Providers for Zip Code 22304

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Obamacare Providers, Plans and 2017 Rates for Loudoun County

The health insurance rates listed below are for calendar year 2017.

2017 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

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

Currently, there are 54 plans offered in Loudoun County.

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:

  • 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)

 

Note: If you are over 65, you qualify for Medicare. Click here to see listings of 2017 Medicare Advantage plans for Loudoun County

 

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 Alexandria, VA area accept this insurance coverage as within the plan's "network".

‡Source: HealthCare.gov has released sample rates for all counties in those states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Loudoun County here.

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CareFirst BlueChoice, Inc.

Local: 1-855-444-3119 | Toll Free: 1-855-444-3119

TTY: 1-202-479-3546

Plan: (HMO) BlueChoice HMO Silver $3,500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

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		 $340.38
$386.33
$435.01
$607.92
$923.79		 $680.76
$772.66
$870.02
$1215.84
$1847.58		 $896.90
$988.80
$1086.16
$1431.98		 $1113.04
$1204.94
$1302.30
$1648.12		 $1329.18
$1421.08
$1518.44
$1864.26		 $556.52
$602.47
$651.15
$824.06		 $772.66
$818.61
$867.29
$1040.20		 $988.80
$1034.75
$1083.43
$1256.34		 $216.14

Plan: (HMO) HealthyBlue HMO Gold $1,000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $1,000 : Family: $2,000
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
Gold 21
30
40
50
60		 $389.63
$442.23
$497.95
$695.88
$1057.46		 $779.26
$884.46
$995.90
$1391.76
$2114.92		 $1026.68
$1131.88
$1243.32
$1639.18		 $1274.10
$1379.30
$1490.74
$1886.60		 $1521.52
$1626.72
$1738.16
$2134.02		 $637.05
$689.65
$745.37
$943.30		 $884.47
$937.07
$992.79
$1190.72		 $1131.89
$1184.49
$1240.21
$1438.14		 $247.42

Plan: (HMO) BlueChoice HMO Young Adult $7,150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Catastrophic 21
30
40
50
60		 $174.31
$197.84
$222.77
$311.32
$473.08		 $348.62
$395.68
$445.54
$622.64
$946.16		 $459.31
$506.37
$556.23
$733.33		 $570.00
$617.06
$666.92
$844.02		 $680.69
$727.75
$777.61
$954.71		 $285.00
$308.53
$333.46
$422.01		 $395.69
$419.22
$444.15
$532.70		 $506.38
$529.91
$554.84
$643.39		 $110.69

Plan: (HMO) BlueChoice HMO HSA Silver $1,500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

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		 $338.15
$383.80
$432.16
$603.94
$917.74		 $676.30
$767.60
$864.32
$1207.88
$1835.48		 $891.03
$982.33
$1079.05
$1422.61		 $1105.76
$1197.06
$1293.78
$1637.34		 $1320.49
$1411.79
$1508.51
$1852.07		 $552.88
$598.53
$646.89
$818.67		 $767.61
$813.26
$861.62
$1033.40		 $982.34
$1027.99
$1076.35
$1248.13		 $214.73

Plan: (POS) BlueChoice Plus Silver $2,500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

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		 $348.98
$396.09
$446.00
$623.28
$947.13		 $697.96
$792.18
$892.00
$1246.56
$1894.26		 $919.56
$1013.78
$1113.60
$1468.16		 $1141.16
$1235.38
$1335.20
$1689.76		 $1362.76
$1456.98
$1556.80
$1911.36		 $570.58
$617.69
$667.60
$844.88		 $792.18
$839.29
$889.20
$1066.48		 $1013.78
$1060.89
$1110.80
$1288.08		 $221.60
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Innovation Health Insurance Company

Local: 1-866-833-2957 | Toll Free: 1-866-833-2957

TTY: 1-866-833-2957

Plan: (PPO) Innovation Health Leap Catastrophic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Catastrophic 21
30
40
50
60		 $159.53
$181.06
$203.88
$284.92
$432.96		 $319.06
$362.12
$407.76
$569.84
$865.92		 $420.36
$463.42
$509.06
$671.14		 $521.66
$564.72
$610.36
$772.44		 $622.96
$666.02
$711.66
$873.74		 $260.83
$282.36
$305.18
$386.22		 $362.13
$383.66
$406.48
$487.52		 $463.43
$484.96
$507.78
$588.82		 $101.30

Plan: (PPO) Innovation Health Leap Silver Basic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $6,075 : Family: $12,150
Out of Pocket Maximum per year: Individual: $6,075 : Family: $12,150

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		 $231.22
$262.44
$295.50
$412.97
$627.54		 $462.44
$524.88
$591.00
$825.94
$1255.08		 $609.27
$671.71
$737.83
$972.77		 $756.10
$818.54
$884.66
$1119.60		 $902.93
$965.37
$1031.49
$1266.43		 $378.05
$409.27
$442.33
$559.80		 $524.88
$556.10
$589.16
$706.63		 $671.71
$702.93
$735.99
$853.46		 $146.83

Plan: (PPO) Innovation Health Leap Silver Plus

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $5,050 : Family: $10,100
Out of Pocket Maximum per year: Individual: $5,050 : Family: $10,100

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		 $250.87
$284.74
$320.61
$448.05
$680.86		 $501.74
$569.48
$641.22
$896.10
$1361.72		 $661.04
$728.78
$800.52
$1055.40		 $820.34
$888.08
$959.82
$1214.70		 $979.64
$1047.38
$1119.12
$1374.00		 $410.17
$444.04
$479.91
$607.35		 $569.47
$603.34
$639.21
$766.65		 $728.77
$762.64
$798.51
$925.95		 $159.30

Plan: (PPO) Innovation Health Leap Bronze

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $7,050 : Family: $14,100
Out of Pocket Maximum per year: Individual: $7,050 : Family: $14,100

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		 $195.70
$222.12
$250.10
$349.51
$531.12		 $391.40
$444.24
$500.20
$699.02
$1062.24		 $515.67
$568.51
$624.47
$823.29		 $639.94
$692.78
$748.74
$947.56		 $764.21
$817.05
$873.01
$1071.83		 $319.97
$346.39
$374.37
$473.78		 $444.24
$470.66
$498.64
$598.05		 $568.51
$594.93
$622.91
$722.32		 $124.27

Plan: (PPO) Innovation Health Leap Gold Diabetes

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $2,835 : Family: $5,670
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		 $310.10
$351.96
$396.31
$553.84
$841.61		 $620.20
$703.92
$792.62
$1107.68
$1683.22		 $817.11
$900.83
$989.53
$1304.59		 $1014.02
$1097.74
$1186.44
$1501.50		 $1210.93
$1294.65
$1383.35
$1698.41		 $507.01
$548.87
$593.22
$750.75		 $703.92
$745.78
$790.13
$947.66		 $900.83
$942.69
$987.04
$1144.57		 $196.91

Plan: (PPO) Innovation Health Leap Silver Diabetes

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $6,300 : Family: $12,600
Out of Pocket Maximum per year: Individual: $6,300 : Family: $12,600

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		 $241.92
$274.57
$309.17
$432.06
$656.56		 $483.84
$549.14
$618.34
$864.12
$1313.12		 $637.46
$702.76
$771.96
$1017.74		 $791.08
$856.38
$925.58
$1171.36		 $944.70
$1010.00
$1079.20
$1324.98		 $395.54
$428.19
$462.79
$585.68		 $549.16
$581.81
$616.41
$739.30		 $702.78
$735.43
$770.03
$892.92		 $153.62

Plan: (PPO) Innovation Health Leap Silver Healthy Minds

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $5,600 : Family: $11,200
Out of Pocket Maximum per year: Individual: $5,600 : Family: $11,200

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		 $256.38
$291.00
$327.66
$457.90
$695.83		 $512.76
$582.00
$655.32
$915.80
$1391.66		 $675.56
$744.80
$818.12
$1078.60		 $838.36
$907.60
$980.92
$1241.40		 $1001.16
$1070.40
$1143.72
$1404.20		 $419.18
$453.80
$490.46
$620.70		 $581.98
$616.60
$653.26
$783.50		 $744.78
$779.40
$816.06
$946.30		 $162.80
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UnitedHealthcare of the Mid-Atlantic Inc

Local: 1-877-632-4195 | Toll Free: 1-877-632-4195

Plan: (HMO) UHC Compass HSA Silver 2800

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

Deductible: Individual: $2,800 : Family: $5,600
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		 $252.02
$286.03
$322.07
$450.09
$683.95		 $504.04
$572.06
$644.14
$900.18
$1367.90		 $664.07
$732.09
$804.17
$1060.21		 $824.10
$892.12
$964.20
$1220.24		 $984.13
$1052.15
$1124.23
$1380.27		 $412.05
$446.06
$482.10
$610.12		 $572.08
$606.09
$642.13
$770.15		 $732.11
$766.12
$802.16
$930.18		 $160.03

Plan: (HMO) UHC Compass Silver 5200

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

Deductible: Individual: $5,200 : Family: $10,400
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $249.77
$283.47
$319.19
$446.06
$677.84		 $499.54
$566.94
$638.38
$892.12
$1355.68		 $658.14
$725.54
$796.98
$1050.72		 $816.74
$884.14
$955.58
$1209.32		 $975.34
$1042.74
$1114.18
$1367.92		 $408.37
$442.07
$477.79
$604.66		 $566.97
$600.67
$636.39
$763.26		 $725.57
$759.27
$794.99
$921.86		 $158.60

Plan: (HMO) UHC Compass HSA Bronze 6550

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

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		 $222.35
$252.36
$284.15
$397.10
$603.43		 $444.70
$504.72
$568.30
$794.20
$1206.86		 $585.89
$645.91
$709.49
$935.39		 $727.08
$787.10
$850.68
$1076.58		 $868.27
$928.29
$991.87
$1217.77		 $363.54
$393.55
$425.34
$538.29		 $504.73
$534.74
$566.53
$679.48		 $645.92
$675.93
$707.72
$820.67		 $141.19

Plan: (HMO) UHC Compass Bronze 7100

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

Deductible: Individual: $7,100 : Family: $14,200
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $230.24
$261.31
$294.23
$411.18
$624.83		 $460.48
$522.62
$588.46
$822.36
$1249.66		 $606.67
$668.81
$734.65
$968.55		 $752.86
$815.00
$880.84
$1114.74		 $899.05
$961.19
$1027.03
$1260.93		 $376.43
$407.50
$440.42
$557.37		 $522.62
$553.69
$586.61
$703.56		 $668.81
$699.88
$732.80
$849.75		 $146.19
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Group Hospitalization and Medical Services Inc.

Local: 1-855-444-3119 | Toll Free: 1-855-444-3119

TTY: 1-202-479-3546

Plan: (PPO) HealthyBlue PPO Gold $1,000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (Group Hospitalization and Medical Services Inc.)

Deductible: Individual: $1,000 : Family: $2,000
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
Gold 21
30
40
50
60		 $434.88
$493.59
$555.78
$776.70
$1180.26		 $869.76
$987.18
$1111.56
$1553.40
$2360.52		 $1145.91
$1263.33
$1387.71
$1829.55		 $1422.06
$1539.48
$1663.86
$2105.70		 $1698.21
$1815.63
$1940.01
$2381.85		 $711.03
$769.74
$831.93
$1052.85		 $987.18
$1045.89
$1108.08
$1329.00		 $1263.33
$1322.04
$1384.23
$1605.15		 $276.15

Plan: (PPO) BluePreferred HSA Silver $2,000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (Group Hospitalization and Medical Services Inc.)

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		 $364.89
$414.15
$466.33
$651.69
$990.31		 $729.78
$828.30
$932.66
$1303.38
$1980.62		 $961.49
$1060.01
$1164.37
$1535.09		 $1193.20
$1291.72
$1396.08
$1766.80		 $1424.91
$1523.43
$1627.79
$1998.51		 $596.60
$645.86
$698.04
$883.40		 $828.31
$877.57
$929.75
$1115.11		 $1060.02
$1109.28
$1161.46
$1346.82		 $231.71
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Cigna Health and Life Insurance Company

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237

TTY: 1-800-676-3777

Plan: (EPO) Cigna Connect HSA 5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Health and Life Insurance Company)

Deductible: Individual: $5,000 : Family: $10,000
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		 $215.78
$244.91
$275.77
$385.39
$585.64		 $431.56
$489.82
$551.54
$770.78
$1171.28		 $568.58
$626.84
$688.56
$907.80		 $705.60
$763.86
$825.58
$1044.82		 $842.62
$900.88
$962.60
$1181.84		 $352.80
$381.93
$412.79
$522.41		 $489.82
$518.95
$549.81
$659.43		 $626.84
$655.97
$686.83
$796.45		 $137.02

Plan: (EPO) Cigna Connect 5750

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Health and Life Insurance Company)

Deductible: Individual: $5,750 : Family: $11,500
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $203.40
$230.86
$259.95
$363.27
$552.03		 $406.80
$461.72
$519.90
$726.54
$1104.06		 $535.96
$590.88
$649.06
$855.70		 $665.12
$720.04
$778.22
$984.86		 $794.28
$849.20
$907.38
$1114.02		 $332.56
$360.02
$389.11
$492.43		 $461.72
$489.18
$518.27
$621.59		 $590.88
$618.34
$647.43
$750.75		 $129.16

Plan: (EPO) Cigna US-VA Connect 6650

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Health and Life Insurance Company)

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $207.11
$235.07
$264.68
$369.89
$562.09		 $414.22
$470.14
$529.36
$739.78
$1124.18		 $545.73
$601.65
$660.87
$871.29		 $677.24
$733.16
$792.38
$1002.80		 $808.75
$864.67
$923.89
$1134.31		 $338.62
$366.58
$396.19
$501.40		 $470.13
$498.09
$527.70
$632.91		 $601.64
$629.60
$659.21
$764.42		 $131.51

Plan: (EPO) Cigna Connect 6400

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Health and Life Insurance Company)

Deductible: Individual: $6,400 : Family: $12,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $219.82
$249.50
$280.93
$392.60
$596.60		 $439.64
$499.00
$561.86
$785.20
$1193.20		 $579.23
$638.59
$701.45
$924.79		 $718.82
$778.18
$841.04
$1064.38		 $858.41
$917.77
$980.63
$1203.97		 $359.41
$389.09
$420.52
$532.19		 $499.00
$528.68
$560.11
$671.78		 $638.59
$668.27
$699.70
$811.37		 $139.59

Plan: (EPO) Cigna Connect 2500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Health and Life Insurance Company)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $257.66
$292.44
$329.29
$460.18
$699.28		 $515.32
$584.88
$658.58
$920.36
$1398.56		 $678.93
$748.49
$822.19
$1083.97		 $842.54
$912.10
$985.80
$1247.58		 $1006.15
$1075.71
$1149.41
$1411.19		 $421.27
$456.05
$492.90
$623.79		 $584.88
$619.66
$656.51
$787.40		 $748.49
$783.27
$820.12
$951.01		 $163.61

Plan: (EPO) Cigna Connect 4500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Health and Life Insurance Company)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $245.14
$278.24
$313.29
$437.82
$665.31		 $490.28
$556.48
$626.58
$875.64
$1330.62		 $645.95
$712.15
$782.25
$1031.31		 $801.62
$867.82
$937.92
$1186.98		 $957.29
$1023.49
$1093.59
$1342.65		 $400.81
$433.91
$468.96
$593.49		 $556.48
$589.58
$624.63
$749.16		 $712.15
$745.25
$780.30
$904.83		 $155.67
ADVERTISEMENT

HealthKeepers, Inc.

Local: 1-855-748-1810 | Toll Free: 1-855-748-1810

Plan: (HMO) Anthem HealthKeepers Bronze X 5900

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $5,900 : Family: $11,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $237.64
$269.72
$303.70
$424.43
$644.95		 $475.28
$539.44
$607.40
$848.86
$1289.90		 $626.18
$690.34
$758.30
$999.76		 $777.08
$841.24
$909.20
$1150.66		 $927.98
$992.14
$1060.10
$1301.56		 $388.54
$420.62
$454.60
$575.33		 $539.44
$571.52
$605.50
$726.23		 $690.34
$722.42
$756.40
$877.13		 $150.90
ADVERTISEMENT

Cigna Health and Life Insurance Company

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237

TTY: 1-800-676-3777

Plan: (EPO) Cigna Connect 2000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Health and Life Insurance Company)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $286.47
$325.15
$366.11
$511.64
$777.49		 $572.94
$650.30
$732.22
$1023.28
$1554.98		 $754.85
$832.21
$914.13
$1205.19		 $936.76
$1014.12
$1096.04
$1387.10		 $1118.67
$1196.03
$1277.95
$1569.01		 $468.38
$507.06
$548.02
$693.55		 $650.29
$688.97
$729.93
$875.46		 $832.20
$870.88
$911.84
$1057.37		 $181.91

Plan: (EPO) Cigna US-VA Connect 3500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Health and Life Insurance Company)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $293.87
$333.55
$375.57
$524.86
$797.57		 $587.74
$667.10
$751.14
$1049.72
$1595.14		 $774.35
$853.71
$937.75
$1236.33		 $960.96
$1040.32
$1124.36
$1422.94		 $1147.57
$1226.93
$1310.97
$1609.55		 $480.48
$520.16
$562.18
$711.47		 $667.09
$706.77
$748.79
$898.08		 $853.70
$893.38
$935.40
$1084.69		 $186.61

Plan: (EPO) Cigna Connect 1200

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Health and Life Insurance Company)

Deductible: Individual: $1,200 : Family: $2,400
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Gold 21
30
40
50
60		 $333.72
$378.77
$426.49
$596.02
$905.71		 $667.44
$757.54
$852.98
$1192.04
$1811.42		 $879.35
$969.45
$1064.89
$1403.95		 $1091.26
$1181.36
$1276.80
$1615.86		 $1303.17
$1393.27
$1488.71
$1827.77		 $545.63
$590.68
$638.40
$807.93		 $757.54
$802.59
$850.31
$1019.84		 $969.45
$1014.50
$1062.22
$1231.75		 $211.91
ADVERTISEMENT

HealthKeepers, Inc.

Local: 1-855-748-1810 | Toll Free: 1-855-748-1810

Plan: (HMO) Anthem HealthKeepers Catastrophic X 7150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Catastrophic 21
30
40
50
60		 $194.29
$220.52
$248.30
$347.00
$527.30		 $388.58
$441.04
$496.60
$694.00
$1054.60		 $511.95
$564.41
$619.97
$817.37		 $635.32
$687.78
$743.34
$940.74		 $758.69
$811.15
$866.71
$1064.11		 $317.66
$343.89
$371.67
$470.37		 $441.03
$467.26
$495.04
$593.74		 $564.40
$590.63
$618.41
$717.11		 $123.37

Plan: (HMO) Anthem HealthKeepers Bronze X 6200 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $6,200 : Family: $12,400
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		 $242.96
$275.76
$310.50
$433.93
$659.39		 $485.92
$551.52
$621.00
$867.86
$1318.78		 $640.20
$705.80
$775.28
$1022.14		 $794.48
$860.08
$929.56
$1176.42		 $948.76
$1014.36
$1083.84
$1330.70		 $397.24
$430.04
$464.78
$588.21		 $551.52
$584.32
$619.06
$742.49		 $705.80
$738.60
$773.34
$896.77		 $154.28

Plan: (HMO) Anthem HealthKeepers Bronze X 5150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $5,150 : Family: $10,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $241.26
$273.83
$308.33
$430.89
$654.78		 $482.52
$547.66
$616.66
$861.78
$1309.56		 $635.72
$700.86
$769.86
$1014.98		 $788.92
$854.06
$923.06
$1168.18		 $942.12
$1007.26
$1076.26
$1321.38		 $394.46
$427.03
$461.53
$584.09		 $547.66
$580.23
$614.73
$737.29		 $700.86
$733.43
$767.93
$890.49		 $153.20

Plan: (HMO) Anthem HealthKeepers Bronze X 4900 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $4,900 : Family: $9,800
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		 $248.33
$281.85
$317.37
$443.52
$673.97		 $496.66
$563.70
$634.74
$887.04
$1347.94		 $654.35
$721.39
$792.43
$1044.73		 $812.04
$879.08
$950.12
$1202.42		 $969.73
$1036.77
$1107.81
$1360.11		 $406.02
$439.54
$475.06
$601.21		 $563.71
$597.23
$632.75
$758.90		 $721.40
$754.92
$790.44
$916.59		 $157.69

Plan: (HMO) Anthem HealthKeepers Silver X 3500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $274.20
$311.22
$350.43
$489.72
$744.18		 $548.40
$622.44
$700.86
$979.44
$1488.36		 $722.52
$796.56
$874.98
$1153.56		 $896.64
$970.68
$1049.10
$1327.68		 $1070.76
$1144.80
$1223.22
$1501.80		 $448.32
$485.34
$524.55
$663.84		 $622.44
$659.46
$698.67
$837.96		 $796.56
$833.58
$872.79
$1012.08		 $174.12

Plan: (HMO) Anthem HealthKeepers Silver X 2800

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $2,800 : Family: $5,600
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $282.10
$320.18
$360.52
$503.83
$765.62		 $564.20
$640.36
$721.04
$1007.66
$1531.24		 $743.33
$819.49
$900.17
$1186.79		 $922.46
$998.62
$1079.30
$1365.92		 $1101.59
$1177.75
$1258.43
$1545.05		 $461.23
$499.31
$539.65
$682.96		 $640.36
$678.44
$718.78
$862.09		 $819.49
$857.57
$897.91
$1041.22		 $179.13

Plan: (HMO) Anthem HealthKeepers Gold X 1300

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $1,300 : Family: $3,900
Out of Pocket Maximum per year: Individual: $4,800 : Family: $9,600

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		 $377.16
$428.08
$482.01
$673.61
$1023.61		 $754.32
$856.16
$964.02
$1347.22
$2047.22		 $993.82
$1095.66
$1203.52
$1586.72		 $1233.32
$1335.16
$1443.02
$1826.22		 $1472.82
$1574.66
$1682.52
$2065.72		 $616.66
$667.58
$721.51
$913.11		 $856.16
$907.08
$961.01
$1152.61		 $1095.66
$1146.58
$1200.51
$1392.11		 $239.50

Plan: (HMO) Anthem HealthKeepers Bronze X 6350

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $6,350 : Family: $12,700
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $234.74
$266.43
$300.00
$419.25
$637.08		 $469.48
$532.86
$600.00
$838.50
$1274.16		 $618.54
$681.92
$749.06
$987.56		 $767.60
$830.98
$898.12
$1136.62		 $916.66
$980.04
$1047.18
$1285.68		 $383.80
$415.49
$449.06
$568.31		 $532.86
$564.55
$598.12
$717.37		 $681.92
$713.61
$747.18
$866.43		 $149.06

Plan: (HMO) Anthem HealthKeepers Silver X 5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $5,000 : Family: $10,000
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
Silver 21
30
40
50
60		 $262.70
$298.16
$335.73
$469.18
$712.97		 $525.40
$596.32
$671.46
$938.36
$1425.94		 $692.21
$763.13
$838.27
$1105.17		 $859.02
$929.94
$1005.08
$1271.98		 $1025.83
$1096.75
$1171.89
$1438.79		 $429.51
$464.97
$502.54
$635.99		 $596.32
$631.78
$669.35
$802.80		 $763.13
$798.59
$836.16
$969.61		 $166.81

Plan: (HMO) Anthem HealthKeepers Silver, a Blue Cross and Blue Shield Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $1,800 : Family: $3,600
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $295.38
$335.26
$377.50
$527.55
$801.66		 $590.76
$670.52
$755.00
$1055.10
$1603.32		 $778.33
$858.09
$942.57
$1242.67		 $965.90
$1045.66
$1130.14
$1430.24		 $1153.47
$1233.23
$1317.71
$1617.81		 $482.95
$522.83
$565.07
$715.12		 $670.52
$710.40
$752.64
$902.69		 $858.09
$897.97
$940.21
$1090.26		 $187.57

Plan: (HMO) Anthem HealthKeepers Gold, a Blue Cross and Blue Shield Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $1,000 : Family: $3,000
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
Gold 21
30
40
50
60		 $378.41
$429.50
$483.61
$675.84
$1027.00		 $756.82
$859.00
$967.22
$1351.68
$2054.00		 $997.11
$1099.29
$1207.51
$1591.97		 $1237.40
$1339.58
$1447.80
$1832.26		 $1477.69
$1579.87
$1688.09
$2072.55		 $618.70
$669.79
$723.90
$916.13		 $858.99
$910.08
$964.19
$1156.42		 $1099.28
$1150.37
$1204.48
$1396.71		 $240.29

Plan: (POS) Anthem HealthKeepers Bronze X POS 4500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $255.18
$289.63
$326.12
$455.75
$692.56		 $510.36
$579.26
$652.24
$911.50
$1385.12		 $672.40
$741.30
$814.28
$1073.54		 $834.44
$903.34
$976.32
$1235.58		 $996.48
$1065.38
$1138.36
$1397.62		 $417.22
$451.67
$488.16
$617.79		 $579.26
$613.71
$650.20
$779.83		 $741.30
$775.75
$812.24
$941.87		 $162.04

Plan: (POS) Anthem HealthKeepers Silver X POS 2300

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $2,300 : Family: $4,600
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $296.30
$336.30
$378.67
$529.19
$804.16		 $592.60
$672.60
$757.34
$1058.38
$1608.32		 $780.75
$860.75
$945.49
$1246.53		 $968.90
$1048.90
$1133.64
$1434.68		 $1157.05
$1237.05
$1321.79
$1622.83		 $484.45
$524.45
$566.82
$717.34		 $672.60
$712.60
$754.97
$905.49		 $860.75
$900.75
$943.12
$1093.64		 $188.15

Plan: (POS) Anthem HealthKeepers Bronze X POS 5750 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $5,750 : Family: $11,500
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		 $253.20
$287.38
$323.59
$452.22
$687.18		 $506.40
$574.76
$647.18
$904.44
$1374.36		 $667.18
$735.54
$807.96
$1065.22		 $827.96
$896.32
$968.74
$1226.00		 $988.74
$1057.10
$1129.52
$1386.78		 $413.98
$448.16
$484.37
$613.00		 $574.76
$608.94
$645.15
$773.78		 $735.54
$769.72
$805.93
$934.56		 $160.78
ADVERTISEMENT

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

Local: 1-800-807-1140 | Toll Free: 1-800-807-1140

TTY: 1-703-359-7616

Plan: (HMO) KP VA Gold 0/20/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

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		 $374.30
$424.83
$478.36
$668.50
$1015.85		 $748.60
$849.66
$956.72
$1337.00
$2031.70		 $986.28
$1087.34
$1194.40
$1574.68		 $1223.96
$1325.02
$1432.08
$1812.36		 $1461.64
$1562.70
$1669.76
$2050.04		 $611.98
$662.51
$716.04
$906.18		 $849.66
$900.19
$953.72
$1143.86		 $1087.34
$1137.87
$1191.40
$1381.54		 $237.68

Plan: (HMO) KP VA Gold 1000/20/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

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		 $357.73
$406.02
$457.18
$638.91
$970.88		 $715.46
$812.04
$914.36
$1277.82
$1941.76		 $942.62
$1039.20
$1141.52
$1504.98		 $1169.78
$1266.36
$1368.68
$1732.14		 $1396.94
$1493.52
$1595.84
$1959.30		 $584.89
$633.18
$684.34
$866.07		 $812.05
$860.34
$911.50
$1093.23		 $1039.21
$1087.50
$1138.66
$1320.39		 $227.16

Plan: (HMO) KP VA Silver 1800/30/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $1,800 : Family: $3,600
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $301.01
$341.65
$384.69
$537.60
$816.94		 $602.02
$683.30
$769.38
$1075.20
$1633.88		 $793.16
$874.44
$960.52
$1266.34		 $984.30
$1065.58
$1151.66
$1457.48		 $1175.44
$1256.72
$1342.80
$1648.62		 $492.15
$532.79
$575.83
$728.74		 $683.29
$723.93
$766.97
$919.88		 $874.43
$915.07
$958.11
$1111.02		 $191.14

Plan: (HMO) KP VA Silver 2800/30/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $2,800 : Family: $5,600
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $286.93
$325.67
$366.70
$512.46
$778.73		 $573.86
$651.34
$733.40
$1024.92
$1557.46		 $756.06
$833.54
$915.60
$1207.12		 $938.26
$1015.74
$1097.80
$1389.32		 $1120.46
$1197.94
$1280.00
$1571.52		 $469.13
$507.87
$548.90
$694.66		 $651.33
$690.07
$731.10
$876.86		 $833.53
$872.27
$913.30
$1059.06		 $182.20

Plan: (HMO) KP VA Silver 2750/20%/HSA/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $2,750 : Family: $5,500
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
Silver 21
30
40
50
60		 $281.55
$319.56
$359.82
$502.85
$764.13		 $563.10
$639.12
$719.64
$1005.70
$1528.26		 $741.88
$817.90
$898.42
$1184.48		 $920.66
$996.68
$1077.20
$1363.26		 $1099.44
$1175.46
$1255.98
$1542.04		 $460.33
$498.34
$538.60
$681.63		 $639.11
$677.12
$717.38
$860.41		 $817.89
$855.90
$896.16
$1039.19		 $178.78

Plan: (HMO) KP VA Bronze 5000/50/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $238.49
$270.69
$304.79
$425.94
$647.26		 $476.98
$541.38
$609.58
$851.88
$1294.52		 $628.42
$692.82
$761.02
$1003.32		 $779.86
$844.26
$912.46
$1154.76		 $931.30
$995.70
$1063.90
$1306.20		 $389.93
$422.13
$456.23
$577.38		 $541.37
$573.57
$607.67
$728.82		 $692.81
$725.01
$759.11
$880.26		 $151.44

Plan: (HMO) KP VA Bronze 6200/20%/HSA/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $6,200 : Family: $12,400
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		 $224.42
$254.72
$286.81
$400.81
$609.08		 $448.84
$509.44
$573.62
$801.62
$1218.16		 $591.35
$651.95
$716.13
$944.13		 $733.86
$794.46
$858.64
$1086.64		 $876.37
$936.97
$1001.15
$1229.15		 $366.93
$397.23
$429.32
$543.32		 $509.44
$539.74
$571.83
$685.83		 $651.95
$682.25
$714.34
$828.34		 $142.51

Plan: (HMO) KP VA Catastrophic 7150/0/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Catastrophic 21
30
40
50
60		 $189.84
$215.47
$242.62
$339.05
$515.23		 $379.68
$430.94
$485.24
$678.10
$1030.46		 $500.23
$551.49
$605.79
$798.65		 $620.78
$672.04
$726.34
$919.20		 $741.33
$792.59
$846.89
$1039.75		 $310.39
$336.02
$363.17
$459.60		 $430.94
$456.57
$483.72
$580.15		 $551.49
$577.12
$604.27
$700.70		 $120.55

Plan: (HMO) KP VA Platinum 0/20/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $0 : Family: $0
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
Platinum 21
30
40
50
60		 $404.11
$458.66
$516.45
$721.74
$1096.75		 $808.22
$917.32
$1032.90
$1443.48
$2193.50		 $1064.83
$1173.93
$1289.51
$1700.09		 $1321.44
$1430.54
$1546.12
$1956.70		 $1578.05
$1687.15
$1802.73
$2213.31		 $660.72
$715.27
$773.06
$978.35		 $917.33
$971.88
$1029.67
$1234.96		 $1173.94
$1228.49
$1286.28
$1491.57		 $256.61

Plan: (HMO) KP VA Bronze 6500/50/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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
Bronze 21
30
40
50
60		 $203.30
$230.75
$259.82
$363.09
$551.76		 $406.60
$461.50
$519.64
$726.18
$1103.52		 $535.70
$590.60
$648.74
$855.28		 $664.80
$719.70
$777.84
$984.38		 $793.90
$848.80
$906.94
$1113.48		 $332.40
$359.85
$388.92
$492.19		 $461.50
$488.95
$518.02
$621.29		 $590.60
$618.05
$647.12
$750.39		 $129.10

Plan: (HMO) KP VA STD Silver 3500/30/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $296.87
$336.95
$379.40
$530.21
$805.71		 $593.74
$673.90
$758.80
$1060.42
$1611.42		 $782.25
$862.41
$947.31
$1248.93		 $970.76
$1050.92
$1135.82
$1437.44		 $1159.27
$1239.43
$1324.33
$1625.95		 $485.38
$525.46
$567.91
$718.72		 $673.89
$713.97
$756.42
$907.23		 $862.40
$902.48
$944.93
$1095.74		 $188.51

Plan: (HMO) KP VA Silver 6000/30/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

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		 $257.54
$292.31
$329.14
$459.97
$698.96		 $515.08
$584.62
$658.28
$919.94
$1397.92		 $678.62
$748.16
$821.82
$1083.48		 $842.16
$911.70
$985.36
$1247.02		 $1005.70
$1075.24
$1148.90
$1410.56		 $421.08
$455.85
$492.68
$623.51		 $584.62
$619.39
$656.22
$787.05		 $748.16
$782.93
$819.76
$950.59		 $163.54

 

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