Obamacare 2024 Rates for Door 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 Ephraim, 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, 83 Plans and 2024 Rates for Door County, Wisconsin

Below, you’ll find a summary of the 83 plans for Door 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

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |

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Chorus Community Health Plans

Local: 1-844-201-4672 | Toll Free: 1-844-201-4672 | TTY: 1-844-531-4856
Toc - Plan #1 Chorus Community Health Plans
Silver

(EPO) Chorus Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.20
$462.16
$520.39
$727.24
$1,105.11 		$718.70
$773.66
$831.89
$1,038.74 		$1,030.20
$1,085.16
$1,143.39
$1,350.24 		$1,341.70
$1,396.66
$1,454.89
$1,661.74 		$311.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.40
$924.32
$1,040.78
$1,454.48
$2,210.22 		$1,125.90
$1,235.82
$1,352.28
$1,765.98 		$1,437.40
$1,547.32
$1,663.78
$2,077.48 		$1,748.90
$1,858.82
$1,975.28
$2,388.98 		$311.50
Toc - Plan #2 Chorus Community Health Plans
Silver

(EPO) Chorus Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$376.66
$427.50
$481.36
$672.70
$1,022.23 		$664.80
$715.64
$769.50
$960.84 		$952.94
$1,003.78
$1,057.64
$1,248.98 		$1,241.08
$1,291.92
$1,345.78
$1,537.12 		$288.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.32
$855.00
$962.72
$1,345.40
$2,044.46 		$1,041.46
$1,143.14
$1,250.86
$1,633.54 		$1,329.60
$1,431.28
$1,539.00
$1,921.68 		$1,617.74
$1,719.42
$1,827.14
$2,209.82 		$288.14
Toc - Plan #3 Chorus Community Health Plans
Gold

(EPO) Chorus Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$441.40
$500.98
$564.10
$788.33
$1,197.94 		$779.07
$838.65
$901.77
$1,126.00 		$1,116.74
$1,176.32
$1,239.44
$1,463.67 		$1,454.41
$1,513.99
$1,577.11
$1,801.34 		$337.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$882.80
$1,001.96
$1,128.20
$1,576.66
$2,395.88 		$1,220.47
$1,339.63
$1,465.87
$1,914.33 		$1,558.14
$1,677.30
$1,803.54
$2,252.00 		$1,895.81
$2,014.97
$2,141.21
$2,589.67 		$337.67
Toc - Plan #4 Chorus Community Health Plans
Expanded Bronze

(EPO) Chorus Bronze HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.83
$386.83
$435.57
$608.70
$924.98 		$601.56
$647.56
$696.30
$869.43 		$862.29
$908.29
$957.03
$1,130.16 		$1,123.02
$1,169.02
$1,217.76
$1,390.89 		$260.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.66
$773.66
$871.14
$1,217.40
$1,849.96 		$942.39
$1,034.39
$1,131.87
$1,478.13 		$1,203.12
$1,295.12
$1,392.60
$1,738.86 		$1,463.85
$1,555.85
$1,653.33
$1,999.59 		$260.73
Toc - Plan #5 Chorus Community Health Plans
Silver

(EPO) Chorus Silver Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 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 		$393.76
$446.91
$503.22
$703.24
$1,068.64 		$694.98
$748.13
$804.44
$1,004.46 		$996.20
$1,049.35
$1,105.66
$1,305.68 		$1,297.42
$1,350.57
$1,406.88
$1,606.90 		$301.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.52
$893.82
$1,006.44
$1,406.48
$2,137.28 		$1,088.74
$1,195.04
$1,307.66
$1,707.70 		$1,389.96
$1,496.26
$1,608.88
$2,008.92 		$1,691.18
$1,797.48
$1,910.10
$2,310.14 		$301.22
Toc - Plan #6 Chorus Community Health Plans
Catastrophic

(EPO) Chorus Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$261.83
$297.17
$334.61
$467.62
$710.59 		$462.12
$497.46
$534.90
$667.91 		$662.41
$697.75
$735.19
$868.20 		$862.70
$898.04
$935.48
$1,068.49 		$200.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523.66
$594.34
$669.22
$935.24
$1,421.18 		$723.95
$794.63
$869.51
$1,135.53 		$924.24
$994.92
$1,069.80
$1,335.82 		$1,124.53
$1,195.21
$1,270.09
$1,536.11 		$200.29
Toc - Plan #7 Chorus Community Health Plans
Expanded Bronze

(EPO) Chorus Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$353.45
$401.16
$451.70
$631.24
$959.24 		$623.83
$671.54
$722.08
$901.62 		$894.21
$941.92
$992.46
$1,172.00 		$1,164.59
$1,212.30
$1,262.84
$1,442.38 		$270.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.90
$802.32
$903.40
$1,262.48
$1,918.48 		$977.28
$1,072.70
$1,173.78
$1,532.86 		$1,247.66
$1,343.08
$1,444.16
$1,803.24 		$1,518.04
$1,613.46
$1,714.54
$2,073.62 		$270.38
Toc - Plan #8 Chorus Community Health Plans
Silver

(EPO) Chorus Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$443.03
$502.83
$566.18
$791.24
$1,202.36 		$781.94
$841.74
$905.09
$1,130.15 		$1,120.85
$1,180.65
$1,244.00
$1,469.06 		$1,459.76
$1,519.56
$1,582.91
$1,807.97 		$338.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.06
$1,005.66
$1,132.36
$1,582.48
$2,404.72 		$1,224.97
$1,344.57
$1,471.27
$1,921.39 		$1,563.88
$1,683.48
$1,810.18
$2,260.30 		$1,902.79
$2,022.39
$2,149.09
$2,599.21 		$338.91
Toc - Plan #9 Chorus Community Health Plans
Bronze

(EPO) Chorus Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$293.59
$333.22
$375.20
$524.34
$796.79 		$518.18
$557.81
$599.79
$748.93 		$742.77
$782.40
$824.38
$973.52 		$967.36
$1,006.99
$1,048.97
$1,198.11 		$224.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.18
$666.44
$750.40
$1,048.68
$1,593.58 		$811.77
$891.03
$974.99
$1,273.27 		$1,036.36
$1,115.62
$1,199.58
$1,497.86 		$1,260.95
$1,340.21
$1,424.17
$1,722.45 		$224.59
Toc - Plan #10 Chorus Community Health Plans
Silver

(EPO) Chorus Core Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$367.70
$417.33
$469.91
$656.70
$997.92 		$648.98
$698.61
$751.19
$937.98 		$930.26
$979.89
$1,032.47
$1,219.26 		$1,211.54
$1,261.17
$1,313.75
$1,500.54 		$281.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.40
$834.66
$939.82
$1,313.40
$1,995.84 		$1,016.68
$1,115.94
$1,221.10
$1,594.68 		$1,297.96
$1,397.22
$1,502.38
$1,875.96 		$1,579.24
$1,678.50
$1,783.66
$2,157.24 		$281.28
Toc - Plan #11 Chorus Community Health Plans
Gold

(EPO) Chorus Core Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$431.63
$489.89
$551.61
$770.88
$1,171.42 		$761.82
$820.08
$881.80
$1,101.07 		$1,092.01
$1,150.27
$1,211.99
$1,431.26 		$1,422.20
$1,480.46
$1,542.18
$1,761.45 		$330.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.26
$979.78
$1,103.22
$1,541.76
$2,342.84 		$1,193.45
$1,309.97
$1,433.41
$1,871.95 		$1,523.64
$1,640.16
$1,763.60
$2,202.14 		$1,853.83
$1,970.35
$2,093.79
$2,532.33 		$330.19
Toc - Plan #12 Chorus Community Health Plans
Expanded Bronze

(EPO) Chorus Core Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$305.40
$346.62
$390.29
$545.43
$828.83 		$539.03
$580.25
$623.92
$779.06 		$772.66
$813.88
$857.55
$1,012.69 		$1,006.29
$1,047.51
$1,091.18
$1,246.32 		$233.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.80
$693.24
$780.58
$1,090.86
$1,657.66 		$844.43
$926.87
$1,014.21
$1,324.49 		$1,078.06
$1,160.50
$1,247.84
$1,558.12 		$1,311.69
$1,394.13
$1,481.47
$1,791.75 		$233.63

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Dean Health Plan

Local: 1-800-279-1302 | Toll Free: 1-800-279-1302 | TTY: 1-800-279-1302
Toc - Plan #13 Dean Health Plan
Gold

(HMO) Prevea360 Gold Copay Plus 1500X (Free Virtual Care)

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 		$499.14
$566.53
$637.91
$891.47
$1,354.68 		$880.99
$948.38
$1,019.76
$1,273.32 		$1,262.84
$1,330.23
$1,401.61
$1,655.17 		$1,644.69
$1,712.08
$1,783.46
$2,037.02 		$381.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$998.28
$1,133.06
$1,275.82
$1,782.94
$2,709.36 		$1,380.13
$1,514.91
$1,657.67
$2,164.79 		$1,761.98
$1,896.76
$2,039.52
$2,546.64 		$2,143.83
$2,278.61
$2,421.37
$2,928.49 		$381.85
Toc - Plan #14 Dean Health Plan
Silver

(HMO) Prevea360 Silver Copay Plus 4800X (Free Virtual Care)

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 		$471.96
$535.67
$603.16
$842.91
$1,280.89 		$833.01
$896.72
$964.21
$1,203.96 		$1,194.06
$1,257.77
$1,325.26
$1,565.01 		$1,555.11
$1,618.82
$1,686.31
$1,926.06 		$361.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$943.92
$1,071.34
$1,206.32
$1,685.82
$2,561.78 		$1,304.97
$1,432.39
$1,567.37
$2,046.87 		$1,666.02
$1,793.44
$1,928.42
$2,407.92 		$2,027.07
$2,154.49
$2,289.47
$2,768.97 		$361.05
Toc - Plan #15 Dean Health Plan
Expanded Bronze

(HMO) Prevea360 Bronze Copay Plus 9400X (Free Virtual Care)

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 		$312.69
$354.90
$399.61
$558.46
$848.63 		$551.89
$594.10
$638.81
$797.66 		$791.09
$833.30
$878.01
$1,036.86 		$1,030.29
$1,072.50
$1,117.21
$1,276.06 		$239.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.38
$709.80
$799.22
$1,116.92
$1,697.26 		$864.58
$949.00
$1,038.42
$1,356.12 		$1,103.78
$1,188.20
$1,277.62
$1,595.32 		$1,342.98
$1,427.40
$1,516.82
$1,834.52 		$239.20
Toc - Plan #16 Dean Health Plan
Silver

(HMO) Prevea360 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 		$473.44
$537.36
$605.06
$845.57
$1,284.92 		$835.62
$899.54
$967.24
$1,207.75 		$1,197.80
$1,261.72
$1,329.42
$1,569.93 		$1,559.98
$1,623.90
$1,691.60
$1,932.11 		$362.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$946.88
$1,074.72
$1,210.12
$1,691.14
$2,569.84 		$1,309.06
$1,436.90
$1,572.30
$2,053.32 		$1,671.24
$1,799.08
$1,934.48
$2,415.50 		$2,033.42
$2,161.26
$2,296.66
$2,777.68 		$362.18
Toc - Plan #17 Dean Health Plan
Expanded Bronze

(HMO) Prevea360 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 		$329.53
$374.01
$421.14
$588.54
$894.34 		$581.62
$626.10
$673.23
$840.63 		$833.71
$878.19
$925.32
$1,092.72 		$1,085.80
$1,130.28
$1,177.41
$1,344.81 		$252.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.06
$748.02
$842.28
$1,177.08
$1,788.68 		$911.15
$1,000.11
$1,094.37
$1,429.17 		$1,163.24
$1,252.20
$1,346.46
$1,681.26 		$1,415.33
$1,504.29
$1,598.55
$1,933.35 		$252.09
Toc - Plan #18 Dean Health Plan
Catastrophic

(HMO) Prevea360 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 		$226.02
$256.53
$288.85
$403.66
$613.41 		$398.92
$429.43
$461.75
$576.56 		$571.82
$602.33
$634.65
$749.46 		$744.72
$775.23
$807.55
$922.36 		$172.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452.04
$513.06
$577.70
$807.32
$1,226.82 		$624.94
$685.96
$750.60
$980.22 		$797.84
$858.86
$923.50
$1,153.12 		$970.74
$1,031.76
$1,096.40
$1,326.02 		$172.90
Toc - Plan #19 Dean Health Plan
Gold

(HMO) Prevea360 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 		$445.41
$505.54
$569.23
$795.50
$1,208.84 		$786.15
$846.28
$909.97
$1,136.24 		$1,126.89
$1,187.02
$1,250.71
$1,476.98 		$1,467.63
$1,527.76
$1,591.45
$1,817.72 		$340.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.82
$1,011.08
$1,138.46
$1,591.00
$2,417.68 		$1,231.56
$1,351.82
$1,479.20
$1,931.74 		$1,572.30
$1,692.56
$1,819.94
$2,272.48 		$1,913.04
$2,033.30
$2,160.68
$2,613.22 		$340.74
Toc - Plan #20 Dean Health Plan
Expanded Bronze

(HMO) Prevea360 Bronze Copay PCP 8000X (Free Virtual Care)

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 		$306.15
$347.48
$391.26
$546.78
$830.89 		$540.35
$581.68
$625.46
$780.98 		$774.55
$815.88
$859.66
$1,015.18 		$1,008.75
$1,050.08
$1,093.86
$1,249.38 		$234.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.30
$694.96
$782.52
$1,093.56
$1,661.78 		$846.50
$929.16
$1,016.72
$1,327.76 		$1,080.70
$1,163.36
$1,250.92
$1,561.96 		$1,314.90
$1,397.56
$1,485.12
$1,796.16 		$234.20
Toc - Plan #21 Dean Health Plan
Silver

(HMO) Prevea360 Silver Copay PCP 4500X (Free Virtual Care)

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 		$448.19
$508.70
$572.79
$800.47
$1,216.39 		$791.06
$851.57
$915.66
$1,143.34 		$1,133.93
$1,194.44
$1,258.53
$1,486.21 		$1,476.80
$1,537.31
$1,601.40
$1,829.08 		$342.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896.38
$1,017.40
$1,145.58
$1,600.94
$2,432.78 		$1,239.25
$1,360.27
$1,488.45
$1,943.81 		$1,582.12
$1,703.14
$1,831.32
$2,286.68 		$1,924.99
$2,046.01
$2,174.19
$2,629.55 		$342.87
Toc - Plan #22 Dean Health Plan
Gold

(HMO) Prevea360 Gold Copay PCP 3000X (Free Virtual Care)

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 		$450.12
$510.88
$575.25
$803.91
$1,221.62 		$794.46
$855.22
$919.59
$1,148.25 		$1,138.80
$1,199.56
$1,263.93
$1,492.59 		$1,483.14
$1,543.90
$1,608.27
$1,836.93 		$344.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.24
$1,021.76
$1,150.50
$1,607.82
$2,443.24 		$1,244.58
$1,366.10
$1,494.84
$1,952.16 		$1,588.92
$1,710.44
$1,839.18
$2,296.50 		$1,933.26
$2,054.78
$2,183.52
$2,640.84 		$344.34
Toc - Plan #23 Dean Health Plan
Gold

(HMO) Prevea360 Gold Standard 1500X (Free Virtual Care)

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 		$463.04
$525.55
$591.77
$826.99
$1,256.70 		$817.27
$879.78
$946.00
$1,181.22 		$1,171.50
$1,234.01
$1,300.23
$1,535.45 		$1,525.73
$1,588.24
$1,654.46
$1,889.68 		$354.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$926.08
$1,051.10
$1,183.54
$1,653.98
$2,513.40 		$1,280.31
$1,405.33
$1,537.77
$2,008.21 		$1,634.54
$1,759.56
$1,892.00
$2,362.44 		$1,988.77
$2,113.79
$2,246.23
$2,716.67 		$354.23
Toc - Plan #24 Dean Health Plan
Silver

(HMO) Prevea360 Silver Standard 5900X (Free Virtual Care)

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 		$451.90
$512.91
$577.53
$807.10
$1,226.47 		$797.61
$858.62
$923.24
$1,152.81 		$1,143.32
$1,204.33
$1,268.95
$1,498.52 		$1,489.03
$1,550.04
$1,614.66
$1,844.23 		$345.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.80
$1,025.82
$1,155.06
$1,614.20
$2,452.94 		$1,249.51
$1,371.53
$1,500.77
$1,959.91 		$1,595.22
$1,717.24
$1,846.48
$2,305.62 		$1,940.93
$2,062.95
$2,192.19
$2,651.33 		$345.71
Toc - Plan #25 Dean Health Plan
Expanded Bronze

(HMO) Prevea360 Bronze Standard 7500X (Free Virtual Care)

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 		$317.24
$360.07
$405.44
$566.60
$861.00 		$559.93
$602.76
$648.13
$809.29 		$802.62
$845.45
$890.82
$1,051.98 		$1,045.31
$1,088.14
$1,133.51
$1,294.67 		$242.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.48
$720.14
$810.88
$1,133.20
$1,722.00 		$877.17
$962.83
$1,053.57
$1,375.89 		$1,119.86
$1,205.52
$1,296.26
$1,618.58 		$1,362.55
$1,448.21
$1,538.95
$1,861.27 		$242.69
Toc - Plan #26 Dean Health Plan
Bronze

(HMO) Prevea360 Bronze Standard 9100X (Free Virtual Care)

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 		$281.50
$319.50
$359.75
$502.75
$763.98 		$496.84
$534.84
$575.09
$718.09 		$712.18
$750.18
$790.43
$933.43 		$927.52
$965.52
$1,005.77
$1,148.77 		$215.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.00
$639.00
$719.50
$1,005.50
$1,527.96 		$778.34
$854.34
$934.84
$1,220.84 		$993.68
$1,069.68
$1,150.18
$1,436.18 		$1,209.02
$1,285.02
$1,365.52
$1,651.52 		$215.34

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-2043 | Toll Free: 1-888-560-2043

Toc - Plan #27 Molina Healthcare
Gold

(HMO) Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

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 		$453.15
$514.32
$579.12
$809.32
$1,229.85 		$799.81
$860.98
$925.78
$1,155.98 		$1,146.47
$1,207.64
$1,272.44
$1,502.64 		$1,493.13
$1,554.30
$1,619.10
$1,849.30 		$346.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$906.30
$1,028.64
$1,158.24
$1,618.64
$2,459.70 		$1,252.96
$1,375.30
$1,504.90
$1,965.30 		$1,599.62
$1,721.96
$1,851.56
$2,311.96 		$1,946.28
$2,068.62
$2,198.22
$2,658.62 		$346.66
Toc - Plan #28 Molina Healthcare
Silver

(HMO) Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

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 		$384.72
$436.66
$491.67
$687.11
$1,044.13 		$679.03
$730.97
$785.98
$981.42 		$973.34
$1,025.28
$1,080.29
$1,275.73 		$1,267.65
$1,319.59
$1,374.60
$1,570.04 		$294.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.44
$873.32
$983.34
$1,374.22
$2,088.26 		$1,063.75
$1,167.63
$1,277.65
$1,668.53 		$1,358.06
$1,461.94
$1,571.96
$1,962.84 		$1,652.37
$1,756.25
$1,866.27
$2,257.15 		$294.31
Toc - Plan #29 Molina Healthcare
Gold

(HMO) Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

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 		$467.76
$530.90
$597.79
$835.41
$1,269.49 		$825.59
$888.73
$955.62
$1,193.24 		$1,183.42
$1,246.56
$1,313.45
$1,551.07 		$1,541.25
$1,604.39
$1,671.28
$1,908.90 		$357.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$935.52
$1,061.80
$1,195.58
$1,670.82
$2,538.98 		$1,293.35
$1,419.63
$1,553.41
$2,028.65 		$1,651.18
$1,777.46
$1,911.24
$2,386.48 		$2,009.01
$2,135.29
$2,269.07
$2,744.31 		$357.83
Toc - Plan #30 Molina Healthcare
Silver

(HMO) Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

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 		$375.68
$426.39
$480.11
$670.96
$1,019.59 		$663.07
$713.78
$767.50
$958.35 		$950.46
$1,001.17
$1,054.89
$1,245.74 		$1,237.85
$1,288.56
$1,342.28
$1,533.13 		$287.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.36
$852.78
$960.22
$1,341.92
$2,039.18 		$1,038.75
$1,140.17
$1,247.61
$1,629.31 		$1,326.14
$1,427.56
$1,535.00
$1,916.70 		$1,613.53
$1,714.95
$1,822.39
$2,204.09 		$287.39
Toc - Plan #31 Molina Healthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

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 		$378.76
$429.89
$484.05
$676.46
$1,027.95 		$668.51
$719.64
$773.80
$966.21 		$958.26
$1,009.39
$1,063.55
$1,255.96 		$1,248.01
$1,299.14
$1,353.30
$1,545.71 		$289.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.52
$859.78
$968.10
$1,352.92
$2,055.90 		$1,047.27
$1,149.53
$1,257.85
$1,642.67 		$1,337.02
$1,439.28
$1,547.60
$1,932.42 		$1,626.77
$1,729.03
$1,837.35
$2,222.17 		$289.75
Toc - Plan #32 Molina Healthcare
Gold

(HMO) Gold 1 with Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

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 		$455.74
$517.27
$582.44
$813.96
$1,236.89 		$804.38
$865.91
$931.08
$1,162.60 		$1,153.02
$1,214.55
$1,279.72
$1,511.24 		$1,501.66
$1,563.19
$1,628.36
$1,859.88 		$348.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.48
$1,034.54
$1,164.88
$1,627.92
$2,473.78 		$1,260.12
$1,383.18
$1,513.52
$1,976.56 		$1,608.76
$1,731.82
$1,862.16
$2,325.20 		$1,957.40
$2,080.46
$2,210.80
$2,673.84 		$348.64
Toc - Plan #33 Molina Healthcare
Silver

(HMO) Silver 1 with Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

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 		$387.07
$439.32
$494.67
$691.30
$1,050.50 		$683.18
$735.43
$790.78
$987.41 		$979.29
$1,031.54
$1,086.89
$1,283.52 		$1,275.40
$1,327.65
$1,383.00
$1,579.63 		$296.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.14
$878.64
$989.34
$1,382.60
$2,101.00 		$1,070.25
$1,174.75
$1,285.45
$1,678.71 		$1,366.36
$1,470.86
$1,581.56
$1,974.82 		$1,662.47
$1,766.97
$1,877.67
$2,270.93 		$296.11

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

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

Toc - Plan #34 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 		$313.94
$356.32
$401.22
$560.70
$852.03 		$554.10
$596.48
$641.38
$800.86 		$794.26
$836.64
$881.54
$1,041.02 		$1,034.42
$1,076.80
$1,121.70
$1,281.18 		$240.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.88
$712.64
$802.44
$1,121.40
$1,704.06 		$868.04
$952.80
$1,042.60
$1,361.56 		$1,108.20
$1,192.96
$1,282.76
$1,601.72 		$1,348.36
$1,433.12
$1,522.92
$1,841.88 		$240.16
Toc - Plan #35 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 		$390.72
$443.47
$499.34
$697.83
$1,060.41 		$689.62
$742.37
$798.24
$996.73 		$988.52
$1,041.27
$1,097.14
$1,295.63 		$1,287.42
$1,340.17
$1,396.04
$1,594.53 		$298.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.44
$886.94
$998.68
$1,395.66
$2,120.82 		$1,080.34
$1,185.84
$1,297.58
$1,694.56 		$1,379.24
$1,484.74
$1,596.48
$1,993.46 		$1,678.14
$1,783.64
$1,895.38
$2,292.36 		$298.90
Toc - Plan #36 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 		$299.27
$339.67
$382.47
$534.50
$812.22 		$528.21
$568.61
$611.41
$763.44 		$757.15
$797.55
$840.35
$992.38 		$986.09
$1,026.49
$1,069.29
$1,221.32 		$228.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.54
$679.34
$764.94
$1,069.00
$1,624.44 		$827.48
$908.28
$993.88
$1,297.94 		$1,056.42
$1,137.22
$1,222.82
$1,526.88 		$1,285.36
$1,366.16
$1,451.76
$1,755.82 		$228.94
Toc - Plan #37 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 		$418.06
$474.50
$534.28
$746.66
$1,134.61 		$737.88
$794.32
$854.10
$1,066.48 		$1,057.70
$1,114.14
$1,173.92
$1,386.30 		$1,377.52
$1,433.96
$1,493.74
$1,706.12 		$319.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.12
$949.00
$1,068.56
$1,493.32
$2,269.22 		$1,155.94
$1,268.82
$1,388.38
$1,813.14 		$1,475.76
$1,588.64
$1,708.20
$2,132.96 		$1,795.58
$1,908.46
$2,028.02
$2,452.78 		$319.82
Toc - Plan #38 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 		$320.14
$363.36
$409.14
$571.77
$868.86 		$565.05
$608.27
$654.05
$816.68 		$809.96
$853.18
$898.96
$1,061.59 		$1,054.87
$1,098.09
$1,143.87
$1,306.50 		$244.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.28
$726.72
$818.28
$1,143.54
$1,737.72 		$885.19
$971.63
$1,063.19
$1,388.45 		$1,130.10
$1,216.54
$1,308.10
$1,633.36 		$1,375.01
$1,461.45
$1,553.01
$1,878.27 		$244.91
Toc - Plan #39 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 		$381.75
$433.29
$487.88
$681.81
$1,036.07 		$673.79
$725.33
$779.92
$973.85 		$965.83
$1,017.37
$1,071.96
$1,265.89 		$1,257.87
$1,309.41
$1,364.00
$1,557.93 		$292.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.50
$866.58
$975.76
$1,363.62
$2,072.14 		$1,055.54
$1,158.62
$1,267.80
$1,655.66 		$1,347.58
$1,450.66
$1,559.84
$1,947.70 		$1,639.62
$1,742.70
$1,851.88
$2,239.74 		$292.04
Toc - Plan #40 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 		$314.22
$356.64
$401.57
$561.20
$852.79 		$554.60
$597.02
$641.95
$801.58 		$794.98
$837.40
$882.33
$1,041.96 		$1,035.36
$1,077.78
$1,122.71
$1,282.34 		$240.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.44
$713.28
$803.14
$1,122.40
$1,705.58 		$868.82
$953.66
$1,043.52
$1,362.78 		$1,109.20
$1,194.04
$1,283.90
$1,603.16 		$1,349.58
$1,434.42
$1,524.28
$1,843.54 		$240.38
Toc - Plan #41 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 		$315.15
$357.70
$402.76
$562.86
$855.32 		$556.24
$598.79
$643.85
$803.95 		$797.33
$839.88
$884.94
$1,045.04 		$1,038.42
$1,080.97
$1,126.03
$1,286.13 		$241.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.30
$715.40
$805.52
$1,125.72
$1,710.64 		$871.39
$956.49
$1,046.61
$1,366.81 		$1,112.48
$1,197.58
$1,287.70
$1,607.90 		$1,353.57
$1,438.67
$1,528.79
$1,848.99 		$241.09
Toc - Plan #42 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 		$390.92
$443.69
$499.60
$698.18
$1,060.96 		$689.97
$742.74
$798.65
$997.23 		$989.02
$1,041.79
$1,097.70
$1,296.28 		$1,288.07
$1,340.84
$1,396.75
$1,595.33 		$299.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.84
$887.38
$999.20
$1,396.36
$2,121.92 		$1,080.89
$1,186.43
$1,298.25
$1,695.41 		$1,379.94
$1,485.48
$1,597.30
$1,994.46 		$1,678.99
$1,784.53
$1,896.35
$2,293.51 		$299.05
Toc - Plan #43 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 		$425.88
$483.37
$544.27
$760.62
$1,155.84 		$751.68
$809.17
$870.07
$1,086.42 		$1,077.48
$1,134.97
$1,195.87
$1,412.22 		$1,403.28
$1,460.77
$1,521.67
$1,738.02 		$325.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.76
$966.74
$1,088.54
$1,521.24
$2,311.68 		$1,177.56
$1,292.54
$1,414.34
$1,847.04 		$1,503.36
$1,618.34
$1,740.14
$2,172.84 		$1,829.16
$1,944.14
$2,065.94
$2,498.64 		$325.80
Toc - Plan #44 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 		$381.44
$432.93
$487.48
$681.25
$1,035.23 		$673.24
$724.73
$779.28
$973.05 		$965.04
$1,016.53
$1,071.08
$1,264.85 		$1,256.84
$1,308.33
$1,362.88
$1,556.65 		$291.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.88
$865.86
$974.96
$1,362.50
$2,070.46 		$1,054.68
$1,157.66
$1,266.76
$1,654.30 		$1,346.48
$1,449.46
$1,558.56
$1,946.10 		$1,638.28
$1,741.26
$1,850.36
$2,237.90 		$291.80
Toc - Plan #45 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 		$371.09
$421.19
$474.25
$662.77
$1,007.14 		$654.97
$705.07
$758.13
$946.65 		$938.85
$988.95
$1,042.01
$1,230.53 		$1,222.73
$1,272.83
$1,325.89
$1,514.41 		$283.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.18
$842.38
$948.50
$1,325.54
$2,014.28 		$1,026.06
$1,126.26
$1,232.38
$1,609.42 		$1,309.94
$1,410.14
$1,516.26
$1,893.30 		$1,593.82
$1,694.02
$1,800.14
$2,177.18 		$283.88
Toc - Plan #46 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 		$439.24
$498.54
$561.35
$784.48
$1,192.10 		$775.26
$834.56
$897.37
$1,120.50 		$1,111.28
$1,170.58
$1,233.39
$1,456.52 		$1,447.30
$1,506.60
$1,569.41
$1,792.54 		$336.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.48
$997.08
$1,122.70
$1,568.96
$2,384.20 		$1,214.50
$1,333.10
$1,458.72
$1,904.98 		$1,550.52
$1,669.12
$1,794.74
$2,241.00 		$1,886.54
$2,005.14
$2,130.76
$2,577.02 		$336.02
Toc - Plan #47 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 		$336.27
$381.67
$429.75
$600.58
$912.64 		$593.52
$638.92
$687.00
$857.83 		$850.77
$896.17
$944.25
$1,115.08 		$1,108.02
$1,153.42
$1,201.50
$1,372.33 		$257.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.54
$763.34
$859.50
$1,201.16
$1,825.28 		$929.79
$1,020.59
$1,116.75
$1,458.41 		$1,187.04
$1,277.84
$1,374.00
$1,715.66 		$1,444.29
$1,535.09
$1,631.25
$1,972.91 		$257.25
Toc - Plan #48 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 		$352.75
$400.37
$450.81
$630.01
$957.36 		$622.60
$670.22
$720.66
$899.86 		$892.45
$940.07
$990.51
$1,169.71 		$1,162.30
$1,209.92
$1,260.36
$1,439.56 		$269.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.50
$800.74
$901.62
$1,260.02
$1,914.72 		$975.35
$1,070.59
$1,171.47
$1,529.87 		$1,245.20
$1,340.44
$1,441.32
$1,799.72 		$1,515.05
$1,610.29
$1,711.17
$2,069.57 		$269.85
Toc - Plan #49 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 		$354.10
$401.90
$452.54
$632.42
$961.03 		$624.99
$672.79
$723.43
$903.31 		$895.88
$943.68
$994.32
$1,174.20 		$1,166.77
$1,214.57
$1,265.21
$1,445.09 		$270.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.20
$803.80
$905.08
$1,264.84
$1,922.06 		$979.09
$1,074.69
$1,175.97
$1,535.73 		$1,249.98
$1,345.58
$1,446.86
$1,806.62 		$1,520.87
$1,616.47
$1,717.75
$2,077.51 		$270.89
Toc - Plan #50 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 		$428.93
$486.84
$548.17
$766.07
$1,164.12 		$757.06
$814.97
$876.30
$1,094.20 		$1,085.19
$1,143.10
$1,204.43
$1,422.33 		$1,413.32
$1,471.23
$1,532.56
$1,750.46 		$328.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.86
$973.68
$1,096.34
$1,532.14
$2,328.24 		$1,185.99
$1,301.81
$1,424.47
$1,860.27 		$1,514.12
$1,629.94
$1,752.60
$2,188.40 		$1,842.25
$1,958.07
$2,080.73
$2,516.53 		$328.13
Toc - Plan #51 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 		$469.70
$533.11
$600.28
$838.88
$1,274.77 		$829.02
$892.43
$959.60
$1,198.20 		$1,188.34
$1,251.75
$1,318.92
$1,557.52 		$1,547.66
$1,611.07
$1,678.24
$1,916.84 		$359.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.40
$1,066.22
$1,200.56
$1,677.76
$2,549.54 		$1,298.72
$1,425.54
$1,559.88
$2,037.08 		$1,658.04
$1,784.86
$1,919.20
$2,396.40 		$2,017.36
$2,144.18
$2,278.52
$2,755.72 		$359.32
Toc - Plan #52 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 		$353.06
$400.72
$451.21
$630.57
$958.20 		$623.15
$670.81
$721.30
$900.66 		$893.24
$940.90
$991.39
$1,170.75 		$1,163.33
$1,210.99
$1,261.48
$1,440.84 		$270.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.12
$801.44
$902.42
$1,261.14
$1,916.40 		$976.21
$1,071.53
$1,172.51
$1,531.23 		$1,246.30
$1,341.62
$1,442.60
$1,801.32 		$1,516.39
$1,611.71
$1,712.69
$2,071.41 		$270.09
Toc - Plan #53 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 		$428.58
$486.44
$547.73
$765.44
$1,163.17 		$756.44
$814.30
$875.59
$1,093.30 		$1,084.30
$1,142.16
$1,203.45
$1,421.16 		$1,412.16
$1,470.02
$1,531.31
$1,749.02 		$327.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.16
$972.88
$1,095.46
$1,530.88
$2,326.34 		$1,185.02
$1,300.74
$1,423.32
$1,858.74 		$1,512.88
$1,628.60
$1,751.18
$2,186.60 		$1,840.74
$1,956.46
$2,079.04
$2,514.46 		$327.86
Toc - Plan #54 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 		$478.53
$543.13
$611.56
$854.65
$1,298.73 		$844.61
$909.21
$977.64
$1,220.73 		$1,210.69
$1,275.29
$1,343.72
$1,586.81 		$1,576.77
$1,641.37
$1,709.80
$1,952.89 		$366.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.06
$1,086.26
$1,223.12
$1,709.30
$2,597.46 		$1,323.14
$1,452.34
$1,589.20
$2,075.38 		$1,689.22
$1,818.42
$1,955.28
$2,441.46 		$2,055.30
$2,184.50
$2,321.36
$2,807.54 		$366.08
Toc - Plan #55 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 		$439.00
$498.27
$561.04
$784.05
$1,191.45 		$774.84
$834.11
$896.88
$1,119.89 		$1,110.68
$1,169.95
$1,232.72
$1,455.73 		$1,446.52
$1,505.79
$1,568.56
$1,791.57 		$335.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.00
$996.54
$1,122.08
$1,568.10
$2,382.90 		$1,213.84
$1,332.38
$1,457.92
$1,903.94 		$1,549.68
$1,668.22
$1,793.76
$2,239.78 		$1,885.52
$2,004.06
$2,129.60
$2,575.62 		$335.84

ADVERTISEMENT

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442
Toc - Plan #56 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$316.55
$359.28
$404.54
$565.35
$859.10 		$558.71
$601.44
$646.70
$807.51 		$800.87
$843.60
$888.86
$1,049.67 		$1,043.03
$1,085.76
$1,131.02
$1,291.83 		$242.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.10
$718.56
$809.08
$1,130.70
$1,718.20 		$875.26
$960.72
$1,051.24
$1,372.86 		$1,117.42
$1,202.88
$1,293.40
$1,615.02 		$1,359.58
$1,445.04
$1,535.56
$1,857.18 		$242.16
Toc - Plan #57 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$494.46
$561.20
$631.91
$883.09
$1,341.94 		$872.71
$939.45
$1,010.16
$1,261.34 		$1,250.96
$1,317.70
$1,388.41
$1,639.59 		$1,629.21
$1,695.95
$1,766.66
$2,017.84 		$378.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$988.92
$1,122.40
$1,263.82
$1,766.18
$2,683.88 		$1,367.17
$1,500.65
$1,642.07
$2,144.43 		$1,745.42
$1,878.90
$2,020.32
$2,522.68 		$2,123.67
$2,257.15
$2,398.57
$2,900.93 		$378.25
Toc - Plan #58 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $3000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,300 $18,600 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 		$430.67
$488.80
$550.39
$769.16
$1,168.82 		$760.13
$818.26
$879.85
$1,098.62 		$1,089.59
$1,147.72
$1,209.31
$1,428.08 		$1,419.05
$1,477.18
$1,538.77
$1,757.54 		$329.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.34
$977.60
$1,100.78
$1,538.32
$2,337.64 		$1,190.80
$1,307.06
$1,430.24
$1,867.78 		$1,520.26
$1,636.52
$1,759.70
$2,197.24 		$1,849.72
$1,965.98
$2,089.16
$2,526.70 		$329.46
Toc - Plan #59 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $1800 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$466.64
$529.63
$596.36
$833.40
$1,266.44 		$823.61
$886.60
$953.33
$1,190.37 		$1,180.58
$1,243.57
$1,310.30
$1,547.34 		$1,537.55
$1,600.54
$1,667.27
$1,904.31 		$356.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$933.28
$1,059.26
$1,192.72
$1,666.80
$2,532.88 		$1,290.25
$1,416.23
$1,549.69
$2,023.77 		$1,647.22
$1,773.20
$1,906.66
$2,380.74 		$2,004.19
$2,130.17
$2,263.63
$2,737.71 		$356.97
Toc - Plan #60 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $4000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$424.90
$482.25
$543.01
$758.86
$1,153.16 		$749.94
$807.29
$868.05
$1,083.90 		$1,074.98
$1,132.33
$1,193.09
$1,408.94 		$1,400.02
$1,457.37
$1,518.13
$1,733.98 		$325.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.80
$964.50
$1,086.02
$1,517.72
$2,306.32 		$1,174.84
$1,289.54
$1,411.06
$1,842.76 		$1,499.88
$1,614.58
$1,736.10
$2,167.80 		$1,824.92
$1,939.62
$2,061.14
$2,492.84 		$325.04
Toc - Plan #61 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$360.12
$408.73
$460.22
$643.16
$977.34 		$635.61
$684.22
$735.71
$918.65 		$911.10
$959.71
$1,011.20
$1,194.14 		$1,186.59
$1,235.20
$1,286.69
$1,469.63 		$275.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.24
$817.46
$920.44
$1,286.32
$1,954.68 		$995.73
$1,092.95
$1,195.93
$1,561.81 		$1,271.22
$1,368.44
$1,471.42
$1,837.30 		$1,546.71
$1,643.93
$1,746.91
$2,112.79 		$275.49
Toc - Plan #62 Common Ground Healthcare Cooperative
Catastrophic

(EPO) CGHC Catastrophic $9450 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$203.62
$231.10
$260.22
$363.65
$552.61 		$359.38
$386.86
$415.98
$519.41 		$515.14
$542.62
$571.74
$675.17 		$670.90
$698.38
$727.50
$830.93 		$155.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$407.24
$462.20
$520.44
$727.30
$1,105.22 		$563.00
$617.96
$676.20
$883.06 		$718.76
$773.72
$831.96
$1,038.82 		$874.52
$929.48
$987.72
$1,194.58 		$155.76
Toc - Plan #63 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $9450 ($35 PCP Copay) - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$302.50
$343.33
$386.59
$540.26
$820.97 		$533.91
$574.74
$618.00
$771.67 		$765.32
$806.15
$849.41
$1,003.08 		$996.73
$1,037.56
$1,080.82
$1,234.49 		$231.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605.00
$686.66
$773.18
$1,080.52
$1,641.94 		$836.41
$918.07
$1,004.59
$1,311.93 		$1,067.82
$1,149.48
$1,236.00
$1,543.34 		$1,299.23
$1,380.89
$1,467.41
$1,774.75 		$231.41
Toc - Plan #64 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$315.29
$357.84
$402.93
$563.09
$855.67 		$556.48
$599.03
$644.12
$804.28 		$797.67
$840.22
$885.31
$1,045.47 		$1,038.86
$1,081.41
$1,126.50
$1,286.66 		$241.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.58
$715.68
$805.86
$1,126.18
$1,711.34 		$871.77
$956.87
$1,047.05
$1,367.37 		$1,112.96
$1,198.06
$1,288.24
$1,608.56 		$1,354.15
$1,439.25
$1,529.43
$1,849.75 		$241.19
Toc - Plan #65 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $3200 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$492.21
$558.65
$629.03
$879.07
$1,335.83 		$868.74
$935.18
$1,005.56
$1,255.60 		$1,245.27
$1,311.71
$1,382.09
$1,632.13 		$1,621.80
$1,688.24
$1,758.62
$2,008.66 		$376.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$984.42
$1,117.30
$1,258.06
$1,758.14
$2,671.66 		$1,360.95
$1,493.83
$1,634.59
$2,134.67 		$1,737.48
$1,870.36
$2,011.12
$2,511.20 		$2,114.01
$2,246.89
$2,387.65
$2,887.73 		$376.53
Toc - Plan #66 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3200 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 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 		$447.18
$507.54
$571.49
$798.65
$1,213.63 		$789.27
$849.63
$913.58
$1,140.74 		$1,131.36
$1,191.72
$1,255.67
$1,482.83 		$1,473.45
$1,533.81
$1,597.76
$1,824.92 		$342.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.36
$1,015.08
$1,142.98
$1,597.30
$2,427.26 		$1,236.45
$1,357.17
$1,485.07
$1,939.39 		$1,578.54
$1,699.26
$1,827.16
$2,281.48 		$1,920.63
$2,041.35
$2,169.25
$2,623.57 		$342.09
Toc - Plan #67 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $6000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$310.56
$352.47
$396.88
$554.63
$842.82 		$548.13
$590.04
$634.45
$792.20 		$785.70
$827.61
$872.02
$1,029.77 		$1,023.27
$1,065.18
$1,109.59
$1,267.34 		$237.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.12
$704.94
$793.76
$1,109.26
$1,685.64 		$858.69
$942.51
$1,031.33
$1,346.83 		$1,096.26
$1,180.08
$1,268.90
$1,584.40 		$1,333.83
$1,417.65
$1,506.47
$1,821.97 		$237.57
Toc - Plan #68 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze Standard $7500 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$306.26
$347.60
$391.39
$546.97
$831.17 		$540.54
$581.88
$625.67
$781.25 		$774.82
$816.16
$859.95
$1,015.53 		$1,009.10
$1,050.44
$1,094.23
$1,249.81 		$234.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.52
$695.20
$782.78
$1,093.94
$1,662.34 		$846.80
$929.48
$1,017.06
$1,328.22 		$1,081.08
$1,163.76
$1,251.34
$1,562.50 		$1,315.36
$1,398.04
$1,485.62
$1,796.78 		$234.28
Toc - Plan #69 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver Standard $5900 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$377.36
$428.29
$482.25
$673.94
$1,024.12 		$666.03
$716.96
$770.92
$962.61 		$954.70
$1,005.63
$1,059.59
$1,251.28 		$1,243.37
$1,294.30
$1,348.26
$1,539.95 		$288.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.72
$856.58
$964.50
$1,347.88
$2,048.24 		$1,043.39
$1,145.25
$1,253.17
$1,636.55 		$1,332.06
$1,433.92
$1,541.84
$1,925.22 		$1,620.73
$1,722.59
$1,830.51
$2,213.89 		$288.67
Toc - Plan #70 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold Standard $1500 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$442.91
$502.70
$566.03
$791.03
$1,202.04 		$781.73
$841.52
$904.85
$1,129.85 		$1,120.55
$1,180.34
$1,243.67
$1,468.67 		$1,459.37
$1,519.16
$1,582.49
$1,807.49 		$338.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$885.82
$1,005.40
$1,132.06
$1,582.06
$2,404.08 		$1,224.64
$1,344.22
$1,470.88
$1,920.88 		$1,563.46
$1,683.04
$1,809.70
$2,259.70 		$1,902.28
$2,021.86
$2,148.52
$2,598.52 		$338.82
Toc - Plan #71 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5650 Ded / $6000 Rx Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$360.00
$408.59
$460.07
$642.94
$977.02 		$635.39
$683.98
$735.46
$918.33 		$910.78
$959.37
$1,010.85
$1,193.72 		$1,186.17
$1,234.76
$1,286.24
$1,469.11 		$275.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.00
$817.18
$920.14
$1,285.88
$1,954.04 		$995.39
$1,092.57
$1,195.53
$1,561.27 		$1,270.78
$1,367.96
$1,470.92
$1,836.66 		$1,546.17
$1,643.35
$1,746.31
$2,112.05 		$275.39
Toc - Plan #72 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $1800 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$469.63
$533.01
$600.17
$838.73
$1,274.54 		$828.89
$892.27
$959.43
$1,197.99 		$1,188.15
$1,251.53
$1,318.69
$1,557.25 		$1,547.41
$1,610.79
$1,677.95
$1,916.51 		$359.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.26
$1,066.02
$1,200.34
$1,677.46
$2,549.08 		$1,298.52
$1,425.28
$1,559.60
$2,036.72 		$1,657.78
$1,784.54
$1,918.86
$2,395.98 		$2,017.04
$2,143.80
$2,278.12
$2,755.24 		$359.26
Toc - Plan #73 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $3000 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,300 $18,600 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 		$433.63
$492.16
$554.16
$774.44
$1,176.84 		$765.35
$823.88
$885.88
$1,106.16 		$1,097.07
$1,155.60
$1,217.60
$1,437.88 		$1,428.79
$1,487.32
$1,549.32
$1,769.60 		$331.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.26
$984.32
$1,108.32
$1,548.88
$2,353.68 		$1,198.98
$1,316.04
$1,440.04
$1,880.60 		$1,530.70
$1,647.76
$1,771.76
$2,212.32 		$1,862.42
$1,979.48
$2,103.48
$2,544.04 		$331.72
Toc - Plan #74 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $4000 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$427.86
$485.61
$546.79
$764.14
$1,161.18 		$755.16
$812.91
$874.09
$1,091.44 		$1,082.46
$1,140.21
$1,201.39
$1,418.74 		$1,409.76
$1,467.51
$1,528.69
$1,746.04 		$327.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.72
$971.22
$1,093.58
$1,528.28
$2,322.36 		$1,183.02
$1,298.52
$1,420.88
$1,855.58 		$1,510.32
$1,625.82
$1,748.18
$2,182.88 		$1,837.62
$1,953.12
$2,075.48
$2,510.18 		$327.30
Toc - Plan #75 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5650 Ded / $6000 Rx Ded - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$362.92
$411.90
$463.79
$648.15
$984.93 		$640.54
$689.52
$741.41
$925.77 		$918.16
$967.14
$1,019.03
$1,203.39 		$1,195.78
$1,244.76
$1,296.65
$1,481.01 		$277.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.84
$823.80
$927.58
$1,296.30
$1,969.86 		$1,003.46
$1,101.42
$1,205.20
$1,573.92 		$1,281.08
$1,379.04
$1,482.82
$1,851.54 		$1,558.70
$1,656.66
$1,760.44
$2,129.16 		$277.62
Toc - Plan #76 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$363.05
$412.05
$463.96
$648.38
$985.28 		$640.77
$689.77
$741.68
$926.10 		$918.49
$967.49
$1,019.40
$1,203.82 		$1,196.21
$1,245.21
$1,297.12
$1,481.54 		$277.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.10
$824.10
$927.92
$1,296.76
$1,970.56 		$1,003.82
$1,101.82
$1,205.64
$1,574.48 		$1,281.54
$1,379.54
$1,483.36
$1,852.20 		$1,559.26
$1,657.26
$1,761.08
$2,129.92 		$277.72
Toc - Plan #77 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $9450 ($35 PCP Copay) - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$305.39
$346.61
$390.27
$545.41
$828.80 		$539.01
$580.23
$623.89
$779.03 		$772.63
$813.85
$857.51
$1,012.65 		$1,006.25
$1,047.47
$1,091.13
$1,246.27 		$233.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.78
$693.22
$780.54
$1,090.82
$1,657.60 		$844.40
$926.84
$1,014.16
$1,324.44 		$1,078.02
$1,160.46
$1,247.78
$1,558.06 		$1,311.64
$1,394.08
$1,481.40
$1,791.68 		$233.62
Toc - Plan #78 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $6000 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$313.45
$355.75
$400.58
$559.80
$850.67 		$553.23
$595.53
$640.36
$799.58 		$793.01
$835.31
$880.14
$1,039.36 		$1,032.79
$1,075.09
$1,119.92
$1,279.14 		$239.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.90
$711.50
$801.16
$1,119.60
$1,701.34 		$866.68
$951.28
$1,040.94
$1,359.38 		$1,106.46
$1,191.06
$1,280.72
$1,599.16 		$1,346.24
$1,430.84
$1,520.50
$1,838.94 		$239.78
Toc - Plan #79 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$318.18
$361.13
$406.63
$568.26
$863.52 		$561.58
$604.53
$650.03
$811.66 		$804.98
$847.93
$893.43
$1,055.06 		$1,048.38
$1,091.33
$1,136.83
$1,298.46 		$243.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.36
$722.26
$813.26
$1,136.52
$1,727.04 		$879.76
$965.66
$1,056.66
$1,379.92 		$1,123.16
$1,209.06
$1,300.06
$1,623.32 		$1,366.56
$1,452.46
$1,543.46
$1,866.72 		$243.40
Toc - Plan #80 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3200 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 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 		$450.15
$510.91
$575.28
$803.95
$1,221.68 		$794.51
$855.27
$919.64
$1,148.31 		$1,138.87
$1,199.63
$1,264.00
$1,492.67 		$1,483.23
$1,543.99
$1,608.36
$1,837.03 		$344.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.30
$1,021.82
$1,150.56
$1,607.90
$2,443.36 		$1,244.66
$1,366.18
$1,494.92
$1,952.26 		$1,589.02
$1,710.54
$1,839.28
$2,296.62 		$1,933.38
$2,054.90
$2,183.64
$2,640.98 		$344.36
Toc - Plan #81 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $3200 - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$495.19
$562.03
$632.84
$884.40
$1,343.93 		$874.01
$940.85
$1,011.66
$1,263.22 		$1,252.83
$1,319.67
$1,390.48
$1,642.04 		$1,631.65
$1,698.49
$1,769.30
$2,020.86 		$378.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$990.38
$1,124.06
$1,265.68
$1,768.80
$2,687.86 		$1,369.20
$1,502.88
$1,644.50
$2,147.62 		$1,748.02
$1,881.70
$2,023.32
$2,526.44 		$2,126.84
$2,260.52
$2,402.14
$2,905.26 		$378.82
Toc - Plan #82 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$319.45
$362.56
$408.24
$570.52
$866.96 		$563.82
$606.93
$652.61
$814.89 		$808.19
$851.30
$896.98
$1,059.26 		$1,052.56
$1,095.67
$1,141.35
$1,303.63 		$244.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.90
$725.12
$816.48
$1,141.04
$1,733.92 		$883.27
$969.49
$1,060.85
$1,385.41 		$1,127.64
$1,213.86
$1,305.22
$1,629.78 		$1,372.01
$1,458.23
$1,549.59
$1,874.15 		$244.37
Toc - Plan #83 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network (Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$497.45
$564.60
$635.73
$888.44
$1,350.07 		$878.00
$945.15
$1,016.28
$1,268.99 		$1,258.55
$1,325.70
$1,396.83
$1,649.54 		$1,639.10
$1,706.25
$1,777.38
$2,030.09 		$380.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$994.90
$1,129.20
$1,271.46
$1,776.88
$2,700.14 		$1,375.45
$1,509.75
$1,652.01
$2,157.43 		$1,756.00
$1,890.30
$2,032.56
$2,537.98 		$2,136.55
$2,270.85
$2,413.11
$2,918.53 		$380.55

‡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 Door County here.

Door County is in “Rating Area 16” of Wisconsin.

Currently, there are 83 plans offered in Rating Area 16.

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2024 Obamacare Plans for Door County, WI

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