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Molina Healthcare

Local: 1-801-858-0400 | Toll Free: 1-888-858-3973

Toc - Plan #1 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$392.06
$544.96
$579.85
$833.90
$1,176.17
$702.96
$855.86
$890.75
$1,144.80
$1,013.86
$1,166.76
$1,201.65
$1,455.70
$1,324.76
$1,477.66
$1,512.55
$1,766.60
$310.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.12
$1,089.92
$1,159.70
$1,667.80
$2,352.34
$1,095.02
$1,400.82
$1,470.60
$1,978.70
$1,405.92
$1,711.72
$1,781.50
$2,289.60
$1,716.82
$2,022.62
$2,092.40
$2,600.50
$310.90
Toc - Plan #2 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.26
$560.53
$596.42
$857.74
$1,209.78
$723.05
$880.32
$916.21
$1,177.53
$1,042.84
$1,200.11
$1,236.00
$1,497.32
$1,362.63
$1,519.90
$1,555.79
$1,817.11
$319.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.52
$1,121.06
$1,192.84
$1,715.48
$2,419.56
$1,126.31
$1,440.85
$1,512.63
$2,035.27
$1,446.10
$1,760.64
$1,832.42
$2,355.06
$1,765.89
$2,080.43
$2,152.21
$2,674.85
$319.79
Toc - Plan #3 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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
$402.19
$559.04
$594.84
$855.46
$1,206.57
$721.13
$877.98
$913.78
$1,174.40
$1,040.07
$1,196.92
$1,232.72
$1,493.34
$1,359.01
$1,515.86
$1,551.66
$1,812.28
$318.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$804.38
$1,118.08
$1,189.68
$1,710.92
$2,413.14
$1,123.32
$1,437.02
$1,508.62
$2,029.86
$1,442.26
$1,755.96
$1,827.56
$2,348.80
$1,761.20
$2,074.90
$2,146.50
$2,667.74
$318.94
Toc - Plan #4 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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
$410.36
$570.40
$606.92
$872.83
$1,231.08
$735.78
$895.82
$932.34
$1,198.25
$1,061.20
$1,221.24
$1,257.76
$1,523.67
$1,386.62
$1,546.66
$1,583.18
$1,849.09
$325.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$820.72
$1,140.80
$1,213.84
$1,745.66
$2,462.16
$1,146.14
$1,466.22
$1,539.26
$2,071.08
$1,471.56
$1,791.64
$1,864.68
$2,396.50
$1,796.98
$2,117.06
$2,190.10
$2,721.92
$325.42
Toc - Plan #5 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.77
$551.51
$586.82
$843.93
$1,190.30
$711.41
$866.15
$901.46
$1,158.57
$1,026.05
$1,180.79
$1,216.10
$1,473.21
$1,340.69
$1,495.43
$1,530.74
$1,787.85
$314.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793.54
$1,103.02
$1,173.64
$1,687.86
$2,380.60
$1,108.18
$1,417.66
$1,488.28
$2,002.50
$1,422.82
$1,732.30
$1,802.92
$2,317.14
$1,737.46
$2,046.94
$2,117.56
$2,631.78
$314.64
Toc - Plan #6 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$406.62
$565.20
$601.39
$864.87
$1,219.85
$729.07
$887.65
$923.84
$1,187.32
$1,051.52
$1,210.10
$1,246.29
$1,509.77
$1,373.97
$1,532.55
$1,568.74
$1,832.22
$322.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$813.24
$1,130.40
$1,202.78
$1,729.74
$2,439.70
$1,135.69
$1,452.85
$1,525.23
$2,052.19
$1,458.14
$1,775.30
$1,847.68
$2,374.64
$1,780.59
$2,097.75
$2,170.13
$2,697.09
$322.45

ADVERTISEMENT

Regence BlueCross BlueShield of Utah

Local: 1-888-231-8424 | Toll Free: 1-888-231-8424

Toc - Plan #7 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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
$334.78
$465.34
$495.13
$712.07
$1,004.33
$600.26
$730.82
$760.61
$977.55
$865.74
$996.30
$1,026.09
$1,243.03
$1,131.22
$1,261.78
$1,291.57
$1,508.51
$265.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$669.56
$930.68
$990.26
$1,424.14
$2,008.66
$935.04
$1,196.16
$1,255.74
$1,689.62
$1,200.52
$1,461.64
$1,521.22
$1,955.10
$1,466.00
$1,727.12
$1,786.70
$2,220.58
$265.48
Toc - Plan #8 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 5500 Separate RX Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$336.68
$467.99
$497.96
$716.12
$1,010.04
$603.67
$734.98
$764.95
$983.11
$870.66
$1,001.97
$1,031.94
$1,250.10
$1,137.65
$1,268.96
$1,298.93
$1,517.09
$266.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$673.36
$935.98
$995.92
$1,432.24
$2,020.08
$940.35
$1,202.97
$1,262.91
$1,699.23
$1,207.34
$1,469.96
$1,529.90
$1,966.22
$1,474.33
$1,736.95
$1,796.89
$2,233.21
$266.99
Toc - Plan #9 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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
$320.75
$445.84
$474.38
$682.24
$962.24
$575.10
$700.19
$728.73
$936.59
$829.45
$954.54
$983.08
$1,190.94
$1,083.80
$1,208.89
$1,237.43
$1,445.29
$254.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.50
$891.68
$948.76
$1,364.48
$1,924.48
$895.85
$1,146.03
$1,203.11
$1,618.83
$1,150.20
$1,400.38
$1,457.46
$1,873.18
$1,404.55
$1,654.73
$1,711.81
$2,127.53
$254.35
Toc - Plan #10 Regence BlueCross BlueShield of Utah
Gold

(EPO) Gold 2500 With Dental and Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$350.32
$486.94
$518.12
$745.13
$1,050.96
$628.13
$764.75
$795.93
$1,022.94
$905.94
$1,042.56
$1,073.74
$1,300.75
$1,183.75
$1,320.37
$1,351.55
$1,578.56
$277.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700.64
$973.88
$1,036.24
$1,490.26
$2,101.92
$978.45
$1,251.69
$1,314.05
$1,768.07
$1,256.26
$1,529.50
$1,591.86
$2,045.88
$1,534.07
$1,807.31
$1,869.67
$2,323.69
$277.81
Toc - Plan #11 Regence BlueCross BlueShield of Utah
Silver

(EPO) SaveWell Silver 5350

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$5,350 $10,700 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
$307.65
$427.63
$455.01
$654.37
$922.94
$551.62
$671.60
$698.98
$898.34
$795.59
$915.57
$942.95
$1,142.31
$1,039.56
$1,159.54
$1,186.92
$1,386.28
$243.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$615.30
$855.26
$910.02
$1,308.74
$1,845.88
$859.27
$1,099.23
$1,153.99
$1,552.71
$1,103.24
$1,343.20
$1,397.96
$1,796.68
$1,347.21
$1,587.17
$1,641.93
$2,040.65
$243.97
Toc - Plan #12 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) SaveWell Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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
$219.74
$305.44
$324.99
$467.38
$659.21
$393.99
$479.69
$499.24
$641.63
$568.24
$653.94
$673.49
$815.88
$742.49
$828.19
$847.74
$990.13
$174.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$439.48
$610.88
$649.98
$934.76
$1,318.42
$613.73
$785.13
$824.23
$1,109.01
$787.98
$959.38
$998.48
$1,283.26
$962.23
$1,133.63
$1,172.73
$1,457.51
$174.25
Toc - Plan #13 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) SaveWell Bronze 8500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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
$216.81
$301.36
$320.66
$461.15
$650.43
$388.74
$473.29
$492.59
$633.08
$560.67
$645.22
$664.52
$805.01
$732.60
$817.15
$836.45
$976.94
$171.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$433.62
$602.72
$641.32
$922.30
$1,300.86
$605.55
$774.65
$813.25
$1,094.23
$777.48
$946.58
$985.18
$1,266.16
$949.41
$1,118.51
$1,157.11
$1,438.09
$171.93
Toc - Plan #14 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze HSA 6750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$6,750 $13,500 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
$253.01
$351.69
$374.21
$538.16
$759.03
$453.65
$552.33
$574.85
$738.80
$654.29
$752.97
$775.49
$939.44
$854.93
$953.61
$976.13
$1,140.08
$200.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$506.02
$703.38
$748.42
$1,076.32
$1,518.06
$706.66
$904.02
$949.06
$1,276.96
$907.30
$1,104.66
$1,149.70
$1,477.60
$1,107.94
$1,305.30
$1,350.34
$1,678.24
$200.64
Toc - Plan #15 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze Essential 8500 With 4 Copay No Deductible Office Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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
$237.46
$330.07
$351.20
$505.08
$712.38
$425.77
$518.38
$539.51
$693.39
$614.08
$706.69
$727.82
$881.70
$802.39
$895.00
$916.13
$1,070.01
$188.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$474.92
$660.14
$702.40
$1,010.16
$1,424.76
$663.23
$848.45
$890.71
$1,198.47
$851.54
$1,036.76
$1,079.02
$1,386.78
$1,039.85
$1,225.07
$1,267.33
$1,575.09
$188.31
Toc - Plan #16 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze 8000 Separate RX Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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
$251.38
$349.43
$371.79
$534.70
$754.14
$450.73
$548.78
$571.14
$734.05
$650.08
$748.13
$770.49
$933.40
$849.43
$947.48
$969.84
$1,132.75
$199.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$502.76
$698.86
$743.58
$1,069.40
$1,508.28
$702.11
$898.21
$942.93
$1,268.75
$901.46
$1,097.56
$1,142.28
$1,468.10
$1,100.81
$1,296.91
$1,341.63
$1,667.45
$199.35
Toc - Plan #17 Regence BlueCross BlueShield of Utah
Gold

(EPO) Regence Standard Gold Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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
$360.21
$500.70
$532.76
$766.17
$1,080.63
$645.86
$786.35
$818.41
$1,051.82
$931.51
$1,072.00
$1,104.06
$1,337.47
$1,217.16
$1,357.65
$1,389.71
$1,623.12
$285.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.42
$1,001.40
$1,065.52
$1,532.34
$2,161.26
$1,006.07
$1,287.05
$1,351.17
$1,817.99
$1,291.72
$1,572.70
$1,636.82
$2,103.64
$1,577.37
$1,858.35
$1,922.47
$2,389.29
$285.65
Toc - Plan #18 Regence BlueCross BlueShield of Utah
Silver

(EPO) Regence Standard Silver Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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
$326.51
$453.85
$482.91
$694.49
$979.53
$585.44
$712.78
$741.84
$953.42
$844.37
$971.71
$1,000.77
$1,212.35
$1,103.30
$1,230.64
$1,259.70
$1,471.28
$258.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$653.02
$907.70
$965.82
$1,388.98
$1,959.06
$911.95
$1,166.63
$1,224.75
$1,647.91
$1,170.88
$1,425.56
$1,483.68
$1,906.84
$1,429.81
$1,684.49
$1,742.61
$2,165.77
$258.93
Toc - Plan #19 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Regence Standard Expanded Bronze Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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
$248.71
$345.72
$367.85
$529.02
$746.13
$445.94
$542.95
$565.08
$726.25
$643.17
$740.18
$762.31
$923.48
$840.40
$937.41
$959.54
$1,120.71
$197.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$497.42
$691.44
$735.70
$1,058.04
$1,492.26
$694.65
$888.67
$932.93
$1,255.27
$891.88
$1,085.90
$1,130.16
$1,452.50
$1,089.11
$1,283.13
$1,327.39
$1,649.73
$197.23

ADVERTISEMENT

BridgeSpan Health Company

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

Toc - Plan #20 BridgeSpan Health Company
Gold

(HMO) BridgeSpan Standard Gold Plan

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

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
$368.21
$511.80
$544.58
$783.17
$1,104.62
$660.20
$803.79
$836.57
$1,075.16
$952.19
$1,095.78
$1,128.56
$1,367.15
$1,244.18
$1,387.77
$1,420.55
$1,659.14
$291.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$736.42
$1,023.60
$1,089.16
$1,566.34
$2,209.24
$1,028.41
$1,315.59
$1,381.15
$1,858.33
$1,320.40
$1,607.58
$1,673.14
$2,150.32
$1,612.39
$1,899.57
$1,965.13
$2,442.31
$291.99
Toc - Plan #21 BridgeSpan Health Company
Silver

(HMO) BridgeSpan Standard Silver Plan

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $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
$333.82
$464.01
$493.72
$710.04
$1,001.46
$598.54
$728.73
$758.44
$974.76
$863.26
$993.45
$1,023.16
$1,239.48
$1,127.98
$1,258.17
$1,287.88
$1,504.20
$264.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$667.64
$928.02
$987.44
$1,420.08
$2,002.92
$932.36
$1,192.74
$1,252.16
$1,684.80
$1,197.08
$1,457.46
$1,516.88
$1,949.52
$1,461.80
$1,722.18
$1,781.60
$2,214.24
$264.72
Toc - Plan #22 BridgeSpan Health Company
Expanded Bronze

(HMO) BridgeSpan Standard Expanded Bronze Plan

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

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
$254.66
$353.98
$376.64
$541.65
$763.97
$456.61
$555.93
$578.59
$743.60
$658.56
$757.88
$780.54
$945.55
$860.51
$959.83
$982.49
$1,147.50
$201.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$509.32
$707.96
$753.28
$1,083.30
$1,527.94
$711.27
$909.91
$955.23
$1,285.25
$913.22
$1,111.86
$1,157.18
$1,487.20
$1,115.17
$1,313.81
$1,359.13
$1,689.15
$201.95
Toc - Plan #23 BridgeSpan Health Company
Expanded Bronze

(HMO) Bronze Virtual Saver 8500

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

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
$235.93
$327.94
$348.94
$501.82
$707.79
$423.02
$515.03
$536.03
$688.91
$610.11
$702.12
$723.12
$876.00
$797.20
$889.21
$910.21
$1,063.09
$187.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$471.86
$655.88
$697.88
$1,003.64
$1,415.58
$658.95
$842.97
$884.97
$1,190.73
$846.04
$1,030.06
$1,072.06
$1,377.82
$1,033.13
$1,217.15
$1,259.15
$1,564.91
$187.09

ADVERTISEMENT

University of Utah Health Plans

Local: 1-801-213-4111x1 | Toll Free: 1-833-981-0214 | TTY: 1-800-346-4128

Toc - Plan #24 University of Utah Health Plans
Gold

(EPO) Healthy Premier Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.24
$592.47
$630.41
$906.61
$1,278.72
$764.25
$930.48
$968.42
$1,244.62
$1,102.26
$1,268.49
$1,306.43
$1,582.63
$1,440.27
$1,606.50
$1,644.44
$1,920.64
$338.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.48
$1,184.94
$1,260.82
$1,813.22
$2,557.44
$1,190.49
$1,522.95
$1,598.83
$2,151.23
$1,528.50
$1,860.96
$1,936.84
$2,489.24
$1,866.51
$2,198.97
$2,274.85
$2,827.25
$338.01
Toc - Plan #25 University of Utah Health Plans
Silver

(EPO) Healthy Premier Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.71
$544.48
$579.34
$833.17
$1,175.13
$702.34
$855.11
$889.97
$1,143.80
$1,012.97
$1,165.74
$1,200.60
$1,454.43
$1,323.60
$1,476.37
$1,511.23
$1,765.06
$310.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.42
$1,088.96
$1,158.68
$1,666.34
$2,350.26
$1,094.05
$1,399.59
$1,469.31
$1,976.97
$1,404.68
$1,710.22
$1,779.94
$2,287.60
$1,715.31
$2,020.85
$2,090.57
$2,598.23
$310.63
Toc - Plan #26 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$254.30
$353.48
$376.11
$540.90
$762.90
$455.96
$555.14
$577.77
$742.56
$657.62
$756.80
$779.43
$944.22
$859.28
$958.46
$981.09
$1,145.88
$201.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$508.60
$706.96
$752.22
$1,081.80
$1,525.80
$710.26
$908.62
$953.88
$1,283.46
$911.92
$1,110.28
$1,155.54
$1,485.12
$1,113.58
$1,311.94
$1,357.20
$1,686.78
$201.66
Toc - Plan #27 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$284.20
$395.04
$420.33
$604.49
$852.60
$509.57
$620.41
$645.70
$829.86
$734.94
$845.78
$871.07
$1,055.23
$960.31
$1,071.15
$1,096.44
$1,280.60
$225.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$568.40
$790.08
$840.66
$1,208.98
$1,705.20
$793.77
$1,015.45
$1,066.03
$1,434.35
$1,019.14
$1,240.82
$1,291.40
$1,659.72
$1,244.51
$1,466.19
$1,516.77
$1,885.09
$225.37
Toc - Plan #28 University of Utah Health Plans
Bronze

(EPO) Healthy Premier Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$267.51
$371.84
$395.65
$568.99
$802.53
$479.65
$583.98
$607.79
$781.13
$691.79
$796.12
$819.93
$993.27
$903.93
$1,008.26
$1,032.07
$1,205.41
$212.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$535.02
$743.68
$791.30
$1,137.98
$1,605.06
$747.16
$955.82
$1,003.44
$1,350.12
$959.30
$1,167.96
$1,215.58
$1,562.26
$1,171.44
$1,380.10
$1,427.72
$1,774.40
$212.14
Toc - Plan #29 University of Utah Health Plans
Gold

(EPO) Healthy Premier Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$412.59
$573.50
$610.22
$877.58
$1,237.77
$739.77
$900.68
$937.40
$1,204.76
$1,066.95
$1,227.86
$1,264.58
$1,531.94
$1,394.13
$1,555.04
$1,591.76
$1,859.12
$327.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$825.18
$1,147.00
$1,220.44
$1,755.16
$2,475.54
$1,152.36
$1,474.18
$1,547.62
$2,082.34
$1,479.54
$1,801.36
$1,874.80
$2,409.52
$1,806.72
$2,128.54
$2,201.98
$2,736.70
$327.18
Toc - Plan #30 University of Utah Health Plans
Silver

(EPO) Healthy Premier Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$389.14
$540.90
$575.54
$827.70
$1,167.42
$697.73
$849.49
$884.13
$1,136.29
$1,006.32
$1,158.08
$1,192.72
$1,444.88
$1,314.91
$1,466.67
$1,501.31
$1,753.47
$308.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.28
$1,081.80
$1,151.08
$1,655.40
$2,334.84
$1,086.87
$1,390.39
$1,459.67
$1,963.99
$1,395.46
$1,698.98
$1,768.26
$2,272.58
$1,704.05
$2,007.57
$2,076.85
$2,581.17
$308.59
Toc - Plan #31 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Expanded Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$286.30
$397.96
$423.44
$608.96
$858.90
$513.34
$625.00
$650.48
$836.00
$740.38
$852.04
$877.52
$1,063.04
$967.42
$1,079.08
$1,104.56
$1,290.08
$227.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$572.60
$795.92
$846.88
$1,217.92
$1,717.80
$799.64
$1,022.96
$1,073.92
$1,444.96
$1,026.68
$1,250.00
$1,300.96
$1,672.00
$1,253.72
$1,477.04
$1,528.00
$1,899.04
$227.04
Toc - Plan #32 University of Utah Health Plans
Gold

(EPO) U Health Plus Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$388.23
$539.64
$574.19
$825.77
$1,164.69
$696.10
$847.51
$882.06
$1,133.64
$1,003.97
$1,155.38
$1,189.93
$1,441.51
$1,311.84
$1,463.25
$1,497.80
$1,749.38
$307.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.46
$1,079.28
$1,148.38
$1,651.54
$2,329.38
$1,084.33
$1,387.15
$1,456.25
$1,959.41
$1,392.20
$1,695.02
$1,764.12
$2,267.28
$1,700.07
$2,002.89
$2,071.99
$2,575.15
$307.87
Toc - Plan #33 University of Utah Health Plans
Silver

(EPO) U Health Plus Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.97
$501.75
$533.87
$767.78
$1,082.91
$647.22
$788.00
$820.12
$1,054.03
$933.47
$1,074.25
$1,106.37
$1,340.28
$1,219.72
$1,360.50
$1,392.62
$1,626.53
$286.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.94
$1,003.50
$1,067.74
$1,535.56
$2,165.82
$1,008.19
$1,289.75
$1,353.99
$1,821.81
$1,294.44
$1,576.00
$1,640.24
$2,108.06
$1,580.69
$1,862.25
$1,926.49
$2,394.31
$286.25
Toc - Plan #34 University of Utah Health Plans
Expanded Bronze

(EPO) U Health Plus Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$261.84
$363.96
$387.26
$556.93
$785.52
$469.48
$571.60
$594.90
$764.57
$677.12
$779.24
$802.54
$972.21
$884.76
$986.88
$1,010.18
$1,179.85
$207.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$523.68
$727.92
$774.52
$1,113.86
$1,571.04
$731.32
$935.56
$982.16
$1,321.50
$938.96
$1,143.20
$1,189.80
$1,529.14
$1,146.60
$1,350.84
$1,397.44
$1,736.78
$207.64
Toc - Plan #35 University of Utah Health Plans
Gold

(EPO) U Health Plus Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$380.33
$528.66
$562.51
$808.96
$1,140.99
$681.93
$830.26
$864.11
$1,110.56
$983.53
$1,131.86
$1,165.71
$1,412.16
$1,285.13
$1,433.46
$1,467.31
$1,713.76
$301.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.66
$1,057.32
$1,125.02
$1,617.92
$2,281.98
$1,062.26
$1,358.92
$1,426.62
$1,919.52
$1,363.86
$1,660.52
$1,728.22
$2,221.12
$1,665.46
$1,962.12
$2,029.82
$2,522.72
$301.60
Toc - Plan #36 University of Utah Health Plans
Silver

(EPO) U Health Plus Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$360.41
$500.97
$533.05
$766.59
$1,081.23
$646.22
$786.78
$818.86
$1,052.40
$932.03
$1,072.59
$1,104.67
$1,338.21
$1,217.84
$1,358.40
$1,390.48
$1,624.02
$285.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.82
$1,001.94
$1,066.10
$1,533.18
$2,162.46
$1,006.63
$1,287.75
$1,351.91
$1,818.99
$1,292.44
$1,573.56
$1,637.72
$2,104.80
$1,578.25
$1,859.37
$1,923.53
$2,390.61
$285.81
Toc - Plan #37 University of Utah Health Plans
Expanded Bronze

(EPO) U Health Plus Expanded Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$263.94
$366.88
$390.37
$561.40
$791.82
$473.24
$576.18
$599.67
$770.70
$682.54
$785.48
$808.97
$980.00
$891.84
$994.78
$1,018.27
$1,189.30
$209.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$527.88
$733.76
$780.74
$1,122.80
$1,583.64
$737.18
$943.06
$990.04
$1,332.10
$946.48
$1,152.36
$1,199.34
$1,541.40
$1,155.78
$1,361.66
$1,408.64
$1,750.70
$209.30
Toc - Plan #38 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Bronze w.3 Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

Annual Out of Pocket Expenses:

Individual Family
$8,750 $17,500 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
$255.49
$355.13
$377.87
$543.43
$766.47
$458.09
$557.73
$580.47
$746.03
$660.69
$760.33
$783.07
$948.63
$863.29
$962.93
$985.67
$1,151.23
$202.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$510.98
$710.26
$755.74
$1,086.86
$1,532.94
$713.58
$912.86
$958.34
$1,289.46
$916.18
$1,115.46
$1,160.94
$1,492.06
$1,118.78
$1,318.06
$1,363.54
$1,694.66
$202.60
Toc - Plan #39 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Expanded Bronze Standard Choice

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-981-0214

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
$286.30
$397.96
$423.44
$608.96
$858.90
$513.34
$625.00
$650.48
$836.00
$740.38
$852.04
$877.52
$1,063.04
$967.42
$1,079.08
$1,104.56
$1,290.08
$227.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$572.60
$795.92
$846.88
$1,217.92
$1,717.80
$799.64
$1,022.96
$1,073.92
$1,444.96
$1,026.68
$1,250.00
$1,300.96
$1,672.00
$1,253.72
$1,477.04
$1,528.00
$1,899.04
$227.04

ADVERTISEMENT

SelectHealth

Local: 1-801-442-5038 | Toll Free: 1-800-538-5038

Toc - Plan #40 SelectHealth
Silver

(HMO) Med Silver 3000 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$347.73
$483.34
$514.29
$739.61
$1,043.18
$623.48
$759.09
$790.04
$1,015.36
$899.23
$1,034.84
$1,065.79
$1,291.11
$1,174.98
$1,310.59
$1,341.54
$1,566.86
$275.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$695.46
$966.68
$1,028.58
$1,479.22
$2,086.36
$971.21
$1,242.43
$1,304.33
$1,754.97
$1,246.96
$1,518.18
$1,580.08
$2,030.72
$1,522.71
$1,793.93
$1,855.83
$2,306.47
$275.75
Toc - Plan #41 SelectHealth
Gold

(HMO) Med Gold 1500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.99
$603.25
$641.88
$923.11
$1,301.97
$778.15
$947.41
$986.04
$1,267.27
$1,122.31
$1,291.57
$1,330.20
$1,611.43
$1,466.47
$1,635.73
$1,674.36
$1,955.59
$344.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.98
$1,206.50
$1,283.76
$1,846.22
$2,603.94
$1,212.14
$1,550.66
$1,627.92
$2,190.38
$1,556.30
$1,894.82
$1,972.08
$2,534.54
$1,900.46
$2,238.98
$2,316.24
$2,878.70
$344.16
Toc - Plan #42 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 6900 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 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
$259.25
$360.35
$383.43
$551.42
$777.74
$464.83
$565.93
$589.01
$757.00
$670.41
$771.51
$794.59
$962.58
$875.99
$977.09
$1,000.17
$1,168.16
$205.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$518.50
$720.70
$766.86
$1,102.84
$1,555.48
$724.08
$926.28
$972.44
$1,308.42
$929.66
$1,131.86
$1,178.02
$1,514.00
$1,135.24
$1,337.44
$1,383.60
$1,719.58
$205.58
Toc - Plan #43 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 7500 HSA Qualified

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$263.67
$366.50
$389.97
$560.83
$791.01
$472.76
$575.59
$599.06
$769.92
$681.85
$784.68
$808.15
$979.01
$890.94
$993.77
$1,017.24
$1,188.10
$209.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$527.34
$733.00
$779.94
$1,121.66
$1,582.02
$736.43
$942.09
$989.03
$1,330.75
$945.52
$1,151.18
$1,198.12
$1,539.84
$1,154.61
$1,360.27
$1,407.21
$1,748.93
$209.09
Toc - Plan #44 SelectHealth
Gold

(HMO) Value Gold 1500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384.18
$534.01
$568.20
$817.15
$1,152.54
$688.83
$838.66
$872.85
$1,121.80
$993.48
$1,143.31
$1,177.50
$1,426.45
$1,298.13
$1,447.96
$1,482.15
$1,731.10
$304.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.36
$1,068.02
$1,136.40
$1,634.30
$2,305.08
$1,073.01
$1,372.67
$1,441.05
$1,938.95
$1,377.66
$1,677.32
$1,745.70
$2,243.60
$1,682.31
$1,981.97
$2,050.35
$2,548.25
$304.65
Toc - Plan #45 SelectHealth
Silver

(HMO) Value Silver 3000 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$307.81
$427.86
$455.25
$654.72
$923.43
$551.91
$671.96
$699.35
$898.82
$796.01
$916.06
$943.45
$1,142.92
$1,040.11
$1,160.16
$1,187.55
$1,387.02
$244.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$615.62
$855.72
$910.50
$1,309.44
$1,846.86
$859.72
$1,099.82
$1,154.60
$1,553.54
$1,103.82
$1,343.92
$1,398.70
$1,797.64
$1,347.92
$1,588.02
$1,642.80
$2,041.74
$244.10
Toc - Plan #46 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 6900 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 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
$229.49
$318.99
$339.41
$488.12
$688.47
$411.47
$500.97
$521.39
$670.10
$593.45
$682.95
$703.37
$852.08
$775.43
$864.93
$885.35
$1,034.06
$181.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$458.98
$637.98
$678.82
$976.24
$1,376.94
$640.96
$819.96
$860.80
$1,158.22
$822.94
$1,001.94
$1,042.78
$1,340.20
$1,004.92
$1,183.92
$1,224.76
$1,522.18
$181.98
Toc - Plan #47 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 7500 HSA Qualified

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$233.40
$324.43
$345.21
$496.45
$700.20
$418.49
$509.52
$530.30
$681.54
$603.58
$694.61
$715.39
$866.63
$788.67
$879.70
$900.48
$1,051.72
$185.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$466.80
$648.86
$690.42
$992.90
$1,400.40
$651.89
$833.95
$875.51
$1,177.99
$836.98
$1,019.04
$1,060.60
$1,363.08
$1,022.07
$1,204.13
$1,245.69
$1,548.17
$185.09
Toc - Plan #48 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 5900 Copay Plan - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$249.17
$346.35
$368.53
$529.99
$747.51
$446.76
$543.94
$566.12
$727.58
$644.35
$741.53
$763.71
$925.17
$841.94
$939.12
$961.30
$1,122.76
$197.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$498.34
$692.70
$737.06
$1,059.98
$1,495.02
$695.93
$890.29
$934.65
$1,257.57
$893.52
$1,087.88
$1,132.24
$1,455.16
$1,091.11
$1,285.47
$1,329.83
$1,652.75
$197.59
Toc - Plan #49 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 5900 Copay Plan - no deductible for all office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$280.92
$390.48
$415.49
$597.52
$842.76
$503.69
$613.25
$638.26
$820.29
$726.46
$836.02
$861.03
$1,043.06
$949.23
$1,058.79
$1,083.80
$1,265.83
$222.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$561.84
$780.96
$830.98
$1,195.04
$1,685.52
$784.61
$1,003.73
$1,053.75
$1,417.81
$1,007.38
$1,226.50
$1,276.52
$1,640.58
$1,230.15
$1,449.27
$1,499.29
$1,863.35
$222.77
Toc - Plan #50 SelectHealth
Gold

(HMO) Signature Gold 1500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$374.61
$520.71
$554.05
$796.80
$1,123.83
$671.68
$817.78
$851.12
$1,093.87
$968.75
$1,114.85
$1,148.19
$1,390.94
$1,265.82
$1,411.92
$1,445.26
$1,688.01
$297.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.22
$1,041.42
$1,108.10
$1,593.60
$2,247.66
$1,046.29
$1,338.49
$1,405.17
$1,890.67
$1,343.36
$1,635.56
$1,702.24
$2,187.74
$1,640.43
$1,932.63
$1,999.31
$2,484.81
$297.07
Toc - Plan #51 SelectHealth
Silver

(HMO) Signature Silver 3000 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$300.15
$417.21
$443.92
$638.42
$900.45
$538.17
$655.23
$681.94
$876.44
$776.19
$893.25
$919.96
$1,114.46
$1,014.21
$1,131.27
$1,157.98
$1,352.48
$238.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$600.30
$834.42
$887.84
$1,276.84
$1,800.90
$838.32
$1,072.44
$1,125.86
$1,514.86
$1,076.34
$1,310.46
$1,363.88
$1,752.88
$1,314.36
$1,548.48
$1,601.90
$1,990.90
$238.02
Toc - Plan #52 SelectHealth
Expanded Bronze

(HMO) Signature Expanded Bronze 6900 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 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
$223.78
$311.05
$330.96
$475.97
$671.33
$401.23
$488.50
$508.41
$653.42
$578.68
$665.95
$685.86
$830.87
$756.13
$843.40
$863.31
$1,008.32
$177.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$447.56
$622.10
$661.92
$951.94
$1,342.66
$625.01
$799.55
$839.37
$1,129.39
$802.46
$977.00
$1,016.82
$1,306.84
$979.91
$1,154.45
$1,194.27
$1,484.29
$177.45
Toc - Plan #53 SelectHealth
Silver

(HMO) Value Silver 6500 - Diabetes Support Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$329.74
$458.34
$487.69
$701.36
$989.22
$591.23
$719.83
$749.18
$962.85
$852.72
$981.32
$1,010.67
$1,224.34
$1,114.21
$1,242.81
$1,272.16
$1,485.83
$261.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$659.48
$916.68
$975.38
$1,402.72
$1,978.44
$920.97
$1,178.17
$1,236.87
$1,664.21
$1,182.46
$1,439.66
$1,498.36
$1,925.70
$1,443.95
$1,701.15
$1,759.85
$2,187.19
$261.49
Toc - Plan #54 SelectHealth
Silver

(HMO) Med Silver 6500 - Diabetes Support Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$372.50
$517.78
$550.93
$792.31
$1,117.50
$667.89
$813.17
$846.32
$1,087.70
$963.28
$1,108.56
$1,141.71
$1,383.09
$1,258.67
$1,403.95
$1,437.10
$1,678.48
$295.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$745.00
$1,035.56
$1,101.86
$1,584.62
$2,235.00
$1,040.39
$1,330.95
$1,397.25
$1,880.01
$1,335.78
$1,626.34
$1,692.64
$2,175.40
$1,631.17
$1,921.73
$1,988.03
$2,470.79
$295.39
Toc - Plan #55 SelectHealth
Silver

(HMO) Signature Silver 6500 - Diabetes Support Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.53
$446.93
$475.55
$683.90
$964.59
$576.51
$701.91
$730.53
$938.88
$831.49
$956.89
$985.51
$1,193.86
$1,086.47
$1,211.87
$1,240.49
$1,448.84
$254.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.06
$893.86
$951.10
$1,367.80
$1,929.18
$898.04
$1,148.84
$1,206.08
$1,622.78
$1,153.02
$1,403.82
$1,461.06
$1,877.76
$1,408.00
$1,658.80
$1,716.04
$2,132.74
$254.98
Toc - Plan #56 SelectHealth
Bronze

(HMO) Value Benchmark Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$214.60
$298.30
$317.40
$456.46
$643.80
$384.78
$468.48
$487.58
$626.64
$554.96
$638.66
$657.76
$796.82
$725.14
$808.84
$827.94
$967.00
$170.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$429.20
$596.60
$634.80
$912.92
$1,287.60
$599.38
$766.78
$804.98
$1,083.10
$769.56
$936.96
$975.16
$1,253.28
$939.74
$1,107.14
$1,145.34
$1,423.46
$170.18
Toc - Plan #57 SelectHealth
Bronze

(HMO) Med Benchmark Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$242.43
$336.98
$358.55
$515.65
$727.29
$434.68
$529.23
$550.80
$707.90
$626.93
$721.48
$743.05
$900.15
$819.18
$913.73
$935.30
$1,092.40
$192.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$484.86
$673.96
$717.10
$1,031.30
$1,454.58
$677.11
$866.21
$909.35
$1,223.55
$869.36
$1,058.46
$1,101.60
$1,415.80
$1,061.61
$1,250.71
$1,293.85
$1,608.05
$192.25
Toc - Plan #58 SelectHealth
Silver

(HMO) Value Benchmark Silver 6300 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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
$297.63
$413.71
$440.20
$633.06
$892.89
$533.65
$649.73
$676.22
$869.08
$769.67
$885.75
$912.24
$1,105.10
$1,005.69
$1,121.77
$1,148.26
$1,341.12
$236.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.26
$827.42
$880.40
$1,266.12
$1,785.78
$831.28
$1,063.44
$1,116.42
$1,502.14
$1,067.30
$1,299.46
$1,352.44
$1,738.16
$1,303.32
$1,535.48
$1,588.46
$1,974.18
$236.02
Toc - Plan #59 SelectHealth
Silver

(HMO) Med Benchmark Silver 6300 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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
$336.22
$467.35
$497.27
$715.15
$1,008.66
$602.85
$733.98
$763.90
$981.78
$869.48
$1,000.61
$1,030.53
$1,248.41
$1,136.11
$1,267.24
$1,297.16
$1,515.04
$266.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.44
$934.70
$994.54
$1,430.30
$2,017.32
$939.07
$1,201.33
$1,261.17
$1,696.93
$1,205.70
$1,467.96
$1,527.80
$1,963.56
$1,472.33
$1,734.59
$1,794.43
$2,230.19
$266.63
Toc - Plan #60 SelectHealth
Expanded Bronze

(HMO) Value Benchmark Expanded Bronze 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$238.86
$332.01
$353.27
$508.05
$716.58
$428.27
$521.42
$542.68
$697.46
$617.68
$710.83
$732.09
$886.87
$807.09
$900.24
$921.50
$1,076.28
$189.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$477.72
$664.02
$706.54
$1,016.10
$1,433.16
$667.13
$853.43
$895.95
$1,205.51
$856.54
$1,042.84
$1,085.36
$1,394.92
$1,045.95
$1,232.25
$1,274.77
$1,584.33
$189.41
Toc - Plan #61 SelectHealth
Expanded Bronze

(HMO) Med Benchmark Expanded Bronze 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$269.83
$375.06
$399.08
$573.93
$809.49
$483.81
$589.04
$613.06
$787.91
$697.79
$803.02
$827.04
$1,001.89
$911.77
$1,017.00
$1,041.02
$1,215.87
$213.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$539.66
$750.12
$798.16
$1,147.86
$1,618.98
$753.64
$964.10
$1,012.14
$1,361.84
$967.62
$1,178.08
$1,226.12
$1,575.82
$1,181.60
$1,392.06
$1,440.10
$1,789.80
$213.98
Toc - Plan #62 SelectHealth
Silver

(HMO) Value Benchmark Silver 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$325.81
$452.88
$481.88
$693.00
$977.43
$584.18
$711.25
$740.25
$951.37
$842.55
$969.62
$998.62
$1,209.74
$1,100.92
$1,227.99
$1,256.99
$1,468.11
$258.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$651.62
$905.76
$963.76
$1,386.00
$1,954.86
$909.99
$1,164.13
$1,222.13
$1,644.37
$1,168.36
$1,422.50
$1,480.50
$1,902.74
$1,426.73
$1,680.87
$1,738.87
$2,161.11
$258.37
Toc - Plan #63 SelectHealth
Silver

(HMO) Med Benchmark Silver 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$368.06
$511.60
$544.36
$782.86
$1,104.18
$659.93
$803.47
$836.23
$1,074.73
$951.80
$1,095.34
$1,128.10
$1,366.60
$1,243.67
$1,387.21
$1,419.97
$1,658.47
$291.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$736.12
$1,023.20
$1,088.72
$1,565.72
$2,208.36
$1,027.99
$1,315.07
$1,380.59
$1,857.59
$1,319.86
$1,606.94
$1,672.46
$2,149.46
$1,611.73
$1,898.81
$1,964.33
$2,441.33
$291.87
Toc - Plan #64 SelectHealth
Bronze

(HMO) Signature Benchmark Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$209.26
$290.87
$309.50
$445.10
$627.78
$375.20
$456.81
$475.44
$611.04
$541.14
$622.75
$641.38
$776.98
$707.08
$788.69
$807.32
$942.92
$165.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$418.52
$581.74
$619.00
$890.20
$1,255.56
$584.46
$747.68
$784.94
$1,056.14
$750.40
$913.62
$950.88
$1,222.08
$916.34
$1,079.56
$1,116.82
$1,388.02
$165.94
Toc - Plan #65 SelectHealth
Silver

(HMO) Signature Benchmark Silver 6300 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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
$290.22
$403.41
$429.24
$617.30
$870.66
$520.36
$633.55
$659.38
$847.44
$750.50
$863.69
$889.52
$1,077.58
$980.64
$1,093.83
$1,119.66
$1,307.72
$230.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.44
$806.82
$858.48
$1,234.60
$1,741.32
$810.58
$1,036.96
$1,088.62
$1,464.74
$1,040.72
$1,267.10
$1,318.76
$1,694.88
$1,270.86
$1,497.24
$1,548.90
$1,925.02
$230.14
Toc - Plan #66 SelectHealth
Expanded Bronze

(HMO) Signature Benchmark Expanded Bronze 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$232.91
$323.75
$344.48
$495.40
$698.73
$417.61
$508.45
$529.18
$680.10
$602.31
$693.15
$713.88
$864.80
$787.01
$877.85
$898.58
$1,049.50
$184.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$465.82
$647.50
$688.96
$990.80
$1,397.46
$650.52
$832.20
$873.66
$1,175.50
$835.22
$1,016.90
$1,058.36
$1,360.20
$1,019.92
$1,201.60
$1,243.06
$1,544.90
$184.70
Toc - Plan #67 SelectHealth
Silver

(HMO) Signature Benchmark Silver 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$317.70
$441.60
$469.88
$675.75
$953.10
$569.64
$693.54
$721.82
$927.69
$821.58
$945.48
$973.76
$1,179.63
$1,073.52
$1,197.42
$1,225.70
$1,431.57
$251.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$635.40
$883.20
$939.76
$1,351.50
$1,906.20
$887.34
$1,135.14
$1,191.70
$1,603.44
$1,139.28
$1,387.08
$1,443.64
$1,855.38
$1,391.22
$1,639.02
$1,695.58
$2,107.32
$251.94
Toc - Plan #68 SelectHealth
Gold

(HMO) Med Benchmark Gold Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$459.61
$638.86
$679.77
$977.60
$1,378.83
$824.08
$1,003.33
$1,044.24
$1,342.07
$1,188.55
$1,367.80
$1,408.71
$1,706.54
$1,553.02
$1,732.27
$1,773.18
$2,071.01
$364.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$919.22
$1,277.72
$1,359.54
$1,955.20
$2,757.66
$1,283.69
$1,642.19
$1,724.01
$2,319.67
$1,648.16
$2,006.66
$2,088.48
$2,684.14
$2,012.63
$2,371.13
$2,452.95
$3,048.61
$364.47
Toc - Plan #69 SelectHealth
Silver

(HMO) Med Benchmark Silver Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$381.32
$530.03
$563.97
$811.07
$1,143.96
$683.71
$832.42
$866.36
$1,113.46
$986.10
$1,134.81
$1,168.75
$1,415.85
$1,288.49
$1,437.20
$1,471.14
$1,718.24
$302.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.64
$1,060.06
$1,127.94
$1,622.14
$2,287.92
$1,065.03
$1,362.45
$1,430.33
$1,924.53
$1,367.42
$1,664.84
$1,732.72
$2,226.92
$1,669.81
$1,967.23
$2,035.11
$2,529.31
$302.39
Toc - Plan #70 SelectHealth
Expanded Bronze

(HMO) Med Benchmark Expanded Bronze Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$288.45
$400.94
$426.62
$613.53
$865.35
$517.19
$629.68
$655.36
$842.27
$745.93
$858.42
$884.10
$1,071.01
$974.67
$1,087.16
$1,112.84
$1,299.75
$228.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.90
$801.88
$853.24
$1,227.06
$1,730.70
$805.64
$1,030.62
$1,081.98
$1,455.80
$1,034.38
$1,259.36
$1,310.72
$1,684.54
$1,263.12
$1,488.10
$1,539.46
$1,913.28
$228.74
Toc - Plan #71 SelectHealth
Gold

(HMO) Value Benchmark Gold Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$406.86
$565.53
$601.74
$865.38
$1,220.57
$729.50
$888.17
$924.38
$1,188.02
$1,052.14
$1,210.81
$1,247.02
$1,510.66
$1,374.78
$1,533.45
$1,569.66
$1,833.30
$322.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$813.72
$1,131.06
$1,203.48
$1,730.76
$2,441.14
$1,136.36
$1,453.70
$1,526.12
$2,053.40
$1,459.00
$1,776.34
$1,848.76
$2,376.04
$1,781.64
$2,098.98
$2,171.40
$2,698.68
$322.64
Toc - Plan #72 SelectHealth
Silver

(HMO) Value Benchmark Silver Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$337.55
$469.20
$499.24
$717.97
$1,012.65
$605.23
$736.88
$766.92
$985.65
$872.91
$1,004.56
$1,034.60
$1,253.33
$1,140.59
$1,272.24
$1,302.28
$1,521.01
$267.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$675.10
$938.40
$998.48
$1,435.94
$2,025.30
$942.78
$1,206.08
$1,266.16
$1,703.62
$1,210.46
$1,473.76
$1,533.84
$1,971.30
$1,478.14
$1,741.44
$1,801.52
$2,238.98
$267.68
Toc - Plan #73 SelectHealth
Gold

(HMO) Signature Benchmark Gold Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$396.73
$551.45
$586.76
$843.84
$1,190.18
$711.33
$866.05
$901.36
$1,158.44
$1,025.93
$1,180.65
$1,215.96
$1,473.04
$1,340.53
$1,495.25
$1,530.56
$1,787.64
$314.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793.46
$1,102.90
$1,173.52
$1,687.68
$2,380.36
$1,108.06
$1,417.50
$1,488.12
$2,002.28
$1,422.66
$1,732.10
$1,802.72
$2,316.88
$1,737.26
$2,046.70
$2,117.32
$2,631.48
$314.60
Toc - Plan #74 SelectHealth
Silver

(HMO) Signature Benchmark Silver Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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
$329.15
$457.51
$486.81
$700.09
$987.44
$590.16
$718.52
$747.82
$961.10
$851.17
$979.53
$1,008.83
$1,222.11
$1,112.18
$1,240.54
$1,269.84
$1,483.12
$261.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$658.30
$915.02
$973.62
$1,400.18
$1,974.88
$919.31
$1,176.03
$1,234.63
$1,661.19
$1,180.32
$1,437.04
$1,495.64
$1,922.20
$1,441.33
$1,698.05
$1,756.65
$2,183.21
$261.01
Toc - Plan #75 SelectHealth
Gold

(HMO) Value Benchmark Gold 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$388.08
$539.43
$573.97
$825.45
$1,164.24
$695.83
$847.18
$881.72
$1,133.20
$1,003.58
$1,154.93
$1,189.47
$1,440.95
$1,311.33
$1,462.68
$1,497.22
$1,748.70
$307.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.16
$1,078.86
$1,147.94
$1,650.90
$2,328.48
$1,083.91
$1,386.61
$1,455.69
$1,958.65
$1,391.66
$1,694.36
$1,763.44
$2,266.40
$1,699.41
$2,002.11
$2,071.19
$2,574.15
$307.75
Toc - Plan #76 SelectHealth
Gold

(HMO) Med Benchmark Gold 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$438.40
$609.38
$648.40
$932.48
$1,315.20
$786.05
$957.03
$996.05
$1,280.13
$1,133.70
$1,304.68
$1,343.70
$1,627.78
$1,481.35
$1,652.33
$1,691.35
$1,975.43
$347.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$876.80
$1,218.76
$1,296.80
$1,864.96
$2,630.40
$1,224.45
$1,566.41
$1,644.45
$2,212.61
$1,572.10
$1,914.06
$1,992.10
$2,560.26
$1,919.75
$2,261.71
$2,339.75
$2,907.91
$347.65
Toc - Plan #77 SelectHealth
Gold

(HMO) Signature Benchmark Gold 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$378.42
$526.00
$559.68
$804.90
$1,135.26
$678.51
$826.09
$859.77
$1,104.99
$978.60
$1,126.18
$1,159.86
$1,405.08
$1,278.69
$1,426.27
$1,459.95
$1,705.17
$300.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.84
$1,052.00
$1,119.36
$1,609.80
$2,270.52
$1,056.93
$1,352.09
$1,419.45
$1,909.89
$1,357.02
$1,652.18
$1,719.54
$2,209.98
$1,657.11
$1,952.27
$2,019.63
$2,510.07
$300.09
Toc - Plan #78 SelectHealth
Platinum

(HMO) Value Benchmark Platinum 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$459.76
$639.06
$679.98
$977.91
$1,379.28
$824.35
$1,003.65
$1,044.57
$1,342.50
$1,188.94
$1,368.24
$1,409.16
$1,707.09
$1,553.53
$1,732.83
$1,773.75
$2,071.68
$364.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$919.52
$1,278.12
$1,359.96
$1,955.82
$2,758.56
$1,284.11
$1,642.71
$1,724.55
$2,320.41
$1,648.70
$2,007.30
$2,089.14
$2,685.00
$2,013.29
$2,371.89
$2,453.73
$3,049.59
$364.59
Toc - Plan #79 SelectHealth
Platinum

(HMO) Med Benchmark Platinum 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$519.37
$721.93
$768.16
$1,104.71
$1,558.11
$931.23
$1,133.79
$1,180.02
$1,516.57
$1,343.09
$1,545.65
$1,591.88
$1,928.43
$1,754.95
$1,957.51
$2,003.74
$2,340.29
$411.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,038.74
$1,443.86
$1,536.32
$2,209.42
$3,116.22
$1,450.60
$1,855.72
$1,948.18
$2,621.28
$1,862.46
$2,267.58
$2,360.04
$3,033.14
$2,274.32
$2,679.44
$2,771.90
$3,445.00
$411.86
Toc - Plan #80 SelectHealth
Platinum

(HMO) Signature Benchmark Platinum 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$448.31
$623.15
$663.05
$953.56
$1,344.93
$803.82
$978.66
$1,018.56
$1,309.07
$1,159.33
$1,334.17
$1,374.07
$1,664.58
$1,514.84
$1,689.68
$1,729.58
$2,020.09
$355.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.62
$1,246.30
$1,326.10
$1,907.12
$2,689.86
$1,252.13
$1,601.81
$1,681.61
$2,262.63
$1,607.64
$1,957.32
$2,037.12
$2,618.14
$1,963.15
$2,312.83
$2,392.63
$2,973.65
$355.51
Toc - Plan #81 SelectHealth
Platinum

(HMO) Med Benchmark Platinum Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 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
$551.21
$766.18
$815.24
$1,172.42
$1,653.63
$988.32
$1,203.29
$1,252.35
$1,609.53
$1,425.43
$1,640.40
$1,689.46
$2,046.64
$1,862.54
$2,077.51
$2,126.57
$2,483.75
$437.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,102.42
$1,532.36
$1,630.48
$2,344.84
$3,307.26
$1,539.53
$1,969.47
$2,067.59
$2,781.95
$1,976.64
$2,406.58
$2,504.70
$3,219.06
$2,413.75
$2,843.69
$2,941.81
$3,656.17
$437.11
Toc - Plan #82 SelectHealth
Platinum

(HMO) Value Benchmark Platinum Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$487.94
$678.24
$721.66
$1,037.85
$1,463.82
$874.88
$1,065.18
$1,108.60
$1,424.79
$1,261.82
$1,452.12
$1,495.54
$1,811.73
$1,648.76
$1,839.06
$1,882.48
$2,198.67
$386.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$975.88
$1,356.48
$1,443.32
$2,075.70
$2,927.64
$1,362.82
$1,743.42
$1,830.26
$2,462.64
$1,749.76
$2,130.36
$2,217.20
$2,849.58
$2,136.70
$2,517.30
$2,604.14
$3,236.52
$386.94
Toc - Plan #83 SelectHealth
Platinum

(HMO) Signature Benchmark Platinum Standardized Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$475.79
$661.35
$703.70
$1,012.01
$1,427.37
$853.09
$1,038.65
$1,081.00
$1,389.31
$1,230.39
$1,415.95
$1,458.30
$1,766.61
$1,607.69
$1,793.25
$1,835.60
$2,143.91
$377.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$951.58
$1,322.70
$1,407.40
$2,024.02
$2,854.74
$1,328.88
$1,700.00
$1,784.70
$2,401.32
$1,706.18
$2,077.30
$2,162.00
$2,778.62
$2,083.48
$2,454.60
$2,539.30
$3,155.92
$377.30

ADVERTISEMENT

Cigna Healthcare

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

Toc - Plan #84 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 4200

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
$278.96
$387.76
$412.59
$593.35
$836.88
$500.18
$608.98
$633.81
$814.57
$721.40
$830.20
$855.03
$1,035.79
$942.62
$1,051.42
$1,076.25
$1,257.01
$221.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$557.92
$775.52
$825.18
$1,186.70
$1,673.76
$779.14
$996.74
$1,046.40
$1,407.92
$1,000.36
$1,217.96
$1,267.62
$1,629.14
$1,221.58
$1,439.18
$1,488.84
$1,850.36
$221.22
Toc - Plan #85 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$289.87
$402.92
$428.72
$616.56
$869.61
$519.74
$632.79
$658.59
$846.43
$749.61
$862.66
$888.46
$1,076.30
$979.48
$1,092.53
$1,118.33
$1,306.17
$229.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$579.74
$805.84
$857.44
$1,233.12
$1,739.22
$809.61
$1,035.71
$1,087.31
$1,462.99
$1,039.48
$1,265.58
$1,317.18
$1,692.86
$1,269.35
$1,495.45
$1,547.05
$1,922.73
$229.87
Toc - Plan #86 Cigna Healthcare
Silver

(EPO) Cigna Connect 1900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354.74
$493.09
$524.66
$754.54
$1,064.22
$636.05
$774.40
$805.97
$1,035.85
$917.36
$1,055.71
$1,087.28
$1,317.16
$1,198.67
$1,337.02
$1,368.59
$1,598.47
$281.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.48
$986.18
$1,049.32
$1,509.08
$2,128.44
$990.79
$1,267.49
$1,330.63
$1,790.39
$1,272.10
$1,548.80
$1,611.94
$2,071.70
$1,553.41
$1,830.11
$1,893.25
$2,353.01
$281.31
Toc - Plan #87 Cigna Healthcare
Silver

(EPO) Cigna Connect 800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$800 $1,600 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
$358.10
$497.75
$529.62
$761.67
$1,074.29
$642.07
$781.72
$813.59
$1,045.64
$926.04
$1,065.69
$1,097.56
$1,329.61
$1,210.01
$1,349.66
$1,381.53
$1,613.58
$283.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716.20
$995.50
$1,059.24
$1,523.34
$2,148.58
$1,000.17
$1,279.47
$1,343.21
$1,807.31
$1,284.14
$1,563.44
$1,627.18
$2,091.28
$1,568.11
$1,847.41
$1,911.15
$2,375.25
$283.97
Toc - Plan #88 Cigna Healthcare
Gold

(EPO) Cigna Connect 500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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
$439.73
$611.23
$650.37
$935.32
$1,319.19
$788.44
$959.94
$999.08
$1,284.03
$1,137.15
$1,308.65
$1,347.79
$1,632.74
$1,485.86
$1,657.36
$1,696.50
$1,981.45
$348.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.46
$1,222.46
$1,300.74
$1,870.64
$2,638.38
$1,228.17
$1,571.17
$1,649.45
$2,219.35
$1,576.88
$1,919.88
$1,998.16
$2,568.06
$1,925.59
$2,268.59
$2,346.87
$2,916.77
$348.71
Toc - Plan #89 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
$360.13
$500.59
$532.64
$766.00
$1,080.39
$645.72
$786.18
$818.23
$1,051.59
$931.31
$1,071.77
$1,103.82
$1,337.18
$1,216.90
$1,357.36
$1,389.41
$1,622.77
$285.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.26
$1,001.18
$1,065.28
$1,532.00
$2,160.78
$1,005.85
$1,286.77
$1,350.87
$1,817.59
$1,291.44
$1,572.36
$1,636.46
$2,103.18
$1,577.03
$1,857.95
$1,922.05
$2,388.77
$285.59
Toc - Plan #90 Cigna Healthcare
Silver

(EPO) Cigna Connect 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.52
$498.34
$530.25
$762.57
$1,075.56
$642.83
$782.65
$814.56
$1,046.88
$927.14
$1,066.96
$1,098.87
$1,331.19
$1,211.45
$1,351.27
$1,383.18
$1,615.50
$284.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.04
$996.68
$1,060.50
$1,525.14
$2,151.12
$1,001.35
$1,280.99
$1,344.81
$1,809.45
$1,285.66
$1,565.30
$1,629.12
$2,093.76
$1,569.97
$1,849.61
$1,913.43
$2,378.07
$284.31
Toc - Plan #91 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
$283.34
$393.84
$419.05
$602.65
$850.01
$508.02
$618.52
$643.73
$827.33
$732.70
$843.20
$868.41
$1,052.01
$957.38
$1,067.88
$1,093.09
$1,276.69
$224.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$566.68
$787.68
$838.10
$1,205.30
$1,700.02
$791.36
$1,012.36
$1,062.78
$1,429.98
$1,016.04
$1,237.04
$1,287.46
$1,654.66
$1,240.72
$1,461.72
$1,512.14
$1,879.34
$224.68
Toc - Plan #92 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect HSA 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 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
$284.86
$395.96
$421.31
$605.91
$854.58
$510.76
$621.86
$647.21
$831.81
$736.66
$847.76
$873.11
$1,057.71
$962.56
$1,073.66
$1,099.01
$1,283.61
$225.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$569.72
$791.92
$842.62
$1,211.82
$1,709.16
$795.62
$1,017.82
$1,068.52
$1,437.72
$1,021.52
$1,243.72
$1,294.42
$1,663.62
$1,247.42
$1,469.62
$1,520.32
$1,889.52
$225.90
Toc - Plan #93 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
$283.51
$394.07
$419.30
$603.02
$850.52
$508.33
$618.89
$644.12
$827.84
$733.15
$843.71
$868.94
$1,052.66
$957.97
$1,068.53
$1,093.76
$1,277.48
$224.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$567.02
$788.14
$838.60
$1,206.04
$1,701.04
$791.84
$1,012.96
$1,063.42
$1,430.86
$1,016.66
$1,237.78
$1,288.24
$1,655.68
$1,241.48
$1,462.60
$1,513.06
$1,880.50
$224.82
Toc - Plan #94 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
$358.22
$497.93
$529.81
$761.94
$1,074.66
$642.29
$782.00
$813.88
$1,046.01
$926.36
$1,066.07
$1,097.95
$1,330.08
$1,210.43
$1,350.14
$1,382.02
$1,614.15
$284.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716.44
$995.86
$1,059.62
$1,523.88
$2,149.32
$1,000.51
$1,279.93
$1,343.69
$1,807.95
$1,284.58
$1,564.00
$1,627.76
$2,092.02
$1,568.65
$1,848.07
$1,911.83
$2,376.09
$284.07
Toc - Plan #95 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
$356.74
$495.87
$527.61
$758.78
$1,070.21
$639.63
$778.76
$810.50
$1,041.67
$922.52
$1,061.65
$1,093.39
$1,324.56
$1,205.41
$1,344.54
$1,376.28
$1,607.45
$282.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.48
$991.74
$1,055.22
$1,517.56
$2,140.42
$996.37
$1,274.63
$1,338.11
$1,800.45
$1,279.26
$1,557.52
$1,621.00
$2,083.34
$1,562.15
$1,840.41
$1,903.89
$2,366.23
$282.89
Toc - Plan #96 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 0

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
$302.18
$420.04
$446.93
$642.75
$906.54
$541.81
$659.67
$686.56
$882.38
$781.44
$899.30
$926.19
$1,122.01
$1,021.07
$1,138.93
$1,165.82
$1,361.64
$239.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.36
$840.08
$893.86
$1,285.50
$1,813.08
$843.99
$1,079.71
$1,133.49
$1,525.13
$1,083.62
$1,319.34
$1,373.12
$1,764.76
$1,323.25
$1,558.97
$1,612.75
$2,004.39
$239.63
Toc - Plan #97 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
$435.62
$605.51
$644.28
$926.56
$1,306.85
$781.06
$950.95
$989.72
$1,272.00
$1,126.50
$1,296.39
$1,335.16
$1,617.44
$1,471.94
$1,641.83
$1,680.60
$1,962.88
$345.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871.24
$1,211.02
$1,288.56
$1,853.12
$2,613.70
$1,216.68
$1,556.46
$1,634.00
$2,198.56
$1,562.12
$1,901.90
$1,979.44
$2,544.00
$1,907.56
$2,247.34
$2,324.88
$2,889.44
$345.44
Toc - Plan #98 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
$270.98
$376.66
$400.78
$576.38
$812.94
$485.87
$591.55
$615.67
$791.27
$700.76
$806.44
$830.56
$1,006.16
$915.65
$1,021.33
$1,045.45
$1,221.05
$214.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$541.96
$753.32
$801.56
$1,152.76
$1,625.88
$756.85
$968.21
$1,016.45
$1,367.65
$971.74
$1,183.10
$1,231.34
$1,582.54
$1,186.63
$1,397.99
$1,446.23
$1,797.43
$214.89
Toc - Plan #99 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
$282.44
$392.60
$417.73
$600.76
$847.32
$506.42
$616.58
$641.71
$824.74
$730.40
$840.56
$865.69
$1,048.72
$954.38
$1,064.54
$1,089.67
$1,272.70
$223.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$564.88
$785.20
$835.46
$1,201.52
$1,694.64
$788.86
$1,009.18
$1,059.44
$1,425.50
$1,012.84
$1,233.16
$1,283.42
$1,649.48
$1,236.82
$1,457.14
$1,507.40
$1,873.46
$223.98

‡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 Salt Lake County here.

Salt Lake County is in “Rating Area 3” of Utah.

Currently, there are 99 plans offered in Rating Area 3.

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2023 Obamacare Plans for Salt Lake County, UT

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