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Providers for Zip Code 84759

LegalConsumer.com/obamacare

ObamacareByZipCode.com

Obamacare 2016 Marketplace Rates For Garfield County, Utah

Friday, April 19th, 2024


The health insurance rates listed below are for calendar year 2016.

2016 Rates and Providers

(click here for 2014)

(click here for 2015)

This page gives you an overview of the rates for individual and family health insurance plans available from HealthCare.gov, the marketplace for Garfield County, Utah.

Obamacare Providers, Plans and 2016 Rates for Garfield County

Garfield County is in “Rating Area 6” of Utah.

Currently, there are 4 providers offering 82 plans to Rating Area 6. †

Below, you’ll find a summary of plans and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options. For detailed information on available subsidies to make your coverage affordable, you must complete an application at HealthCare.gov or contact the provider directly.

The table below shows premiums for the following scenarios for:

  • Individual
  • Couple
  • Couple with 1 2 or 3 children
  • Individual with 1 2 or 3 children
  • A child alone

Each scenario is covered for age

  • Age 21, 30, 40, 50
  • Age 60 (Individual and Couple only)

For each plan, there are links that go to the insurance provider's website in a new window. You can find links to:

  • a summary of plan benefits and costs,
  • a plan brochure, and
  • a "Provider Directory" -- where you can find out which doctors and hospitals in the Panguitch, UT area accept this insurance coverage as within the plan's "network".
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Arches Mutual Insurance Company

Local: 1-801-312-9853 | Toll Free: 1-877-337-6633

Plan: (HMO) Arches Secure WELLth - $6000/100%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $185.32
$257.59
$274.08
$394.17
$555.95		 $370.64
$515.18
$548.16
$788.34
$1111.90		 $517.60
$662.14
$695.12
$935.30		 $664.56
$809.10
$842.08
$1082.26		 $811.52
$956.06
$989.04
$1229.22		 $332.28
$404.55
$421.04
$541.13		 $479.24
$551.51
$568.00
$688.09		 $626.20
$698.47
$714.96
$835.05		 $146.96

Plan: (HMO) Arches Classic - $5000/$25/40%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $188.42
$261.90
$278.67
$400.76
$565.25		 $376.84
$523.80
$557.34
$801.52
$1130.50		 $526.25
$673.21
$706.75
$950.93		 $675.66
$822.62
$856.16
$1100.34		 $825.07
$972.03
$1005.57
$1249.75		 $337.83
$411.31
$428.08
$550.17		 $487.24
$560.72
$577.49
$699.58		 $636.65
$710.13
$726.90
$848.99		 $149.41

Plan: (HMO) Arches Secure WELLth - $3500/50%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $191.97
$266.83
$283.92
$408.31
$575.90		 $383.94
$533.66
$567.84
$816.62
$1151.80		 $536.17
$685.89
$720.07
$968.85		 $688.40
$838.12
$872.30
$1121.08		 $840.63
$990.35
$1024.53
$1273.31		 $344.20
$419.06
$436.15
$560.54		 $496.43
$571.29
$588.38
$712.77		 $648.66
$723.52
$740.61
$865.00		 $152.23

Plan: (HMO) Arches Preferred Care - $3000/$5/40%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $251.03
$348.94
$371.28
$533.95
$753.09		 $502.06
$697.88
$742.56
$1067.90
$1506.18		 $701.13
$896.95
$941.63
$1266.97		 $900.20
$1096.02
$1140.70
$1466.04		 $1099.27
$1295.09
$1339.77
$1665.11		 $450.10
$548.01
$570.35
$733.02		 $649.17
$747.08
$769.42
$932.09		 $848.24
$946.15
$968.49
$1131.16		 $199.07

Plan: (HMO) Arches Preferred Care $6800/$5 2 visits/40% Basic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $6,800 : Family: $13,600
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $179.18
$249.06
$265.00
$381.11
$537.54		 $358.36
$498.12
$530.00
$762.22
$1075.08		 $500.45
$640.21
$672.09
$904.31		 $642.54
$782.30
$814.18
$1046.40		 $784.63
$924.39
$956.27
$1188.49		 $321.27
$391.15
$407.09
$523.20		 $463.36
$533.24
$549.18
$665.29		 $605.45
$675.33
$691.27
$807.38		 $142.09

Plan: (HMO) Arches Preferred Care $6800/$5 2 visits/40%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $6,800 : Family: $13,600
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $179.95
$250.12
$266.14
$382.74
$539.84		 $359.90
$500.24
$532.28
$765.48
$1079.68		 $502.60
$642.94
$674.98
$908.18		 $645.30
$785.64
$817.68
$1050.88		 $788.00
$928.34
$960.38
$1193.58		 $322.65
$392.82
$408.84
$525.44		 $465.35
$535.52
$551.54
$668.14		 $608.05
$678.22
$694.24
$810.84		 $142.70

Plan: (HMO) Arches Preferred Care - $1000/$5/20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $308.16
$428.34
$455.77
$655.45
$924.47		 $616.32
$856.68
$911.54
$1310.90
$1848.94		 $860.69
$1101.05
$1155.91
$1555.27		 $1105.06
$1345.42
$1400.28
$1799.64		 $1349.43
$1589.79
$1644.65
$2044.01		 $552.53
$672.71
$700.14
$899.82		 $796.90
$917.08
$944.51
$1144.19		 $1041.27
$1161.45
$1188.88
$1388.56		 $244.37

Plan: (HMO) Arches Secure WELLth - $6550/100%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $201.46
$280.03
$297.96
$428.50
$604.38		 $402.92
$560.06
$595.92
$857.00
$1208.76		 $562.68
$719.82
$755.68
$1016.76		 $722.44
$879.58
$915.44
$1176.52		 $882.20
$1039.34
$1075.20
$1336.28		 $361.22
$439.79
$457.72
$588.26		 $520.98
$599.55
$617.48
$748.02		 $680.74
$759.31
$777.24
$907.78		 $159.76

Plan: (POS) CO-OPtions Arches Gold, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $500 : Family: $1,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $331.93
$461.39
$490.93
$706.02
$995.79		 $663.86
$922.78
$981.86
$1412.04
$1991.58		 $927.08
$1186.00
$1245.08
$1675.26		 $1190.30
$1449.22
$1508.30
$1938.48		 $1453.52
$1712.44
$1771.52
$2201.70		 $595.15
$724.61
$754.15
$969.24		 $858.37
$987.83
$1017.37
$1232.46		 $1121.59
$1251.05
$1280.59
$1495.68		 $263.22

Plan: (POS) CO-OPtions Arches Silver, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-337-6633 - Provider Directory for This Plan: (Arches Mutual Insurance Company)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $268.47
$373.17
$397.06
$571.03
$805.40		 $536.94
$746.34
$794.12
$1142.06
$1610.80		 $749.83
$959.23
$1007.01
$1354.95		 $962.72
$1172.12
$1219.90
$1567.84		 $1175.61
$1385.01
$1432.79
$1780.73		 $481.36
$586.06
$609.95
$783.92		 $694.25
$798.95
$822.84
$996.81		 $907.14
$1011.84
$1035.73
$1209.70		 $212.89
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SelectHealth

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

Plan: (HMO) Select Med Preference Gold 250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $250 : Family: $750
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $244.08
$339.28
$361.00
$519.16
$732.23		 $488.16
$678.56
$722.00
$1038.32
$1464.46		 $681.72
$872.12
$915.56
$1231.88		 $875.28
$1065.68
$1109.12
$1425.44		 $1068.84
$1259.24
$1302.68
$1619.00		 $437.64
$532.84
$554.56
$712.72		 $631.20
$726.40
$748.12
$906.28		 $824.76
$919.96
$941.68
$1099.84		 $193.56

Plan: (HMO) Select Med Preference Gold 250 w/no deductible for office visits

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $250 : Family: $750
Out of Pocket Maximum per year: Individual: $5,400 : Family: $10,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $248.92
$346.01
$368.16
$529.46
$746.75		 $497.84
$692.02
$736.32
$1058.92
$1493.50		 $695.24
$889.42
$933.72
$1256.32		 $892.64
$1086.82
$1131.12
$1453.72		 $1090.04
$1284.22
$1328.52
$1651.12		 $446.32
$543.41
$565.56
$726.86		 $643.72
$740.81
$762.96
$924.26		 $841.12
$938.21
$960.36
$1121.66		 $197.40

Plan: (HMO) Select Med Preference Gold 500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $500 : Family: $1,500
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $237.72
$330.44
$351.59
$505.63
$713.14		 $475.44
$660.88
$703.18
$1011.26
$1426.28		 $663.96
$849.40
$891.70
$1199.78		 $852.48
$1037.92
$1080.22
$1388.30		 $1041.00
$1226.44
$1268.74
$1576.82		 $426.24
$518.96
$540.11
$694.15		 $614.76
$707.48
$728.63
$882.67		 $803.28
$896.00
$917.15
$1071.19		 $188.52

Plan: (HMO) Select Med Preference Gold 500 w/no deductible for office visits

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $500 : Family: $1,500
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $244.38
$339.69
$361.43
$519.79
$733.11		 $488.76
$679.38
$722.86
$1039.58
$1466.22		 $682.55
$873.17
$916.65
$1233.37		 $876.34
$1066.96
$1110.44
$1427.16		 $1070.13
$1260.75
$1304.23
$1620.95		 $438.17
$533.48
$555.22
$713.58		 $631.96
$727.27
$749.01
$907.37		 $825.75
$921.06
$942.80
$1101.16		 $193.79

Plan: (HMO) Select Med Preference Silver 1250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $198.05
$275.29
$292.92
$421.25
$594.13		 $396.10
$550.58
$585.84
$842.50
$1188.26		 $553.16
$707.64
$742.90
$999.56		 $710.22
$864.70
$899.96
$1156.62		 $867.28
$1021.76
$1057.02
$1313.68		 $355.11
$432.35
$449.98
$578.31		 $512.17
$589.41
$607.04
$735.37		 $669.23
$746.47
$764.10
$892.43		 $157.06

Plan: (HMO) Select Med Preference Gold 1000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,000 : Family: $2,500
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $238.62
$331.68
$352.93
$507.55
$715.85		 $477.24
$663.36
$705.86
$1015.10
$1431.70		 $666.47
$852.59
$895.09
$1204.33		 $855.70
$1041.82
$1084.32
$1393.56		 $1044.93
$1231.05
$1273.55
$1582.79		 $427.85
$520.91
$542.16
$696.78		 $617.08
$710.14
$731.39
$886.01		 $806.31
$899.37
$920.62
$1075.24		 $189.23

Plan: (HMO) Select Med Preference Gold 1000 w/no deductible for office visits

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,000 : Family: $2,500
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $255.89
$355.68
$378.45
$544.27
$767.63		 $511.78
$711.36
$756.90
$1088.54
$1535.26		 $714.69
$914.27
$959.81
$1291.45		 $917.60
$1117.18
$1162.72
$1494.36		 $1120.51
$1320.09
$1365.63
$1697.27		 $458.80
$558.59
$581.36
$747.18		 $661.71
$761.50
$784.27
$950.09		 $864.62
$964.41
$987.18
$1153.00		 $202.91

Plan: (HMO) Select Med Preference Silver 2500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $208.95
$290.44
$309.04
$444.43
$626.83		 $417.90
$580.88
$618.08
$888.86
$1253.66		 $583.60
$746.58
$783.78
$1054.56		 $749.30
$912.28
$949.48
$1220.26		 $915.00
$1077.98
$1115.18
$1385.96		 $374.65
$456.14
$474.74
$610.13		 $540.35
$621.84
$640.44
$775.83		 $706.05
$787.54
$806.14
$941.53		 $165.70

Plan: (HMO) Select Med Preference Silver 2500 w/limited office visit waiver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $217.73
$302.64
$322.02
$463.10
$653.16		 $435.46
$605.28
$644.04
$926.20
$1306.32		 $608.12
$777.94
$816.70
$1098.86		 $780.78
$950.60
$989.36
$1271.52		 $953.44
$1123.26
$1162.02
$1444.18		 $390.39
$475.30
$494.68
$635.76		 $563.05
$647.96
$667.34
$808.42		 $735.71
$820.62
$840.00
$981.08		 $172.66

Plan: (HMO) Select Med Preference Bronze 5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $170.49
$236.97
$252.16
$362.63
$511.46		 $340.98
$473.94
$504.32
$725.26
$1022.92		 $476.18
$609.14
$639.52
$860.46		 $611.38
$744.34
$774.72
$995.66		 $746.58
$879.54
$909.92
$1130.86		 $305.69
$372.17
$387.36
$497.83		 $440.89
$507.37
$522.56
$633.03		 $576.09
$642.57
$657.76
$768.23		 $135.20

Plan: (HMO) Select Med Preference Bronze 6000 w/limited office visit waiver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $176.55
$245.40
$261.11
$375.51
$529.62		 $353.10
$490.80
$522.22
$751.02
$1059.24		 $493.11
$630.81
$662.23
$891.03		 $633.12
$770.82
$802.24
$1031.04		 $773.13
$910.83
$942.25
$1171.05		 $316.56
$385.41
$401.12
$515.52		 $456.57
$525.42
$541.13
$655.53		 $596.58
$665.43
$681.14
$795.54		 $140.01

Plan: (HMO) Select Med Preference Silver 3800 Copay Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $3,800 : Family: $7,600
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $215.62
$299.71
$318.90
$458.62
$646.83		 $431.24
$599.42
$637.80
$917.24
$1293.66		 $602.22
$770.40
$808.78
$1088.22		 $773.20
$941.38
$979.76
$1259.20		 $944.18
$1112.36
$1150.74
$1430.18		 $386.60
$470.69
$489.88
$629.60		 $557.58
$641.67
$660.86
$800.58		 $728.56
$812.65
$831.84
$971.56		 $170.98

Plan: (HMO) Select Med HealthSave Silver 1500 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $217.13
$301.81
$321.13
$461.83
$651.37		 $434.26
$603.62
$642.26
$923.66
$1302.74		 $606.44
$775.80
$814.44
$1095.84		 $778.62
$947.98
$986.62
$1268.02		 $950.80
$1120.16
$1158.80
$1440.20		 $389.31
$473.99
$493.31
$634.01		 $561.49
$646.17
$665.49
$806.19		 $733.67
$818.35
$837.67
$978.37		 $172.18

Plan: (HMO) Select Med HealthSave Silver 2000 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $203.81
$283.29
$301.42
$433.49
$611.39		 $407.62
$566.58
$602.84
$866.98
$1222.78		 $569.24
$728.20
$764.46
$1028.60		 $730.86
$889.82
$926.08
$1190.22		 $892.48
$1051.44
$1087.70
$1351.84		 $365.43
$444.91
$463.04
$595.11		 $527.05
$606.53
$624.66
$756.73		 $688.67
$768.15
$786.28
$918.35		 $161.62

Plan: (HMO) Select Med HealthSave Bronze 4500 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $171.71
$238.68
$253.95
$365.22
$515.11		 $343.42
$477.36
$507.90
$730.44
$1030.22		 $479.58
$613.52
$644.06
$866.60		 $615.74
$749.68
$780.22
$1002.76		 $751.90
$885.84
$916.38
$1138.92		 $307.87
$374.84
$390.11
$501.38		 $444.03
$511.00
$526.27
$637.54		 $580.19
$647.16
$662.43
$773.70		 $136.16

Plan: (HMO) Select Med HealthSave Silver 3500 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $208.65
$290.02
$308.58
$443.79
$625.92		 $417.30
$580.04
$617.16
$887.58
$1251.84		 $582.76
$745.50
$782.62
$1053.04		 $748.22
$910.96
$948.08
$1218.50		 $913.68
$1076.42
$1113.54
$1383.96		 $374.11
$455.48
$474.04
$609.25		 $539.57
$620.94
$639.50
$774.71		 $705.03
$786.40
$804.96
$940.17		 $165.46

Plan: (HMO) Select Med HealthSave Bronze 6550 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $176.24
$244.98
$260.66
$374.87
$528.71		 $352.48
$489.96
$521.32
$749.74
$1057.42		 $492.25
$629.73
$661.09
$889.51		 $632.02
$769.50
$800.86
$1029.28		 $771.79
$909.27
$940.63
$1169.05		 $316.01
$384.75
$400.43
$514.64		 $455.78
$524.52
$540.20
$654.41		 $595.55
$664.29
$679.97
$794.18		 $139.77

Plan: (HMO) Select Med Millennial 6850 (Catastrophic Plan)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $155.35
$215.93
$229.76
$330.42
$466.03		 $310.70
$431.86
$459.52
$660.84
$932.06		 $433.89
$555.05
$582.71
$784.03		 $557.08
$678.24
$705.90
$907.22		 $680.27
$801.43
$829.09
$1030.41		 $278.54
$339.12
$352.95
$453.61		 $401.73
$462.31
$476.14
$576.80		 $524.92
$585.50
$599.33
$699.99		 $123.19

Plan: (HMO) Select Care Preference Gold 250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $250 : Family: $750
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $281.92
$391.86
$416.96
$599.63
$845.72		 $563.84
$783.72
$833.92
$1199.26
$1691.44		 $787.40
$1007.28
$1057.48
$1422.82		 $1010.96
$1230.84
$1281.04
$1646.38		 $1234.52
$1454.40
$1504.60
$1869.94		 $505.48
$615.42
$640.52
$823.19		 $729.04
$838.98
$864.08
$1046.75		 $952.60
$1062.54
$1087.64
$1270.31		 $223.56

Plan: (HMO) Select Care Preference Gold 250 w/no deductible for office visits

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $250 : Family: $750
Out of Pocket Maximum per year: Individual: $5,400 : Family: $10,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $287.51
$399.64
$425.23
$611.53
$862.50		 $575.02
$799.28
$850.46
$1223.06
$1725.00		 $803.02
$1027.28
$1078.46
$1451.06		 $1031.02
$1255.28
$1306.46
$1679.06		 $1259.02
$1483.28
$1534.46
$1907.06		 $515.51
$627.64
$653.23
$839.53		 $743.51
$855.64
$881.23
$1067.53		 $971.51
$1083.64
$1109.23
$1295.53		 $228.00

Plan: (HMO) Select Care Preference Gold 500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $500 : Family: $1,500
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $274.57
$381.65
$406.09
$584.00
$823.68		 $549.14
$763.30
$812.18
$1168.00
$1647.36		 $766.88
$981.04
$1029.92
$1385.74		 $984.62
$1198.78
$1247.66
$1603.48		 $1202.36
$1416.52
$1465.40
$1821.22		 $492.31
$599.39
$623.83
$801.74		 $710.05
$817.13
$841.57
$1019.48		 $927.79
$1034.87
$1059.31
$1237.22		 $217.74

Plan: (HMO) Select Care Preference Gold 500 w/no deductible for office visits

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $500 : Family: $1,500
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $282.26
$392.34
$417.45
$600.36
$846.74		 $564.52
$784.68
$834.90
$1200.72
$1693.48		 $788.35
$1008.51
$1058.73
$1424.55		 $1012.18
$1232.34
$1282.56
$1648.38		 $1236.01
$1456.17
$1506.39
$1872.21		 $506.09
$616.17
$641.28
$824.19		 $729.92
$840.00
$865.11
$1048.02		 $953.75
$1063.83
$1088.94
$1271.85		 $223.83

Plan: (HMO) Select Care Preference Silver 1250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $228.75
$317.96
$338.32
$486.54
$686.22		 $457.50
$635.92
$676.64
$973.08
$1372.44		 $638.90
$817.32
$858.04
$1154.48		 $820.30
$998.72
$1039.44
$1335.88		 $1001.70
$1180.12
$1220.84
$1517.28		 $410.15
$499.36
$519.72
$667.94		 $591.55
$680.76
$701.12
$849.34		 $772.95
$862.16
$882.52
$1030.74		 $181.40

Plan: (HMO) Select Care Preference Gold 1000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,000 : Family: $2,500
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $275.61
$383.10
$407.63
$586.22
$826.80		 $551.22
$766.20
$815.26
$1172.44
$1653.60		 $769.78
$984.76
$1033.82
$1391.00		 $988.34
$1203.32
$1252.38
$1609.56		 $1206.90
$1421.88
$1470.94
$1828.12		 $494.17
$601.66
$626.19
$804.78		 $712.73
$820.22
$844.75
$1023.34		 $931.29
$1038.78
$1063.31
$1241.90		 $218.56

Plan: (HMO) Select Care Preference Gold 1000 w/no deductible for office visits

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,000 : Family: $2,500
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $295.55
$410.81
$437.11
$628.63
$886.62		 $591.10
$821.62
$874.22
$1257.26
$1773.24		 $825.46
$1055.98
$1108.58
$1491.62		 $1059.82
$1290.34
$1342.94
$1725.98		 $1294.18
$1524.70
$1577.30
$1960.34		 $529.91
$645.17
$671.47
$862.99		 $764.27
$879.53
$905.83
$1097.35		 $998.63
$1113.89
$1140.19
$1331.71		 $234.36

Plan: (HMO) Select Care Preference Silver 2500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $241.34
$335.46
$356.94
$513.32
$723.99		 $482.68
$670.92
$713.88
$1026.64
$1447.98		 $674.06
$862.30
$905.26
$1218.02		 $865.44
$1053.68
$1096.64
$1409.40		 $1056.82
$1245.06
$1288.02
$1600.78		 $432.72
$526.84
$548.32
$704.70		 $624.10
$718.22
$739.70
$896.08		 $815.48
$909.60
$931.08
$1087.46		 $191.38

Plan: (HMO) Select Care Preference Silver 2500 w/limited office visit waiver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $251.48
$349.55
$371.94
$534.88
$754.40		 $502.96
$699.10
$743.88
$1069.76
$1508.80		 $702.38
$898.52
$943.30
$1269.18		 $901.80
$1097.94
$1142.72
$1468.60		 $1101.22
$1297.36
$1342.14
$1668.02		 $450.90
$548.97
$571.36
$734.30		 $650.32
$748.39
$770.78
$933.72		 $849.74
$947.81
$970.20
$1133.14		 $199.42

Plan: (HMO) Select Care Preference Bronze 5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $196.91
$273.71
$291.24
$418.84
$590.73		 $393.82
$547.42
$582.48
$837.68
$1181.46		 $549.97
$703.57
$738.63
$993.83		 $706.12
$859.72
$894.78
$1149.98		 $862.27
$1015.87
$1050.93
$1306.13		 $353.06
$429.86
$447.39
$574.99		 $509.21
$586.01
$603.54
$731.14		 $665.36
$742.16
$759.69
$887.29		 $156.15

Plan: (HMO) Select Care Preference Bronze 6000 w/limited office visit waiver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $203.91
$283.43
$301.59
$433.72
$611.71		 $407.82
$566.86
$603.18
$867.44
$1223.42		 $569.53
$728.57
$764.89
$1029.15		 $731.24
$890.28
$926.60
$1190.86		 $892.95
$1051.99
$1088.31
$1352.57		 $365.62
$445.14
$463.30
$595.43		 $527.33
$606.85
$625.01
$757.14		 $689.04
$768.56
$786.72
$918.85		 $161.71

Plan: (HMO) Select Care Preference Silver 3800 Copay Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $3,800 : Family: $7,600
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $249.04
$346.17
$368.32
$529.70
$747.09		 $498.08
$692.34
$736.64
$1059.40
$1494.18		 $695.56
$889.82
$934.12
$1256.88		 $893.04
$1087.30
$1131.60
$1454.36		 $1090.52
$1284.78
$1329.08
$1651.84		 $446.52
$543.65
$565.80
$727.18		 $644.00
$741.13
$763.28
$924.66		 $841.48
$938.61
$960.76
$1122.14		 $197.48

Plan: (HMO) Select Care HealthSave Silver 1500 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $250.78
$348.59
$370.91
$533.42
$752.33		 $501.56
$697.18
$741.82
$1066.84
$1504.66		 $700.43
$896.05
$940.69
$1265.71		 $899.30
$1094.92
$1139.56
$1464.58		 $1098.17
$1293.79
$1338.43
$1663.45		 $449.65
$547.46
$569.78
$732.29		 $648.52
$746.33
$768.65
$931.16		 $847.39
$945.20
$967.52
$1130.03		 $198.87

Plan: (HMO) Select Care HealthSave Silver 2000 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $235.39
$327.20
$348.14
$500.68
$706.16		 $470.78
$654.40
$696.28
$1001.36
$1412.32		 $657.45
$841.07
$882.95
$1188.03		 $844.12
$1027.74
$1069.62
$1374.70		 $1030.79
$1214.41
$1256.29
$1561.37		 $422.06
$513.87
$534.81
$687.35		 $608.73
$700.54
$721.48
$874.02		 $795.40
$887.21
$908.15
$1060.69		 $186.67

Plan: (HMO) Select Care HealthSave Bronze 4500 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $198.32
$275.67
$293.32
$421.83
$594.95		 $396.64
$551.34
$586.64
$843.66
$1189.90		 $553.91
$708.61
$743.91
$1000.93		 $711.18
$865.88
$901.18
$1158.20		 $868.45
$1023.15
$1058.45
$1315.47		 $355.59
$432.94
$450.59
$579.10		 $512.86
$590.21
$607.86
$736.37		 $670.13
$747.48
$765.13
$893.64		 $157.27

Plan: (HMO) Select Care HealthSave Silver 3500 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $240.99
$334.97
$356.42
$512.58
$722.93		 $481.98
$669.94
$712.84
$1025.16
$1445.86		 $673.09
$861.05
$903.95
$1216.27		 $864.20
$1052.16
$1095.06
$1407.38		 $1055.31
$1243.27
$1286.17
$1598.49		 $432.10
$526.08
$547.53
$703.69		 $623.21
$717.19
$738.64
$894.80		 $814.32
$908.30
$929.75
$1085.91		 $191.11

Plan: (HMO) Select Care HealthSave Bronze 6550 (HSA Qualified)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $203.56
$282.95
$301.07
$432.98
$610.66		 $407.12
$565.90
$602.14
$865.96
$1221.32		 $568.55
$727.33
$763.57
$1027.39		 $729.98
$888.76
$925.00
$1188.82		 $891.41
$1050.19
$1086.43
$1350.25		 $364.99
$444.38
$462.50
$594.41		 $526.42
$605.81
$623.93
$755.84		 $687.85
$767.24
$785.36
$917.27		 $161.43

Plan: (HMO) Select Care Millennial 6850 (Catastrophic Plan)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $179.43
$249.40
$265.37
$381.64
$538.27		 $358.86
$498.80
$530.74
$763.28
$1076.54		 $501.14
$641.08
$673.02
$905.56		 $643.42
$783.36
$815.30
$1047.84		 $785.70
$925.64
$957.58
$1190.12		 $321.71
$391.68
$407.65
$523.92		 $463.99
$533.96
$549.93
$666.20		 $606.27
$676.24
$692.21
$808.48		 $142.28

Plan: (HMO) Select Med Preference Benchmark Silver 1250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $195.63
$271.92
$289.33
$416.09
$586.86		 $391.26
$543.84
$578.66
$832.18
$1173.72		 $546.39
$698.97
$733.79
$987.31		 $701.52
$854.10
$888.92
$1142.44		 $856.65
$1009.23
$1044.05
$1297.57		 $350.76
$427.05
$444.46
$571.22		 $505.89
$582.18
$599.59
$726.35		 $661.02
$737.31
$754.72
$881.48		 $155.13

Plan: (HMO) Select Med Preference Benchmark Bronze 5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $168.37
$234.03
$249.02
$358.11
$505.09		 $336.74
$468.06
$498.04
$716.22
$1010.18		 $470.26
$601.58
$631.56
$849.74		 $603.78
$735.10
$765.08
$983.26		 $737.30
$868.62
$898.60
$1116.78		 $301.89
$367.55
$382.54
$491.63		 $435.41
$501.07
$516.06
$625.15		 $568.93
$634.59
$649.58
$758.67		 $133.52

Plan: (HMO) Select Care Preference Benchmark Silver 1250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $225.95
$314.07
$334.17
$480.59
$677.82		 $451.90
$628.14
$668.34
$961.18
$1355.64		 $631.07
$807.31
$847.51
$1140.35		 $810.24
$986.48
$1026.68
$1319.52		 $989.41
$1165.65
$1205.85
$1498.69		 $405.12
$493.24
$513.34
$659.76		 $584.29
$672.41
$692.51
$838.93		 $763.46
$851.58
$871.68
$1018.10		 $179.17

Plan: (HMO) Select Care Preference Benchmark Bronze 5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-538-5038 - Provider Directory for This Plan: (SelectHealth)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $194.46
$270.31
$287.62
$413.62
$583.38		 $388.92
$540.62
$575.24
$827.24
$1166.76		 $543.13
$694.83
$729.45
$981.45		 $697.34
$849.04
$883.66
$1135.66		 $851.55
$1003.25
$1037.87
$1289.87		 $348.67
$424.52
$441.83
$567.83		 $502.88
$578.73
$596.04
$722.04		 $657.09
$732.94
$750.25
$876.25		 $154.21

†Source: Our summary of lowest costs and numbers of providers is based on a government report released September 25, 2013. For more detailed information about specific plans and providers, see HealthCare.gov.

‡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 Garfield County here.

 

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