 PCP Copay at Blue of TN + Free Telehealth

21. Silver Silver S23E 2 Free PCP Visits + Free Telehealth

22. Silver Silver S24S $35 PCP Copay + Free Telehealth

23. Silver Silver S24E $35 PCP Copay + Free Telehealth

24. Silver Silver S25S $45 PCP Copay + Free Telehealth

25. Gold Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays

26. Gold Gold G07S $10 PCP Copay at Blue of TN + Free Telehealth

27. Gold Gold G06E $35 PCP Copay + Free Telehealth + Rx Copays

28. Gold Gold G07E $10 PCP Copay at Blue of TN + Free Telehealth

29. Gold Gold G08S $30 PCP Copay + Free Telehealth

30. Gold Gold G08E $30 PCP Copay + Free Telehealth

31. Bronze Bronze B15E + Free Telehealth

32. Expanded Bronze Bronze B16S $50 PCP Copay + Free Telehealth

33. Expanded Bronze Bronze B16E $50 PCP Copay + Free Telehealth

34. Silver Silver S25E $45 PCP Copay + Free Telehealth

35. Silver Silver S26S $40 PCP Copay + Free Telehealth

36. Silver Silver S26E $40 PCP Copay + Free Telehealth

37. Silver Silver S27S $60 PCP Copay + Free Telehealth

38. Silver Silver S28E $30 PCP Copay at Blue of TN + Free Telehealth

Oscar Insurance Company

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

39. Expanded Bronze Bronze Simple

40. Expanded Bronze Bronze Classic- PCP Saver

41. Expanded Bronze Bronze Classic

42. Expanded Bronze Bronze Elite- $0 Ded+PCP Saver

43. Silver Silver Classic

44. Silver Silver Simple- Specialist Saver

45. Catastrophic Secure

46. Expanded Bronze Bronze Elite- $0 Ded+Specialist Saver

47. Gold Gold Classic

48. Expanded Bronze Bronze Simple- HSA

49. Silver Silver Elite

50. Silver Silver Classic- $0 Ded

51. Expanded Bronze Bronze Classic- $0 PCP

52. Expanded Bronze Bronze Classic- $4700 Ded

53. Silver Silver Simple- PCP Saver

54. Gold Gold Elite- $0 Ded

55. Gold Gold Elite

56. Expanded Bronze Bronze Classic- Standard

57. Bronze Bronze Simple- Standard

58. Silver Silver Classic- Standard

59. Gold Gold Classic- Standard

UnitedHealthcare

Local: 1-877-250-8188 | Toll Free: 1-877-250-8188 | TTY: 1-877-250-8188

60. Silver UHC Silver Value $3,350 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

61. Expanded Bronze UHC Bronze Value $7,500 Deductible 1 (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

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

64. Gold UHC Gold Standard

65. Silver UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

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

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

69. Silver UHC Silver Standard

70. Expanded Bronze UHC Bronze Value $7,500 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

71. Expanded Bronze UHC Bronze Value HSA

72. Bronze UHC Bronze Essential $9,100 Deductible ($3 T1 Preferred Rx)

73. Expanded Bronze UHC Bronze Standard $7,500 Deductible

74. Bronze UHC Bronze Standard $9,100 Deductible

75. Bronze UHC Bronze Essential $6,350 Deductible ($3 T1 Preferred Rx)

Ambetter of Tennessee

Local: 1-833-709-4735 | Toll Free: 1-833-709-4735

76. Bronze Clear Bronze

77. Silver Complete Silver

78. Gold Complete Gold

79. Expanded Bronze Choice Bronze HSA

80. Silver Everyday Silver

81. Expanded Bronze Everyday Bronze

82. Expanded Bronze Elite Bronze

83. Silver Clear Silver

84. Silver Focused Silver

85. Gold Everyday Gold

86. Gold Elite Gold

87. Bronze CMS Standard Bronze

88. Expanded Bronze CMS Standard Expanded Bronze

89. Silver CMS Standard Silver

90. Gold CMS Standard Gold

91. Bronze Clear Bronze + Vision + Adult Dental

92. Silver Complete Silver + Vision + Adult Dental

93. Gold Complete Gold + Vision + Adult Dental

94. Expanded Bronze Choice Bronze HSA + Vision + Adult Dental

95. Silver Everyday Silver + Vision + Adult Dental

96. Expanded Bronze Everyday Bronze + Vision + Adult Dental

97. Expanded Bronze Elite Bronze + Vision + Adult Dental

98. Silver Focused Silver + Vision + Adult Dental

99. Gold Everyday Gold + Vision + Adult Dental

100. Silver Clear Silver + Vision + Adult Dental

101. Gold Elite Gold + Vision + Adult Dental

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

102. Silver Cigna Connect 4100

103. Gold Cigna Connect 1000

104. Bronze Cigna Connect 6500

105. Expanded Bronze Cigna Connect 5900

106. Silver Cigna Connect 3200

107. Bronze Cigna Connect 9100

108. Silver Cigna Connect 5450

109. Silver Cigna Connect 3800 Enhanced Diabetes Care

110. Expanded Bronze Cigna Connect 6800 Enhanced Diabetes Care

111. Expanded Bronze Cigna Connect 7800

112. Silver Cigna Connect 4200 Enhanced Asthma COPD Care

113. Silver Cigna Connect 0B

114. Expanded Bronze Cigna Connect HSA 6000

115. Expanded Bronze Cigna Connect 0A

116. Expanded Bronze Cigna Connect 7600 Enhanced Asthma COPD Care

117. Bronze Cigna Simple Choice 9100

118. Expanded Bronze Cigna Simple Choice 7500

119. Silver Cigna Simple Choice 5800

120. Gold Cigna Simple Choice 2000

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Tennessee Obamacare 2023 Rates

Obamacare Rates and Providers for Other Years

How To Sign Up for Obamacare in Tennessee for 2023

Where's the Tennessee Health Care Exchange?

Tennessee Medicaid Expansion: Do I Qualify for Medicaid Under the ACA?

Tennessee Has Not Expanded Medicaid

The Medicaid Coverage Gap

Get Help Finding a Health Insurance Plan in Tennessee

Get Help From Tennessee's Health Insurance Exchange

Get Help From a Licensed Insurance Broker

More Information

BlueCross BlueShield of Tennessee

(EPO) Bronze B07S HSA + Free Preventive Care

Annual Out of Pocket Expenses:

Individual Family $5,950 $11,900 Annual Deductible $6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze B08S Free Telehealth

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Bronze B11S $25 PCP Copay at Blue of TN + Free Telehealth

Annual Out of Pocket Expenses:

Individual Family $6,400 $12,800 Annual Deductible $8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze B13S 2 Free PCP Visits + Free Telehealth

Annual Out of Pocket Expenses:

Individual Family $5,000 $10,000 Annual Deductible $8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze B07E HSA + Free Preventive Care

Annual Out of Pocket Expenses:

Individual Family $5,950 $11,900 Annual Deductible $6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze B08E Free Telehealth

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Bronze B10S Free Telehealth

Annual Out of Pocket Expenses:

Individual Family $6,600 $13,200 Annual Deductible $8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze B10E Free Telehealth

Annual Out of Pocket Expenses:

Individual Family $6,600 $13,200 Annual Deductible $8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze B11E $25 PCP Copay at Blue of TN + Free Telehealth

Annual Out of Pocket Expenses:

Individual Family $6,400 $12,800 Annual Deductible $8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze B13E 2 Free PCP Visits + Free Telehealth

Annual Out of Pocket Expenses:

Individual Family $5,000 $10,000 Annual Deductible $8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze B14S $70 PCP Copay + Free Telehealth

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:

(EPO) Bronze B14E $70 PCP Copay + Free Telehealth

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:

(EPO) Bronze B15S + Free Telehealth

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:

(EPO) Silver S01S Free Telehealth

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:

(EPO) Silver S04S Free Telehealth

Annual Out of Pocket Expenses:

Individual Family $3,000 $6,000 Annual Deductible $6,200 $12,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Silver S21S $10 PCP Copay at Blue of TN + Free Telehealth

Annual Out of Pocket Expenses:

Individual Family $2,300 $4,600 Annual Deductible $6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Silver S23S 2 Free PCP Visits + Free Telehealth

Annual Out of Pocket Expenses:

Individual Family $2,200 $4,400 Annual Deductible $7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

Individual Family

$5,950 $11,900 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Individual Family

$8,700 $17,400 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,400 $12,800 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Individual Family

$5,000 $10,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Individual Family

$5,950 $11,900 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Individual Family

$8,700 $17,400 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,600 $13,200 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Individual Family

$6,600 $13,200 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Individual Family

$6,400 $12,800 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Individual Family

$5,000 $10,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Individual Family

$8,000 $16,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$8,000 $16,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$3,000 $6,000 Annual Deductible

$6,200 $12,400 Maximum Out of Pocket Per Year

Individual Family

$2,300 $4,600 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Individual Family

$2,200 $4,400 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$3,000 $6,000 Annual Deductible

$6,200 $12,400 Maximum Out of Pocket Per Year

Individual Family

$2,300 $4,600 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Individual Family

$2,200 $4,400 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$5,150 $10,300 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Individual Family

$5,150 $10,300 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$2,750 $5,500 Annual Deductible

$6,350 $12,700 Maximum Out of Pocket Per Year

Individual Family

$500 $1,000 Annual Deductible

$4,200 $8,400 Maximum Out of Pocket Per Year

Individual Family

$2,750 $5,500 Annual Deductible

$6,350 $12,700 Maximum Out of Pocket Per Year

Individual Family

$1,000 $2,000 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year