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Providers for Zip Code 53704

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ObamacareByZipCode.com

Obamacare 2019 Marketplace Rates For Dane County, Wisconsin

Friday, April 19th, 2024


The health insurance rates listed below are for calendar year 2019.

2019 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

(click here for 2017)

(click here for 2018)

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

Obamacare Providers, Plans and 2019 Rates for Dane County

Dane County is in “Rating Area 2” of Wisconsin.

Currently, there are 60 plans offered in Rating Area 2.

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 Madison, WI area accept this insurance coverage as within the plan's "network".
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Unity Health Plans Insurance Corporation

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

TTY: 1-800-877-8973

Plan: (HMO) Prime Silver 5000 - Copay $50/$100 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: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $405.68
$460.44
$518.45
$724.53
$1,101.00		 $811.36
$920.88
$1,036.90
$1,449.06
$2,202.00		 $1,121.70
$1,231.22
$1,347.24
$1,759.40		 $1,432.04
$1,541.56
$1,657.58
$2,069.74		 $1,742.38
$1,851.90
$1,967.92
$2,380.08		 $716.02
$770.78
$828.79
$1,034.87		 $1,026.36
$1,081.12
$1,139.13
$1,345.21		 $1,336.70
$1,391.46
$1,449.47
$1,655.55		 $370.38

Plan: (HMO) Prime Silver 7900 - Copay $80/$160 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: $7,900 : Family: $15,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $392.46
$445.44
$501.56
$700.93
$1,065.13		 $784.92
$890.88
$1,003.12
$1,401.86
$2,130.26		 $1,085.15
$1,191.11
$1,303.35
$1,702.09		 $1,385.38
$1,491.34
$1,603.58
$2,002.32		 $1,685.61
$1,791.57
$1,903.81
$2,302.55		 $692.69
$745.67
$801.79
$1,001.16		 $992.92
$1,045.90
$1,102.02
$1,301.39		 $1,293.15
$1,346.13
$1,402.25
$1,601.62		 $358.31

Plan: (HMO) Prime Gold Maintenance - Copay $40/$90 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: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $343.03
$389.33
$438.39
$612.65
$930.97		 $686.06
$778.66
$876.78
$1,225.30
$1,861.94		 $948.48
$1,041.08
$1,139.20
$1,487.72		 $1,210.90
$1,303.50
$1,401.62
$1,750.14		 $1,473.32
$1,565.92
$1,664.04
$2,012.56		 $605.45
$651.75
$700.81
$875.07		 $867.87
$914.17
$963.23
$1,137.49		 $1,130.29
$1,176.59
$1,225.65
$1,399.91		 $313.18

Plan: (HMO) Prime Gold 2000 - Copay $30/$70 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: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $334.74
$379.92
$427.79
$597.83
$908.46		 $669.48
$759.84
$855.58
$1,195.66
$1,816.92		 $925.55
$1,015.91
$1,111.65
$1,451.73		 $1,181.62
$1,271.98
$1,367.72
$1,707.80		 $1,437.69
$1,528.05
$1,623.79
$1,963.87		 $590.81
$635.99
$683.86
$853.90		 $846.88
$892.06
$939.93
$1,109.97		 $1,102.95
$1,148.13
$1,196.00
$1,366.04		 $305.61

Plan: (HMO) Prime Silver 4000 - Copay $45/$90 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: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $410.18
$465.55
$524.21
$732.58
$1,113.22		 $820.36
$931.10
$1,048.42
$1,465.16
$2,226.44		 $1,134.15
$1,244.89
$1,362.21
$1,778.95		 $1,447.94
$1,558.68
$1,676.00
$2,092.74		 $1,761.73
$1,872.47
$1,989.79
$2,406.53		 $723.97
$779.34
$838.00
$1,046.37		 $1,037.76
$1,093.13
$1,151.79
$1,360.16		 $1,351.55
$1,406.92
$1,465.58
$1,673.95		 $374.49

Plan: (HMO) Prime Bronze 7500 - Copay $80/$160 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: $7,500 : Family: $15,000
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Expanded Bronze 21
30
40
50
60		 $254.31
$288.63
$325.00
$454.19
$690.18		 $508.62
$577.26
$650.00
$908.38
$1,380.36		 $703.16
$771.80
$844.54
$1,102.92		 $897.70
$966.34
$1,039.08
$1,297.46		 $1,092.24
$1,160.88
$1,233.62
$1,492.00		 $448.85
$483.17
$519.54
$648.73		 $643.39
$677.71
$714.08
$843.27		 $837.93
$872.25
$908.62
$1,037.81		 $232.18

Plan: (HMO) Prime Bronze 7900 - Copay $50/$100 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: $7,900 : Family: $15,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $247.90
$281.37
$316.81
$442.75
$672.80		 $495.80
$562.74
$633.62
$885.50
$1,345.60		 $685.44
$752.38
$823.26
$1,075.14		 $875.08
$942.02
$1,012.90
$1,264.78		 $1,064.72
$1,131.66
$1,202.54
$1,454.42		 $437.54
$471.01
$506.45
$632.39		 $627.18
$660.65
$696.09
$822.03		 $816.82
$850.29
$885.73
$1,011.67		 $226.33

Plan: (HMO) Prime Silver 5000 - Copay $50/$100

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: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $386.49
$438.66
$493.93
$690.27
$1,048.93		 $772.98
$877.32
$987.86
$1,380.54
$2,097.86		 $1,068.64
$1,172.98
$1,283.52
$1,676.20		 $1,364.30
$1,468.64
$1,579.18
$1,971.86		 $1,659.96
$1,764.30
$1,874.84
$2,267.52		 $682.15
$734.32
$789.59
$985.93		 $977.81
$1,029.98
$1,085.25
$1,281.59		 $1,273.47
$1,325.64
$1,380.91
$1,577.25		 $352.86

Plan: (HMO) Prime Silver 7900 - Copay $80/$160

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: $7,900 : Family: $15,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $373.90
$424.37
$477.84
$667.78
$1,014.76		 $747.80
$848.74
$955.68
$1,335.56
$2,029.52		 $1,033.83
$1,134.77
$1,241.71
$1,621.59		 $1,319.86
$1,420.80
$1,527.74
$1,907.62		 $1,605.89
$1,706.83
$1,813.77
$2,193.65		 $659.93
$710.40
$763.87
$953.81		 $945.96
$996.43
$1,049.90
$1,239.84		 $1,231.99
$1,282.46
$1,335.93
$1,525.87		 $341.37

Plan: (HMO) Prime Gold Maintenance - Copay $40/$90

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: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $326.81
$370.92
$417.65
$583.67
$886.94		 $653.62
$741.84
$835.30
$1,167.34
$1,773.88		 $903.62
$991.84
$1,085.30
$1,417.34		 $1,153.62
$1,241.84
$1,335.30
$1,667.34		 $1,403.62
$1,491.84
$1,585.30
$1,917.34		 $576.81
$620.92
$667.65
$833.67		 $826.81
$870.92
$917.65
$1,083.67		 $1,076.81
$1,120.92
$1,167.65
$1,333.67		 $298.37

Plan: (HMO) Prime Gold 2000 - Copay $30/$70

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: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $318.91
$361.95
$407.56
$569.56
$865.50		 $637.82
$723.90
$815.12
$1,139.12
$1,731.00		 $881.78
$967.86
$1,059.08
$1,383.08		 $1,125.74
$1,211.82
$1,303.04
$1,627.04		 $1,369.70
$1,455.78
$1,547.00
$1,871.00		 $562.87
$605.91
$651.52
$813.52		 $806.83
$849.87
$895.48
$1,057.48		 $1,050.79
$1,093.83
$1,139.44
$1,301.44		 $291.16

Plan: (HMO) Prime Silver 4000 - Copay $45/$90

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: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $390.78
$443.53
$499.41
$697.93
$1,060.57		 $781.56
$887.06
$998.82
$1,395.86
$2,121.14		 $1,080.51
$1,186.01
$1,297.77
$1,694.81		 $1,379.46
$1,484.96
$1,596.72
$1,993.76		 $1,678.41
$1,783.91
$1,895.67
$2,292.71		 $689.73
$742.48
$798.36
$996.88		 $988.68
$1,041.43
$1,097.31
$1,295.83		 $1,287.63
$1,340.38
$1,396.26
$1,594.78		 $356.78

Plan: (HMO) Prime Bronze 7500 - Copay $80/$160

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: $7,500 : Family: $15,000
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Expanded Bronze 21
30
40
50
60		 $242.28
$274.98
$309.63
$432.71
$657.54		 $484.56
$549.96
$619.26
$865.42
$1,315.08		 $669.90
$735.30
$804.60
$1,050.76		 $855.24
$920.64
$989.94
$1,236.10		 $1,040.58
$1,105.98
$1,175.28
$1,421.44		 $427.62
$460.32
$494.97
$618.05		 $612.96
$645.66
$680.31
$803.39		 $798.30
$831.00
$865.65
$988.73		 $221.20

Plan: (HMO) Prime Bronze 7900 - Copay $50/$100

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: $7,900 : Family: $15,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $236.18
$268.06
$301.83
$421.81
$640.98		 $472.36
$536.12
$603.66
$843.62
$1,281.96		 $653.03
$716.79
$784.33
$1,024.29		 $833.70
$897.46
$965.00
$1,204.96		 $1,014.37
$1,078.13
$1,145.67
$1,385.63		 $416.85
$448.73
$482.50
$602.48		 $597.52
$629.40
$663.17
$783.15		 $778.19
$810.07
$843.84
$963.82		 $215.63

Plan: (HMO) Prime Gold HSA 2000

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: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,650 : Family: $13,300

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		 $334.01
$379.10
$426.86
$596.53
$906.49		 $668.02
$758.20
$853.72
$1,193.06
$1,812.98		 $923.53
$1,013.71
$1,109.23
$1,448.57		 $1,179.04
$1,269.22
$1,364.74
$1,704.08		 $1,434.55
$1,524.73
$1,620.25
$1,959.59		 $589.52
$634.61
$682.37
$852.04		 $845.03
$890.12
$937.88
$1,107.55		 $1,100.54
$1,145.63
$1,193.39
$1,363.06		 $304.95

Plan: (HMO) Prime Bronze HSA 6750

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

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $246.83
$280.15
$315.45
$440.83
$669.89		 $493.66
$560.30
$630.90
$881.66
$1,339.78		 $682.48
$749.12
$819.72
$1,070.48		 $871.30
$937.94
$1,008.54
$1,259.30		 $1,060.12
$1,126.76
$1,197.36
$1,448.12		 $435.65
$468.97
$504.27
$629.65		 $624.47
$657.79
$693.09
$818.47		 $813.29
$846.61
$881.91
$1,007.29		 $225.35

Plan: (HMO) Prime 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: $7,900 : Family: $15,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $183.26
$208.00
$234.20
$327.30
$497.36		 $366.52
$416.00
$468.40
$654.60
$994.72		 $506.71
$556.19
$608.59
$794.79		 $646.90
$696.38
$748.78
$934.98		 $787.09
$836.57
$888.97
$1,075.17		 $323.45
$348.19
$374.39
$467.49		 $463.64
$488.38
$514.58
$607.68		 $603.83
$628.57
$654.77
$747.87		 $167.31

Plan: (HMO) Prime Silver HSA 5250

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: $5,250 : Family: $10,500
Out of Pocket Maximum per year: Individual: $5,250 : Family: $10,500

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		 $400.07
$454.07
$511.28
$714.51
$1,085.77		 $800.14
$908.14
$1,022.56
$1,429.02
$2,171.54		 $1,106.19
$1,214.19
$1,328.61
$1,735.07		 $1,412.24
$1,520.24
$1,634.66
$2,041.12		 $1,718.29
$1,826.29
$1,940.71
$2,347.17		 $706.12
$760.12
$817.33
$1,020.56		 $1,012.17
$1,066.17
$1,123.38
$1,326.61		 $1,318.22
$1,372.22
$1,429.43
$1,632.66		 $365.26

Plan: (HMO) Prime Gold 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: $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		 $337.56
$383.13
$431.40
$602.88
$916.13		 $675.12
$766.26
$862.80
$1,205.76
$1,832.26		 $933.35
$1,024.49
$1,121.03
$1,463.99		 $1,191.58
$1,282.72
$1,379.26
$1,722.22		 $1,449.81
$1,540.95
$1,637.49
$1,980.45		 $595.79
$641.36
$689.63
$861.11		 $854.02
$899.59
$947.86
$1,119.34		 $1,112.25
$1,157.82
$1,206.09
$1,377.57		 $308.19
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: $7,900 : Family: $15,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $151.88
$172.38
$194.10
$271.25
$412.19		 $303.76
$344.76
$388.20
$542.50
$824.38		 $419.95
$460.95
$504.39
$658.69		 $536.14
$577.14
$620.58
$774.88		 $652.33
$693.33
$736.77
$891.07		 $268.07
$288.57
$310.29
$387.44		 $384.26
$404.76
$426.48
$503.63		 $500.45
$520.95
$542.67
$619.82		 $138.66

Plan: (HMO) Dean Silver Copay Plus 3600X

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

Deductible: Individual: $3,600 : Family: $7,200
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $332.68
$377.59
$425.17
$594.17
$902.90		 $665.36
$755.18
$850.34
$1,188.34
$1,805.80		 $919.86
$1,009.68
$1,104.84
$1,442.84		 $1,174.36
$1,264.18
$1,359.34
$1,697.34		 $1,428.86
$1,518.68
$1,613.84
$1,951.84		 $587.18
$632.09
$679.67
$848.67		 $841.68
$886.59
$934.17
$1,103.17		 $1,096.18
$1,141.09
$1,188.67
$1,357.67		 $303.74

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		 $323.18
$366.81
$413.03
$577.21
$877.12		 $646.36
$733.62
$826.06
$1,154.42
$1,754.24		 $893.60
$980.86
$1,073.30
$1,401.66		 $1,140.84
$1,228.10
$1,320.54
$1,648.90		 $1,388.08
$1,475.34
$1,567.78
$1,896.14		 $570.42
$614.05
$660.27
$824.45		 $817.66
$861.29
$907.51
$1,071.69		 $1,064.90
$1,108.53
$1,154.75
$1,318.93		 $295.07

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		 $329.43
$373.91
$421.02
$588.37
$894.09		 $658.86
$747.82
$842.04
$1,176.74
$1,788.18		 $910.88
$999.84
$1,094.06
$1,428.76		 $1,162.90
$1,251.86
$1,346.08
$1,680.78		 $1,414.92
$1,503.88
$1,598.10
$1,932.80		 $581.45
$625.93
$673.04
$840.39		 $833.47
$877.95
$925.06
$1,092.41		 $1,085.49
$1,129.97
$1,177.08
$1,344.43		 $300.77

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		 $314.75
$357.24
$402.25
$562.15
$854.24		 $629.50
$714.48
$804.50
$1,124.30
$1,708.48		 $870.29
$955.27
$1,045.29
$1,365.09		 $1,111.08
$1,196.06
$1,286.08
$1,605.88		 $1,351.87
$1,436.85
$1,526.87
$1,846.67		 $555.54
$598.03
$643.04
$802.94		 $796.33
$838.82
$883.83
$1,043.73		 $1,037.12
$1,079.61
$1,124.62
$1,284.52		 $287.37

Plan: (HMO) Dean Bronze Value Copay 7800X

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

Deductible: Individual: $7,800 : Family: $15,600
Out of Pocket Maximum per year: Individual: $7,800 : Family: $15,600

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
Bronze 21
30
40
50
60		 $220.35
$250.10
$281.61
$393.55
$598.03		 $440.70
$500.20
$563.22
$787.10
$1,196.06		 $609.27
$668.77
$731.79
$955.67		 $777.84
$837.34
$900.36
$1,124.24		 $946.41
$1,005.91
$1,068.93
$1,292.81		 $388.92
$418.67
$450.18
$562.12		 $557.49
$587.24
$618.75
$730.69		 $726.06
$755.81
$787.32
$899.26		 $201.18

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		 $316.96
$359.75
$405.08
$566.10
$860.24		 $633.92
$719.50
$810.16
$1,132.20
$1,720.48		 $876.40
$961.98
$1,052.64
$1,374.68		 $1,118.88
$1,204.46
$1,295.12
$1,617.16		 $1,361.36
$1,446.94
$1,537.60
$1,859.64		 $559.44
$602.23
$647.56
$808.58		 $801.92
$844.71
$890.04
$1,051.06		 $1,044.40
$1,087.19
$1,132.52
$1,293.54		 $289.39

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: $3,500 : 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		 $327.25
$371.43
$418.23
$584.47
$888.16		 $654.50
$742.86
$836.46
$1,168.94
$1,776.32		 $904.85
$993.21
$1,086.81
$1,419.29		 $1,155.20
$1,243.56
$1,337.16
$1,669.64		 $1,405.55
$1,493.91
$1,587.51
$1,919.99		 $577.60
$621.78
$668.58
$834.82		 $827.95
$872.13
$918.93
$1,085.17		 $1,078.30
$1,122.48
$1,169.28
$1,335.52		 $298.78

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		 $217.43
$246.78
$277.88
$388.33
$590.11		 $434.86
$493.56
$555.76
$776.66
$1,180.22		 $601.19
$659.89
$722.09
$942.99		 $767.52
$826.22
$888.42
$1,109.32		 $933.85
$992.55
$1,054.75
$1,275.65		 $383.76
$413.11
$444.21
$554.66		 $550.09
$579.44
$610.54
$720.99		 $716.42
$745.77
$776.87
$887.32		 $198.51

Plan: (EPO) Dean Focus Network 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		 $299.80
$340.27
$383.14
$535.44
$813.65		 $599.60
$680.54
$766.28
$1,070.88
$1,627.30		 $828.94
$909.88
$995.62
$1,300.22		 $1,058.28
$1,139.22
$1,224.96
$1,529.56		 $1,287.62
$1,368.56
$1,454.30
$1,758.90		 $529.14
$569.61
$612.48
$764.78		 $758.48
$798.95
$841.82
$994.12		 $987.82
$1,028.29
$1,071.16
$1,223.46		 $273.71

Plan: (EPO) Dean Focus Network Bronze Value Copay 7800X

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

Deductible: Individual: $7,800 : Family: $15,600
Out of Pocket Maximum per year: Individual: $7,800 : Family: $15,600

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
Bronze 21
30
40
50
60		 $198.90
$225.75
$254.19
$355.24
$539.81		 $397.80
$451.50
$508.38
$710.48
$1,079.62		 $549.96
$603.66
$660.54
$862.64		 $702.12
$755.82
$812.70
$1,014.80		 $854.28
$907.98
$964.86
$1,166.96		 $351.06
$377.91
$406.35
$507.40		 $503.22
$530.07
$558.51
$659.56		 $655.38
$682.23
$710.67
$811.72		 $181.60

Plan: (EPO) Dean Focus Network 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		 $287.95
$326.83
$368.00
$514.28
$781.50		 $575.90
$653.66
$736.00
$1,028.56
$1,563.00		 $796.18
$873.94
$956.28
$1,248.84		 $1,016.46
$1,094.22
$1,176.56
$1,469.12		 $1,236.74
$1,314.50
$1,396.84
$1,689.40		 $508.23
$547.11
$588.28
$734.56		 $728.51
$767.39
$808.56
$954.84		 $948.79
$987.67
$1,028.84
$1,175.12		 $262.90

Plan: (EPO) Dean Focus Network 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		 $196.31
$222.81
$250.88
$350.60
$532.78		 $392.62
$445.62
$501.76
$701.20
$1,065.56		 $542.79
$595.79
$651.93
$851.37		 $692.96
$745.96
$802.10
$1,001.54		 $843.13
$896.13
$952.27
$1,151.71		 $346.48
$372.98
$401.05
$500.77		 $496.65
$523.15
$551.22
$650.94		 $646.82
$673.32
$701.39
$801.11		 $179.23

Plan: (EPO) Dean Focus Network 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		 $283.07
$321.28
$361.76
$505.56
$768.24		 $566.14
$642.56
$723.52
$1,011.12
$1,536.48		 $782.69
$859.11
$940.07
$1,227.67		 $999.24
$1,075.66
$1,156.62
$1,444.22		 $1,215.79
$1,292.21
$1,373.17
$1,660.77		 $499.62
$537.83
$578.31
$722.11		 $716.17
$754.38
$794.86
$938.66		 $932.72
$970.93
$1,011.41
$1,155.21		 $258.44
ADVERTISEMENT

Group Health Cooperative of South Central Wisconsin

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

TTY: 1-608-828-4815

Plan: (HMO) Platinum 500 Ded/1500 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: $1,500 : Family: $3,000

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		 $453.73
$514.98
$579.87
$810.36
$1,231.42		 $907.46
$1,029.96
$1,159.74
$1,620.72
$2,462.84		 $1,254.56
$1,377.06
$1,506.84
$1,967.82		 $1,601.66
$1,724.16
$1,853.94
$2,314.92		 $1,948.76
$2,071.26
$2,201.04
$2,662.02		 $800.83
$862.08
$926.97
$1,157.46		 $1,147.93
$1,209.18
$1,274.07
$1,504.56		 $1,495.03
$1,556.28
$1,621.17
$1,851.66		 $414.26

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		 $398.08
$451.82
$508.74
$710.96
$1,080.37		 $796.16
$903.64
$1,017.48
$1,421.92
$2,160.74		 $1,100.69
$1,208.17
$1,322.01
$1,726.45		 $1,405.22
$1,512.70
$1,626.54
$2,030.98		 $1,709.75
$1,817.23
$1,931.07
$2,335.51		 $702.61
$756.35
$813.27
$1,015.49		 $1,007.14
$1,060.88
$1,117.80
$1,320.02		 $1,311.67
$1,365.41
$1,422.33
$1,624.55		 $363.45

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		 $435.36
$494.13
$556.38
$777.54
$1,181.55		 $870.72
$988.26
$1,112.76
$1,555.08
$2,363.10		 $1,203.77
$1,321.31
$1,445.81
$1,888.13		 $1,536.82
$1,654.36
$1,778.86
$2,221.18		 $1,869.87
$1,987.41
$2,111.91
$2,554.23		 $768.41
$827.18
$889.43
$1,110.59		 $1,101.46
$1,160.23
$1,222.48
$1,443.64		 $1,434.51
$1,493.28
$1,555.53
$1,776.69		 $397.48

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		 $310.06
$351.92
$396.26
$553.77
$841.50		 $620.12
$703.84
$792.52
$1,107.54
$1,683.00		 $857.32
$941.04
$1,029.72
$1,344.74		 $1,094.52
$1,178.24
$1,266.92
$1,581.94		 $1,331.72
$1,415.44
$1,504.12
$1,819.14		 $547.26
$589.12
$633.46
$790.97		 $784.46
$826.32
$870.66
$1,028.17		 $1,021.66
$1,063.52
$1,107.86
$1,265.37		 $283.09

Plan: (HMO) Select Platinum 500 Ded/1500 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: $1,500 : Family: $3,000

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		 $412.52
$468.21
$527.20
$736.76
$1,119.57		 $825.04
$936.42
$1,054.40
$1,473.52
$2,239.14		 $1,140.62
$1,252.00
$1,369.98
$1,789.10		 $1,456.20
$1,567.58
$1,685.56
$2,104.68		 $1,771.78
$1,883.16
$2,001.14
$2,420.26		 $728.10
$783.79
$842.78
$1,052.34		 $1,043.68
$1,099.37
$1,158.36
$1,367.92		 $1,359.26
$1,414.95
$1,473.94
$1,683.50		 $376.63

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		 $361.97
$410.84
$462.60
$646.48
$982.38		 $723.94
$821.68
$925.20
$1,292.96
$1,964.76		 $1,000.85
$1,098.59
$1,202.11
$1,569.87		 $1,277.76
$1,375.50
$1,479.02
$1,846.78		 $1,554.67
$1,652.41
$1,755.93
$2,123.69		 $638.88
$687.75
$739.51
$923.39		 $915.79
$964.66
$1,016.42
$1,200.30		 $1,192.70
$1,241.57
$1,293.33
$1,477.21		 $330.48

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		 $395.85
$449.29
$505.89
$706.98
$1,074.32		 $791.70
$898.58
$1,011.78
$1,413.96
$2,148.64		 $1,094.52
$1,201.40
$1,314.60
$1,716.78		 $1,397.34
$1,504.22
$1,617.42
$2,019.60		 $1,700.16
$1,807.04
$1,920.24
$2,322.42		 $698.67
$752.11
$808.71
$1,009.80		 $1,001.49
$1,054.93
$1,111.53
$1,312.62		 $1,304.31
$1,357.75
$1,414.35
$1,615.44		 $361.41

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		 $281.90
$319.95
$360.26
$503.46
$765.06		 $563.80
$639.90
$720.52
$1,006.92
$1,530.12		 $779.45
$855.55
$936.17
$1,222.57		 $995.10
$1,071.20
$1,151.82
$1,438.22		 $1,210.75
$1,286.85
$1,367.47
$1,653.87		 $497.55
$535.60
$575.91
$719.11		 $713.20
$751.25
$791.56
$934.76		 $928.85
$966.90
$1,007.21
$1,150.41		 $257.37

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		 $302.84
$343.72
$387.03
$540.87
$821.90		 $605.68
$687.44
$774.06
$1,081.74
$1,643.80		 $837.35
$919.11
$1,005.73
$1,313.41		 $1,069.02
$1,150.78
$1,237.40
$1,545.08		 $1,300.69
$1,382.45
$1,469.07
$1,776.75		 $534.51
$575.39
$618.70
$772.54		 $766.18
$807.06
$850.37
$1,004.21		 $997.85
$1,038.73
$1,082.04
$1,235.88		 $276.49

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		 $275.36
$312.53
$351.90
$491.78
$747.31		 $550.72
$625.06
$703.80
$983.56
$1,494.62		 $761.37
$835.71
$914.45
$1,194.21		 $972.02
$1,046.36
$1,125.10
$1,404.86		 $1,182.67
$1,257.01
$1,335.75
$1,615.51		 $486.01
$523.18
$562.55
$702.43		 $696.66
$733.83
$773.20
$913.08		 $907.31
$944.48
$983.85
$1,123.73		 $251.40

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		 $369.50
$419.38
$472.21
$659.92
$1,002.80		 $739.00
$838.76
$944.42
$1,319.84
$2,005.60		 $1,021.67
$1,121.43
$1,227.09
$1,602.51		 $1,304.34
$1,404.10
$1,509.76
$1,885.18		 $1,587.01
$1,686.77
$1,792.43
$2,167.85		 $652.17
$702.05
$754.88
$942.59		 $934.84
$984.72
$1,037.55
$1,225.26		 $1,217.51
$1,267.39
$1,320.22
$1,507.93		 $337.35

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		 $335.96
$381.31
$429.36
$600.02
$911.79		 $671.92
$762.62
$858.72
$1,200.04
$1,823.58		 $928.93
$1,019.63
$1,115.73
$1,457.05		 $1,185.94
$1,276.64
$1,372.74
$1,714.06		 $1,442.95
$1,533.65
$1,629.75
$1,971.07		 $592.97
$638.32
$686.37
$857.03		 $849.98
$895.33
$943.38
$1,114.04		 $1,106.99
$1,152.34
$1,200.39
$1,371.05		 $306.73

Plan: (HMO) Select Gold Simple Choice 1400 Ded/5000 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: $1,400 : 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		 $358.12
$406.46
$457.67
$639.59
$971.92		 $716.24
$812.92
$915.34
$1,279.18
$1,943.84		 $990.20
$1,086.88
$1,189.30
$1,553.14		 $1,264.16
$1,360.84
$1,463.26
$1,827.10		 $1,538.12
$1,634.80
$1,737.22
$2,101.06		 $632.08
$680.42
$731.63
$913.55		 $906.04
$954.38
$1,005.59
$1,187.51		 $1,180.00
$1,228.34
$1,279.55
$1,461.47		 $326.96

Plan: (HMO) Select Silver Simple Choice 4000X 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: $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		 $380.38
$431.74
$486.13
$679.36
$1,032.35		 $760.76
$863.48
$972.26
$1,358.72
$2,064.70		 $1,051.76
$1,154.48
$1,263.26
$1,649.72		 $1,342.76
$1,445.48
$1,554.26
$1,940.72		 $1,633.76
$1,736.48
$1,845.26
$2,231.72		 $671.38
$722.74
$777.13
$970.36		 $962.38
$1,013.74
$1,068.13
$1,261.36		 $1,253.38
$1,304.74
$1,359.13
$1,552.36		 $347.29

Plan: (HMO) Select Bronze Simple Choice 6650 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: $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		 $281.71
$319.74
$360.02
$503.12
$764.54		 $563.42
$639.48
$720.04
$1,006.24
$1,529.08		 $778.93
$854.99
$935.55
$1,221.75		 $994.44
$1,070.50
$1,151.06
$1,437.26		 $1,209.95
$1,286.01
$1,366.57
$1,652.77		 $497.22
$535.25
$575.53
$718.63		 $712.73
$750.76
$791.04
$934.14		 $928.24
$966.27
$1,006.55
$1,149.65		 $257.20

Plan: (HMO) Select Catastrophic 7900 Ded/7900 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: $7,900 : Family: $15,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $207.38
$235.37
$265.03
$370.37
$562.82		 $414.76
$470.74
$530.06
$740.74
$1,125.64		 $573.41
$629.39
$688.71
$899.39		 $732.06
$788.04
$847.36
$1,058.04		 $890.71
$946.69
$1,006.01
$1,216.69		 $366.03
$394.02
$423.68
$529.02		 $524.68
$552.67
$582.33
$687.67		 $683.33
$711.32
$740.98
$846.32		 $189.34

Plan: (HMO) Gold Simple Choice 1400 Ded/5000 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: $1,400 : 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		 $393.88
$447.05
$503.38
$703.47
$1,068.99		 $787.76
$894.10
$1,006.76
$1,406.94
$2,137.98		 $1,089.08
$1,195.42
$1,308.08
$1,708.26		 $1,390.40
$1,496.74
$1,609.40
$2,009.58		 $1,691.72
$1,798.06
$1,910.72
$2,310.90		 $695.20
$748.37
$804.70
$1,004.79		 $996.52
$1,049.69
$1,106.02
$1,306.11		 $1,297.84
$1,351.01
$1,407.34
$1,607.43		 $359.61

Plan: (HMO) Silver Simple Choice 4000X 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: $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		 $418.34
$474.82
$534.64
$747.16
$1,135.37		 $836.68
$949.64
$1,069.28
$1,494.32
$2,270.74		 $1,156.71
$1,269.67
$1,389.31
$1,814.35		 $1,476.74
$1,589.70
$1,709.34
$2,134.38		 $1,796.77
$1,909.73
$2,029.37
$2,454.41		 $738.37
$794.85
$854.67
$1,067.19		 $1,058.40
$1,114.88
$1,174.70
$1,387.22		 $1,378.43
$1,434.91
$1,494.73
$1,707.25		 $381.95

Plan: (HMO) Bronze Simple Choice 6650 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: $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		 $309.80
$351.62
$395.92
$553.30
$840.78		 $619.60
$703.24
$791.84
$1,106.60
$1,681.56		 $856.60
$940.24
$1,028.84
$1,343.60		 $1,093.60
$1,177.24
$1,265.84
$1,580.60		 $1,330.60
$1,414.24
$1,502.84
$1,817.60		 $546.80
$588.62
$632.92
$790.30		 $783.80
$825.62
$869.92
$1,027.30		 $1,020.80
$1,062.62
$1,106.92
$1,264.30		 $282.85

Plan: (HMO) Platinum No Ded/2000 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: $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
Platinum 21
30
40
50
60		 $459.74
$521.81
$587.55
$821.09
$1,247.73		 $919.48
$1,043.62
$1,175.10
$1,642.18
$2,495.46		 $1,271.18
$1,395.32
$1,526.80
$1,993.88		 $1,622.88
$1,747.02
$1,878.50
$2,345.58		 $1,974.58
$2,098.72
$2,230.20
$2,697.28		 $811.44
$873.51
$939.25
$1,172.79		 $1,163.14
$1,225.21
$1,290.95
$1,524.49		 $1,514.84
$1,576.91
$1,642.65
$1,876.19		 $419.74

Plan: (HMO) Select Platinum No Ded/2000 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: $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
Platinum 21
30
40
50
60		 $418.00
$474.43
$534.21
$746.55
$1,134.45		 $836.00
$948.86
$1,068.42
$1,493.10
$2,268.90		 $1,155.77
$1,268.63
$1,388.19
$1,812.87		 $1,475.54
$1,588.40
$1,707.96
$2,132.64		 $1,795.31
$1,908.17
$2,027.73
$2,452.41		 $737.77
$794.20
$853.98
$1,066.32		 $1,057.54
$1,113.97
$1,173.75
$1,386.09		 $1,377.31
$1,433.74
$1,493.52
$1,705.86		 $381.64

Plan: (HMO) Bronze 7900 Ded/7900 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: $7,900 : Family: $15,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $293.31
$332.91
$374.85
$523.85
$796.05		 $586.62
$665.82
$749.70
$1,047.70
$1,592.10		 $811.01
$890.21
$974.09
$1,272.09		 $1,035.40
$1,114.60
$1,198.48
$1,496.48		 $1,259.79
$1,338.99
$1,422.87
$1,720.87		 $517.70
$557.30
$599.24
$748.24		 $742.09
$781.69
$823.63
$972.63		 $966.48
$1,006.08
$1,048.02
$1,197.02		 $267.80

Plan: (HMO) Select Bronze 7900 Ded/7900 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: $7,900 : Family: $15,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $266.70
$302.70
$340.84
$476.32
$723.81		 $533.40
$605.40
$681.68
$952.64
$1,447.62		 $737.42
$809.42
$885.70
$1,156.66		 $941.44
$1,013.44
$1,089.72
$1,360.68		 $1,145.46
$1,217.46
$1,293.74
$1,564.70		 $470.72
$506.72
$544.86
$680.34		 $674.74
$710.74
$748.88
$884.36		 $878.76
$914.76
$952.90
$1,088.38		 $243.50

Plan: (HMO) Silver 4900 Ded/7900 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: $4,900 : Family: $9,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $424.20
$481.47
$542.13
$757.62
$1,151.28		 $848.40
$962.94
$1,084.26
$1,515.24
$2,302.56		 $1,172.92
$1,287.46
$1,408.78
$1,839.76		 $1,497.44
$1,611.98
$1,733.30
$2,164.28		 $1,821.96
$1,936.50
$2,057.82
$2,488.80		 $748.72
$805.99
$866.65
$1,082.14		 $1,073.24
$1,130.51
$1,191.17
$1,406.66		 $1,397.76
$1,455.03
$1,515.69
$1,731.18		 $387.30

Plan: (HMO) Select Silver 4900 Ded/7900 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: $4,900 : Family: $9,800
Out of Pocket Maximum per year: Individual: $7,900 : Family: $15,800

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $385.68
$437.74
$492.89
$688.82
$1,046.72		 $771.36
$875.48
$985.78
$1,377.64
$2,093.44		 $1,066.40
$1,170.52
$1,280.82
$1,672.68		 $1,361.44
$1,465.56
$1,575.86
$1,967.72		 $1,656.48
$1,760.60
$1,870.90
$2,262.76		 $680.72
$732.78
$787.93
$983.86		 $975.76
$1,027.82
$1,082.97
$1,278.90		 $1,270.80
$1,322.86
$1,378.01
$1,573.94		 $352.12

Plan: (HMO) Silver 5250 Ded/5250 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: $5,250 : Family: $10,500
Out of Pocket Maximum per year: Individual: $5,250 : Family: $10,500

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		 $422.16
$479.15
$539.52
$753.98
$1,145.74		 $844.32
$958.30
$1,079.04
$1,507.96
$2,291.48		 $1,167.27
$1,281.25
$1,401.99
$1,830.91		 $1,490.22
$1,604.20
$1,724.94
$2,153.86		 $1,813.17
$1,927.15
$2,047.89
$2,476.81		 $745.11
$802.10
$862.47
$1,076.93		 $1,068.06
$1,125.05
$1,185.42
$1,399.88		 $1,391.01
$1,448.00
$1,508.37
$1,722.83		 $385.43

Plan: (HMO) Select Silver 5250 Ded/5250 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: $5,250 : Family: $10,500
Out of Pocket Maximum per year: Individual: $5,250 : Family: $10,500

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		 $383.82
$435.64
$490.53
$685.51
$1,041.69		 $767.64
$871.28
$981.06
$1,371.02
$2,083.38		 $1,061.27
$1,164.91
$1,274.69
$1,664.65		 $1,354.90
$1,458.54
$1,568.32
$1,958.28		 $1,648.53
$1,752.17
$1,861.95
$2,251.91		 $677.45
$729.27
$784.16
$979.14		 $971.08
$1,022.90
$1,077.79
$1,272.77		 $1,264.71
$1,316.53
$1,371.42
$1,566.40		 $350.43

‡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 Dane County here.

 

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