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Molina Healthcare

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

Toc - Plan #1 Molina Healthcare
Gold

(HMO) Gold 1

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

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 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
$360.81
$501.53
$533.64
$767.45
$1,082.43
$646.94
$787.66
$819.77
$1,053.58
$933.07
$1,073.79
$1,105.90
$1,339.71
$1,219.20
$1,359.92
$1,392.03
$1,625.84
$286.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.62
$1,003.06
$1,067.28
$1,534.90
$2,164.86
$1,007.75
$1,289.19
$1,353.41
$1,821.03
$1,293.88
$1,575.32
$1,639.54
$2,107.16
$1,580.01
$1,861.45
$1,925.67
$2,393.29
$286.13
Toc - Plan #2 Molina Healthcare
Silver

(HMO) Silver 1

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 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
$375.38
$521.78
$555.19
$798.44
$1,126.14
$673.06
$819.46
$852.87
$1,096.12
$970.74
$1,117.14
$1,150.55
$1,393.80
$1,268.42
$1,414.82
$1,448.23
$1,691.48
$297.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.76
$1,043.56
$1,110.38
$1,596.88
$2,252.28
$1,048.44
$1,341.24
$1,408.06
$1,894.56
$1,346.12
$1,638.92
$1,705.74
$2,192.24
$1,643.80
$1,936.60
$2,003.42
$2,489.92
$297.68
Toc - Plan #3 Molina Healthcare
Gold

(HMO) Gold 8

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$374.37
$520.37
$553.69
$796.27
$1,123.10
$671.24
$817.24
$850.56
$1,093.14
$968.11
$1,114.11
$1,147.43
$1,390.01
$1,264.98
$1,410.98
$1,444.30
$1,686.88
$296.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$748.74
$1,040.74
$1,107.38
$1,592.54
$2,246.20
$1,045.61
$1,337.61
$1,404.25
$1,889.41
$1,342.48
$1,634.48
$1,701.12
$2,186.28
$1,639.35
$1,931.35
$1,997.99
$2,483.15
$296.87
Toc - Plan #4 Molina Healthcare
Silver

(HMO) Silver 8

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

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
$384.83
$534.91
$569.16
$818.53
$1,154.49
$690.00
$840.08
$874.33
$1,123.70
$995.17
$1,145.25
$1,179.50
$1,428.87
$1,300.34
$1,450.42
$1,484.67
$1,734.04
$305.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$769.66
$1,069.82
$1,138.32
$1,637.06
$2,308.98
$1,074.83
$1,374.99
$1,443.49
$1,942.23
$1,380.00
$1,680.16
$1,748.66
$2,247.40
$1,685.17
$1,985.33
$2,053.83
$2,552.57
$305.17
Toc - Plan #5 Molina Healthcare
Silver

(HMO) Silver 12 with First 4 Primary Care Visits Free

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$371.12
$515.85
$548.88
$789.37
$1,113.35
$665.42
$810.15
$843.18
$1,083.67
$959.72
$1,104.45
$1,137.48
$1,377.97
$1,254.02
$1,398.75
$1,431.78
$1,672.27
$294.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.24
$1,031.70
$1,097.76
$1,578.74
$2,226.70
$1,036.54
$1,326.00
$1,392.06
$1,873.04
$1,330.84
$1,620.30
$1,686.36
$2,167.34
$1,625.14
$1,914.60
$1,980.66
$2,461.64
$294.30
Toc - Plan #6 Molina Healthcare
Gold

(HMO) Gold 1 with Adult Vision Services

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

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 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
$363.97
$505.92
$538.31
$774.16
$1,091.91
$652.60
$794.55
$826.94
$1,062.79
$941.23
$1,083.18
$1,115.57
$1,351.42
$1,229.86
$1,371.81
$1,404.20
$1,640.05
$288.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.94
$1,011.84
$1,076.62
$1,548.32
$2,183.82
$1,016.57
$1,300.47
$1,365.25
$1,836.95
$1,305.20
$1,589.10
$1,653.88
$2,125.58
$1,593.83
$1,877.73
$1,942.51
$2,414.21
$288.63
Toc - Plan #7 Molina Healthcare
Silver

(HMO) Silver 1 with Adult Vision Services

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 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
$378.84
$526.59
$560.31
$805.80
$1,136.52
$679.26
$827.01
$860.73
$1,106.22
$979.68
$1,127.43
$1,161.15
$1,406.64
$1,280.10
$1,427.85
$1,461.57
$1,707.06
$300.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.68
$1,053.18
$1,120.62
$1,611.60
$2,273.04
$1,058.10
$1,353.60
$1,421.04
$1,912.02
$1,358.52
$1,654.02
$1,721.46
$2,212.44
$1,658.94
$1,954.44
$2,021.88
$2,512.86
$300.42

ADVERTISEMENT

Regence BlueCross BlueShield of Utah

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

Toc - Plan #8 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 4500 Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.71
$498.61
$530.54
$762.98
$1,076.13
$643.17
$783.07
$815.00
$1,047.44
$927.63
$1,067.53
$1,099.46
$1,331.90
$1,212.09
$1,351.99
$1,383.92
$1,616.36
$284.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.42
$997.22
$1,061.08
$1,525.96
$2,152.26
$1,001.88
$1,281.68
$1,345.54
$1,810.42
$1,286.34
$1,566.14
$1,630.00
$2,094.88
$1,570.80
$1,850.60
$1,914.46
$2,379.34
$284.46
Toc - Plan #9 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 6500 Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$348.28
$484.10
$515.10
$740.79
$1,044.83
$624.46
$760.28
$791.28
$1,016.97
$900.64
$1,036.46
$1,067.46
$1,293.15
$1,176.82
$1,312.64
$1,343.64
$1,569.33
$276.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696.56
$968.20
$1,030.20
$1,481.58
$2,089.66
$972.74
$1,244.38
$1,306.38
$1,757.76
$1,248.92
$1,520.56
$1,582.56
$2,033.94
$1,525.10
$1,796.74
$1,858.74
$2,310.12
$276.18
Toc - Plan #10 Regence BlueCross BlueShield of Utah
Gold

(EPO) Gold 2500 Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370.61
$515.15
$548.13
$788.29
$1,111.83
$664.51
$809.05
$842.03
$1,082.19
$958.41
$1,102.95
$1,135.93
$1,376.09
$1,252.31
$1,396.85
$1,429.83
$1,669.99
$293.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$741.22
$1,030.30
$1,096.26
$1,576.58
$2,223.66
$1,035.12
$1,324.20
$1,390.16
$1,870.48
$1,329.02
$1,618.10
$1,684.06
$2,164.38
$1,622.92
$1,912.00
$1,977.96
$2,458.28
$293.90
Toc - Plan #11 Regence BlueCross BlueShield of Utah
Silver

(EPO) SaveWell Silver 5000 Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.71
$498.61
$530.54
$762.98
$1,076.13
$643.17
$783.07
$815.00
$1,047.44
$927.63
$1,067.53
$1,099.46
$1,331.90
$1,212.09
$1,351.99
$1,383.92
$1,616.36
$284.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.42
$997.22
$1,061.08
$1,525.96
$2,152.26
$1,001.88
$1,281.68
$1,345.54
$1,810.42
$1,286.34
$1,566.14
$1,630.00
$2,094.88
$1,570.80
$1,850.60
$1,914.46
$2,379.34
$284.46
Toc - Plan #12 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) SaveWell Bronze 7500 Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$255.32
$354.90
$377.62
$543.07
$765.96
$457.79
$557.37
$580.09
$745.54
$660.26
$759.84
$782.56
$948.01
$862.73
$962.31
$985.03
$1,150.48
$202.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$510.64
$709.80
$755.24
$1,086.14
$1,531.92
$713.11
$912.27
$957.71
$1,288.61
$915.58
$1,114.74
$1,160.18
$1,491.08
$1,118.05
$1,317.21
$1,362.65
$1,693.55
$202.47
Toc - Plan #13 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) SaveWell Bronze 8500 Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$248.58
$345.53
$367.65
$528.73
$745.73
$445.70
$542.65
$564.77
$725.85
$642.82
$739.77
$761.89
$922.97
$839.94
$936.89
$959.01
$1,120.09
$197.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$497.16
$691.06
$735.30
$1,057.46
$1,491.46
$694.28
$888.18
$932.42
$1,254.58
$891.40
$1,085.30
$1,129.54
$1,451.70
$1,088.52
$1,282.42
$1,326.66
$1,648.82
$197.12
Toc - Plan #14 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze HSA 7000 Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,050 $16,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$272.73
$379.09
$403.36
$580.08
$818.18
$489.00
$595.36
$619.63
$796.35
$705.27
$811.63
$835.90
$1,012.62
$921.54
$1,027.90
$1,052.17
$1,228.89
$216.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$545.46
$758.18
$806.72
$1,160.16
$1,636.36
$761.73
$974.45
$1,022.99
$1,376.43
$978.00
$1,190.72
$1,239.26
$1,592.70
$1,194.27
$1,406.99
$1,455.53
$1,808.97
$216.27
Toc - Plan #15 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze Essential 8500 Deductible 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$255.96
$355.79
$378.57
$544.43
$767.88
$458.94
$558.77
$581.55
$747.41
$661.92
$761.75
$784.53
$950.39
$864.90
$964.73
$987.51
$1,153.37
$202.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$511.92
$711.58
$757.14
$1,088.86
$1,535.76
$714.90
$914.56
$960.12
$1,291.84
$917.88
$1,117.54
$1,163.10
$1,494.82
$1,120.86
$1,320.52
$1,366.08
$1,697.80
$202.98
Toc - Plan #16 Regence BlueCross BlueShield of Utah
Gold

(EPO) Regence Standard Gold 1500 Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$397.28
$552.22
$587.58
$845.02
$1,191.84
$712.32
$867.26
$902.62
$1,160.06
$1,027.36
$1,182.30
$1,217.66
$1,475.10
$1,342.40
$1,497.34
$1,532.70
$1,790.14
$315.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$794.56
$1,104.44
$1,175.16
$1,690.04
$2,383.68
$1,109.60
$1,419.48
$1,490.20
$2,005.08
$1,424.64
$1,734.52
$1,805.24
$2,320.12
$1,739.68
$2,049.56
$2,120.28
$2,635.16
$315.04
Toc - Plan #17 Regence BlueCross BlueShield of Utah
Silver

(EPO) Regence Standard Silver 5900 Deductible

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

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
$353.14
$490.87
$522.30
$751.13
$1,059.42
$633.18
$770.91
$802.34
$1,031.17
$913.22
$1,050.95
$1,082.38
$1,311.21
$1,193.26
$1,330.99
$1,362.42
$1,591.25
$280.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.28
$981.74
$1,044.60
$1,502.26
$2,118.84
$986.32
$1,261.78
$1,324.64
$1,782.30
$1,266.36
$1,541.82
$1,604.68
$2,062.34
$1,546.40
$1,821.86
$1,884.72
$2,342.38
$280.04
Toc - Plan #18 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Regence Standard Bronze 7500 Deductible

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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$266.40
$370.29
$394.01
$566.62
$799.19
$477.65
$581.54
$605.26
$777.87
$688.90
$792.79
$816.51
$989.12
$900.15
$1,004.04
$1,027.76
$1,200.37
$211.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$532.80
$740.58
$788.02
$1,133.24
$1,598.38
$744.05
$951.83
$999.27
$1,344.49
$955.30
$1,163.08
$1,210.52
$1,555.74
$1,166.55
$1,374.33
$1,421.77
$1,766.99
$211.25
Toc - Plan #19 Regence BlueCross BlueShield of Utah
Gold

(EPO) SaveWell Standard Gold 1500 Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$387.55
$538.70
$573.19
$824.32
$1,162.65
$694.88
$846.03
$880.52
$1,131.65
$1,002.21
$1,153.36
$1,187.85
$1,438.98
$1,309.54
$1,460.69
$1,495.18
$1,746.31
$307.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.10
$1,077.40
$1,146.38
$1,648.64
$2,325.30
$1,082.43
$1,384.73
$1,453.71
$1,955.97
$1,389.76
$1,692.06
$1,761.04
$2,263.30
$1,697.09
$1,999.39
$2,068.37
$2,570.63
$307.33
Toc - Plan #20 Regence BlueCross BlueShield of Utah
Silver

(EPO) SaveWell Standard Silver 5900 Deductible

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

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
$344.47
$478.81
$509.47
$732.69
$1,033.41
$617.63
$751.97
$782.63
$1,005.85
$890.79
$1,025.13
$1,055.79
$1,279.01
$1,163.95
$1,298.29
$1,328.95
$1,552.17
$273.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.94
$957.62
$1,018.94
$1,465.38
$2,066.82
$962.10
$1,230.78
$1,292.10
$1,738.54
$1,235.26
$1,503.94
$1,565.26
$2,011.70
$1,508.42
$1,777.10
$1,838.42
$2,284.86
$273.16
Toc - Plan #21 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) SaveWell Standard Bronze 7500 Deductible

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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$259.83
$361.16
$384.29
$552.65
$779.48
$465.88
$567.21
$590.34
$758.70
$671.93
$773.26
$796.39
$964.75
$877.98
$979.31
$1,002.44
$1,170.80
$206.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$519.66
$722.32
$768.58
$1,105.30
$1,558.96
$725.71
$928.37
$974.63
$1,311.35
$931.76
$1,134.42
$1,180.68
$1,517.40
$1,137.81
$1,340.47
$1,386.73
$1,723.45
$206.05

ADVERTISEMENT

BridgeSpan Health Company

Local: 1-855-857-9945 | Toll Free: 1-855-857-9945 | TTY: 1-800-735-2900

Toc - Plan #22 BridgeSpan Health Company
Gold

(HMO) BridgeSpan Standard Gold Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9945

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$402.59
$559.60
$595.43
$856.31
$1,207.77
$721.85
$878.86
$914.69
$1,175.57
$1,041.11
$1,198.12
$1,233.95
$1,494.83
$1,360.37
$1,517.38
$1,553.21
$1,814.09
$319.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.18
$1,119.20
$1,190.86
$1,712.62
$2,415.54
$1,124.44
$1,438.46
$1,510.12
$2,031.88
$1,443.70
$1,757.72
$1,829.38
$2,351.14
$1,762.96
$2,076.98
$2,148.64
$2,670.40
$319.26
Toc - Plan #23 BridgeSpan Health Company
Silver

(HMO) BridgeSpan Standard Silver Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9945

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
$357.84
$497.40
$529.25
$761.13
$1,073.52
$641.61
$781.17
$813.02
$1,044.90
$925.38
$1,064.94
$1,096.79
$1,328.67
$1,209.15
$1,348.71
$1,380.56
$1,612.44
$283.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.68
$994.80
$1,058.50
$1,522.26
$2,147.04
$999.45
$1,278.57
$1,342.27
$1,806.03
$1,283.22
$1,562.34
$1,626.04
$2,089.80
$1,566.99
$1,846.11
$1,909.81
$2,373.57
$283.77
Toc - Plan #24 BridgeSpan Health Company
Expanded Bronze

(HMO) BridgeSpan Standard Bronze Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9945

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$270.37
$375.82
$399.88
$575.08
$811.11
$484.77
$590.22
$614.28
$789.48
$699.17
$804.62
$828.68
$1,003.88
$913.57
$1,019.02
$1,043.08
$1,218.28
$214.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$540.74
$751.64
$799.76
$1,150.16
$1,622.22
$755.14
$966.04
$1,014.16
$1,364.56
$969.54
$1,180.44
$1,228.56
$1,578.96
$1,183.94
$1,394.84
$1,442.96
$1,793.36
$214.40

ADVERTISEMENT

Aetna CVS Health

Local: 1-844-365-7373 | Toll Free: 1-844-365-7373

Toc - Plan #25 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 2 HSA: Aetna network of doctors & hospitals + MinuteClinic + Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 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
$227.20
$315.81
$336.03
$483.26
$681.60
$407.37
$495.98
$516.20
$663.43
$587.54
$676.15
$696.37
$843.60
$767.71
$856.32
$876.54
$1,023.77
$180.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$454.40
$631.62
$672.06
$966.52
$1,363.20
$634.57
$811.79
$852.23
$1,146.69
$814.74
$991.96
$1,032.40
$1,326.86
$994.91
$1,172.13
$1,212.57
$1,507.03
$180.17
Toc - Plan #26 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,395 $18,790 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$255.24
$354.79
$377.50
$542.90
$765.72
$457.65
$557.20
$579.91
$745.31
$660.06
$759.61
$782.32
$947.72
$862.47
$962.02
$984.73
$1,150.13
$202.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$510.48
$709.58
$755.00
$1,085.80
$1,531.44
$712.89
$911.99
$957.41
$1,288.21
$915.30
$1,114.40
$1,159.82
$1,490.62
$1,117.71
$1,316.81
$1,362.23
$1,693.03
$202.41
Toc - Plan #27 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$256.23
$356.16
$378.96
$544.99
$768.67
$459.42
$559.35
$582.15
$748.18
$662.61
$762.54
$785.34
$951.37
$865.80
$965.73
$988.53
$1,154.56
$203.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$512.46
$712.32
$757.92
$1,089.98
$1,537.34
$715.65
$915.51
$961.11
$1,293.17
$918.84
$1,118.70
$1,164.30
$1,496.36
$1,122.03
$1,321.89
$1,367.49
$1,699.55
$203.19
Toc - Plan #28 Aetna CVS Health
Gold

(HMO) Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,445 $18,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.97
$473.95
$504.30
$725.24
$1,022.91
$611.36
$744.34
$774.69
$995.63
$881.75
$1,014.73
$1,045.08
$1,266.02
$1,152.14
$1,285.12
$1,315.47
$1,536.41
$270.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$681.94
$947.90
$1,008.60
$1,450.48
$2,045.82
$952.33
$1,218.29
$1,278.99
$1,720.87
$1,222.72
$1,488.68
$1,549.38
$1,991.26
$1,493.11
$1,759.07
$1,819.77
$2,261.65
$270.39
Toc - Plan #29 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$369.73
$513.92
$546.83
$786.41
$1,109.18
$662.93
$807.12
$840.03
$1,079.61
$956.13
$1,100.32
$1,133.23
$1,372.81
$1,249.33
$1,393.52
$1,426.43
$1,666.01
$293.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$739.46
$1,027.84
$1,093.66
$1,572.82
$2,218.36
$1,032.66
$1,321.04
$1,386.86
$1,866.02
$1,325.86
$1,614.24
$1,680.06
$2,159.22
$1,619.06
$1,907.44
$1,973.26
$2,452.42
$293.20
Toc - Plan #30 Aetna CVS Health
Silver

(HMO) Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$7,495 $14,990 Annual Deductible
$9,075 $18,150 Maximum Out of Pocket Per 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
$432.52
$460.21
$661.84
$933.48
$557.91
$679.27
$706.96
$908.59
$804.66
$926.02
$953.71
$1,155.34
$1,051.41
$1,172.77
$1,200.46
$1,402.09
$246.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$622.32
$865.04
$920.42
$1,323.68
$1,866.96
$869.07
$1,111.79
$1,167.17
$1,570.43
$1,115.82
$1,358.54
$1,413.92
$1,817.18
$1,362.57
$1,605.29
$1,660.67
$2,063.93
$246.75
Toc - Plan #31 Aetna CVS Health
Silver

(HMO) Silver 7: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$7,945 $15,890 Annual Deductible
$8,695 $17,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.43
$431.49
$459.12
$660.27
$931.27
$556.60
$677.66
$705.29
$906.44
$802.77
$923.83
$951.46
$1,152.61
$1,048.94
$1,170.00
$1,197.63
$1,398.78
$246.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.86
$862.98
$918.24
$1,320.54
$1,862.54
$867.03
$1,109.15
$1,164.41
$1,566.71
$1,113.20
$1,355.32
$1,410.58
$1,812.88
$1,359.37
$1,601.49
$1,656.75
$2,059.05
$246.17
Toc - Plan #32 Aetna CVS Health
Silver

(HMO) Silver 6: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,675 $17,350 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.17
$431.13
$458.73
$659.72
$930.49
$556.13
$677.09
$704.69
$905.68
$802.09
$923.05
$950.65
$1,151.64
$1,048.05
$1,169.01
$1,196.61
$1,397.60
$245.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.34
$862.26
$917.46
$1,319.44
$1,860.98
$866.30
$1,108.22
$1,163.42
$1,565.40
$1,112.26
$1,354.18
$1,409.38
$1,811.36
$1,358.22
$1,600.14
$1,655.34
$2,057.32
$245.96
Toc - Plan #33 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

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
$340.09
$472.72
$502.99
$723.37
$1,020.26
$609.78
$742.41
$772.68
$993.06
$879.47
$1,012.10
$1,042.37
$1,262.75
$1,149.16
$1,281.79
$1,312.06
$1,532.44
$269.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.18
$945.44
$1,005.98
$1,446.74
$2,040.52
$949.87
$1,215.13
$1,275.67
$1,716.43
$1,219.56
$1,484.82
$1,545.36
$1,986.12
$1,489.25
$1,754.51
$1,815.05
$2,255.81
$269.69

ADVERTISEMENT

University of Utah Health Plans

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

Toc - Plan #34 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
$461.25
$641.14
$682.19
$981.08
$1,383.75
$827.02
$1,006.91
$1,047.96
$1,346.85
$1,192.79
$1,372.68
$1,413.73
$1,712.62
$1,558.56
$1,738.45
$1,779.50
$2,078.39
$365.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$922.50
$1,282.28
$1,364.38
$1,962.16
$2,767.50
$1,288.27
$1,648.05
$1,730.15
$2,327.93
$1,654.04
$2,013.82
$2,095.92
$2,693.70
$2,019.81
$2,379.59
$2,461.69
$3,059.47
$365.77
Toc - Plan #35 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
$5,000 $10,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$420.39
$584.34
$621.76
$894.17
$1,261.17
$753.76
$917.71
$955.13
$1,227.54
$1,087.13
$1,251.08
$1,288.50
$1,560.91
$1,420.50
$1,584.45
$1,621.87
$1,894.28
$333.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$840.78
$1,168.68
$1,243.52
$1,788.34
$2,522.34
$1,174.15
$1,502.05
$1,576.89
$2,121.71
$1,507.52
$1,835.42
$1,910.26
$2,455.08
$1,840.89
$2,168.79
$2,243.63
$2,788.45
$333.37
Toc - Plan #36 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
$8,050 $16,100 Annual Deductible
$8,050 $16,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$281.76
$391.65
$416.72
$599.30
$845.28
$505.20
$615.09
$640.16
$822.74
$728.64
$838.53
$863.60
$1,046.18
$952.08
$1,061.97
$1,087.04
$1,269.62
$223.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$563.52
$783.30
$833.44
$1,198.60
$1,690.56
$786.96
$1,006.74
$1,056.88
$1,422.04
$1,010.40
$1,230.18
$1,280.32
$1,645.48
$1,233.84
$1,453.62
$1,503.76
$1,868.92
$223.44
Toc - Plan #37 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
$305.41
$424.52
$451.70
$649.61
$916.23
$547.60
$666.71
$693.89
$891.80
$789.79
$908.90
$936.08
$1,133.99
$1,031.98
$1,151.09
$1,178.27
$1,376.18
$242.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610.82
$849.04
$903.40
$1,299.22
$1,832.46
$853.01
$1,091.23
$1,145.59
$1,541.41
$1,095.20
$1,333.42
$1,387.78
$1,783.60
$1,337.39
$1,575.61
$1,629.97
$2,025.79
$242.19
Toc - Plan #38 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
$1,500 $3,000 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
$445.70
$619.52
$659.19
$948.00
$1,337.10
$799.14
$972.96
$1,012.63
$1,301.44
$1,152.58
$1,326.40
$1,366.07
$1,654.88
$1,506.02
$1,679.84
$1,719.51
$2,008.32
$353.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$891.40
$1,239.04
$1,318.38
$1,896.00
$2,674.20
$1,244.84
$1,592.48
$1,671.82
$2,249.44
$1,598.28
$1,945.92
$2,025.26
$2,602.88
$1,951.72
$2,299.36
$2,378.70
$2,956.32
$353.44
Toc - Plan #39 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
$5,900 $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
$418.27
$581.40
$618.62
$889.66
$1,254.81
$749.96
$913.09
$950.31
$1,221.35
$1,081.65
$1,244.78
$1,282.00
$1,553.04
$1,413.34
$1,576.47
$1,613.69
$1,884.73
$331.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.54
$1,162.80
$1,237.24
$1,779.32
$2,509.62
$1,168.23
$1,494.49
$1,568.93
$2,111.01
$1,499.92
$1,826.18
$1,900.62
$2,442.70
$1,831.61
$2,157.87
$2,232.31
$2,774.39
$331.69
Toc - Plan #40 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.60
$431.73
$459.38
$660.65
$931.80
$556.91
$678.04
$705.69
$906.96
$803.22
$924.35
$952.00
$1,153.27
$1,049.53
$1,170.66
$1,198.31
$1,399.58
$246.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.20
$863.46
$918.76
$1,321.30
$1,863.60
$867.51
$1,109.77
$1,165.07
$1,567.61
$1,113.82
$1,356.08
$1,411.38
$1,813.92
$1,360.13
$1,602.39
$1,657.69
$2,060.23
$246.31
Toc - Plan #41 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
$370.20
$514.58
$547.53
$787.42
$1,110.60
$663.77
$808.15
$841.10
$1,080.99
$957.34
$1,101.72
$1,134.67
$1,374.56
$1,250.91
$1,395.29
$1,428.24
$1,668.13
$293.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.40
$1,029.16
$1,095.06
$1,574.84
$2,221.20
$1,033.97
$1,322.73
$1,388.63
$1,868.41
$1,327.54
$1,616.30
$1,682.20
$2,161.98
$1,621.11
$1,909.87
$1,975.77
$2,455.55
$293.57
Toc - Plan #42 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
$5,000 $10,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.80
$498.73
$530.67
$763.17
$1,076.40
$643.33
$783.26
$815.20
$1,047.70
$927.86
$1,067.79
$1,099.73
$1,332.23
$1,212.39
$1,352.32
$1,384.26
$1,616.76
$284.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.60
$997.46
$1,061.34
$1,526.34
$2,152.80
$1,002.13
$1,281.99
$1,345.87
$1,810.87
$1,286.66
$1,566.52
$1,630.40
$2,095.40
$1,571.19
$1,851.05
$1,914.93
$2,379.93
$284.53
Toc - Plan #43 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
$250.05
$347.57
$369.82
$531.86
$750.15
$448.34
$545.86
$568.11
$730.15
$646.63
$744.15
$766.40
$928.44
$844.92
$942.44
$964.69
$1,126.73
$198.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$500.10
$695.14
$739.64
$1,063.72
$1,500.30
$698.39
$893.43
$937.93
$1,262.01
$896.68
$1,091.72
$1,136.22
$1,460.30
$1,094.97
$1,290.01
$1,334.51
$1,658.59
$198.29
Toc - Plan #44 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
$1,500 $3,000 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
$361.40
$502.35
$534.51
$768.70
$1,084.20
$647.99
$788.94
$821.10
$1,055.29
$934.58
$1,075.53
$1,107.69
$1,341.88
$1,221.17
$1,362.12
$1,394.28
$1,628.47
$286.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.80
$1,004.70
$1,069.02
$1,537.40
$2,168.40
$1,009.39
$1,291.29
$1,355.61
$1,823.99
$1,295.98
$1,577.88
$1,642.20
$2,110.58
$1,582.57
$1,864.47
$1,928.79
$2,397.17
$286.59
Toc - Plan #45 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
$5,900 $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
$356.91
$496.10
$527.87
$759.15
$1,070.73
$639.94
$779.13
$810.90
$1,042.18
$922.97
$1,062.16
$1,093.93
$1,325.21
$1,206.00
$1,345.19
$1,376.96
$1,608.24
$283.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.82
$992.20
$1,055.74
$1,518.30
$2,141.46
$996.85
$1,275.23
$1,338.77
$1,801.33
$1,279.88
$1,558.26
$1,621.80
$2,084.36
$1,562.91
$1,841.29
$1,904.83
$2,367.39
$283.03
Toc - Plan #46 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$251.87
$350.10
$372.52
$535.73
$755.61
$451.60
$549.83
$572.25
$735.46
$651.33
$749.56
$771.98
$935.19
$851.06
$949.29
$971.71
$1,134.92
$199.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$503.74
$700.20
$745.04
$1,071.46
$1,511.22
$703.47
$899.93
$944.77
$1,271.19
$903.20
$1,099.66
$1,144.50
$1,470.92
$1,102.93
$1,299.39
$1,344.23
$1,670.65
$199.73
Toc - Plan #47 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
$311.56
$433.07
$460.80
$662.69
$934.68
$558.63
$680.14
$707.87
$909.76
$805.70
$927.21
$954.94
$1,156.83
$1,052.77
$1,174.28
$1,202.01
$1,403.90
$247.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$623.12
$866.14
$921.60
$1,325.38
$1,869.36
$870.19
$1,113.21
$1,168.67
$1,572.45
$1,117.26
$1,360.28
$1,415.74
$1,819.52
$1,364.33
$1,607.35
$1,662.81
$2,066.59
$247.07
Toc - Plan #48 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.60
$431.73
$459.38
$660.65
$931.80
$556.91
$678.04
$705.69
$906.96
$803.22
$924.35
$952.00
$1,153.27
$1,049.53
$1,170.66
$1,198.31
$1,399.58
$246.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.20
$863.46
$918.76
$1,321.30
$1,863.60
$867.51
$1,109.77
$1,165.07
$1,567.61
$1,113.82
$1,356.08
$1,411.38
$1,813.92
$1,360.13
$1,602.39
$1,657.69
$2,060.23
$246.31

ADVERTISEMENT

Select Health

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

Toc - Plan #49 Select Health
Gold

(HMO) Med Gold 1500 Medical Deductible - 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
$446.06
$620.03
$659.73
$948.78
$1,338.18
$799.79
$973.76
$1,013.46
$1,302.51
$1,153.52
$1,327.49
$1,367.19
$1,656.24
$1,507.25
$1,681.22
$1,720.92
$2,009.97
$353.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$892.12
$1,240.06
$1,319.46
$1,897.56
$2,676.36
$1,245.85
$1,593.79
$1,673.19
$2,251.29
$1,599.58
$1,947.52
$2,026.92
$2,605.02
$1,953.31
$2,301.25
$2,380.65
$2,958.75
$353.73
Toc - Plan #50 Select Health
Expanded Bronze

(HMO) Med Expanded Bronze 8050 Deductible - HSA Qualified

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

Annual Out of Pocket Expenses:

Individual Family
$8,050 $16,100 Annual Deductible
$8,050 $16,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.89
$450.20
$479.03
$688.91
$971.66
$580.73
$707.04
$735.87
$945.75
$837.57
$963.88
$992.71
$1,202.59
$1,094.41
$1,220.72
$1,249.55
$1,459.43
$256.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$647.78
$900.40
$958.06
$1,377.82
$1,943.32
$904.62
$1,157.24
$1,214.90
$1,634.66
$1,161.46
$1,414.08
$1,471.74
$1,891.50
$1,418.30
$1,670.92
$1,728.58
$2,148.34
$256.84
Toc - Plan #51 Select Health
Gold

(HMO) Value Gold 1500 Medical Deductible - 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
$390.00
$542.11
$576.82
$829.54
$1,170.00
$699.27
$851.38
$886.09
$1,138.81
$1,008.54
$1,160.65
$1,195.36
$1,448.08
$1,317.81
$1,469.92
$1,504.63
$1,757.35
$309.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.00
$1,084.22
$1,153.64
$1,659.08
$2,340.00
$1,089.27
$1,393.49
$1,462.91
$1,968.35
$1,398.54
$1,702.76
$1,772.18
$2,277.62
$1,707.81
$2,012.03
$2,081.45
$2,586.89
$309.27
Toc - Plan #52 Select Health
Silver

(HMO) Value Silver 3000 Medical Deductible - 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
$333.45
$463.50
$493.17
$709.25
$1,000.35
$597.88
$727.93
$757.60
$973.68
$862.31
$992.36
$1,022.03
$1,238.11
$1,126.74
$1,256.79
$1,286.46
$1,502.54
$264.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.90
$927.00
$986.34
$1,418.50
$2,000.70
$931.33
$1,191.43
$1,250.77
$1,682.93
$1,195.76
$1,455.86
$1,515.20
$1,947.36
$1,460.19
$1,720.29
$1,779.63
$2,211.79
$264.43
Toc - Plan #53 Select Health
Expanded Bronze

(HMO) Value Expanded Bronze 6900 Medical Deductible - 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$257.63
$358.10
$381.03
$547.98
$772.89
$461.93
$562.40
$585.33
$752.28
$666.23
$766.70
$789.63
$956.58
$870.53
$971.00
$993.93
$1,160.88
$204.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$515.26
$716.20
$762.06
$1,095.96
$1,545.78
$719.56
$920.50
$966.36
$1,300.26
$923.86
$1,124.80
$1,170.66
$1,504.56
$1,128.16
$1,329.10
$1,374.96
$1,708.86
$204.30
Toc - Plan #54 Select Health
Gold

(HMO) Signature Gold 1500 Medical Deductible - 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
$379.92
$528.09
$561.90
$808.09
$1,139.76
$681.20
$829.37
$863.18
$1,109.37
$982.48
$1,130.65
$1,164.46
$1,410.65
$1,283.76
$1,431.93
$1,465.74
$1,711.93
$301.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$759.84
$1,056.18
$1,123.80
$1,616.18
$2,279.52
$1,061.12
$1,357.46
$1,425.08
$1,917.46
$1,362.40
$1,658.74
$1,726.36
$2,218.74
$1,663.68
$1,960.02
$2,027.64
$2,520.02
$301.28
Toc - Plan #55 Select Health
Silver

(HMO) Value Benchmark Silver 5900 Medical Deductible - 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
$9,000 $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
$318.37
$442.53
$470.87
$677.17
$955.11
$570.84
$695.00
$723.34
$929.64
$823.31
$947.47
$975.81
$1,182.11
$1,075.78
$1,199.94
$1,228.28
$1,434.58
$252.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636.74
$885.06
$941.74
$1,354.34
$1,910.22
$889.21
$1,137.53
$1,194.21
$1,606.81
$1,141.68
$1,390.00
$1,446.68
$1,859.28
$1,394.15
$1,642.47
$1,699.15
$2,111.75
$252.47
Toc - Plan #56 Select Health
Silver

(HMO) Med Benchmark Silver 5900 Medical Deductible - 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
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364.13
$506.14
$538.55
$774.51
$1,092.39
$652.89
$794.90
$827.31
$1,063.27
$941.65
$1,083.66
$1,116.07
$1,352.03
$1,230.41
$1,372.42
$1,404.83
$1,640.79
$288.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728.26
$1,012.28
$1,077.10
$1,549.02
$2,184.78
$1,017.02
$1,301.04
$1,365.86
$1,837.78
$1,305.78
$1,589.80
$1,654.62
$2,126.54
$1,594.54
$1,878.56
$1,943.38
$2,415.30
$288.76
Toc - Plan #57 Select Health
Expanded Bronze

(HMO) Value Benchmark Expanded Bronze 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$266.42
$370.32
$394.04
$566.68
$799.26
$477.69
$581.59
$605.31
$777.95
$688.96
$792.86
$816.58
$989.22
$900.23
$1,004.13
$1,027.85
$1,200.49
$211.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$532.84
$740.64
$788.08
$1,133.36
$1,598.52
$744.11
$951.91
$999.35
$1,344.63
$955.38
$1,163.18
$1,210.62
$1,555.90
$1,166.65
$1,374.45
$1,421.89
$1,767.17
$211.27
Toc - Plan #58 Select Health
Expanded Bronze

(HMO) Med Benchmark Expanded Bronze 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304.72
$423.56
$450.68
$648.13
$914.15
$546.36
$665.20
$692.32
$889.77
$788.00
$906.84
$933.96
$1,131.41
$1,029.64
$1,148.48
$1,175.60
$1,373.05
$241.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$609.44
$847.12
$901.36
$1,296.26
$1,828.30
$851.08
$1,088.76
$1,143.00
$1,537.90
$1,092.72
$1,330.40
$1,384.64
$1,779.54
$1,334.36
$1,572.04
$1,626.28
$2,021.18
$241.64
Toc - Plan #59 Select Health
Silver

(HMO) Signature Benchmark Silver 5900 Medical Deductible - 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
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.14
$431.09
$458.69
$659.66
$930.41
$556.08
$677.03
$704.63
$905.60
$802.02
$922.97
$950.57
$1,151.54
$1,047.96
$1,168.91
$1,196.51
$1,397.48
$245.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.28
$862.18
$917.38
$1,319.32
$1,860.82
$866.22
$1,108.12
$1,163.32
$1,565.26
$1,112.16
$1,354.06
$1,409.26
$1,811.20
$1,358.10
$1,600.00
$1,655.20
$2,057.14
$245.94
Toc - Plan #60 Select Health
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
$1,500 $3,000 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
$493.02
$685.30
$729.17
$1,048.65
$1,479.05
$883.98
$1,076.26
$1,120.13
$1,439.61
$1,274.94
$1,467.22
$1,511.09
$1,830.57
$1,665.90
$1,858.18
$1,902.05
$2,221.53
$390.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$986.04
$1,370.60
$1,458.34
$2,097.30
$2,958.10
$1,377.00
$1,761.56
$1,849.30
$2,488.26
$1,767.96
$2,152.52
$2,240.26
$2,879.22
$2,158.92
$2,543.48
$2,631.22
$3,270.18
$390.96
Toc - Plan #61 Select Health
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
$5,900 $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
$417.34
$580.10
$617.24
$887.68
$1,252.01
$748.29
$911.05
$948.19
$1,218.63
$1,079.24
$1,242.00
$1,279.14
$1,549.58
$1,410.19
$1,572.95
$1,610.09
$1,880.53
$330.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.68
$1,160.20
$1,234.48
$1,775.36
$2,504.02
$1,165.63
$1,491.15
$1,565.43
$2,106.31
$1,496.58
$1,822.10
$1,896.38
$2,437.26
$1,827.53
$2,153.05
$2,227.33
$2,768.21
$330.95
Toc - Plan #62 Select Health
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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.50
$462.18
$491.77
$707.24
$997.50
$596.18
$725.86
$755.45
$970.92
$859.86
$989.54
$1,019.13
$1,234.60
$1,123.54
$1,253.22
$1,282.81
$1,498.28
$263.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.00
$924.36
$983.54
$1,414.48
$1,995.00
$928.68
$1,188.04
$1,247.22
$1,678.16
$1,192.36
$1,451.72
$1,510.90
$1,941.84
$1,456.04
$1,715.40
$1,774.58
$2,205.52
$263.68
Toc - Plan #63 Select Health
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
$1,500 $3,000 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
$431.06
$599.17
$637.53
$916.86
$1,293.17
$772.89
$941.00
$979.36
$1,258.69
$1,114.72
$1,282.83
$1,321.19
$1,600.52
$1,456.55
$1,624.66
$1,663.02
$1,942.35
$341.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$862.12
$1,198.34
$1,275.06
$1,833.72
$2,586.34
$1,203.95
$1,540.17
$1,616.89
$2,175.55
$1,545.78
$1,882.00
$1,958.72
$2,517.38
$1,887.61
$2,223.83
$2,300.55
$2,859.21
$341.83
Toc - Plan #64 Select Health
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
$5,900 $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
$364.89
$507.19
$539.67
$776.11
$1,094.66
$654.25
$796.55
$829.03
$1,065.47
$943.61
$1,085.91
$1,118.39
$1,354.83
$1,232.97
$1,375.27
$1,407.75
$1,644.19
$289.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.78
$1,014.38
$1,079.34
$1,552.22
$2,189.32
$1,019.14
$1,303.74
$1,368.70
$1,841.58
$1,308.50
$1,593.10
$1,658.06
$2,130.94
$1,597.86
$1,882.46
$1,947.42
$2,420.30
$289.36
Toc - Plan #65 Select Health
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
$1,500 $3,000 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
$419.91
$583.68
$621.05
$893.15
$1,259.73
$752.90
$916.67
$954.04
$1,226.14
$1,085.89
$1,249.66
$1,287.03
$1,559.13
$1,418.88
$1,582.65
$1,620.02
$1,892.12
$332.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839.82
$1,167.36
$1,242.10
$1,786.30
$2,519.46
$1,172.81
$1,500.35
$1,575.09
$2,119.29
$1,505.80
$1,833.34
$1,908.08
$2,452.28
$1,838.79
$2,166.33
$2,241.07
$2,785.27
$332.99
Toc - Plan #66 Select Health
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
$5,900 $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
$355.45
$494.08
$525.72
$756.05
$1,066.35
$637.32
$775.95
$807.59
$1,037.92
$919.19
$1,057.82
$1,089.46
$1,319.79
$1,201.06
$1,339.69
$1,371.33
$1,601.66
$281.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.90
$988.16
$1,051.44
$1,512.10
$2,132.70
$992.77
$1,270.03
$1,333.31
$1,793.97
$1,274.64
$1,551.90
$1,615.18
$2,075.84
$1,556.51
$1,833.77
$1,897.05
$2,357.71
$281.87
Toc - Plan #67 Select Health
Gold

(HMO) Signature Benchmark Gold

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
$388.09
$539.44
$573.98
$825.46
$1,164.26
$695.84
$847.19
$881.73
$1,133.21
$1,003.59
$1,154.94
$1,189.48
$1,440.96
$1,311.34
$1,462.69
$1,497.23
$1,748.71
$307.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.18
$1,078.88
$1,147.96
$1,650.92
$2,328.52
$1,083.93
$1,386.63
$1,455.71
$1,958.67
$1,391.68
$1,694.38
$1,763.46
$2,266.42
$1,699.43
$2,002.13
$2,071.21
$2,574.17
$307.75
Toc - Plan #68 Select Health
Platinum

(HMO) Value Benchmark Platinum

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
$480.06
$667.29
$710.01
$1,021.09
$1,440.18
$860.75
$1,047.98
$1,090.70
$1,401.78
$1,241.44
$1,428.67
$1,471.39
$1,782.47
$1,622.13
$1,809.36
$1,852.08
$2,163.16
$380.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$960.12
$1,334.58
$1,420.02
$2,042.18
$2,880.36
$1,340.81
$1,715.27
$1,800.71
$2,422.87
$1,721.50
$2,095.96
$2,181.40
$2,803.56
$2,102.19
$2,476.65
$2,562.09
$3,184.25
$380.69
Toc - Plan #69 Select Health
Platinum

(HMO) Med Benchmark Platinum

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
$549.07
$763.20
$812.07
$1,167.87
$1,647.20
$984.48
$1,198.61
$1,247.48
$1,603.28
$1,419.89
$1,634.02
$1,682.89
$2,038.69
$1,855.30
$2,069.43
$2,118.30
$2,474.10
$435.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,098.14
$1,526.40
$1,624.14
$2,335.74
$3,294.40
$1,533.55
$1,961.81
$2,059.55
$2,771.15
$1,968.96
$2,397.22
$2,494.96
$3,206.56
$2,404.37
$2,832.63
$2,930.37
$3,641.97
$435.41
Toc - Plan #70 Select Health
Platinum

(HMO) Signature Benchmark Platinum

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
$467.65
$650.03
$691.66
$994.69
$1,402.95
$838.50
$1,020.88
$1,062.51
$1,365.54
$1,209.35
$1,391.73
$1,433.36
$1,736.39
$1,580.20
$1,762.58
$1,804.21
$2,107.24
$370.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$935.30
$1,300.06
$1,383.32
$1,989.38
$2,805.90
$1,306.15
$1,670.91
$1,754.17
$2,360.23
$1,677.00
$2,041.76
$2,125.02
$2,731.08
$2,047.85
$2,412.61
$2,495.87
$3,101.93
$370.85
Toc - Plan #71 Select Health
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
$3,200 $6,400 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
$597.01
$829.84
$882.98
$1,269.84
$1,791.03
$1,070.44
$1,303.27
$1,356.41
$1,743.27
$1,543.87
$1,776.70
$1,829.84
$2,216.70
$2,017.30
$2,250.13
$2,303.27
$2,690.13
$473.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,194.02
$1,659.68
$1,765.96
$2,539.68
$3,582.06
$1,667.45
$2,133.11
$2,239.39
$3,013.11
$2,140.88
$2,606.54
$2,712.82
$3,486.54
$2,614.31
$3,079.97
$3,186.25
$3,959.97
$473.43
Toc - Plan #72 Select Health
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
$3,200 $6,400 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
$521.98
$725.55
$772.01
$1,110.25
$1,565.93
$935.91
$1,139.48
$1,185.94
$1,524.18
$1,349.84
$1,553.41
$1,599.87
$1,938.11
$1,763.77
$1,967.34
$2,013.80
$2,352.04
$413.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,043.96
$1,451.10
$1,544.02
$2,220.50
$3,131.86
$1,457.89
$1,865.03
$1,957.95
$2,634.43
$1,871.82
$2,278.96
$2,371.88
$3,048.36
$2,285.75
$2,692.89
$2,785.81
$3,462.29
$413.93
Toc - Plan #73 Select Health
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
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$508.48
$706.79
$752.05
$1,081.54
$1,525.44
$911.71
$1,110.02
$1,155.28
$1,484.77
$1,314.94
$1,513.25
$1,558.51
$1,888.00
$1,718.17
$1,916.48
$1,961.74
$2,291.23
$403.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,016.96
$1,413.58
$1,504.10
$2,163.08
$3,050.88
$1,420.19
$1,816.81
$1,907.33
$2,566.31
$1,823.42
$2,220.04
$2,310.56
$2,969.54
$2,226.65
$2,623.27
$2,713.79
$3,372.77
$403.23

ADVERTISEMENT

Cigna Healthcare

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

Toc - Plan #74 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 4500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$282.03
$392.02
$417.12
$599.88
$846.09
$505.68
$615.67
$640.77
$823.53
$729.33
$839.32
$864.42
$1,047.18
$952.98
$1,062.97
$1,088.07
$1,270.83
$223.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$564.06
$784.04
$834.24
$1,199.76
$1,692.18
$787.71
$1,007.69
$1,057.89
$1,423.41
$1,011.36
$1,231.34
$1,281.54
$1,647.06
$1,235.01
$1,454.99
$1,505.19
$1,870.71
$223.65
Toc - Plan #75 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 5500 Indiv Med Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$284.99
$396.13
$421.50
$606.17
$854.96
$510.98
$622.12
$647.49
$832.16
$736.97
$848.11
$873.48
$1,058.15
$962.96
$1,074.10
$1,099.47
$1,284.14
$225.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$569.98
$792.26
$843.00
$1,212.34
$1,709.92
$795.97
$1,018.25
$1,068.99
$1,438.33
$1,021.96
$1,244.24
$1,294.98
$1,664.32
$1,247.95
$1,470.23
$1,520.97
$1,890.31
$225.99
Toc - Plan #76 Cigna Healthcare
Silver

(EPO) Connect Silver 800 Indiv Med Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.41
$494.02
$525.65
$755.95
$1,066.22
$637.25
$775.86
$807.49
$1,037.79
$919.09
$1,057.70
$1,089.33
$1,319.63
$1,200.93
$1,339.54
$1,371.17
$1,601.47
$281.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.82
$988.04
$1,051.30
$1,511.90
$2,132.44
$992.66
$1,269.88
$1,333.14
$1,793.74
$1,274.50
$1,551.72
$1,614.98
$2,075.58
$1,556.34
$1,833.56
$1,896.82
$2,357.42
$281.84
Toc - Plan #77 Cigna Healthcare
Silver

(EPO) Connect Silver 5000 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.66
$497.14
$528.97
$760.74
$1,072.97
$641.28
$780.76
$812.59
$1,044.36
$924.90
$1,064.38
$1,096.21
$1,327.98
$1,208.52
$1,348.00
$1,379.83
$1,611.60
$283.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.32
$994.28
$1,057.94
$1,521.48
$2,145.94
$998.94
$1,277.90
$1,341.56
$1,805.10
$1,282.56
$1,561.52
$1,625.18
$2,088.72
$1,566.18
$1,845.14
$1,908.80
$2,372.34
$283.62
Toc - Plan #78 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 6500 Indiv Med Deductible Enhanced Diabetes Care

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$284.63
$395.64
$420.97
$605.42
$853.89
$510.35
$621.36
$646.69
$831.14
$736.07
$847.08
$872.41
$1,056.86
$961.79
$1,072.80
$1,098.13
$1,282.58
$225.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$569.26
$791.28
$841.94
$1,210.84
$1,707.78
$794.98
$1,017.00
$1,067.66
$1,436.56
$1,020.70
$1,242.72
$1,293.38
$1,662.28
$1,246.42
$1,468.44
$1,519.10
$1,888.00
$225.72
Toc - Plan #79 Cigna Healthcare
Silver

(EPO) Connect Silver CMS Standard

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
$355.89
$494.69
$526.36
$756.98
$1,067.67
$638.11
$776.91
$808.58
$1,039.20
$920.33
$1,059.13
$1,090.80
$1,321.42
$1,202.55
$1,341.35
$1,373.02
$1,603.64
$282.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.78
$989.38
$1,052.72
$1,513.96
$2,135.34
$994.00
$1,271.60
$1,334.94
$1,796.18
$1,276.22
$1,553.82
$1,617.16
$2,078.40
$1,558.44
$1,836.04
$1,899.38
$2,360.62
$282.22
Toc - Plan #80 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 0 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.30
$438.27
$466.33
$670.64
$945.90
$565.33
$688.30
$716.36
$920.67
$815.36
$938.33
$966.39
$1,170.70
$1,065.39
$1,188.36
$1,216.42
$1,420.73
$250.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.60
$876.54
$932.66
$1,341.28
$1,891.80
$880.63
$1,126.57
$1,182.69
$1,591.31
$1,130.66
$1,376.60
$1,432.72
$1,841.34
$1,380.69
$1,626.63
$1,682.75
$2,091.37
$250.03
Toc - Plan #81 Cigna Healthcare
Gold

(EPO) Connect Gold CMS Standard

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$433.81
$603.00
$641.61
$922.72
$1,301.43
$777.82
$947.01
$985.62
$1,266.73
$1,121.83
$1,291.02
$1,329.63
$1,610.74
$1,465.84
$1,635.03
$1,673.64
$1,954.75
$344.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.62
$1,206.00
$1,283.22
$1,845.44
$2,602.86
$1,211.63
$1,550.01
$1,627.23
$2,189.45
$1,555.64
$1,894.02
$1,971.24
$2,533.46
$1,899.65
$2,238.03
$2,315.25
$2,877.47
$344.01
Toc - Plan #82 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze CMS Standard

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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$284.19
$395.03
$420.32
$604.48
$852.57
$509.56
$620.40
$645.69
$829.85
$734.93
$845.77
$871.06
$1,055.22
$960.30
$1,071.14
$1,096.43
$1,280.59
$225.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$568.38
$790.06
$840.64
$1,208.96
$1,705.14
$793.75
$1,015.43
$1,066.01
$1,434.33
$1,019.12
$1,240.80
$1,291.38
$1,659.70
$1,244.49
$1,466.17
$1,516.75
$1,885.07
$225.37

ADVERTISEMENT

Imperial Health Plan of the Southwest, Inc.

Local: 1-626-838-5100x8 | Toll Free: 1-800-595-0619 | TTY: 1-800-595-0619

Toc - Plan #83 Imperial Health Plan of the Southwest, Inc.
Expanded Bronze

(HMO) Imperial Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$262.39
$364.72
$388.07
$558.10
$787.16
$470.47
$572.80
$596.15
$766.18
$678.55
$780.88
$804.23
$974.26
$886.63
$988.96
$1,012.31
$1,182.34
$208.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$524.78
$729.44
$776.14
$1,116.20
$1,574.32
$732.86
$937.52
$984.22
$1,324.28
$940.94
$1,145.60
$1,192.30
$1,532.36
$1,149.02
$1,353.68
$1,400.38
$1,740.44
$208.08
Toc - Plan #84 Imperial Health Plan of the Southwest, Inc.
Silver

(HMO) Imperial Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

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
$349.32
$485.56
$516.65
$743.01
$1,047.96
$626.33
$762.57
$793.66
$1,020.02
$903.34
$1,039.58
$1,070.67
$1,297.03
$1,180.35
$1,316.59
$1,347.68
$1,574.04
$277.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.64
$971.12
$1,033.30
$1,486.02
$2,095.92
$975.65
$1,248.13
$1,310.31
$1,763.03
$1,252.66
$1,525.14
$1,587.32
$2,040.04
$1,529.67
$1,802.15
$1,864.33
$2,317.05
$277.01
Toc - Plan #85 Imperial Health Plan of the Southwest, Inc.
Gold

(HMO) Imperial Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$406.42
$564.93
$601.10
$864.46
$1,219.25
$728.71
$887.22
$923.39
$1,186.75
$1,051.00
$1,209.51
$1,245.68
$1,509.04
$1,373.29
$1,531.80
$1,567.97
$1,831.33
$322.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$812.84
$1,129.86
$1,202.20
$1,728.92
$2,438.50
$1,135.13
$1,452.15
$1,524.49
$2,051.21
$1,457.42
$1,774.44
$1,846.78
$2,373.50
$1,779.71
$2,096.73
$2,169.07
$2,695.79
$322.29
Toc - Plan #86 Imperial Health Plan of the Southwest, Inc.
Silver

(HMO) Imperial Preferred Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

Annual Out of Pocket Expenses:

Individual Family
$3,750 $7,500 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.78
$491.76
$523.24
$752.50
$1,061.33
$634.33
$772.31
$803.79
$1,033.05
$914.88
$1,052.86
$1,084.34
$1,313.60
$1,195.43
$1,333.41
$1,364.89
$1,594.15
$280.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.56
$983.52
$1,046.48
$1,505.00
$2,122.66
$988.11
$1,264.07
$1,327.03
$1,785.55
$1,268.66
$1,544.62
$1,607.58
$2,066.10
$1,549.21
$1,825.17
$1,888.13
$2,346.65
$280.55
Toc - Plan #87 Imperial Health Plan of the Southwest, Inc.
Gold

(HMO) Imperial Preferred Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$419.88
$583.64
$621.01
$893.09
$1,259.63
$752.85
$916.61
$953.98
$1,226.06
$1,085.82
$1,249.58
$1,286.95
$1,559.03
$1,418.79
$1,582.55
$1,619.92
$1,892.00
$332.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839.76
$1,167.28
$1,242.02
$1,786.18
$2,519.26
$1,172.73
$1,500.25
$1,574.99
$2,119.15
$1,505.70
$1,833.22
$1,907.96
$2,452.12
$1,838.67
$2,166.19
$2,240.93
$2,785.09
$332.97

‡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 87 plans offered in Rating Area 3.

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