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Providers for Zip Code 54153

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ObamacareByZipCode.com

Obamacare 2016 Marketplace Rates For Oconto County, Wisconsin

Thursday, April 25th, 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 Oconto County, Wisconsin.

Obamacare Providers, Plans and 2016 Rates for Oconto County

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

Currently, there are 6 providers offering 115 plans to Rating Area 16. †

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 Oconto, WI area accept this insurance coverage as within the plan's "network".
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Dean Health Plan

Local: 1-608-828-1301 | Toll Free: 1-800-279-1301

TTY: 1-608-827-4086

Plan: (HMO) Prevea360 Catastrophic Safety Net

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

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		 $142.08
$161.26
$181.58
$253.75
$385.60		 $284.16
$322.52
$363.16
$507.50
$771.20		 $374.38
$412.74
$453.38
$597.72		 $464.60
$502.96
$543.60
$687.94		 $554.82
$593.18
$633.82
$778.16		 $232.30
$251.48
$271.80
$343.97		 $322.52
$341.70
$362.02
$434.19		 $412.74
$431.92
$452.24
$524.41		 $90.22

Plan: (HMO) Prevea360 Silver Copay Plus 2000X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $2,000 : Family: $4,000
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		 $286.31
$324.97
$365.91
$511.36
$777.07		 $572.62
$649.94
$731.82
$1022.72
$1554.14		 $754.43
$831.75
$913.63
$1204.53		 $936.24
$1013.56
$1095.44
$1386.34		 $1118.05
$1195.37
$1277.25
$1568.15		 $468.12
$506.78
$547.72
$693.17		 $649.93
$688.59
$729.53
$874.98		 $831.74
$870.40
$911.34
$1056.79		 $181.81

Plan: (HMO) Prevea360 Silver Classic 2500X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $2,500 : Family: $5,000
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		 $274.12
$311.12
$350.32
$489.58
$743.96		 $548.24
$622.24
$700.64
$979.16
$1487.92		 $722.30
$796.30
$874.70
$1153.22		 $896.36
$970.36
$1048.76
$1327.28		 $1070.42
$1144.42
$1222.82
$1501.34		 $448.18
$485.18
$524.38
$663.64		 $622.24
$659.24
$698.44
$837.70		 $796.30
$833.30
$872.50
$1011.76		 $174.06

Plan: (HMO) Prevea360 Silver Classic 4500X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

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

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		 $248.21
$281.72
$317.21
$443.30
$673.65		 $496.42
$563.44
$634.42
$886.60
$1347.30		 $654.03
$721.05
$792.03
$1044.21		 $811.64
$878.66
$949.64
$1201.82		 $969.25
$1036.27
$1107.25
$1359.43		 $405.82
$439.33
$474.82
$600.91		 $563.43
$596.94
$632.43
$758.52		 $721.04
$754.55
$790.04
$916.13		 $157.61

Plan: (HMO) Prevea360 Silver Value Copay 5150X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $5,150 : Family: $10,300
Out of Pocket Maximum per year: Individual: $5,150 : Family: $10,300

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		 $238.46
$270.65
$304.75
$425.89
$647.19		 $476.92
$541.30
$609.50
$851.78
$1294.38		 $628.34
$692.72
$760.92
$1003.20		 $779.76
$844.14
$912.34
$1154.62		 $931.18
$995.56
$1063.76
$1306.04		 $389.88
$422.07
$456.17
$577.31		 $541.30
$573.49
$607.59
$728.73		 $692.72
$724.91
$759.01
$880.15		 $151.42

Plan: (HMO) Prevea360 Bronze Value Copay 5500X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $5,500 : Family: $11,000
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		 $218.75
$248.28
$279.56
$390.69
$593.69		 $437.50
$496.56
$559.12
$781.38
$1187.38		 $576.40
$635.46
$698.02
$920.28		 $715.30
$774.36
$836.92
$1059.18		 $854.20
$913.26
$975.82
$1198.08		 $357.65
$387.18
$418.46
$529.59		 $496.55
$526.08
$557.36
$668.49		 $635.45
$664.98
$696.26
$807.39		 $138.90

Plan: (HMO) Prevea360 Gold Classic 1500X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $1,500 : Family: $3,000
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		 $310.65
$352.58
$397.01
$554.82
$843.10		 $621.30
$705.16
$794.02
$1109.64
$1686.20		 $818.56
$902.42
$991.28
$1306.90		 $1015.82
$1099.68
$1188.54
$1504.16		 $1213.08
$1296.94
$1385.80
$1701.42		 $507.91
$549.84
$594.27
$752.08		 $705.17
$747.10
$791.53
$949.34		 $902.43
$944.36
$988.79
$1146.60		 $197.26

Plan: (HMO) Prevea360 Gold Value Copay 2250X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $2,250 : Family: $4,500
Out of Pocket Maximum per year: Individual: $2,250 : Family: $4,500

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		 $295.02
$334.85
$377.04
$526.92
$800.71		 $590.04
$669.70
$754.08
$1053.84
$1601.42		 $777.38
$857.04
$941.42
$1241.18		 $964.72
$1044.38
$1128.76
$1428.52		 $1152.06
$1231.72
$1316.10
$1615.86		 $482.36
$522.19
$564.38
$714.26		 $669.70
$709.53
$751.72
$901.60		 $857.04
$896.87
$939.06
$1088.94		 $187.34

Plan: (HMO) Prevea360 Gold HSA 2000X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

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

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		 $303.28
$344.22
$387.59
$541.66
$823.10		 $606.56
$688.44
$775.18
$1083.32
$1646.20		 $799.14
$881.02
$967.76
$1275.90		 $991.72
$1073.60
$1160.34
$1468.48		 $1184.30
$1266.18
$1352.92
$1661.06		 $495.86
$536.80
$580.17
$734.24		 $688.44
$729.38
$772.75
$926.82		 $881.02
$921.96
$965.33
$1119.40		 $192.58

Plan: (HMO) Prevea360 Bronze Value Copay 6750X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $6,750 : Family: $13,500
Out of Pocket Maximum per year: Individual: $6,750 : Family: $13,500

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		 $211.70
$240.28
$270.56
$378.11
$574.57		 $423.40
$480.56
$541.12
$756.22
$1149.14		 $557.83
$614.99
$675.55
$890.65		 $692.26
$749.42
$809.98
$1025.08		 $826.69
$883.85
$944.41
$1159.51		 $346.13
$374.71
$404.99
$512.54		 $480.56
$509.14
$539.42
$646.97		 $614.99
$643.57
$673.85
$781.40		 $134.43

Plan: (HMO) Prevea360 Bronze HSA-E 6000X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

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		 $212.42
$241.10
$271.47
$379.39
$576.52		 $424.84
$482.20
$542.94
$758.78
$1153.04		 $559.72
$617.08
$677.82
$893.66		 $694.60
$751.96
$812.70
$1028.54		 $829.48
$886.84
$947.58
$1163.42		 $347.30
$375.98
$406.35
$514.27		 $482.18
$510.86
$541.23
$649.15		 $617.06
$645.74
$676.11
$784.03		 $134.88

Plan: (HMO) Prevea360 Bronze HSA-E 6450X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $6,450 : Family: $12,900
Out of Pocket Maximum per year: Individual: $6,450 : Family: $12,900

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		 $203.15
$230.57
$259.62
$362.83
$551.35		 $406.30
$461.14
$519.24
$725.66
$1102.70		 $535.30
$590.14
$648.24
$854.66		 $664.30
$719.14
$777.24
$983.66		 $793.30
$848.14
$906.24
$1112.66		 $332.15
$359.57
$388.62
$491.83		 $461.15
$488.57
$517.62
$620.83		 $590.15
$617.57
$646.62
$749.83		 $129.00

Plan: (HMO) Prevea360 Silver HSA-E 3400X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $3,400 : Family: $6,800
Out of Pocket Maximum per year: Individual: $3,400 : Family: $6,800

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
Silver 21
30
40
50
60		 $268.25
$304.47
$342.83
$479.10
$728.04		 $536.50
$608.94
$685.66
$958.20
$1456.08		 $706.84
$779.28
$856.00
$1128.54		 $877.18
$949.62
$1026.34
$1298.88		 $1047.52
$1119.96
$1196.68
$1469.22		 $438.59
$474.81
$513.17
$649.44		 $608.93
$645.15
$683.51
$819.78		 $779.27
$815.49
$853.85
$990.12		 $170.34

Plan: (HMO) Prevea360 Platinum Copay Plus 500X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

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

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
Platinum 21
30
40
50
60		 $365.15
$414.44
$466.66
$652.16
$991.02		 $730.30
$828.88
$933.32
$1304.32
$1982.04		 $962.17
$1060.75
$1165.19
$1536.19		 $1194.04
$1292.62
$1397.06
$1768.06		 $1425.91
$1524.49
$1628.93
$1999.93		 $597.02
$646.31
$698.53
$884.03		 $828.89
$878.18
$930.40
$1115.90		 $1060.76
$1110.05
$1162.27
$1347.77		 $231.87

Plan: (HMO) Prevea360 Gold Copay Plus 1000X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $3,000 : Family: $6,000

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		 $326.30
$370.36
$417.02
$582.78
$885.60		 $652.60
$740.72
$834.04
$1165.56
$1771.20		 $859.80
$947.92
$1041.24
$1372.76		 $1067.00
$1155.12
$1248.44
$1579.96		 $1274.20
$1362.32
$1455.64
$1787.16		 $533.50
$577.56
$624.22
$789.98		 $740.70
$784.76
$831.42
$997.18		 $947.90
$991.96
$1038.62
$1204.38		 $207.20

Plan: (HMO) Prevea360 Silver Copay Plus 3500X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1301 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $3,500 : Family: $7,000
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		 $288.37
$327.30
$368.54
$515.04
$782.65		 $576.74
$654.60
$737.08
$1030.08
$1565.30		 $759.86
$837.72
$920.20
$1213.20		 $942.98
$1020.84
$1103.32
$1396.32		 $1126.10
$1203.96
$1286.44
$1579.44		 $471.49
$510.42
$551.66
$698.16		 $654.61
$693.54
$734.78
$881.28		 $837.73
$876.66
$917.90
$1064.40		 $183.12
ADVERTISEMENT

All Savers Insurance Company

Local: 1-877-887-0450 | Toll Free: 1-877-887-0450

Plan: (EPO) Gold Compass 1000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers Insurance Company)

Deductible: Individual: $1,000 : Family: $2,000
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
Gold 21
30
40
50
60		 $357.04
$405.23
$456.29
$637.66
$968.99		 $714.08
$810.46
$912.58
$1275.32
$1937.98		 $940.80
$1037.18
$1139.30
$1502.04		 $1167.52
$1263.90
$1366.02
$1728.76		 $1394.24
$1490.62
$1592.74
$1955.48		 $583.76
$631.95
$683.01
$864.38		 $810.48
$858.67
$909.73
$1091.10		 $1037.20
$1085.39
$1136.45
$1317.82		 $226.72

Plan: (EPO) Gold Compass 500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers Insurance Company)

Deductible: Individual: $500 : Family: $1,000
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
Gold 21
30
40
50
60		 $355.52
$403.50
$454.34
$634.93
$964.84		 $711.04
$807.00
$908.68
$1269.86
$1929.68		 $936.79
$1032.75
$1134.43
$1495.61		 $1162.54
$1258.50
$1360.18
$1721.36		 $1388.29
$1484.25
$1585.93
$1947.11		 $581.27
$629.25
$680.09
$860.68		 $807.02
$855.00
$905.84
$1086.43		 $1032.77
$1080.75
$1131.59
$1312.18		 $225.75

Plan: (EPO) Silver Compass HSA 3000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers 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		 $296.52
$336.54
$378.94
$529.57
$804.73		 $593.04
$673.08
$757.88
$1059.14
$1609.46		 $781.32
$861.36
$946.16
$1247.42		 $969.60
$1049.64
$1134.44
$1435.70		 $1157.88
$1237.92
$1322.72
$1623.98		 $484.80
$524.82
$567.22
$717.85		 $673.08
$713.10
$755.50
$906.13		 $861.36
$901.38
$943.78
$1094.41		 $188.28

Plan: (EPO) Silver Compass 2000 1

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers Insurance Company)

Deductible: Individual: $2,000 : Family: $4,000
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		 $308.75
$350.42
$394.57
$551.40
$837.91		 $617.50
$700.84
$789.14
$1102.80
$1675.82		 $813.55
$896.89
$985.19
$1298.85		 $1009.60
$1092.94
$1181.24
$1494.90		 $1205.65
$1288.99
$1377.29
$1690.95		 $504.80
$546.47
$590.62
$747.45		 $700.85
$742.52
$786.67
$943.50		 $896.90
$938.57
$982.72
$1139.55		 $196.05

Plan: (EPO) Silver Compass 2000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers Insurance Company)

Deductible: Individual: $2,000 : Family: $4,000
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		 $311.19
$353.19
$397.69
$555.77
$844.55		 $622.38
$706.38
$795.38
$1111.54
$1689.10		 $819.98
$903.98
$992.98
$1309.14		 $1017.58
$1101.58
$1190.58
$1506.74		 $1215.18
$1299.18
$1388.18
$1704.34		 $508.79
$550.79
$595.29
$753.37		 $706.39
$748.39
$792.89
$950.97		 $903.99
$945.99
$990.49
$1148.57		 $197.60

Plan: (EPO) Silver Compass 3500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers Insurance Company)

Deductible: Individual: $3,500 : Family: $7,000
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		 $313.33
$355.62
$400.42
$559.59
$850.35		 $626.66
$711.24
$800.84
$1119.18
$1700.70		 $825.62
$910.20
$999.80
$1318.14		 $1024.58
$1109.16
$1198.76
$1517.10		 $1223.54
$1308.12
$1397.72
$1716.06		 $512.29
$554.58
$599.38
$758.55		 $711.25
$753.54
$798.34
$957.51		 $910.21
$952.50
$997.30
$1156.47		 $198.96

Plan: (EPO) Silver Compass 4500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers Insurance Company)

Deductible: Individual: $4,500 : Family: $9,000
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		 $320.36
$363.60
$409.41
$572.15
$869.44		 $640.72
$727.20
$818.82
$1144.30
$1738.88		 $844.14
$930.62
$1022.24
$1347.72		 $1047.56
$1134.04
$1225.66
$1551.14		 $1250.98
$1337.46
$1429.08
$1754.56		 $523.78
$567.02
$612.83
$775.57		 $727.20
$770.44
$816.25
$978.99		 $930.62
$973.86
$1019.67
$1182.41		 $203.42

Plan: (EPO) Bronze Compass HSA 5500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers Insurance Company)

Deductible: Individual: $5,500 : Family: $11,000
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
Bronze 21
30
40
50
60		 $258.61
$293.52
$330.50
$461.87
$701.85		 $517.22
$587.04
$661.00
$923.74
$1403.70		 $681.43
$751.25
$825.21
$1087.95		 $845.64
$915.46
$989.42
$1252.16		 $1009.85
$1079.67
$1153.63
$1416.37		 $422.82
$457.73
$494.71
$626.08		 $587.03
$621.94
$658.92
$790.29		 $751.24
$786.15
$823.13
$954.50		 $164.21

Plan: (EPO) Bronze Compass 6500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers Insurance Company)

Deductible: Individual: $6,500 : Family: $13,000
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		 $272.68
$309.48
$348.47
$486.98
$740.02		 $545.36
$618.96
$696.94
$973.96
$1480.04		 $718.50
$792.10
$870.08
$1147.10		 $891.64
$965.24
$1043.22
$1320.24		 $1064.78
$1138.38
$1216.36
$1493.38		 $445.82
$482.62
$521.61
$660.12		 $618.96
$655.76
$694.75
$833.26		 $792.10
$828.90
$867.89
$1006.40		 $173.14

Plan: (EPO) Gold Compass 0

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-887-0450 - Provider Directory for This Plan: (All Savers Insurance Company)

Deductible: Individual: $0 : Family: $0
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
Gold 21
30
40
50
60		 $351.54
$398.99
$449.26
$627.84
$954.06		 $703.08
$797.98
$898.52
$1255.68
$1908.12		 $926.30
$1021.20
$1121.74
$1478.90		 $1149.52
$1244.42
$1344.96
$1702.12		 $1372.74
$1467.64
$1568.18
$1925.34		 $574.76
$622.21
$672.48
$851.06		 $797.98
$845.43
$895.70
$1074.28		 $1021.20
$1068.65
$1118.92
$1297.50		 $223.22
ADVERTISEMENT

Molina Healthcare of Wisconsin, Inc.

Local: 1-855-540-1979 | Toll Free: 1-855-540-1979

Plan: (HMO) Molina Marketplace Gold Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-540-1979 - Provider Directory for This Plan: (Molina Healthcare of Wisconsin, Inc.)

Deductible: Individual: $500 : Family: $1,000
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
Gold 21
30
40
50
60		 $271.15
$307.75
$346.53
$484.27
$735.90		 $542.30
$615.50
$693.06
$968.54
$1471.80		 $714.48
$787.68
$865.24
$1140.72		 $886.66
$959.86
$1037.42
$1312.90		 $1058.84
$1132.04
$1209.60
$1485.08		 $443.33
$479.93
$518.71
$656.45		 $615.51
$652.11
$690.89
$828.63		 $787.69
$824.29
$863.07
$1000.81		 $172.18

Plan: (HMO) Molina Marketplace Silver Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-540-1979 - Provider Directory for This Plan: (Molina Healthcare of Wisconsin, Inc.)

Deductible: Individual: $2,000 : Family: $4,000
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		 $217.39
$246.74
$277.83
$388.26
$590.00		 $434.78
$493.48
$555.66
$776.52
$1180.00		 $572.82
$631.52
$693.70
$914.56		 $710.86
$769.56
$831.74
$1052.60		 $848.90
$907.60
$969.78
$1190.64		 $355.43
$384.78
$415.87
$526.30		 $493.47
$522.82
$553.91
$664.34		 $631.51
$660.86
$691.95
$802.38		 $138.04

Plan: (HMO) Molina Marketplace Bronze Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-540-1979 - Provider Directory for This Plan: (Molina Healthcare of Wisconsin, Inc.)

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		 $187.95
$213.32
$240.20
$335.68
$510.09		 $375.90
$426.64
$480.40
$671.36
$1020.18		 $495.25
$545.99
$599.75
$790.71		 $614.60
$665.34
$719.10
$910.06		 $733.95
$784.69
$838.45
$1029.41		 $307.30
$332.67
$359.55
$455.03		 $426.65
$452.02
$478.90
$574.38		 $546.00
$571.37
$598.25
$693.73		 $119.35
ADVERTISEMENT

Compcare Health Serv Ins Co(Anthem BCBS)

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

Plan: (POS) Anthem Catastrophic Blue Priority X WI 6850/0%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

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		 $195.43
$221.81
$249.76
$349.04
$530.40		 $390.86
$443.62
$499.52
$698.08
$1060.80		 $514.96
$567.72
$623.62
$822.18		 $639.06
$691.82
$747.72
$946.28		 $763.16
$815.92
$871.82
$1070.38		 $319.53
$345.91
$373.86
$473.14		 $443.63
$470.01
$497.96
$597.24		 $567.73
$594.11
$622.06
$721.34		 $124.10

Plan: (POS) Anthem Bronze Blue Priority X WI 5850 20

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $5,850 : Family: $11,700
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
Bronze 21
30
40
50
60		 $252.81
$286.94
$323.09
$451.52
$686.13		 $505.62
$573.88
$646.18
$903.04
$1372.26		 $666.15
$734.41
$806.71
$1063.57		 $826.68
$894.94
$967.24
$1224.10		 $987.21
$1055.47
$1127.77
$1384.63		 $413.34
$447.47
$483.62
$612.05		 $573.87
$608.00
$644.15
$772.58		 $734.40
$768.53
$804.68
$933.11		 $160.53

Plan: (POS) Anthem Bronze Blue Priority X WI 6050 25

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $6,050 : Family: $12,100
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		 $249.51
$283.19
$318.87
$445.62
$677.17		 $499.02
$566.38
$637.74
$891.24
$1354.34		 $657.46
$724.82
$796.18
$1049.68		 $815.90
$883.26
$954.62
$1208.12		 $974.34
$1041.70
$1113.06
$1366.56		 $407.95
$441.63
$477.31
$604.06		 $566.39
$600.07
$635.75
$762.50		 $724.83
$758.51
$794.19
$920.94		 $158.44

Plan: (POS) Anthem Bronze Blue Priority X WI 0 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

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		 $249.15
$282.79
$318.41
$444.98
$676.19		 $498.30
$565.58
$636.82
$889.96
$1352.38		 $656.51
$723.79
$795.03
$1048.17		 $814.72
$882.00
$953.24
$1206.38		 $972.93
$1040.21
$1111.45
$1364.59		 $407.36
$441.00
$476.62
$603.19		 $565.57
$599.21
$634.83
$761.40		 $723.78
$757.42
$793.04
$919.61		 $158.21

Plan: (POS) Anthem Bronze Blue Priority X WI 30 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $4,650 : Family: $9,300
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		 $244.28
$277.26
$312.19
$436.28
$662.98		 $488.56
$554.52
$624.38
$872.56
$1325.96		 $643.68
$709.64
$779.50
$1027.68		 $798.80
$864.76
$934.62
$1182.80		 $953.92
$1019.88
$1089.74
$1337.92		 $399.40
$432.38
$467.31
$591.40		 $554.52
$587.50
$622.43
$746.52		 $709.64
$742.62
$777.55
$901.64		 $155.12

Plan: (POS) Anthem Silver Blue Priority X WI 3750 10

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $3,750 : Family: $7,500
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

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		 $268.78
$305.07
$343.50
$480.04
$729.47		 $537.56
$610.14
$687.00
$960.08
$1458.94		 $708.24
$780.82
$857.68
$1130.76		 $878.92
$951.50
$1028.36
$1301.44		 $1049.60
$1122.18
$1199.04
$1472.12		 $439.46
$475.75
$514.18
$650.72		 $610.14
$646.43
$684.86
$821.40		 $780.82
$817.11
$855.54
$992.08		 $170.68

Plan: (POS) Anthem Silver Blue Priority X WI 2500/10%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $2,500 : Family: $5,000
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		 $282.29
$320.40
$360.77
$504.17
$766.14		 $564.58
$640.80
$721.54
$1008.34
$1532.28		 $743.83
$820.05
$900.79
$1187.59		 $923.08
$999.30
$1080.04
$1366.84		 $1102.33
$1178.55
$1259.29
$1546.09		 $461.54
$499.65
$540.02
$683.42		 $640.79
$678.90
$719.27
$862.67		 $820.04
$858.15
$898.52
$1041.92		 $179.25

Plan: (POS) Anthem Silver Blue Priority X WI 10 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $3,000 : Family: $6,000
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		 $271.57
$308.23
$347.07
$485.02
$737.04		 $543.14
$616.46
$694.14
$970.04
$1474.08		 $715.59
$788.91
$866.59
$1142.49		 $888.04
$961.36
$1039.04
$1314.94		 $1060.49
$1133.81
$1211.49
$1487.39		 $444.02
$480.68
$519.52
$657.47		 $616.47
$653.13
$691.97
$829.92		 $788.92
$825.58
$864.42
$1002.37		 $172.45

Plan: (POS) Anthem Silver Blue Priority X WI 1850/20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $1,850 : Family: $3,700
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
Silver 21
30
40
50
60		 $281.53
$319.54
$359.80
$502.81
$764.07		 $563.06
$639.08
$719.60
$1005.62
$1528.14		 $741.83
$817.85
$898.37
$1184.39		 $920.60
$996.62
$1077.14
$1363.16		 $1099.37
$1175.39
$1255.91
$1541.93		 $460.30
$498.31
$538.57
$681.58		 $639.07
$677.08
$717.34
$860.35		 $817.84
$855.85
$896.11
$1039.12		 $178.77

Plan: (POS) Anthem Bronze Blue Priority X WI 40 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $5,500 : Family: $11,000
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		 $236.52
$268.45
$302.27
$422.42
$641.92		 $473.04
$536.90
$604.54
$844.84
$1283.84		 $623.23
$687.09
$754.73
$995.03		 $773.42
$837.28
$904.92
$1145.22		 $923.61
$987.47
$1055.11
$1295.41		 $386.71
$418.64
$452.46
$572.61		 $536.90
$568.83
$602.65
$722.80		 $687.09
$719.02
$752.84
$872.99		 $150.19

Plan: (POS) Anthem Bronze Blue Priority X WI 5450 30

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $5,450 : Family: $10,900
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		 $239.16
$271.45
$305.65
$427.14
$649.08		 $478.32
$542.90
$611.30
$854.28
$1298.16		 $630.19
$694.77
$763.17
$1006.15		 $782.06
$846.64
$915.04
$1158.02		 $933.93
$998.51
$1066.91
$1309.89		 $391.03
$423.32
$457.52
$579.01		 $542.90
$575.19
$609.39
$730.88		 $694.77
$727.06
$761.26
$882.75		 $151.87

Plan: (POS) Anthem Silver Blue Priority X WI 4000 25

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $4,000 : Family: $8,000
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		 $260.26
$295.40
$332.61
$464.82
$706.35		 $520.52
$590.80
$665.22
$929.64
$1412.70		 $685.79
$756.07
$830.49
$1094.91		 $851.06
$921.34
$995.76
$1260.18		 $1016.33
$1086.61
$1161.03
$1425.45		 $425.53
$460.67
$497.88
$630.09		 $590.80
$625.94
$663.15
$795.36		 $756.07
$791.21
$828.42
$960.63		 $165.27

Plan: (POS) Anthem Blue Cross and Blue Shield Silver DirectAccess, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $1,750 : Family: $3,500
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		 $284.64
$323.07
$363.77
$508.37
$772.51		 $569.28
$646.14
$727.54
$1016.74
$1545.02		 $750.03
$826.89
$908.29
$1197.49		 $930.78
$1007.64
$1089.04
$1378.24		 $1111.53
$1188.39
$1269.79
$1558.99		 $465.39
$503.82
$544.52
$689.12		 $646.14
$684.57
$725.27
$869.87		 $826.89
$865.32
$906.02
$1050.62		 $180.75

Plan: (POS) Anthem Blue Cross and Blue Shield Gold DirectAccess, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1813 - Provider Directory for This Plan: (Compcare Health Serv Ins Co(Anthem BCBS))

Deductible: Individual: $1,000 : Family: $2,000
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
Gold 21
30
40
50
60		 $384.89
$436.85
$491.89
$687.41
$1044.59		 $769.78
$873.70
$983.78
$1374.82
$2089.18		 $1014.19
$1118.11
$1228.19
$1619.23		 $1258.60
$1362.52
$1472.60
$1863.64		 $1503.01
$1606.93
$1717.01
$2108.05		 $629.30
$681.26
$736.30
$931.82		 $873.71
$925.67
$980.71
$1176.23		 $1118.12
$1170.08
$1225.12
$1420.64		 $244.41
ADVERTISEMENT

WPS Health Plan, Inc.

Local: 1-920-490-6900 | Toll Free: 1-888-711-1444

TTY: 1-888-332-0144

Plan: (HMO) Aurora and Bellin HMO 4000 Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

Deductible: Individual: $4,000 : Family: $8,000
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		 $317.61
$360.49
$405.91
$567.25
$861.99		 $635.22
$720.98
$811.82
$1134.50
$1723.98		 $836.90
$922.66
$1013.50
$1336.18		 $1038.58
$1124.34
$1215.18
$1537.86		 $1240.26
$1326.02
$1416.86
$1739.54		 $519.29
$562.17
$607.59
$768.93		 $720.97
$763.85
$809.27
$970.61		 $922.65
$965.53
$1010.95
$1172.29		 $201.68

Plan: (HMO) Aurora and Bellin HMO 1500 Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $3,250 : Family: $6,500

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		 $404.23
$458.80
$516.61
$721.95
$1097.08		 $808.46
$917.60
$1033.22
$1443.90
$2194.16		 $1065.15
$1174.29
$1289.91
$1700.59		 $1321.84
$1430.98
$1546.60
$1957.28		 $1578.53
$1687.67
$1803.29
$2213.97		 $660.92
$715.49
$773.30
$978.64		 $917.61
$972.18
$1029.99
$1235.33		 $1174.30
$1228.87
$1286.68
$1492.02		 $256.69

Plan: (HMO) Aurora and Bellin HMO 6850 Catastrophic Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

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		 $216.74
$246.00
$276.99
$387.10
$588.23		 $433.48
$492.00
$553.98
$774.20
$1176.46		 $571.11
$629.63
$691.61
$911.83		 $708.74
$767.26
$829.24
$1049.46		 $846.37
$904.89
$966.87
$1187.09		 $354.37
$383.63
$414.62
$524.73		 $492.00
$521.26
$552.25
$662.36		 $629.63
$658.89
$689.88
$799.99		 $137.63

Plan: (HMO) Aurora and Bellin HMO 5500 HDHP Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,450 : Family: $12,900

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		 $255.48
$289.97
$326.50
$456.29
$693.37		 $510.96
$579.94
$653.00
$912.58
$1386.74		 $673.19
$742.17
$815.23
$1074.81		 $835.42
$904.40
$977.46
$1237.04		 $997.65
$1066.63
$1139.69
$1399.27		 $417.71
$452.20
$488.73
$618.52		 $579.94
$614.43
$650.96
$780.75		 $742.17
$776.66
$813.19
$942.98		 $162.23

Plan: (HMO) Aurora and Bellin HMO 6450 HDHP Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

Deductible: Individual: $6,450 : Family: $12,900
Out of Pocket Maximum per year: Individual: $6,450 : Family: $12,900

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		 $251.25
$285.17
$321.10
$448.73
$681.89		 $502.50
$570.34
$642.20
$897.46
$1363.78		 $662.04
$729.88
$801.74
$1057.00		 $821.58
$889.42
$961.28
$1216.54		 $981.12
$1048.96
$1120.82
$1376.08		 $410.79
$444.71
$480.64
$608.27		 $570.33
$604.25
$640.18
$767.81		 $729.87
$763.79
$799.72
$927.35		 $159.54

Plan: (HMO) Aurora and Bellin HMO 3500 HDHP Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

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		 $320.74
$364.04
$409.91
$572.84
$870.49		 $641.48
$728.08
$819.82
$1145.68
$1740.98		 $845.15
$931.75
$1023.49
$1349.35		 $1048.82
$1135.42
$1227.16
$1553.02		 $1252.49
$1339.09
$1430.83
$1756.69		 $524.41
$567.71
$613.58
$776.51		 $728.08
$771.38
$817.25
$980.18		 $931.75
$975.05
$1020.92
$1183.85		 $203.67

Plan: (HMO) Aurora and Bellin HMO 2600 HDHP Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

Deductible: Individual: $2,600 : Family: $5,200
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
Silver 21
30
40
50
60		 $324.15
$367.91
$414.26
$578.93
$879.74		 $648.30
$735.82
$828.52
$1157.86
$1759.48		 $854.14
$941.66
$1034.36
$1363.70		 $1059.98
$1147.50
$1240.20
$1569.54		 $1265.82
$1353.34
$1446.04
$1775.38		 $529.99
$573.75
$620.10
$784.77		 $735.83
$779.59
$825.94
$990.61		 $941.67
$985.43
$1031.78
$1196.45		 $205.84

Plan: (HMO) Aurora and Bellin HMO 5000 Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

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
Silver 21
30
40
50
60		 $315.97
$358.63
$403.81
$564.32
$857.54		 $631.94
$717.26
$807.62
$1128.64
$1715.08		 $832.58
$917.90
$1008.26
$1329.28		 $1033.22
$1118.54
$1208.90
$1529.92		 $1233.86
$1319.18
$1409.54
$1730.56		 $516.61
$559.27
$604.45
$764.96		 $717.25
$759.91
$805.09
$965.60		 $917.89
$960.55
$1005.73
$1166.24		 $200.64

Plan: (HMO) Aurora and Bellin HMO 6000 Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

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
Silver 21
30
40
50
60		 $314.19
$356.61
$401.53
$561.14
$852.71		 $628.38
$713.22
$803.06
$1122.28
$1705.42		 $827.89
$912.73
$1002.57
$1321.79		 $1027.40
$1112.24
$1202.08
$1521.30		 $1226.91
$1311.75
$1401.59
$1720.81		 $513.70
$556.12
$601.04
$760.65		 $713.21
$755.63
$800.55
$960.16		 $912.72
$955.14
$1000.06
$1159.67		 $199.51

Plan: (HMO) Aurora and Bellin HMO 6850 Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

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
Silver 21
30
40
50
60		 $309.09
$350.82
$395.02
$552.03
$838.87		 $618.18
$701.64
$790.04
$1104.06
$1677.74		 $814.45
$897.91
$986.31
$1300.33		 $1010.72
$1094.18
$1182.58
$1496.60		 $1206.99
$1290.45
$1378.85
$1692.87		 $505.36
$547.09
$591.29
$748.30		 $701.63
$743.36
$787.56
$944.57		 $897.90
$939.63
$983.83
$1140.84		 $196.27

Plan: (POS) Aurora and Bellin 4000 Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

Deductible: Individual: $4,000 : Family: $8,000
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		 $331.19
$375.90
$423.26
$591.51
$898.85		 $662.38
$751.80
$846.52
$1183.02
$1797.70		 $872.69
$962.11
$1056.83
$1393.33		 $1083.00
$1172.42
$1267.14
$1603.64		 $1293.31
$1382.73
$1477.45
$1813.95		 $541.50
$586.21
$633.57
$801.82		 $751.81
$796.52
$843.88
$1012.13		 $962.12
$1006.83
$1054.19
$1222.44		 $210.31

Plan: (POS) Aurora and Bellin 5500 HDHP Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,450 : Family: $12,900

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		 $266.40
$302.36
$340.46
$475.79
$723.01		 $532.80
$604.72
$680.92
$951.58
$1446.02		 $701.96
$773.88
$850.08
$1120.74		 $871.12
$943.04
$1019.24
$1289.90		 $1040.28
$1112.20
$1188.40
$1459.06		 $435.56
$471.52
$509.62
$644.95		 $604.72
$640.68
$678.78
$814.11		 $773.88
$809.84
$847.94
$983.27		 $169.16

Plan: (POS) Aurora and Bellin 2600 HDHP Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

Deductible: Individual: $2,600 : Family: $5,200
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
Silver 21
30
40
50
60		 $338.01
$383.64
$431.98
$603.69
$917.36		 $676.02
$767.28
$863.96
$1207.38
$1834.72		 $890.66
$981.92
$1078.60
$1422.02		 $1105.30
$1196.56
$1293.24
$1636.66		 $1319.94
$1411.20
$1507.88
$1851.30		 $552.65
$598.28
$646.62
$818.33		 $767.29
$812.92
$861.26
$1032.97		 $981.93
$1027.56
$1075.90
$1247.61		 $214.64

Plan: (POS) Aurora and Bellin 6850 Featuring the AboutHealth Network

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-711-1444 - Provider Directory for This Plan: (WPS Health Plan, Inc.)

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
Silver 21
30
40
50
60		 $322.30
$365.81
$411.90
$575.63
$874.72		 $644.60
$731.62
$823.80
$1151.26
$1749.44		 $849.26
$936.28
$1028.46
$1355.92		 $1053.92
$1140.94
$1233.12
$1560.58		 $1258.58
$1345.60
$1437.78
$1765.24		 $526.96
$570.47
$616.56
$780.29		 $731.62
$775.13
$821.22
$984.95		 $936.28
$979.79
$1025.88
$1189.61		 $204.66
ADVERTISEMENT

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442

TTY: 1-855-643-5001

Plan: (PPO) Envision Aurora Bellin PPO - Gold 600/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $600 : Family: $1,200
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
Gold 21
30
40
50
60		 $305.16
$346.35
$389.98
$545.00
$828.18		 $610.32
$692.70
$779.96
$1090.00
$1656.36		 $804.09
$886.47
$973.73
$1283.77		 $997.86
$1080.24
$1167.50
$1477.54		 $1191.63
$1274.01
$1361.27
$1671.31		 $498.93
$540.12
$583.75
$738.77		 $692.70
$733.89
$777.52
$932.54		 $886.47
$927.66
$971.29
$1126.31		 $193.77

Plan: (PPO) Envision Aurora Bellin PPO - Gold 1000/90

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $1,000 : Family: $2,000
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
Gold 21
30
40
50
60		 $324.06
$367.80
$414.14
$578.76
$879.48		 $648.12
$735.60
$828.28
$1157.52
$1758.96		 $853.89
$941.37
$1034.05
$1363.29		 $1059.66
$1147.14
$1239.82
$1569.06		 $1265.43
$1352.91
$1445.59
$1774.83		 $529.83
$573.57
$619.91
$784.53		 $735.60
$779.34
$825.68
$990.30		 $941.37
$985.11
$1031.45
$1196.07		 $205.77

Plan: (PPO) Envision Aurora Bellin PPO - Silver 3600/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $3,600 : Family: $7,200
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		 $254.00
$288.28
$324.60
$453.62
$689.32		 $508.00
$576.56
$649.20
$907.24
$1378.64		 $669.28
$737.84
$810.48
$1068.52		 $830.56
$899.12
$971.76
$1229.80		 $991.84
$1060.40
$1133.04
$1391.08		 $415.28
$449.56
$485.88
$614.90		 $576.56
$610.84
$647.16
$776.18		 $737.84
$772.12
$808.44
$937.46		 $161.28

Plan: (PPO) Envision Aurora Bellin PPO - Silver 2400/80/Copay35

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $2,400 : Family: $4,800
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		 $270.31
$306.78
$345.44
$482.75
$733.58		 $540.62
$613.56
$690.88
$965.50
$1467.16		 $712.26
$785.20
$862.52
$1137.14		 $883.90
$956.84
$1034.16
$1308.78		 $1055.54
$1128.48
$1205.80
$1480.42		 $441.95
$478.42
$517.08
$654.39		 $613.59
$650.06
$688.72
$826.03		 $785.23
$821.70
$860.36
$997.67		 $171.64

Plan: (PPO) Envision Aurora Bellin PPO - Silver 2400/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $2,400 : Family: $4,800
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		 $256.08
$290.64
$327.26
$457.35
$694.98		 $512.16
$581.28
$654.52
$914.70
$1389.96		 $674.77
$743.89
$817.13
$1077.31		 $837.38
$906.50
$979.74
$1239.92		 $999.99
$1069.11
$1142.35
$1402.53		 $418.69
$453.25
$489.87
$619.96		 $581.30
$615.86
$652.48
$782.57		 $743.91
$778.47
$815.09
$945.18		 $162.61

Plan: (PPO) Envision Aurora Bellin PPO - Silver 1800/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $1,800 : Family: $3,600
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
Silver 21
30
40
50
60		 $264.42
$300.10
$337.91
$472.23
$717.61		 $528.84
$600.20
$675.82
$944.46
$1435.22		 $696.74
$768.10
$843.72
$1112.36		 $864.64
$936.00
$1011.62
$1280.26		 $1032.54
$1103.90
$1179.52
$1448.16		 $432.32
$468.00
$505.81
$640.13		 $600.22
$635.90
$673.71
$808.03		 $768.12
$803.80
$841.61
$975.93		 $167.90

Plan: (PPO) Envision Aurora Bellin PPO - Catastrophic 6850/100

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

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		 $167.78
$190.42
$214.41
$299.63
$455.32		 $335.56
$380.84
$428.82
$599.26
$910.64		 $442.09
$487.37
$535.35
$705.79		 $548.62
$593.90
$641.88
$812.32		 $655.15
$700.43
$748.41
$918.85		 $274.31
$296.95
$320.94
$406.16		 $380.84
$403.48
$427.47
$512.69		 $487.37
$510.01
$534.00
$619.22		 $106.53

Plan: (PPO) Envision Aurora Bellin PPO - Bronze 6850/100

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

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
Bronze 21
30
40
50
60		 $197.93
$224.64
$252.94
$353.48
$537.15		 $395.86
$449.28
$505.88
$706.96
$1074.30		 $521.54
$574.96
$631.56
$832.64		 $647.22
$700.64
$757.24
$958.32		 $772.90
$826.32
$882.92
$1084.00		 $323.61
$350.32
$378.62
$479.16		 $449.29
$476.00
$504.30
$604.84		 $574.97
$601.68
$629.98
$730.52		 $125.68

Plan: (PPO) Envision Aurora Bellin PPO - HSA Silver 3000/80

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

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		 $252.49
$286.57
$322.67
$450.93
$685.24		 $504.98
$573.14
$645.34
$901.86
$1370.48		 $665.31
$733.47
$805.67
$1062.19		 $825.64
$893.80
$966.00
$1222.52		 $985.97
$1054.13
$1126.33
$1382.85		 $412.82
$446.90
$483.00
$611.26		 $573.15
$607.23
$643.33
$771.59		 $733.48
$767.56
$803.66
$931.92		 $160.33

Plan: (PPO) Envision Aurora Bellin PPO - HSA Bronze 5650/90

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-514-2442 - Provider Directory for This Plan: (Common Ground Healthcare Cooperative)

Deductible: Individual: $5,650 : Family: $11,300
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
Bronze 21
30
40
50
60		 $205.67
$233.43
$262.84
$367.31
$558.17		 $411.34
$466.86
$525.68
$734.62
$1116.34		 $541.94
$597.46
$656.28
$865.22		 $672.54
$728.06
$786.88
$995.82		 $803.14
$858.66
$917.48
$1126.42		 $336.27
$364.03
$393.44
$497.91		 $466.87
$494.63
$524.04
$628.51		 $597.47
$625.23
$654.64
$759.11		 $130.60

†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 Oconto County here.

 

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