ADVERTISEMENT

Providers for Zip Code 53530

LegalConsumer.com/obamacare

ObamacareByZipCode.com

Obamacare 2018 Marketplace Rates For Lafayette County, Wisconsin

Friday, April 19th, 2024


The health insurance rates listed below are for calendar year 2018.

2018 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

(click here for 2017)

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

Obamacare Providers, Plans and 2018 Rates for Lafayette County

Lafayette County is in “Rating Area 7” of Wisconsin.

Currently, there are 65 plans offered in Rating Area 7.

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 Darlington, WI area accept this insurance coverage as within the plan's "network".
ADVERTISEMENT

Group Health Cooperative of South Central Wisconsin

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729

Plan: (HMO) Gold 1500 Ded/5200X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $2,200 : Family: $4,400

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		 $418.11
$474.55
$534.34
$746.74
$1,134.74		 $836.22
$949.10
$1,068.68
$1,493.48
$2,269.48		 $1,156.08
$1,268.96
$1,388.54
$1,813.34		 $1,475.94
$1,588.82
$1,708.40
$2,133.20		 $1,795.80
$1,908.68
$2,028.26
$2,453.06		 $737.97
$794.41
$854.20
$1,066.60		 $1,057.83
$1,114.27
$1,174.06
$1,386.46		 $1,377.69
$1,434.13
$1,493.92
$1,706.32		 $319.86

Plan: (HMO) Platinum No Ded/3000X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $0 : Family: $0
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		 $465.26
$528.07
$594.61
$830.96
$1,262.72		 $930.52
$1,056.14
$1,189.22
$1,661.92
$2,525.44		 $1,286.45
$1,412.07
$1,545.15
$2,017.85		 $1,642.38
$1,768.00
$1,901.08
$2,373.78		 $1,998.31
$2,123.93
$2,257.01
$2,729.71		 $821.19
$884.00
$950.54
$1,186.89		 $1,177.12
$1,239.93
$1,306.47
$1,542.82		 $1,533.05
$1,595.86
$1,662.40
$1,898.75		 $355.93
ADVERTISEMENT

Unity Health Plans Insurance Corporation

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310

TTY: 1-608-643-1421

Plan: (HMO) Elite Gold Healthy You - PCP Copay $30 with Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $2,900 : Family: $5,800
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $467.43
$530.53
$597.37
$834.83
$1,268.60		 $934.86
$1,061.06
$1,194.74
$1,669.66
$2,537.20		 $1,292.44
$1,418.64
$1,552.32
$2,027.24		 $1,650.02
$1,776.22
$1,909.90
$2,384.82		 $2,007.60
$2,133.80
$2,267.48
$2,742.40		 $825.01
$888.11
$954.95
$1,192.41		 $1,182.59
$1,245.69
$1,312.53
$1,549.99		 $1,540.17
$1,603.27
$1,670.11
$1,907.57		 $357.58

Plan: (HMO) Elite Silver 5000 Value - PCP Copay $35 with Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $457.34
$519.08
$584.47
$816.80
$1,241.21		 $914.68
$1,038.16
$1,168.94
$1,633.60
$2,482.42		 $1,264.54
$1,388.02
$1,518.80
$1,983.46		 $1,614.40
$1,737.88
$1,868.66
$2,333.32		 $1,964.26
$2,087.74
$2,218.52
$2,683.18		 $807.20
$868.94
$934.33
$1,166.66		 $1,157.06
$1,218.80
$1,284.19
$1,516.52		 $1,506.92
$1,568.66
$1,634.05
$1,866.38		 $349.86

Plan: (HMO) Elite Silver 7100 Value - PCP Copay $75 with Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $7,100 : Family: $14,200
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $448.17
$508.67
$572.76
$800.43
$1,216.33		 $896.34
$1,017.34
$1,145.52
$1,600.86
$2,432.66		 $1,239.19
$1,360.19
$1,488.37
$1,943.71		 $1,582.04
$1,703.04
$1,831.22
$2,286.56		 $1,924.89
$2,045.89
$2,174.07
$2,629.41		 $791.02
$851.52
$915.61
$1,143.28		 $1,133.87
$1,194.37
$1,258.46
$1,486.13		 $1,476.72
$1,537.22
$1,601.31
$1,828.98		 $342.85

Plan: (HMO) Elite Gold First $500 with Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $3,500 : Family: $7,000
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
Gold 21
30
40
50
60		 $507.08
$575.52
$648.04
$905.63
$1,376.19		 $1,014.16
$1,151.04
$1,296.08
$1,811.26
$2,752.38		 $1,402.07
$1,538.95
$1,683.99
$2,199.17		 $1,789.98
$1,926.86
$2,071.90
$2,587.08		 $2,177.89
$2,314.77
$2,459.81
$2,974.99		 $894.99
$963.43
$1,035.95
$1,293.54		 $1,282.90
$1,351.34
$1,423.86
$1,681.45		 $1,670.81
$1,739.25
$1,811.77
$2,069.36		 $387.91

Plan: (HMO) Elite Bronze Deductible $6500 with Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $350.60
$397.92
$448.05
$626.15
$951.50		 $701.20
$795.84
$896.10
$1,252.30
$1,903.00		 $969.40
$1,064.04
$1,164.30
$1,520.50		 $1,237.60
$1,332.24
$1,432.50
$1,788.70		 $1,505.80
$1,600.44
$1,700.70
$2,056.90		 $618.80
$666.12
$716.25
$894.35		 $887.00
$934.32
$984.45
$1,162.55		 $1,155.20
$1,202.52
$1,252.65
$1,430.75		 $268.20

Plan: (HMO) Elite Gold Maintenance - PCP Copay $20 with Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $1,700 : Family: $3,400
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $499.61
$567.05
$638.49
$892.29
$1,355.92		 $999.22
$1,134.10
$1,276.98
$1,784.58
$2,711.84		 $1,381.42
$1,516.30
$1,659.18
$2,166.78		 $1,763.62
$1,898.50
$2,041.38
$2,548.98		 $2,145.82
$2,280.70
$2,423.58
$2,931.18		 $881.81
$949.25
$1,020.69
$1,274.49		 $1,264.01
$1,331.45
$1,402.89
$1,656.69		 $1,646.21
$1,713.65
$1,785.09
$2,038.89		 $382.20

Plan: (HMO) Elite Gold Healthy You - PCP Copay $30

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $2,900 : Family: $5,800
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $448.66
$509.22
$573.37
$801.29
$1,217.64		 $897.32
$1,018.44
$1,146.74
$1,602.58
$2,435.28		 $1,240.54
$1,361.66
$1,489.96
$1,945.80		 $1,583.76
$1,704.88
$1,833.18
$2,289.02		 $1,926.98
$2,048.10
$2,176.40
$2,632.24		 $791.88
$852.44
$916.59
$1,144.51		 $1,135.10
$1,195.66
$1,259.81
$1,487.73		 $1,478.32
$1,538.88
$1,603.03
$1,830.95		 $343.22

Plan: (HMO) Elite Silver 5000 Value - PCP Copay $35

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $438.97
$498.22
$560.99
$783.98
$1,191.34		 $877.94
$996.44
$1,121.98
$1,567.96
$2,382.68		 $1,213.75
$1,332.25
$1,457.79
$1,903.77		 $1,549.56
$1,668.06
$1,793.60
$2,239.58		 $1,885.37
$2,003.87
$2,129.41
$2,575.39		 $774.78
$834.03
$896.80
$1,119.79		 $1,110.59
$1,169.84
$1,232.61
$1,455.60		 $1,446.40
$1,505.65
$1,568.42
$1,791.41		 $335.81

Plan: (HMO) Elite Silver 7100 Value - PCP Copay $75

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $7,100 : Family: $14,200
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $430.17
$488.23
$549.75
$768.27
$1,167.46		 $860.34
$976.46
$1,099.50
$1,536.54
$2,334.92		 $1,189.41
$1,305.53
$1,428.57
$1,865.61		 $1,518.48
$1,634.60
$1,757.64
$2,194.68		 $1,847.55
$1,963.67
$2,086.71
$2,523.75		 $759.24
$817.30
$878.82
$1,097.34		 $1,088.31
$1,146.37
$1,207.89
$1,426.41		 $1,417.38
$1,475.44
$1,536.96
$1,755.48		 $329.07

Plan: (HMO) Elite Gold First $500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $3,500 : Family: $7,000
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
Gold 21
30
40
50
60		 $486.70
$552.40
$622.00
$869.24
$1,320.90		 $973.40
$1,104.80
$1,244.00
$1,738.48
$2,641.80		 $1,345.72
$1,477.12
$1,616.32
$2,110.80		 $1,718.04
$1,849.44
$1,988.64
$2,483.12		 $2,090.36
$2,221.76
$2,360.96
$2,855.44		 $859.02
$924.72
$994.32
$1,241.56		 $1,231.34
$1,297.04
$1,366.64
$1,613.88		 $1,603.66
$1,669.36
$1,738.96
$1,986.20		 $372.32

Plan: (HMO) Elite Gold Standard - PCP Copay $20

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $1,400 : Family: $2,800
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		 $488.29
$554.20
$624.03
$872.07
$1,325.20		 $976.58
$1,108.40
$1,248.06
$1,744.14
$2,650.40		 $1,350.12
$1,481.94
$1,621.60
$2,117.68		 $1,723.66
$1,855.48
$1,995.14
$2,491.22		 $2,097.20
$2,229.02
$2,368.68
$2,864.76		 $861.83
$927.74
$997.57
$1,245.61		 $1,235.37
$1,301.28
$1,371.11
$1,619.15		 $1,608.91
$1,674.82
$1,744.65
$1,992.69		 $373.54

Plan: (HMO) Elite Silver Standard - PCP Copay $30

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $437.59
$496.66
$559.23
$781.52
$1,187.60		 $875.18
$993.32
$1,118.46
$1,563.04
$2,375.20		 $1,209.93
$1,328.07
$1,453.21
$1,897.79		 $1,544.68
$1,662.82
$1,787.96
$2,232.54		 $1,879.43
$1,997.57
$2,122.71
$2,567.29		 $772.34
$831.41
$893.98
$1,116.27		 $1,107.09
$1,166.16
$1,228.73
$1,451.02		 $1,441.84
$1,500.91
$1,563.48
$1,785.77		 $334.75

Plan: (HMO) Elite Bronze Standard - PCP Copay $35

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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
Expanded Bronze 21
30
40
50
60		 $343.95
$390.38
$439.57
$614.29
$933.48		 $687.90
$780.76
$879.14
$1,228.58
$1,866.96		 $951.02
$1,043.88
$1,142.26
$1,491.70		 $1,214.14
$1,307.00
$1,405.38
$1,754.82		 $1,477.26
$1,570.12
$1,668.50
$2,017.94		 $607.07
$653.50
$702.69
$877.41		 $870.19
$916.62
$965.81
$1,140.53		 $1,133.31
$1,179.74
$1,228.93
$1,403.65		 $263.12

Plan: (HMO) Elite Bronze Deductible $6500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $336.51
$381.93
$430.05
$601.00
$913.27		 $673.02
$763.86
$860.10
$1,202.00
$1,826.54		 $930.45
$1,021.29
$1,117.53
$1,459.43		 $1,187.88
$1,278.72
$1,374.96
$1,716.86		 $1,445.31
$1,536.15
$1,632.39
$1,974.29		 $593.94
$639.36
$687.48
$858.43		 $851.37
$896.79
$944.91
$1,115.86		 $1,108.80
$1,154.22
$1,202.34
$1,373.29		 $257.43

Plan: (HMO) Elite Gold Maintenance - PCP Copay $20

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $1,700 : Family: $3,400
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $479.53
$544.27
$612.84
$856.44
$1,301.44		 $959.06
$1,088.54
$1,225.68
$1,712.88
$2,602.88		 $1,325.90
$1,455.38
$1,592.52
$2,079.72		 $1,692.74
$1,822.22
$1,959.36
$2,446.56		 $2,059.58
$2,189.06
$2,326.20
$2,813.40		 $846.37
$911.11
$979.68
$1,223.28		 $1,213.21
$1,277.95
$1,346.52
$1,590.12		 $1,580.05
$1,644.79
$1,713.36
$1,956.96		 $366.84

Plan: (HMO) Elite Gold HSA $1800

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $1,800 : Family: $3,600
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
Gold 21
30
40
50
60		 $482.98
$548.18
$617.24
$862.60
$1,310.80		 $965.96
$1,096.36
$1,234.48
$1,725.20
$2,621.60		 $1,335.44
$1,465.84
$1,603.96
$2,094.68		 $1,704.92
$1,835.32
$1,973.44
$2,464.16		 $2,074.40
$2,204.80
$2,342.92
$2,833.64		 $852.46
$917.66
$986.72
$1,232.08		 $1,221.94
$1,287.14
$1,356.20
$1,601.56		 $1,591.42
$1,656.62
$1,725.68
$1,971.04		 $369.48

Plan: (HMO) Elite Silver HSA $3000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $445.85
$506.04
$569.79
$796.28
$1,210.03		 $891.70
$1,012.08
$1,139.58
$1,592.56
$2,420.06		 $1,232.77
$1,353.15
$1,480.65
$1,933.63		 $1,573.84
$1,694.22
$1,821.72
$2,274.70		 $1,914.91
$2,035.29
$2,162.79
$2,615.77		 $786.92
$847.11
$910.86
$1,137.35		 $1,127.99
$1,188.18
$1,251.93
$1,478.42		 $1,469.06
$1,529.25
$1,593.00
$1,819.49		 $341.07

Plan: (HMO) Elite Bronze HSA $6550

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

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		 $343.47
$389.83
$438.95
$613.43
$932.17		 $686.94
$779.66
$877.90
$1,226.86
$1,864.34		 $949.69
$1,042.41
$1,140.65
$1,489.61		 $1,212.44
$1,305.16
$1,403.40
$1,752.36		 $1,475.19
$1,567.91
$1,666.15
$2,015.11		 $606.22
$652.58
$701.70
$876.18		 $868.97
$915.33
$964.45
$1,138.93		 $1,131.72
$1,178.08
$1,227.20
$1,401.68		 $262.75

Plan: (HMO) Elite Catastrophic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

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

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		 $245.66
$278.82
$313.95
$438.75
$666.72		 $491.32
$557.64
$627.90
$877.50
$1,333.44		 $679.25
$745.57
$815.83
$1,065.43		 $867.18
$933.50
$1,003.76
$1,253.36		 $1,055.11
$1,121.43
$1,191.69
$1,441.29		 $433.59
$466.75
$501.88
$626.68		 $621.52
$654.68
$689.81
$814.61		 $809.45
$842.61
$877.74
$1,002.54

Plan: (HMO) Elite Bronze HSA $5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

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		 $347.54
$394.45
$444.15
$620.69
$943.21		 $695.08
$788.90
$888.30
$1,241.38
$1,886.42		 $960.94
$1,054.76
$1,154.16
$1,507.24		 $1,226.80
$1,320.62
$1,420.02
$1,773.10		 $1,492.66
$1,586.48
$1,685.88
$2,038.96		 $613.40
$660.31
$710.01
$886.55		 $879.26
$926.17
$975.87
$1,152.41		 $1,145.12
$1,192.03
$1,241.73
$1,418.27		 $265.86

Plan: (HMO) Elite Bronze Standard HSA $6000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

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
Expanded Bronze 21
30
40
50
60		 $351.12
$398.52
$448.73
$627.10
$952.93		 $702.24
$797.04
$897.46
$1,254.20
$1,905.86		 $970.84
$1,065.64
$1,166.06
$1,522.80		 $1,239.44
$1,334.24
$1,434.66
$1,791.40		 $1,508.04
$1,602.84
$1,703.26
$2,060.00		 $619.72
$667.12
$717.33
$895.70		 $888.32
$935.72
$985.93
$1,164.30		 $1,156.92
$1,204.32
$1,254.53
$1,432.90		 $268.60

Plan: (HMO) Elite Silver HSA $5050

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-362-3310 - Provider Directory for This Plan: (Unity Health Plans Insurance Corporation)

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		 $448.61
$509.16
$573.31
$801.20
$1,217.51		 $897.22
$1,018.32
$1,146.62
$1,602.40
$2,435.02		 $1,240.40
$1,361.50
$1,489.80
$1,945.58		 $1,583.58
$1,704.68
$1,832.98
$2,288.76		 $1,926.76
$2,047.86
$2,176.16
$2,631.94		 $791.79
$852.34
$916.49
$1,144.38		 $1,134.97
$1,195.52
$1,259.67
$1,487.56		 $1,478.15
$1,538.70
$1,602.85
$1,830.74		 $343.18
ADVERTISEMENT

Dean Health Plan

Local: 1-608-828-1302 | Toll Free: 1-800-279-1302

TTY: 1-608-827-4086

Plan: (HMO) Dean Catastrophic Safety Net

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1302 - Provider Directory for This Plan: (Dean Health Plan)

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

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		 $186.80
$212.02
$238.73
$333.62
$506.97		 $373.60
$424.04
$477.46
$667.24
$1,013.94		 $516.50
$566.94
$620.36
$810.14		 $659.40
$709.84
$763.26
$953.04		 $802.30
$852.74
$906.16
$1,095.94		 $329.70
$354.92
$381.63
$476.52		 $472.60
$497.82
$524.53
$619.42		 $615.50
$640.72
$667.43
$762.32		 $142.90
ADVERTISEMENT

Group Health Cooperative of South Central Wisconsin

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729

Plan: (HMO) Platinum 500 Ded/3000X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $454.63
$516.01
$581.02
$811.97
$1,233.86		 $909.26
$1,032.02
$1,162.04
$1,623.94
$2,467.72		 $1,257.05
$1,379.81
$1,509.83
$1,971.73		 $1,604.84
$1,727.60
$1,857.62
$2,319.52		 $1,952.63
$2,075.39
$2,205.41
$2,667.31		 $802.42
$863.80
$928.81
$1,159.76		 $1,150.21
$1,211.59
$1,276.60
$1,507.55		 $1,498.00
$1,559.38
$1,624.39
$1,855.34		 $347.79
ADVERTISEMENT

Dean Health Plan

Local: 1-608-828-1302 | Toll Free: 1-800-279-1302

TTY: 1-608-827-4086

Plan: (HMO) Dean Silver Copay Plus 3250X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1302 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $3,250 : Family: $6,500
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $367.13
$416.69
$469.19
$655.70
$996.39		 $734.26
$833.38
$938.38
$1,311.40
$1,992.78		 $1,015.12
$1,114.24
$1,219.24
$1,592.26		 $1,295.98
$1,395.10
$1,500.10
$1,873.12		 $1,576.84
$1,675.96
$1,780.96
$2,153.98		 $647.99
$697.55
$750.05
$936.56		 $928.85
$978.41
$1,030.91
$1,217.42		 $1,209.71
$1,259.27
$1,311.77
$1,498.28		 $280.86

Plan: (HMO) Dean Silver Classic 4750X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1302 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $4,750 : Family: $9,500
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $368.04
$417.73
$470.36
$657.32
$998.87		 $736.08
$835.46
$940.72
$1,314.64
$1,997.74		 $1,017.63
$1,117.01
$1,222.27
$1,596.19		 $1,299.18
$1,398.56
$1,503.82
$1,877.74		 $1,580.73
$1,680.11
$1,785.37
$2,159.29		 $649.59
$699.28
$751.91
$938.87		 $931.14
$980.83
$1,033.46
$1,220.42		 $1,212.69
$1,262.38
$1,315.01
$1,501.97		 $281.55

Plan: (HMO) Dean Silver Value Copay 5000X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1302 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $384.18
$436.05
$490.98
$686.15
$1,042.67		 $768.36
$872.10
$981.96
$1,372.30
$2,085.34		 $1,062.26
$1,166.00
$1,275.86
$1,666.20		 $1,356.16
$1,459.90
$1,569.76
$1,960.10		 $1,650.06
$1,753.80
$1,863.66
$2,254.00		 $678.08
$729.95
$784.88
$980.05		 $971.98
$1,023.85
$1,078.78
$1,273.95		 $1,265.88
$1,317.75
$1,372.68
$1,567.85		 $293.90

Plan: (HMO) Dean Gold Value Copay 3500X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1302 - Provider Directory for This Plan: (Dean Health Plan)

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
Gold 21
30
40
50
60		 $324.46
$368.26
$414.66
$579.48
$880.58		 $648.92
$736.52
$829.32
$1,158.96
$1,761.16		 $897.13
$984.73
$1,077.53
$1,407.17		 $1,145.34
$1,232.94
$1,325.74
$1,655.38		 $1,393.55
$1,481.15
$1,573.95
$1,903.59		 $572.67
$616.47
$662.87
$827.69		 $820.88
$864.68
$911.08
$1,075.90		 $1,069.09
$1,112.89
$1,159.29
$1,324.11		 $248.21

Plan: (HMO) Dean Bronze Value Copay 7350X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1302 - Provider Directory for This Plan: (Dean Health Plan)

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

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		 $271.14
$307.74
$346.52
$484.26
$735.88		 $542.28
$615.48
$693.04
$968.52
$1,471.76		 $749.70
$822.90
$900.46
$1,175.94		 $957.12
$1,030.32
$1,107.88
$1,383.36		 $1,164.54
$1,237.74
$1,315.30
$1,590.78		 $478.56
$515.16
$553.94
$691.68		 $685.98
$722.58
$761.36
$899.10		 $893.40
$930.00
$968.78
$1,106.52		 $207.42

Plan: (HMO) Dean Silver HSA-E 3500X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1302 - Provider Directory for This Plan: (Dean Health Plan)

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $387.57
$439.90
$495.32
$692.21
$1,051.87		 $775.14
$879.80
$990.64
$1,384.42
$2,103.74		 $1,071.63
$1,176.29
$1,287.13
$1,680.91		 $1,368.12
$1,472.78
$1,583.62
$1,977.40		 $1,664.61
$1,769.27
$1,880.11
$2,273.89		 $684.06
$736.39
$791.81
$988.70		 $980.55
$1,032.88
$1,088.30
$1,285.19		 $1,277.04
$1,329.37
$1,384.79
$1,581.68		 $296.49

Plan: (HMO) Dean Gold Copay Plus 1500X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1302 - Provider Directory for This Plan: (Dean Health Plan)

Deductible: Individual: $1,500 : Family: $3,000
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		 $333.06
$378.03
$425.65
$594.85
$903.93		 $666.12
$756.06
$851.30
$1,189.70
$1,807.86		 $920.91
$1,010.85
$1,106.09
$1,444.49		 $1,175.70
$1,265.64
$1,360.88
$1,699.28		 $1,430.49
$1,520.43
$1,615.67
$1,954.07		 $587.85
$632.82
$680.44
$849.64		 $842.64
$887.61
$935.23
$1,104.43		 $1,097.43
$1,142.40
$1,190.02
$1,359.22		 $254.79

Plan: (HMO) Dean Bronze HSA-E 6550X

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-279-1302 - Provider Directory for This Plan: (Dean Health Plan)

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		 $259.27
$294.27
$331.35
$463.06
$703.66		 $518.54
$588.54
$662.70
$926.12
$1,407.32		 $716.88
$786.88
$861.04
$1,124.46		 $915.22
$985.22
$1,059.38
$1,322.80		 $1,113.56
$1,183.56
$1,257.72
$1,521.14		 $457.61
$492.61
$529.69
$661.40		 $655.95
$690.95
$728.03
$859.74		 $854.29
$889.29
$926.37
$1,058.08		 $198.34
ADVERTISEMENT

Group Health Cooperative of South Central Wisconsin

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729

Plan: (HMO) Platinum 500 Ded/1000 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $468.19
$531.40
$598.35
$836.19
$1,270.66		 $936.38
$1,062.80
$1,196.70
$1,672.38
$2,541.32		 $1,294.55
$1,420.97
$1,554.87
$2,030.55		 $1,652.72
$1,779.14
$1,913.04
$2,388.72		 $2,010.89
$2,137.31
$2,271.21
$2,746.89		 $826.36
$889.57
$956.52
$1,194.36		 $1,184.53
$1,247.74
$1,314.69
$1,552.53		 $1,542.70
$1,605.91
$1,672.86
$1,910.70		 $358.17

Plan: (HMO) Gold 1000 Ded/4000 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $402.82
$457.20
$514.80
$719.43
$1,093.23		 $805.64
$914.40
$1,029.60
$1,438.86
$2,186.46		 $1,113.80
$1,222.56
$1,337.76
$1,747.02		 $1,421.96
$1,530.72
$1,645.92
$2,055.18		 $1,730.12
$1,838.88
$1,954.08
$2,363.34		 $710.98
$765.36
$822.96
$1,027.59		 $1,019.14
$1,073.52
$1,131.12
$1,335.75		 $1,327.30
$1,381.68
$1,439.28
$1,643.91		 $308.16

Plan: (HMO) Gold 2000 Ded/2000 MOOP HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $398.39
$452.17
$509.14
$711.51
$1,081.21		 $796.78
$904.34
$1,018.28
$1,423.02
$2,162.42		 $1,101.55
$1,209.11
$1,323.05
$1,727.79		 $1,406.32
$1,513.88
$1,627.82
$2,032.56		 $1,711.09
$1,818.65
$1,932.59
$2,337.33		 $703.16
$756.94
$813.91
$1,016.28		 $1,007.93
$1,061.71
$1,118.68
$1,321.05		 $1,312.70
$1,366.48
$1,423.45
$1,625.82		 $304.77

Plan: (HMO) Silver 2000 Ded/6000 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $439.22
$498.52
$561.32
$784.45
$1,192.04		 $878.44
$997.04
$1,122.64
$1,568.90
$2,384.08		 $1,214.45
$1,333.05
$1,458.65
$1,904.91		 $1,550.46
$1,669.06
$1,794.66
$2,240.92		 $1,886.47
$2,005.07
$2,130.67
$2,576.93		 $775.23
$834.53
$897.33
$1,120.46		 $1,111.24
$1,170.54
$1,233.34
$1,456.47		 $1,447.25
$1,506.55
$1,569.35
$1,792.48		 $336.01

Plan: (HMO) Bronze 4000 Ded/7350 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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
Expanded Bronze 21
30
40
50
60		 $315.29
$357.85
$402.94
$563.10
$855.68		 $630.58
$715.70
$805.88
$1,126.20
$1,711.36		 $871.78
$956.90
$1,047.08
$1,367.40		 $1,112.98
$1,198.10
$1,288.28
$1,608.60		 $1,354.18
$1,439.30
$1,529.48
$1,849.80		 $556.49
$599.05
$644.14
$804.30		 $797.69
$840.25
$885.34
$1,045.50		 $1,038.89
$1,081.45
$1,126.54
$1,286.70		 $241.20

Plan: (HMO) Select Platinum 500 Ded/1000 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $425.66
$483.12
$543.99
$760.23
$1,155.24		 $851.32
$966.24
$1,087.98
$1,520.46
$2,310.48		 $1,176.95
$1,291.87
$1,413.61
$1,846.09		 $1,502.58
$1,617.50
$1,739.24
$2,171.72		 $1,828.21
$1,943.13
$2,064.87
$2,497.35		 $751.29
$808.75
$869.62
$1,085.86		 $1,076.92
$1,134.38
$1,195.25
$1,411.49		 $1,402.55
$1,460.01
$1,520.88
$1,737.12		 $325.63

Plan: (HMO) Select Gold 1000 Ded/4000 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $366.22
$415.66
$468.03
$654.06
$993.91		 $732.44
$831.32
$936.06
$1,308.12
$1,987.82		 $1,012.60
$1,111.48
$1,216.22
$1,588.28		 $1,292.76
$1,391.64
$1,496.38
$1,868.44		 $1,572.92
$1,671.80
$1,776.54
$2,148.60		 $646.38
$695.82
$748.19
$934.22		 $926.54
$975.98
$1,028.35
$1,214.38		 $1,206.70
$1,256.14
$1,308.51
$1,494.54		 $280.16

Plan: (HMO) Select Gold 2000 Ded/2000 MOOP HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $362.21
$411.11
$462.90
$646.91
$983.03		 $724.42
$822.22
$925.80
$1,293.82
$1,966.06		 $1,001.51
$1,099.31
$1,202.89
$1,570.91		 $1,278.60
$1,376.40
$1,479.98
$1,848.00		 $1,555.69
$1,653.49
$1,757.07
$2,125.09		 $639.30
$688.20
$739.99
$924.00		 $916.39
$965.29
$1,017.08
$1,201.09		 $1,193.48
$1,242.38
$1,294.17
$1,478.18		 $277.09

Plan: (HMO) Select Silver 2000 Ded/6000 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $399.31
$453.22
$510.32
$713.16
$1,083.72		 $798.62
$906.44
$1,020.64
$1,426.32
$2,167.44		 $1,104.09
$1,211.91
$1,326.11
$1,731.79		 $1,409.56
$1,517.38
$1,631.58
$2,037.26		 $1,715.03
$1,822.85
$1,937.05
$2,342.73		 $704.78
$758.69
$815.79
$1,018.63		 $1,010.25
$1,064.16
$1,121.26
$1,324.10		 $1,315.72
$1,369.63
$1,426.73
$1,629.57		 $305.47

Plan: (HMO) Select Bronze 4000 Ded/7350 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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
Expanded Bronze 21
30
40
50
60		 $286.67
$325.36
$366.36
$511.98
$778.00		 $573.34
$650.72
$732.72
$1,023.96
$1,556.00		 $792.64
$870.02
$952.02
$1,243.26		 $1,011.94
$1,089.32
$1,171.32
$1,462.56		 $1,231.24
$1,308.62
$1,390.62
$1,681.86		 $505.97
$544.66
$585.66
$731.28		 $725.27
$763.96
$804.96
$950.58		 $944.57
$983.26
$1,024.26
$1,169.88		 $219.30

Plan: (HMO) Bronze 6550 Ded/6550 MOOP HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $301.27
$341.94
$385.02
$538.06
$817.63		 $602.54
$683.88
$770.04
$1,076.12
$1,635.26		 $833.01
$914.35
$1,000.51
$1,306.59		 $1,063.48
$1,144.82
$1,230.98
$1,537.06		 $1,293.95
$1,375.29
$1,461.45
$1,767.53		 $531.74
$572.41
$615.49
$768.53		 $762.21
$802.88
$845.96
$999.00		 $992.68
$1,033.35
$1,076.43
$1,229.47		 $230.47

Plan: (HMO) Select Bronze 6550 Ded/6550 MOOP HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $273.91
$310.89
$350.06
$489.21
$743.39		 $547.82
$621.78
$700.12
$978.42
$1,486.78		 $757.36
$831.32
$909.66
$1,187.96		 $966.90
$1,040.86
$1,119.20
$1,397.50		 $1,176.44
$1,250.40
$1,328.74
$1,607.04		 $483.45
$520.43
$559.60
$698.75		 $692.99
$729.97
$769.14
$908.29		 $902.53
$939.51
$978.68
$1,117.83		 $209.54

Plan: (HMO) Gold 2500 Ded/6500 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $2,500 : Family: $5,000
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
Gold 21
30
40
50
60		 $368.88
$418.67
$471.42
$658.81
$1,001.12		 $737.76
$837.34
$942.84
$1,317.62
$2,002.24		 $1,019.95
$1,119.53
$1,225.03
$1,599.81		 $1,302.14
$1,401.72
$1,507.22
$1,882.00		 $1,584.33
$1,683.91
$1,789.41
$2,164.19		 $651.07
$700.86
$753.61
$941.00		 $933.26
$983.05
$1,035.80
$1,223.19		 $1,215.45
$1,265.24
$1,317.99
$1,505.38		 $282.19

Plan: (HMO) Select Gold 2500 Ded/6500 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $2,500 : Family: $5,000
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
Gold 21
30
40
50
60		 $335.36
$380.63
$428.59
$598.95
$910.16		 $670.72
$761.26
$857.18
$1,197.90
$1,820.32		 $927.27
$1,017.81
$1,113.73
$1,454.45		 $1,183.82
$1,274.36
$1,370.28
$1,711.00		 $1,440.37
$1,530.91
$1,626.83
$1,967.55		 $591.91
$637.18
$685.14
$855.50		 $848.46
$893.73
$941.69
$1,112.05		 $1,105.01
$1,150.28
$1,198.24
$1,368.60		 $256.55

Plan: (HMO) Gold 2500 Ded/7000X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $2,500 : Family: $5,000
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		 $402.35
$456.67
$514.21
$718.60
$1,091.98		 $804.70
$913.34
$1,028.42
$1,437.20
$2,183.96		 $1,112.50
$1,221.14
$1,336.22
$1,745.00		 $1,420.30
$1,528.94
$1,644.02
$2,052.80		 $1,728.10
$1,836.74
$1,951.82
$2,360.60		 $710.15
$764.47
$822.01
$1,026.40		 $1,017.95
$1,072.27
$1,129.81
$1,334.20		 $1,325.75
$1,380.07
$1,437.61
$1,642.00		 $307.80

Plan: (HMO) Silver 4000 Ded/7350X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $441.53
$501.14
$564.28
$788.57
$1,198.31		 $883.06
$1,002.28
$1,128.56
$1,577.14
$2,396.62		 $1,220.83
$1,340.05
$1,466.33
$1,914.91		 $1,558.60
$1,677.82
$1,804.10
$2,252.68		 $1,896.37
$2,015.59
$2,141.87
$2,590.45		 $779.30
$838.91
$902.05
$1,126.34		 $1,117.07
$1,176.68
$1,239.82
$1,464.11		 $1,454.84
$1,514.45
$1,577.59
$1,801.88		 $337.77

Plan: (HMO) Select Platinum No Ded/3000X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $0 : Family: $0
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		 $423.00
$480.11
$540.60
$755.48
$1,148.02		 $846.00
$960.22
$1,081.20
$1,510.96
$2,296.04		 $1,169.60
$1,283.82
$1,404.80
$1,834.56		 $1,493.20
$1,607.42
$1,728.40
$2,158.16		 $1,816.80
$1,931.02
$2,052.00
$2,481.76		 $746.60
$803.71
$864.20
$1,079.08		 $1,070.20
$1,127.31
$1,187.80
$1,402.68		 $1,393.80
$1,450.91
$1,511.40
$1,726.28		 $323.60

Plan: (HMO) Select Platinum 500 Ded/3000X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $413.33
$469.13
$528.24
$738.21
$1,121.78		 $826.66
$938.26
$1,056.48
$1,476.42
$2,243.56		 $1,142.86
$1,254.46
$1,372.68
$1,792.62		 $1,459.06
$1,570.66
$1,688.88
$2,108.82		 $1,775.26
$1,886.86
$2,005.08
$2,425.02		 $729.53
$785.33
$844.44
$1,054.41		 $1,045.73
$1,101.53
$1,160.64
$1,370.61		 $1,361.93
$1,417.73
$1,476.84
$1,686.81		 $316.20

Plan: (HMO) Select Gold 1500 Ded/5200X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $2,200 : Family: $4,400

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		 $380.13
$431.44
$485.80
$678.90
$1,031.65		 $760.26
$862.88
$971.60
$1,357.80
$2,063.30		 $1,051.06
$1,153.68
$1,262.40
$1,648.60		 $1,341.86
$1,444.48
$1,553.20
$1,939.40		 $1,632.66
$1,735.28
$1,844.00
$2,230.20		 $670.93
$722.24
$776.60
$969.70		 $961.73
$1,013.04
$1,067.40
$1,260.50		 $1,252.53
$1,303.84
$1,358.20
$1,551.30		 $290.80

Plan: (HMO) Select Gold 2500 Ded/7000X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $2,500 : Family: $5,000
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		 $365.83
$415.22
$467.53
$653.37
$992.86		 $731.66
$830.44
$935.06
$1,306.74
$1,985.72		 $1,011.52
$1,110.30
$1,214.92
$1,586.60		 $1,291.38
$1,390.16
$1,494.78
$1,866.46		 $1,571.24
$1,670.02
$1,774.64
$2,146.32		 $645.69
$695.08
$747.39
$933.23		 $925.55
$974.94
$1,027.25
$1,213.09		 $1,205.41
$1,254.80
$1,307.11
$1,492.95		 $279.86

Plan: (HMO) Select Silver 4000 Ded/7350X MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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		 $401.43
$455.62
$513.03
$716.95
$1,089.47		 $802.86
$911.24
$1,026.06
$1,433.90
$2,178.94		 $1,109.95
$1,218.33
$1,333.15
$1,740.99		 $1,417.04
$1,525.42
$1,640.24
$2,048.08		 $1,724.13
$1,832.51
$1,947.33
$2,355.17		 $708.52
$762.71
$820.12
$1,024.04		 $1,015.61
$1,069.80
$1,127.21
$1,331.13		 $1,322.70
$1,376.89
$1,434.30
$1,638.22		 $307.09

Plan: (HMO) Select Gold Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $1,400 : Family: $2,800
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		 $346.11
$392.83
$442.32
$618.15
$939.33		 $692.22
$785.66
$884.64
$1,236.30
$1,878.66		 $956.99
$1,050.43
$1,149.41
$1,501.07		 $1,221.76
$1,315.20
$1,414.18
$1,765.84		 $1,486.53
$1,579.97
$1,678.95
$2,030.61		 $610.88
$657.60
$707.09
$882.92		 $875.65
$922.37
$971.86
$1,147.69		 $1,140.42
$1,187.14
$1,236.63
$1,412.46		 $264.77

Plan: (HMO) Select Silver Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $367.76
$417.41
$469.99
$656.81
$998.09		 $735.52
$834.82
$939.98
$1,313.62
$1,996.18		 $1,016.86
$1,116.16
$1,221.32
$1,594.96		 $1,298.20
$1,397.50
$1,502.66
$1,876.30		 $1,579.54
$1,678.84
$1,784.00
$2,157.64		 $649.10
$698.75
$751.33
$938.15		 $930.44
$980.09
$1,032.67
$1,219.49		 $1,211.78
$1,261.43
$1,314.01
$1,500.83		 $281.34

Plan: (HMO) Select Bronze Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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
Expanded Bronze 21
30
40
50
60		 $279.27
$316.97
$356.90
$498.77
$757.93		 $558.54
$633.94
$713.80
$997.54
$1,515.86		 $772.18
$847.58
$927.44
$1,211.18		 $985.82
$1,061.22
$1,141.08
$1,424.82		 $1,199.46
$1,274.86
$1,354.72
$1,638.46		 $492.91
$530.61
$570.54
$712.41		 $706.55
$744.25
$784.18
$926.05		 $920.19
$957.89
$997.82
$1,139.69		 $213.64

Plan: (HMO) Catastrophic 7350 Ded/7350 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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

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		 $232.38
$263.76
$296.99
$415.03
$630.68		 $464.76
$527.52
$593.98
$830.06
$1,261.36		 $642.54
$705.30
$771.76
$1,007.84		 $820.32
$883.08
$949.54
$1,185.62		 $998.10
$1,060.86
$1,127.32
$1,363.40		 $410.16
$441.54
$474.77
$592.81		 $587.94
$619.32
$652.55
$770.59		 $765.72
$797.10
$830.33
$948.37		 $177.78

Plan: (HMO) Select Catastrophic 7350 Ded/7350 MOOP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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

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		 $211.27
$239.79
$270.01
$377.33
$573.39		 $422.54
$479.58
$540.02
$754.66
$1,146.78		 $584.16
$641.20
$701.64
$916.28		 $745.78
$802.82
$863.26
$1,077.90		 $907.40
$964.44
$1,024.88
$1,239.52		 $372.89
$401.41
$431.63
$538.95		 $534.51
$563.03
$593.25
$700.57		 $696.13
$724.65
$754.87
$862.19		 $161.62

Plan: (HMO) Select Bronze Simple Choice Plan HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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
Expanded Bronze 21
30
40
50
60		 $281.58
$319.59
$359.86
$502.90
$764.20		 $563.16
$639.18
$719.72
$1,005.80
$1,528.40		 $778.57
$854.59
$935.13
$1,221.21		 $993.98
$1,070.00
$1,150.54
$1,436.62		 $1,209.39
$1,285.41
$1,365.95
$1,652.03		 $496.99
$535.00
$575.27
$718.31		 $712.40
$750.41
$790.68
$933.72		 $927.81
$965.82
$1,006.09
$1,149.13		 $215.41

Plan: (HMO) Gold Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $1,400 : Family: $2,800
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		 $380.70
$432.10
$486.54
$679.93
$1,033.22		 $761.40
$864.20
$973.08
$1,359.86
$2,066.44		 $1,052.64
$1,155.44
$1,264.32
$1,651.10		 $1,343.88
$1,446.68
$1,555.56
$1,942.34		 $1,635.12
$1,737.92
$1,846.80
$2,233.58		 $671.94
$723.34
$777.78
$971.17		 $963.18
$1,014.58
$1,069.02
$1,262.41		 $1,254.42
$1,305.82
$1,360.26
$1,553.65		 $291.24

Plan: (HMO) Silver Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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		 $404.47
$459.08
$516.91
$722.38
$1,097.73		 $808.94
$918.16
$1,033.82
$1,444.76
$2,195.46		 $1,118.36
$1,227.58
$1,343.24
$1,754.18		 $1,427.78
$1,537.00
$1,652.66
$2,063.60		 $1,737.20
$1,846.42
$1,962.08
$2,373.02		 $713.89
$768.50
$826.33
$1,031.80		 $1,023.31
$1,077.92
$1,135.75
$1,341.22		 $1,332.73
$1,387.34
$1,445.17
$1,650.64		 $309.42

Plan: (HMO) Bronze Simple Choice Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

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
Expanded Bronze 21
30
40
50
60		 $307.16
$348.63
$392.55
$548.58
$833.62		 $614.32
$697.26
$785.10
$1,097.16
$1,667.24		 $849.30
$932.24
$1,020.08
$1,332.14		 $1,084.28
$1,167.22
$1,255.06
$1,567.12		 $1,319.26
$1,402.20
$1,490.04
$1,802.10		 $542.14
$583.61
$627.53
$783.56		 $777.12
$818.59
$862.51
$1,018.54		 $1,012.10
$1,053.57
$1,097.49
$1,253.52		 $234.98

Plan: (HMO) Bronze Simple Choice Plan HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-344-2729 - Provider Directory for This Plan: ( Group Health Cooperative of South Central Wisconsin)

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
Expanded Bronze 21
30
40
50
60		 $309.70
$351.51
$395.80
$553.12
$840.52		 $619.40
$703.02
$791.60
$1,106.24
$1,681.04		 $856.32
$939.94
$1,028.52
$1,343.16		 $1,093.24
$1,176.86
$1,265.44
$1,580.08		 $1,330.16
$1,413.78
$1,502.36
$1,817.00		 $546.62
$588.43
$632.72
$790.04		 $783.54
$825.35
$869.64
$1,026.96		 $1,020.46
$1,062.27
$1,106.56
$1,263.88		 $236.92

‡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 Lafayette County here.

 

Speak with a Health Insurance Expert 800-943-6832Ads by +HealthNetwork