Obamacare 2024 Rates for Rock County, Wisconsin

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Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Beloit, WI.

The health insurance rates listed below are for calendar year 2024.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 79 Plans and 2024 Rates for Rock County, Wisconsin

Below, you’ll find a summary of the 79 plans for Rock County, Wisconsin and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Obamacare Rates and Providers for Other Years

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Quartz

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310 | TTY: 1-800-877-8973
Toc - Plan #1 Quartz
Gold

(HMO) QUARTZ ONE GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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 		$475.18
$539.32
$607.27
$848.66
$1,289.61 		$838.69
$902.83
$970.78
$1,212.17 		$1,202.20
$1,266.34
$1,334.29
$1,575.68 		$1,565.71
$1,629.85
$1,697.80
$1,939.19 		$363.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$950.36
$1,078.64
$1,214.54
$1,697.32
$2,579.22 		$1,313.87
$1,442.15
$1,578.05
$2,060.83 		$1,677.38
$1,805.66
$1,941.56
$2,424.34 		$2,040.89
$2,169.17
$2,305.07
$2,787.85 		$363.51
Toc - Plan #2 Quartz
Gold

(HMO) QUARTZ ONE GOLD I410 STANDARD W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$478.88
$543.52
$612.00
$855.26
$1,299.66 		$845.22
$909.86
$978.34
$1,221.60 		$1,211.56
$1,276.20
$1,344.68
$1,587.94 		$1,577.90
$1,642.54
$1,711.02
$1,954.28 		$366.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.76
$1,087.04
$1,224.00
$1,710.52
$2,599.32 		$1,324.10
$1,453.38
$1,590.34
$2,076.86 		$1,690.44
$1,819.72
$1,956.68
$2,443.20 		$2,056.78
$2,186.06
$2,323.02
$2,809.54 		$366.34
Toc - Plan #3 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$506.21
$574.54
$646.93
$904.08
$1,373.84 		$893.46
$961.79
$1,034.18
$1,291.33 		$1,280.71
$1,349.04
$1,421.43
$1,678.58 		$1,667.96
$1,736.29
$1,808.68
$2,065.83 		$387.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,012.42
$1,149.08
$1,293.86
$1,808.16
$2,747.68 		$1,399.67
$1,536.33
$1,681.11
$2,195.41 		$1,786.92
$1,923.58
$2,068.36
$2,582.66 		$2,174.17
$2,310.83
$2,455.61
$2,969.91 		$387.25
Toc - Plan #4 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$376.64
$427.48
$481.34
$672.67
$1,022.18 		$664.76
$715.60
$769.46
$960.79 		$952.88
$1,003.72
$1,057.58
$1,248.91 		$1,241.00
$1,291.84
$1,345.70
$1,537.03 		$288.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.28
$854.96
$962.68
$1,345.34
$2,044.36 		$1,041.40
$1,143.08
$1,250.80
$1,633.46 		$1,329.52
$1,431.20
$1,538.92
$1,921.58 		$1,617.64
$1,719.32
$1,827.04
$2,209.70 		$288.12
Toc - Plan #5 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$366.57
$416.05
$468.46
$654.68
$994.84 		$646.99
$696.47
$748.88
$935.10 		$927.41
$976.89
$1,029.30
$1,215.52 		$1,207.83
$1,257.31
$1,309.72
$1,495.94 		$280.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.14
$832.10
$936.92
$1,309.36
$1,989.68 		$1,013.56
$1,112.52
$1,217.34
$1,589.78 		$1,293.98
$1,392.94
$1,497.76
$1,870.20 		$1,574.40
$1,673.36
$1,778.18
$2,150.62 		$280.42
Toc - Plan #6 Quartz
Silver

(HMO) QUARTZ ONE SILVER I320 VALUE TIER RX W/DENTAL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$518.25
$588.21
$662.32
$925.59
$1,406.52 		$914.71
$984.67
$1,058.78
$1,322.05 		$1,311.17
$1,381.13
$1,455.24
$1,718.51 		$1,707.63
$1,777.59
$1,851.70
$2,114.97 		$396.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,036.50
$1,176.42
$1,324.64
$1,851.18
$2,813.04 		$1,432.96
$1,572.88
$1,721.10
$2,247.64 		$1,829.42
$1,969.34
$2,117.56
$2,644.10 		$2,225.88
$2,365.80
$2,514.02
$3,040.56 		$396.46
Toc - Plan #7 Quartz
Gold

(HMO) QUARTZ ONE GOLD I420 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$435.40
$494.17
$556.43
$777.61
$1,181.66 		$768.48
$827.25
$889.51
$1,110.69 		$1,101.56
$1,160.33
$1,222.59
$1,443.77 		$1,434.64
$1,493.41
$1,555.67
$1,776.85 		$333.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.80
$988.34
$1,112.86
$1,555.22
$2,363.32 		$1,203.88
$1,321.42
$1,445.94
$1,888.30 		$1,536.96
$1,654.50
$1,779.02
$2,221.38 		$1,870.04
$1,987.58
$2,112.10
$2,554.46 		$333.08
Toc - Plan #8 Quartz
Gold

(HMO) QUARTZ ONE GOLD I402 MAINTENANCE VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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 		$452.53
$513.61
$578.32
$808.20
$1,228.14 		$798.71
$859.79
$924.50
$1,154.38 		$1,144.89
$1,205.97
$1,270.68
$1,500.56 		$1,491.07
$1,552.15
$1,616.86
$1,846.74 		$346.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$905.06
$1,027.22
$1,156.64
$1,616.40
$2,456.28 		$1,251.24
$1,373.40
$1,502.82
$1,962.58 		$1,597.42
$1,719.58
$1,849.00
$2,308.76 		$1,943.60
$2,065.76
$2,195.18
$2,654.94 		$346.18
Toc - Plan #9 Quartz
Gold

(HMO) QUARTZ ONE GOLD I410 STANDARD

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$456.05
$517.61
$582.82
$814.50
$1,237.71 		$804.92
$866.48
$931.69
$1,163.37 		$1,153.79
$1,215.35
$1,280.56
$1,512.24 		$1,502.66
$1,564.22
$1,629.43
$1,861.11 		$348.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$912.10
$1,035.22
$1,165.64
$1,629.00
$2,475.42 		$1,260.97
$1,384.09
$1,514.51
$1,977.87 		$1,609.84
$1,732.96
$1,863.38
$2,326.74 		$1,958.71
$2,081.83
$2,212.25
$2,675.61 		$348.87
Toc - Plan #10 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$482.08
$547.15
$616.09
$860.98
$1,308.35 		$850.87
$915.94
$984.88
$1,229.77 		$1,219.66
$1,284.73
$1,353.67
$1,598.56 		$1,588.45
$1,653.52
$1,722.46
$1,967.35 		$368.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$964.16
$1,094.30
$1,232.18
$1,721.96
$2,616.70 		$1,332.95
$1,463.09
$1,600.97
$2,090.75 		$1,701.74
$1,831.88
$1,969.76
$2,459.54 		$2,070.53
$2,200.67
$2,338.55
$2,828.33 		$368.79
Toc - Plan #11 Quartz
Silver

(HMO) QUARTZ ONE SILVER I309 STANDARD

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$469.22
$532.56
$599.66
$838.02
$1,273.45 		$828.17
$891.51
$958.61
$1,196.97 		$1,187.12
$1,250.46
$1,317.56
$1,555.92 		$1,546.07
$1,609.41
$1,676.51
$1,914.87 		$358.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$938.44
$1,065.12
$1,199.32
$1,676.04
$2,546.90 		$1,297.39
$1,424.07
$1,558.27
$2,034.99 		$1,656.34
$1,783.02
$1,917.22
$2,393.94 		$2,015.29
$2,141.97
$2,276.17
$2,752.89 		$358.95
Toc - Plan #12 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$358.69
$407.10
$458.39
$640.60
$973.46 		$633.08
$681.49
$732.78
$914.99 		$907.47
$955.88
$1,007.17
$1,189.38 		$1,181.86
$1,230.27
$1,281.56
$1,463.77 		$274.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.38
$814.20
$916.78
$1,281.20
$1,946.92 		$991.77
$1,088.59
$1,191.17
$1,555.59 		$1,266.16
$1,362.98
$1,465.56
$1,829.98 		$1,540.55
$1,637.37
$1,739.95
$2,104.37 		$274.39
Toc - Plan #13 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$349.09
$396.21
$446.13
$623.47
$947.42 		$616.14
$663.26
$713.18
$890.52 		$883.19
$930.31
$980.23
$1,157.57 		$1,150.24
$1,197.36
$1,247.28
$1,424.62 		$267.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.18
$792.42
$892.26
$1,246.94
$1,894.84 		$965.23
$1,059.47
$1,159.31
$1,513.99 		$1,232.28
$1,326.52
$1,426.36
$1,781.04 		$1,499.33
$1,593.57
$1,693.41
$2,048.09 		$267.05
Toc - Plan #14 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I206 STANDARD

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$333.18
$378.15
$425.79
$595.04
$904.23 		$588.06
$633.03
$680.67
$849.92 		$842.94
$887.91
$935.55
$1,104.80 		$1,097.82
$1,142.79
$1,190.43
$1,359.68 		$254.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.36
$756.30
$851.58
$1,190.08
$1,808.46 		$921.24
$1,011.18
$1,106.46
$1,444.96 		$1,176.12
$1,266.06
$1,361.34
$1,699.84 		$1,431.00
$1,520.94
$1,616.22
$1,954.72 		$254.88
Toc - Plan #15 Quartz
Silver

(HMO) QUARTZ ONE SILVER I320 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$493.55
$560.17
$630.75
$881.47
$1,339.48 		$871.11
$937.73
$1,008.31
$1,259.03 		$1,248.67
$1,315.29
$1,385.87
$1,636.59 		$1,626.23
$1,692.85
$1,763.43
$2,014.15 		$377.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$987.10
$1,120.34
$1,261.50
$1,762.94
$2,678.96 		$1,364.66
$1,497.90
$1,639.06
$2,140.50 		$1,742.22
$1,875.46
$2,016.62
$2,518.06 		$2,119.78
$2,253.02
$2,394.18
$2,895.62 		$377.56
Toc - Plan #16 Quartz
Gold

(HMO) QUARTZ ONE GOLD I401 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$428.81
$486.70
$548.02
$765.85
$1,163.78 		$756.85
$814.74
$876.06
$1,093.89 		$1,084.89
$1,142.78
$1,204.10
$1,421.93 		$1,412.93
$1,470.82
$1,532.14
$1,749.97 		$328.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.62
$973.40
$1,096.04
$1,531.70
$2,327.56 		$1,185.66
$1,301.44
$1,424.08
$1,859.74 		$1,513.70
$1,629.48
$1,752.12
$2,187.78 		$1,841.74
$1,957.52
$2,080.16
$2,515.82 		$328.04
Toc - Plan #17 Quartz
Silver

(HMO) QUARTZ ONE SILVER I303 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$458.61
$520.52
$586.10
$819.07
$1,244.66 		$809.45
$871.36
$936.94
$1,169.91 		$1,160.29
$1,222.20
$1,287.78
$1,520.75 		$1,511.13
$1,573.04
$1,638.62
$1,871.59 		$350.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.22
$1,041.04
$1,172.20
$1,638.14
$2,489.32 		$1,268.06
$1,391.88
$1,523.04
$1,988.98 		$1,618.90
$1,742.72
$1,873.88
$2,339.82 		$1,969.74
$2,093.56
$2,224.72
$2,690.66 		$350.84
Toc - Plan #18 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I201 VALUE TIER RX

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$9,400 $18,800 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 		$313.96
$356.34
$401.23
$560.72
$852.07 		$554.14
$596.52
$641.41
$800.90 		$794.32
$836.70
$881.59
$1,041.08 		$1,034.50
$1,076.88
$1,121.77
$1,281.26 		$240.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.92
$712.68
$802.46
$1,121.44
$1,704.14 		$868.10
$952.86
$1,042.64
$1,361.62 		$1,108.28
$1,193.04
$1,282.82
$1,601.80 		$1,348.46
$1,433.22
$1,523.00
$1,841.98 		$240.18
Toc - Plan #19 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I203 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$341.23
$387.29
$436.09
$609.43
$926.09 		$602.27
$648.33
$697.13
$870.47 		$863.31
$909.37
$958.17
$1,131.51 		$1,124.35
$1,170.41
$1,219.21
$1,392.55 		$261.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.46
$774.58
$872.18
$1,218.86
$1,852.18 		$943.50
$1,035.62
$1,133.22
$1,479.90 		$1,204.54
$1,296.66
$1,394.26
$1,740.94 		$1,465.58
$1,557.70
$1,655.30
$2,001.98 		$261.04
Toc - Plan #20 Quartz
Catastrophic

(HMO) QUARTZ ONE CATASTROPHIC I101

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$247.75
$281.19
$316.62
$442.47
$672.38 		$437.28
$470.72
$506.15
$632.00 		$626.81
$660.25
$695.68
$821.53 		$816.34
$849.78
$885.21
$1,011.06 		$189.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$495.50
$562.38
$633.24
$884.94
$1,344.76 		$685.03
$751.91
$822.77
$1,074.47 		$874.56
$941.44
$1,012.30
$1,264.00 		$1,064.09
$1,130.97
$1,201.83
$1,453.53 		$189.53
Toc - Plan #21 Quartz
Silver

(HMO) QUARTZ ONE SILVER I304 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$486.41
$552.07
$621.63
$868.72
$1,320.10 		$858.51
$924.17
$993.73
$1,240.82 		$1,230.61
$1,296.27
$1,365.83
$1,612.92 		$1,602.71
$1,668.37
$1,737.93
$1,985.02 		$372.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$972.82
$1,104.14
$1,243.26
$1,737.44
$2,640.20 		$1,344.92
$1,476.24
$1,615.36
$2,109.54 		$1,717.02
$1,848.34
$1,987.46
$2,481.64 		$2,089.12
$2,220.44
$2,359.56
$2,853.74 		$372.10
Toc - Plan #22 Quartz
Gold

(HMO) QUARTZ ONE GOLD I403 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$3,500 $7,000 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 		$446.25
$506.49
$570.31
$797.00
$1,211.12 		$787.63
$847.87
$911.69
$1,138.38 		$1,129.01
$1,189.25
$1,253.07
$1,479.76 		$1,470.39
$1,530.63
$1,594.45
$1,821.14 		$341.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.50
$1,012.98
$1,140.62
$1,594.00
$2,422.24 		$1,233.88
$1,354.36
$1,482.00
$1,935.38 		$1,575.26
$1,695.74
$1,823.38
$2,276.76 		$1,916.64
$2,037.12
$2,164.76
$2,618.14 		$341.38

ADVERTISEMENT

Dean Health Plan

Local: 1-800-279-1302 | Toll Free: 1-800-279-1302 | TTY: 1-800-279-1302
Toc - Plan #23 Dean Health Plan
Gold

(HMO) Dean Gold Copay Plus 1500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,700 $11,400 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 		$447.60
$508.03
$572.03
$799.41
$1,214.79 		$790.01
$850.44
$914.44
$1,141.82 		$1,132.42
$1,192.85
$1,256.85
$1,484.23 		$1,474.83
$1,535.26
$1,599.26
$1,826.64 		$342.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.20
$1,016.06
$1,144.06
$1,598.82
$2,429.58 		$1,237.61
$1,358.47
$1,486.47
$1,941.23 		$1,580.02
$1,700.88
$1,828.88
$2,283.64 		$1,922.43
$2,043.29
$2,171.29
$2,626.05 		$342.41
Toc - Plan #24 Dean Health Plan
Silver

(HMO) Dean Silver Copay Plus 4800X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$423.22
$480.35
$540.87
$755.86
$1,148.61 		$746.98
$804.11
$864.63
$1,079.62 		$1,070.74
$1,127.87
$1,188.39
$1,403.38 		$1,394.50
$1,451.63
$1,512.15
$1,727.14 		$323.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.44
$960.70
$1,081.74
$1,511.72
$2,297.22 		$1,170.20
$1,284.46
$1,405.50
$1,835.48 		$1,493.96
$1,608.22
$1,729.26
$2,159.24 		$1,817.72
$1,931.98
$2,053.02
$2,483.00 		$323.76
Toc - Plan #25 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Copay Plus 9400X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$280.40
$318.25
$358.35
$500.79
$761.00 		$494.90
$532.75
$572.85
$715.29 		$709.40
$747.25
$787.35
$929.79 		$923.90
$961.75
$1,001.85
$1,144.29 		$214.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560.80
$636.50
$716.70
$1,001.58
$1,522.00 		$775.30
$851.00
$931.20
$1,216.08 		$989.80
$1,065.50
$1,145.70
$1,430.58 		$1,204.30
$1,280.00
$1,360.20
$1,645.08 		$214.50
Toc - Plan #26 Dean Health Plan
Silver

(HMO) Dean Silver HSA-E HDHP 3550X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,550 $7,100 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 		$424.55
$481.87
$542.58
$758.25
$1,152.23 		$749.33
$806.65
$867.36
$1,083.03 		$1,074.11
$1,131.43
$1,192.14
$1,407.81 		$1,398.89
$1,456.21
$1,516.92
$1,732.59 		$324.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.10
$963.74
$1,085.16
$1,516.50
$2,304.46 		$1,173.88
$1,288.52
$1,409.94
$1,841.28 		$1,498.66
$1,613.30
$1,734.72
$2,166.06 		$1,823.44
$1,938.08
$2,059.50
$2,490.84 		$324.78
Toc - Plan #27 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze HSA-E HDHP 7450X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$295.50
$335.39
$377.65
$527.76
$801.98 		$521.56
$561.45
$603.71
$753.82 		$747.62
$787.51
$829.77
$979.88 		$973.68
$1,013.57
$1,055.83
$1,205.94 		$226.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591.00
$670.78
$755.30
$1,055.52
$1,603.96 		$817.06
$896.84
$981.36
$1,281.58 		$1,043.12
$1,122.90
$1,207.42
$1,507.64 		$1,269.18
$1,348.96
$1,433.48
$1,733.70 		$226.06
Toc - Plan #28 Dean Health Plan
Catastrophic

(HMO) Dean Catastrophic Safety Net

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$202.67
$230.04
$259.02
$361.98
$550.06 		$357.72
$385.09
$414.07
$517.03 		$512.77
$540.14
$569.12
$672.08 		$667.82
$695.19
$724.17
$827.13 		$155.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$405.34
$460.08
$518.04
$723.96
$1,100.12 		$560.39
$615.13
$673.09
$879.01 		$715.44
$770.18
$828.14
$1,034.06 		$870.49
$925.23
$983.19
$1,189.11 		$155.05
Toc - Plan #29 Dean Health Plan
Gold

(HMO) Dean Gold HSA HDHP 2000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,500 $9,000 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 		$399.41
$453.33
$510.45
$713.35
$1,084.00 		$704.96
$758.88
$816.00
$1,018.90 		$1,010.51
$1,064.43
$1,121.55
$1,324.45 		$1,316.06
$1,369.98
$1,427.10
$1,630.00 		$305.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.82
$906.66
$1,020.90
$1,426.70
$2,168.00 		$1,104.37
$1,212.21
$1,326.45
$1,732.25 		$1,409.92
$1,517.76
$1,632.00
$2,037.80 		$1,715.47
$1,823.31
$1,937.55
$2,343.35 		$305.55
Toc - Plan #30 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Copay PCP 8000X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$274.53
$311.59
$350.85
$490.31
$745.08 		$484.55
$521.61
$560.87
$700.33 		$694.57
$731.63
$770.89
$910.35 		$904.59
$941.65
$980.91
$1,120.37 		$210.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.06
$623.18
$701.70
$980.62
$1,490.16 		$759.08
$833.20
$911.72
$1,190.64 		$969.10
$1,043.22
$1,121.74
$1,400.66 		$1,179.12
$1,253.24
$1,331.76
$1,610.68 		$210.02
Toc - Plan #31 Dean Health Plan
Silver

(HMO) Dean Silver Copay PCP 4500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.90
$456.16
$513.63
$717.80
$1,090.76 		$709.36
$763.62
$821.09
$1,025.26 		$1,016.82
$1,071.08
$1,128.55
$1,332.72 		$1,324.28
$1,378.54
$1,436.01
$1,640.18 		$307.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.80
$912.32
$1,027.26
$1,435.60
$2,181.52 		$1,111.26
$1,219.78
$1,334.72
$1,743.06 		$1,418.72
$1,527.24
$1,642.18
$2,050.52 		$1,726.18
$1,834.70
$1,949.64
$2,357.98 		$307.46
Toc - Plan #32 Dean Health Plan
Gold

(HMO) Dean Gold Copay PCP 3000X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$4,900 $9,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.64
$458.13
$515.85
$720.89
$1,095.47 		$712.42
$766.91
$824.63
$1,029.67 		$1,021.20
$1,075.69
$1,133.41
$1,338.45 		$1,329.98
$1,384.47
$1,442.19
$1,647.23 		$308.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.28
$916.26
$1,031.70
$1,441.78
$2,190.94 		$1,116.06
$1,225.04
$1,340.48
$1,750.56 		$1,424.84
$1,533.82
$1,649.26
$2,059.34 		$1,733.62
$1,842.60
$1,958.04
$2,368.12 		$308.78
Toc - Plan #33 Dean Health Plan
Gold

(HMO) Dean Gold Standard 1500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$415.22
$471.27
$530.65
$741.58
$1,126.90 		$732.86
$788.91
$848.29
$1,059.22 		$1,050.50
$1,106.55
$1,165.93
$1,376.86 		$1,368.14
$1,424.19
$1,483.57
$1,694.50 		$317.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.44
$942.54
$1,061.30
$1,483.16
$2,253.80 		$1,148.08
$1,260.18
$1,378.94
$1,800.80 		$1,465.72
$1,577.82
$1,696.58
$2,118.44 		$1,783.36
$1,895.46
$2,014.22
$2,436.08 		$317.64
Toc - Plan #34 Dean Health Plan
Silver

(HMO) Dean Silver Standard 5900X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$405.23
$459.94
$517.89
$723.75
$1,099.81 		$715.23
$769.94
$827.89
$1,033.75 		$1,025.23
$1,079.94
$1,137.89
$1,343.75 		$1,335.23
$1,389.94
$1,447.89
$1,653.75 		$310.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.46
$919.88
$1,035.78
$1,447.50
$2,199.62 		$1,120.46
$1,229.88
$1,345.78
$1,757.50 		$1,430.46
$1,539.88
$1,655.78
$2,067.50 		$1,740.46
$1,849.88
$1,965.78
$2,377.50 		$310.00
Toc - Plan #35 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Standard 7500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$284.48
$322.89
$363.57
$508.09
$772.09 		$502.11
$540.52
$581.20
$725.72 		$719.74
$758.15
$798.83
$943.35 		$937.37
$975.78
$1,016.46
$1,160.98 		$217.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$568.96
$645.78
$727.14
$1,016.18
$1,544.18 		$786.59
$863.41
$944.77
$1,233.81 		$1,004.22
$1,081.04
$1,162.40
$1,451.44 		$1,221.85
$1,298.67
$1,380.03
$1,669.07 		$217.63
Toc - Plan #36 Dean Health Plan
Bronze

(HMO) Dean Bronze Standard 9100X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 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 		$252.42
$286.50
$322.59
$450.82
$685.06 		$445.52
$479.60
$515.69
$643.92 		$638.62
$672.70
$708.79
$837.02 		$831.72
$865.80
$901.89
$1,030.12 		$193.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.84
$573.00
$645.18
$901.64
$1,370.12 		$697.94
$766.10
$838.28
$1,094.74 		$891.04
$959.20
$1,031.38
$1,287.84 		$1,084.14
$1,152.30
$1,224.48
$1,480.94 		$193.10
Toc - Plan #37 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver HSA-E HDHP 3550X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,550 $7,100 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 		$390.27
$442.95
$498.76
$697.02
$1,059.19 		$688.82
$741.50
$797.31
$995.57 		$987.37
$1,040.05
$1,095.86
$1,294.12 		$1,285.92
$1,338.60
$1,394.41
$1,592.67 		$298.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.54
$885.90
$997.52
$1,394.04
$2,118.38 		$1,079.09
$1,184.45
$1,296.07
$1,692.59 		$1,377.64
$1,483.00
$1,594.62
$1,991.14 		$1,676.19
$1,781.55
$1,893.17
$2,289.69 		$298.55
Toc - Plan #38 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze HSA-E HDHP 7450X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$271.63
$308.30
$347.14
$485.13
$737.21 		$479.43
$516.10
$554.94
$692.93 		$687.23
$723.90
$762.74
$900.73 		$895.03
$931.70
$970.54
$1,108.53 		$207.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543.26
$616.60
$694.28
$970.26
$1,474.42 		$751.06
$824.40
$902.08
$1,178.06 		$958.86
$1,032.20
$1,109.88
$1,385.86 		$1,166.66
$1,240.00
$1,317.68
$1,593.66 		$207.80
Toc - Plan #39 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Copay Plus 9400X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$257.76
$292.56
$329.41
$460.36
$699.55 		$454.94
$489.74
$526.59
$657.54 		$652.12
$686.92
$723.77
$854.72 		$849.30
$884.10
$920.95
$1,051.90 		$197.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$515.52
$585.12
$658.82
$920.72
$1,399.10 		$712.70
$782.30
$856.00
$1,117.90 		$909.88
$979.48
$1,053.18
$1,315.08 		$1,107.06
$1,176.66
$1,250.36
$1,512.26 		$197.18
Toc - Plan #40 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Copay Plus 1500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,700 $11,400 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 		$411.46
$467.00
$525.84
$734.86
$1,116.69 		$726.22
$781.76
$840.60
$1,049.62 		$1,040.98
$1,096.52
$1,155.36
$1,364.38 		$1,355.74
$1,411.28
$1,470.12
$1,679.14 		$314.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.92
$934.00
$1,051.68
$1,469.72
$2,233.38 		$1,137.68
$1,248.76
$1,366.44
$1,784.48 		$1,452.44
$1,563.52
$1,681.20
$2,099.24 		$1,767.20
$1,878.28
$1,995.96
$2,414.00 		$314.76
Toc - Plan #41 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Copay Plus 4800X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$389.04
$441.56
$497.19
$694.82
$1,055.85 		$686.65
$739.17
$794.80
$992.43 		$984.26
$1,036.78
$1,092.41
$1,290.04 		$1,281.87
$1,334.39
$1,390.02
$1,587.65 		$297.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.08
$883.12
$994.38
$1,389.64
$2,111.70 		$1,075.69
$1,180.73
$1,291.99
$1,687.25 		$1,373.30
$1,478.34
$1,589.60
$1,984.86 		$1,670.91
$1,775.95
$1,887.21
$2,282.47 		$297.61
Toc - Plan #42 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold HSA HDHP 2000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,500 $9,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.16
$416.72
$469.23
$655.74
$996.46 		$648.03
$697.59
$750.10
$936.61 		$928.90
$978.46
$1,030.97
$1,217.48 		$1,209.77
$1,259.33
$1,311.84
$1,498.35 		$280.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.32
$833.44
$938.46
$1,311.48
$1,992.92 		$1,015.19
$1,114.31
$1,219.33
$1,592.35 		$1,296.06
$1,395.18
$1,500.20
$1,873.22 		$1,576.93
$1,676.05
$1,781.07
$2,154.09 		$280.87
Toc - Plan #43 Dean Health Plan
Catastrophic

(EPO) Dean Focus Network Catastrophic Safety Net

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$186.30
$211.45
$238.09
$332.73
$505.62 		$328.82
$353.97
$380.61
$475.25 		$471.34
$496.49
$523.13
$617.77 		$613.86
$639.01
$665.65
$760.29 		$142.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$372.60
$422.90
$476.18
$665.46
$1,011.24 		$515.12
$565.42
$618.70
$807.98 		$657.64
$707.94
$761.22
$950.50 		$800.16
$850.46
$903.74
$1,093.02 		$142.52
Toc - Plan #44 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Copay PCP 8000X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$252.37
$286.44
$322.52
$450.73
$684.92 		$445.43
$479.50
$515.58
$643.79 		$638.49
$672.56
$708.64
$836.85 		$831.55
$865.62
$901.70
$1,029.91 		$193.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.74
$572.88
$645.04
$901.46
$1,369.84 		$697.80
$765.94
$838.10
$1,094.52 		$890.86
$959.00
$1,031.16
$1,287.58 		$1,083.92
$1,152.06
$1,224.22
$1,480.64 		$193.06
Toc - Plan #45 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Copay PCP 4500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$369.45
$419.32
$472.15
$659.83
$1,002.68 		$652.08
$701.95
$754.78
$942.46 		$934.71
$984.58
$1,037.41
$1,225.09 		$1,217.34
$1,267.21
$1,320.04
$1,507.72 		$282.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.90
$838.64
$944.30
$1,319.66
$2,005.36 		$1,021.53
$1,121.27
$1,226.93
$1,602.29 		$1,304.16
$1,403.90
$1,509.56
$1,884.92 		$1,586.79
$1,686.53
$1,792.19
$2,167.55 		$282.63
Toc - Plan #46 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Copay PCP 3000X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$4,900 $9,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.03
$421.12
$474.18
$662.67
$1,006.99 		$654.87
$704.96
$758.02
$946.51 		$938.71
$988.80
$1,041.86
$1,230.35 		$1,222.55
$1,272.64
$1,325.70
$1,514.19 		$283.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.06
$842.24
$948.36
$1,325.34
$2,013.98 		$1,025.90
$1,126.08
$1,232.20
$1,609.18 		$1,309.74
$1,409.92
$1,516.04
$1,893.02 		$1,593.58
$1,693.76
$1,799.88
$2,176.86 		$283.84
Toc - Plan #47 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Standard 1500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$381.69
$433.22
$487.80
$681.70
$1,035.91 		$673.68
$725.21
$779.79
$973.69 		$965.67
$1,017.20
$1,071.78
$1,265.68 		$1,257.66
$1,309.19
$1,363.77
$1,557.67 		$291.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.38
$866.44
$975.60
$1,363.40
$2,071.82 		$1,055.37
$1,158.43
$1,267.59
$1,655.39 		$1,347.36
$1,450.42
$1,559.58
$1,947.38 		$1,639.35
$1,742.41
$1,851.57
$2,239.37 		$291.99
Toc - Plan #48 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Standard 5900X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$372.51
$422.79
$476.06
$665.30
$1,010.98 		$657.48
$707.76
$761.03
$950.27 		$942.45
$992.73
$1,046.00
$1,235.24 		$1,227.42
$1,277.70
$1,330.97
$1,520.21 		$284.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.02
$845.58
$952.12
$1,330.60
$2,021.96 		$1,029.99
$1,130.55
$1,237.09
$1,615.57 		$1,314.96
$1,415.52
$1,522.06
$1,900.54 		$1,599.93
$1,700.49
$1,807.03
$2,185.51 		$284.97
Toc - Plan #49 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Standard 7500X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$261.51
$296.81
$334.21
$467.06
$709.74 		$461.57
$496.87
$534.27
$667.12 		$661.63
$696.93
$734.33
$867.18 		$861.69
$896.99
$934.39
$1,067.24 		$200.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523.02
$593.62
$668.42
$934.12
$1,419.48 		$723.08
$793.68
$868.48
$1,134.18 		$923.14
$993.74
$1,068.54
$1,334.24 		$1,123.20
$1,193.80
$1,268.60
$1,534.30 		$200.06
Toc - Plan #50 Dean Health Plan
Bronze

(EPO) Dean Focus Network Bronze Standard 9100X (Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 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 		$232.04
$263.37
$296.55
$414.42
$629.76 		$409.55
$440.88
$474.06
$591.93 		$587.06
$618.39
$651.57
$769.44 		$764.57
$795.90
$829.08
$946.95 		$177.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$464.08
$526.74
$593.10
$828.84
$1,259.52 		$641.59
$704.25
$770.61
$1,006.35 		$819.10
$881.76
$948.12
$1,183.86 		$996.61
$1,059.27
$1,125.63
$1,361.37 		$177.51

ADVERTISEMENT

MercyCare Health Plans

Local: 1-800-895-2421 | Toll Free: 1-800-895-2421

Toc - Plan #51 MercyCare Health Plans
Silver

(HMO) MercyCare HMO Silver Option A

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-895-2421

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,800 $17,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.73
$402.62
$453.35
$633.55
$962.74 		$626.10
$673.99
$724.72
$904.92 		$897.47
$945.36
$996.09
$1,176.29 		$1,168.84
$1,216.73
$1,267.46
$1,447.66 		$271.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.46
$805.24
$906.70
$1,267.10
$1,925.48 		$980.83
$1,076.61
$1,178.07
$1,538.47 		$1,252.20
$1,347.98
$1,449.44
$1,809.84 		$1,523.57
$1,619.35
$1,720.81
$2,081.21 		$271.37
Toc - Plan #52 MercyCare Health Plans
Gold

(HMO) MercyCare HMO Gold Option B

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-895-2421

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 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 		$369.39
$419.26
$472.08
$659.73
$1,002.51 		$651.97
$701.84
$754.66
$942.31 		$934.55
$984.42
$1,037.24
$1,224.89 		$1,217.13
$1,267.00
$1,319.82
$1,507.47 		$282.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.78
$838.52
$944.16
$1,319.46
$2,005.02 		$1,021.36
$1,121.10
$1,226.74
$1,602.04 		$1,303.94
$1,403.68
$1,509.32
$1,884.62 		$1,586.52
$1,686.26
$1,791.90
$2,167.20 		$282.58
Toc - Plan #53 MercyCare Health Plans
Silver

(HMO) MercyCare HMO Silver Option B

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-895-2421

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.40
$407.91
$459.31
$641.88
$975.39 		$634.34
$682.85
$734.25
$916.82 		$909.28
$957.79
$1,009.19
$1,191.76 		$1,184.22
$1,232.73
$1,284.13
$1,466.70 		$274.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.80
$815.82
$918.62
$1,283.76
$1,950.78 		$993.74
$1,090.76
$1,193.56
$1,558.70 		$1,268.68
$1,365.70
$1,468.50
$1,833.64 		$1,543.62
$1,640.64
$1,743.44
$2,108.58 		$274.94
Toc - Plan #54 MercyCare Health Plans
Gold

(HMO) MercyCare HMO Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-895-2421

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 		$360.69
$409.38
$460.95
$644.18
$978.89 		$636.62
$685.31
$736.88
$920.11 		$912.55
$961.24
$1,012.81
$1,196.04 		$1,188.48
$1,237.17
$1,288.74
$1,471.97 		$275.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.38
$818.76
$921.90
$1,288.36
$1,957.78 		$997.31
$1,094.69
$1,197.83
$1,564.29 		$1,273.24
$1,370.62
$1,473.76
$1,840.22 		$1,549.17
$1,646.55
$1,749.69
$2,116.15 		$275.93
Toc - Plan #55 MercyCare Health Plans
Silver

(HMO) MercyCare HMO Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-895-2421

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 		$354.89
$402.80
$453.54
$633.83
$963.16 		$626.38
$674.29
$725.03
$905.32 		$897.87
$945.78
$996.52
$1,176.81 		$1,169.36
$1,217.27
$1,268.01
$1,448.30 		$271.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.78
$805.60
$907.08
$1,267.66
$1,926.32 		$981.27
$1,077.09
$1,178.57
$1,539.15 		$1,252.76
$1,348.58
$1,450.06
$1,810.64 		$1,524.25
$1,620.07
$1,721.55
$2,082.13 		$271.49
Toc - Plan #56 MercyCare Health Plans
Expanded Bronze

(HMO) MercyCare HMO Bronze Standard Expanded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-895-2421

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 		$278.11
$315.66
$355.43
$496.70
$754.79 		$490.87
$528.42
$568.19
$709.46 		$703.63
$741.18
$780.95
$922.22 		$916.39
$953.94
$993.71
$1,134.98 		$212.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.22
$631.32
$710.86
$993.40
$1,509.58 		$768.98
$844.08
$923.62
$1,206.16 		$981.74
$1,056.84
$1,136.38
$1,418.92 		$1,194.50
$1,269.60
$1,349.14
$1,631.68 		$212.76
Toc - Plan #57 MercyCare Health Plans
Bronze

(HMO) MercyCare HMO Bronze Option B

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-895-2421

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 		$255.06
$289.49
$325.96
$455.53
$692.22 		$450.18
$484.61
$521.08
$650.65 		$645.30
$679.73
$716.20
$845.77 		$840.42
$874.85
$911.32
$1,040.89 		$195.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$510.12
$578.98
$651.92
$911.06
$1,384.44 		$705.24
$774.10
$847.04
$1,106.18 		$900.36
$969.22
$1,042.16
$1,301.30 		$1,095.48
$1,164.34
$1,237.28
$1,496.42 		$195.12

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1813 | Toll Free: 1-855-748-1813

Toc - Plan #58 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Priority/Lean 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$7,900 $15,800 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 		$287.06
$325.81
$366.86
$512.69
$779.08 		$506.66
$545.41
$586.46
$732.29 		$726.26
$765.01
$806.06
$951.89 		$945.86
$984.61
$1,025.66
$1,171.49 		$219.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.12
$651.62
$733.72
$1,025.38
$1,558.16 		$793.72
$871.22
$953.32
$1,244.98 		$1,013.32
$1,090.82
$1,172.92
$1,464.58 		$1,232.92
$1,310.42
$1,392.52
$1,684.18 		$219.60
Toc - Plan #59 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Priority/Lean 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$357.25
$405.48
$456.57
$638.05
$969.58 		$630.55
$678.78
$729.87
$911.35 		$903.85
$952.08
$1,003.17
$1,184.65 		$1,177.15
$1,225.38
$1,276.47
$1,457.95 		$273.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.50
$810.96
$913.14
$1,276.10
$1,939.16 		$987.80
$1,084.26
$1,186.44
$1,549.40 		$1,261.10
$1,357.56
$1,459.74
$1,822.70 		$1,534.40
$1,630.86
$1,733.04
$2,096.00 		$273.30
Toc - Plan #60 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Blue Priority/Lean 9450 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$273.65
$310.59
$349.72
$488.74
$742.69 		$482.99
$519.93
$559.06
$698.08 		$692.33
$729.27
$768.40
$907.42 		$901.67
$938.61
$977.74
$1,116.76 		$209.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$547.30
$621.18
$699.44
$977.48
$1,485.38 		$756.64
$830.52
$908.78
$1,186.82 		$965.98
$1,039.86
$1,118.12
$1,396.16 		$1,175.32
$1,249.20
$1,327.46
$1,605.50 		$209.34
Toc - Plan #61 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Priority/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,800 $13,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382.28
$433.89
$488.55
$682.75
$1,037.51 		$674.72
$726.33
$780.99
$975.19 		$967.16
$1,018.77
$1,073.43
$1,267.63 		$1,259.60
$1,311.21
$1,365.87
$1,560.07 		$292.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.56
$867.78
$977.10
$1,365.50
$2,075.02 		$1,057.00
$1,160.22
$1,269.54
$1,657.94 		$1,349.44
$1,452.66
$1,561.98
$1,950.38 		$1,641.88
$1,745.10
$1,854.42
$2,242.82 		$292.44
Toc - Plan #62 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Priority/Lean 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$292.72
$332.24
$374.10
$522.80
$794.44 		$516.65
$556.17
$598.03
$746.73 		$740.58
$780.10
$821.96
$970.66 		$964.51
$1,004.03
$1,045.89
$1,194.59 		$223.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.44
$664.48
$748.20
$1,045.60
$1,588.88 		$809.37
$888.41
$972.13
$1,269.53 		$1,033.30
$1,112.34
$1,196.06
$1,493.46 		$1,257.23
$1,336.27
$1,419.99
$1,717.39 		$223.93
Toc - Plan #63 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Priority/Lean 5300 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.09
$396.22
$446.14
$623.47
$947.43 		$616.14
$663.27
$713.19
$890.52 		$883.19
$930.32
$980.24
$1,157.57 		$1,150.24
$1,197.37
$1,247.29
$1,424.62 		$267.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.18
$792.44
$892.28
$1,246.94
$1,894.86 		$965.23
$1,059.49
$1,159.33
$1,513.99 		$1,232.28
$1,326.54
$1,426.38
$1,781.04 		$1,499.33
$1,593.59
$1,693.43
$2,048.09 		$267.05
Toc - Plan #64 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Priority/Lean 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$287.32
$326.11
$367.19
$513.15
$779.79 		$507.12
$545.91
$586.99
$732.95 		$726.92
$765.71
$806.79
$952.75 		$946.72
$985.51
$1,026.59
$1,172.55 		$219.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.64
$652.22
$734.38
$1,026.30
$1,559.58 		$794.44
$872.02
$954.18
$1,246.10 		$1,014.24
$1,091.82
$1,173.98
$1,465.90 		$1,234.04
$1,311.62
$1,393.78
$1,685.70 		$219.80
Toc - Plan #65 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Priority/Lean 5000 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$288.17
$327.07
$368.28
$514.67
$782.09 		$508.62
$547.52
$588.73
$735.12 		$729.07
$767.97
$809.18
$955.57 		$949.52
$988.42
$1,029.63
$1,176.02 		$220.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.34
$654.14
$736.56
$1,029.34
$1,564.18 		$796.79
$874.59
$957.01
$1,249.79 		$1,017.24
$1,095.04
$1,177.46
$1,470.24 		$1,237.69
$1,315.49
$1,397.91
$1,690.69 		$220.45
Toc - Plan #66 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Priority/Lean 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,700 $15,400 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 		$357.45
$405.71
$456.82
$638.41
$970.12 		$630.90
$679.16
$730.27
$911.86 		$904.35
$952.61
$1,003.72
$1,185.31 		$1,177.80
$1,226.06
$1,277.17
$1,458.76 		$273.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.90
$811.42
$913.64
$1,276.82
$1,940.24 		$988.35
$1,084.87
$1,187.09
$1,550.27 		$1,261.80
$1,358.32
$1,460.54
$1,823.72 		$1,535.25
$1,631.77
$1,733.99
$2,097.17 		$273.45
Toc - Plan #67 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Priority/Lean 1500/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$389.44
$442.01
$497.70
$695.54
$1,056.94 		$687.36
$739.93
$795.62
$993.46 		$985.28
$1,037.85
$1,093.54
$1,291.38 		$1,283.20
$1,335.77
$1,391.46
$1,589.30 		$297.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.88
$884.02
$995.40
$1,391.08
$2,113.88 		$1,076.80
$1,181.94
$1,293.32
$1,689.00 		$1,374.72
$1,479.86
$1,591.24
$1,986.92 		$1,672.64
$1,777.78
$1,889.16
$2,284.84 		$297.92
Toc - Plan #68 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Priority/Lean 5900/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$348.77
$395.85
$445.73
$622.90
$946.56 		$615.58
$662.66
$712.54
$889.71 		$882.39
$929.47
$979.35
$1,156.52 		$1,149.20
$1,196.28
$1,246.16
$1,423.33 		$266.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.54
$791.70
$891.46
$1,245.80
$1,893.12 		$964.35
$1,058.51
$1,158.27
$1,512.61 		$1,231.16
$1,325.32
$1,425.08
$1,779.42 		$1,497.97
$1,592.13
$1,691.89
$2,046.23 		$266.81
Toc - Plan #69 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Blue Preferred/Broad 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$314.58
$357.05
$402.03
$561.84
$853.77 		$555.23
$597.70
$642.68
$802.49 		$795.88
$838.35
$883.33
$1,043.14 		$1,036.53
$1,079.00
$1,123.98
$1,283.79 		$240.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.16
$714.10
$804.06
$1,123.68
$1,707.54 		$869.81
$954.75
$1,044.71
$1,364.33 		$1,110.46
$1,195.40
$1,285.36
$1,604.98 		$1,351.11
$1,436.05
$1,526.01
$1,845.63 		$240.65
Toc - Plan #70 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,700 $15,400 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 		$372.36
$422.63
$475.88
$665.03
$1,010.59 		$657.22
$707.49
$760.74
$949.89 		$942.08
$992.35
$1,045.60
$1,234.75 		$1,226.94
$1,277.21
$1,330.46
$1,519.61 		$284.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.72
$845.26
$951.76
$1,330.06
$2,021.18 		$1,029.58
$1,130.12
$1,236.62
$1,614.92 		$1,314.44
$1,414.98
$1,521.48
$1,899.78 		$1,599.30
$1,699.84
$1,806.34
$2,184.64 		$284.86
Toc - Plan #71 Anthem Blue Cross and Blue Shield
Bronze

(POS) Anthem Bronze Blue Preferred/Broad 9450 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$285.06
$323.54
$364.31
$509.12
$773.65 		$503.13
$541.61
$582.38
$727.19 		$721.20
$759.68
$800.45
$945.26 		$939.27
$977.75
$1,018.52
$1,163.33 		$218.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.12
$647.08
$728.62
$1,018.24
$1,547.30 		$788.19
$865.15
$946.69
$1,236.31 		$1,006.26
$1,083.22
$1,164.76
$1,454.38 		$1,224.33
$1,301.29
$1,382.83
$1,672.45 		$218.07
Toc - Plan #72 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Blue Preferred/Broad 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$7,900 $15,800 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 		$299.03
$339.40
$382.16
$534.07
$811.57 		$527.79
$568.16
$610.92
$762.83 		$756.55
$796.92
$839.68
$991.59 		$985.31
$1,025.68
$1,068.44
$1,220.35 		$228.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.06
$678.80
$764.32
$1,068.14
$1,623.14 		$826.82
$907.56
$993.08
$1,296.90 		$1,055.58
$1,136.32
$1,221.84
$1,525.66 		$1,284.34
$1,365.08
$1,450.60
$1,754.42 		$228.76
Toc - Plan #73 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Blue Preferred/Broad 5000 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$300.17
$340.69
$383.62
$536.10
$814.66 		$529.80
$570.32
$613.25
$765.73 		$759.43
$799.95
$842.88
$995.36 		$989.06
$1,029.58
$1,072.51
$1,224.99 		$229.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.34
$681.38
$767.24
$1,072.20
$1,629.32 		$829.97
$911.01
$996.87
$1,301.83 		$1,059.60
$1,140.64
$1,226.50
$1,531.46 		$1,289.23
$1,370.27
$1,456.13
$1,761.09 		$229.63
Toc - Plan #74 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 5300 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.61
$412.70
$464.69
$649.41
$986.84 		$641.77
$690.86
$742.85
$927.57 		$919.93
$969.02
$1,021.01
$1,205.73 		$1,198.09
$1,247.18
$1,299.17
$1,483.89 		$278.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.22
$825.40
$929.38
$1,298.82
$1,973.68 		$1,005.38
$1,103.56
$1,207.54
$1,576.98 		$1,283.54
$1,381.72
$1,485.70
$1,855.14 		$1,561.70
$1,659.88
$1,763.86
$2,133.30 		$278.16
Toc - Plan #75 Anthem Blue Cross and Blue Shield
Gold

(POS) Anthem Gold Blue Preferred/Broad 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,800 $13,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$398.18
$451.93
$508.87
$711.15
$1,080.66 		$702.79
$756.54
$813.48
$1,015.76 		$1,007.40
$1,061.15
$1,118.09
$1,320.37 		$1,312.01
$1,365.76
$1,422.70
$1,624.98 		$304.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.36
$903.86
$1,017.74
$1,422.30
$2,161.32 		$1,100.97
$1,208.47
$1,322.35
$1,726.91 		$1,405.58
$1,513.08
$1,626.96
$2,031.52 		$1,710.19
$1,817.69
$1,931.57
$2,336.13 		$304.61
Toc - Plan #76 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Blue Preferred/Broad 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$299.29
$339.69
$382.49
$534.53
$812.27 		$528.25
$568.65
$611.45
$763.49 		$757.21
$797.61
$840.41
$992.45 		$986.17
$1,026.57
$1,069.37
$1,221.41 		$228.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.58
$679.38
$764.98
$1,069.06
$1,624.54 		$827.54
$908.34
$993.94
$1,298.02 		$1,056.50
$1,137.30
$1,222.90
$1,526.98 		$1,285.46
$1,366.26
$1,451.86
$1,755.94 		$228.96
Toc - Plan #77 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 5900/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$363.32
$412.37
$464.32
$648.89
$986.05 		$641.26
$690.31
$742.26
$926.83 		$919.20
$968.25
$1,020.20
$1,204.77 		$1,197.14
$1,246.19
$1,298.14
$1,482.71 		$277.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.64
$824.74
$928.64
$1,297.78
$1,972.10 		$1,004.58
$1,102.68
$1,206.58
$1,575.72 		$1,282.52
$1,380.62
$1,484.52
$1,853.66 		$1,560.46
$1,658.56
$1,762.46
$2,131.60 		$277.94
Toc - Plan #78 Anthem Blue Cross and Blue Shield
Gold

(POS) Anthem Gold Blue Preferred/Broad 1500/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$405.66
$460.42
$518.43
$724.51
$1,100.96 		$715.99
$770.75
$828.76
$1,034.84 		$1,026.32
$1,081.08
$1,139.09
$1,345.17 		$1,336.65
$1,391.41
$1,449.42
$1,655.50 		$310.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.32
$920.84
$1,036.86
$1,449.02
$2,201.92 		$1,121.65
$1,231.17
$1,347.19
$1,759.35 		$1,431.98
$1,541.50
$1,657.52
$2,069.68 		$1,742.31
$1,851.83
$1,967.85
$2,380.01 		$310.33
Toc - Plan #79 Anthem Blue Cross and Blue Shield
Silver

(POS) Anthem Silver Blue Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$372.15
$422.39
$475.61
$664.66
$1,010.02 		$656.84
$707.08
$760.30
$949.35 		$941.53
$991.77
$1,044.99
$1,234.04 		$1,226.22
$1,276.46
$1,329.68
$1,518.73 		$284.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.30
$844.78
$951.22
$1,329.32
$2,020.04 		$1,028.99
$1,129.47
$1,235.91
$1,614.01 		$1,313.68
$1,414.16
$1,520.60
$1,898.70 		$1,598.37
$1,698.85
$1,805.29
$2,183.39 		$284.69

‡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 Rock County here.

Rock County is in “Rating Area 14” of Wisconsin.

Currently, there are 79 plans offered in Rating Area 14.

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2024 Obamacare Plans for Rock County, WI

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