Obamacare 2021 Rates for Tuscarawas County

Obamacare > Rates > Ohio > Tuscarawas County

Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Tuscarawas County, OH.

The health insurance rates listed below are for calendar year 2021.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 75 Plans and 2021 Rates for Tuscarawas County, Ohio

Below, you’ll find a summary of the 75 plans for Tuscarawas County, Ohio and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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AultCare Insurance Company

Local: 1-330-363-6360 | Toll Free: 1-800-344-8858 | TTY: 1-330-363-2393
Toc - Plan #1 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$429,14
$487,06
$548,43
$766,43
$1 164,66 		$757,42
$815,34
$876,71
$1 094,71 		$1 085,70
$1 143,62
$1 204,99
$1 422,99 		$1 413,98
$1 471,90
$1 533,27
$1 751,27 		$328,28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858,28
$974,12
$1 096,86
$1 532,86
$2 329,32 		$1 186,56
$1 302,40
$1 425,14
$1 861,14 		$1 514,84
$1 630,68
$1 753,42
$2 189,42 		$1 843,12
$1 958,96
$2 081,70
$2 517,70 		$328,28
Toc - Plan #2 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$569,47
$646,34
$727,78
$1 017,06
$1 545,53 		$1 005,11
$1 081,98
$1 163,42
$1 452,70 		$1 440,75
$1 517,62
$1 599,06
$1 888,34 		$1 876,39
$1 953,26
$2 034,70
$2 323,98 		$435,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 138,94
$1 292,68
$1 455,56
$2 034,12
$3 091,06 		$1 574,58
$1 728,32
$1 891,20
$2 469,76 		$2 010,22
$2 163,96
$2 326,84
$2 905,40 		$2 445,86
$2 599,60
$2 762,48
$3 341,04 		$435,64
Toc - Plan #3 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1000 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$693,30
$786,89
$886,03
$1 238,22
$1 881,60 		$1 223,67
$1 317,26
$1 416,40
$1 768,59 		$1 754,04
$1 847,63
$1 946,77
$2 298,96 		$2 284,41
$2 378,00
$2 477,14
$2 829,33 		$530,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 386,60
$1 573,78
$1 772,06
$2 476,44
$3 763,20 		$1 916,97
$2 104,15
$2 302,43
$3 006,81 		$2 447,34
$2 634,52
$2 832,80
$3 537,18 		$2 977,71
$3 164,89
$3 363,17
$4 067,55 		$530,37
Toc - Plan #4 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$218,01
$247,44
$278,62
$389,37
$591,68 		$384,79
$414,22
$445,40
$556,15 		$551,57
$581,00
$612,18
$722,93 		$718,35
$747,78
$778,96
$889,71 		$166,78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$436,02
$494,88
$557,24
$778,74
$1 183,36 		$602,80
$661,66
$724,02
$945,52 		$769,58
$828,44
$890,80
$1 112,30 		$936,36
$995,22
$1 057,58
$1 279,08 		$166,78
Toc - Plan #5 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$338,96
$384,71
$433,18
$605,37
$919,92 		$598,26
$644,01
$692,48
$864,67 		$857,56
$903,31
$951,78
$1 123,97 		$1 116,86
$1 162,61
$1 211,08
$1 383,27 		$259,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677,92
$769,42
$866,36
$1 210,74
$1 839,84 		$937,22
$1 028,72
$1 125,66
$1 470,04 		$1 196,52
$1 288,02
$1 384,96
$1 729,34 		$1 455,82
$1 547,32
$1 644,26
$1 988,64 		$259,30
Toc - Plan #6 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$448,74
$509,31
$573,48
$801,44
$1 217,86 		$792,02
$852,59
$916,76
$1 144,72 		$1 135,30
$1 195,87
$1 260,04
$1 488,00 		$1 478,58
$1 539,15
$1 603,32
$1 831,28 		$343,28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$897,48
$1 018,62
$1 146,96
$1 602,88
$2 435,72 		$1 240,76
$1 361,90
$1 490,24
$1 946,16 		$1 584,04
$1 705,18
$1 833,52
$2 289,44 		$1 927,32
$2 048,46
$2 176,80
$2 632,72 		$343,28
Toc - Plan #7 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1000 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$547,30
$621,18
$699,44
$977,46
$1 485,35 		$965,98
$1 039,86
$1 118,12
$1 396,14 		$1 384,66
$1 458,54
$1 536,80
$1 814,82 		$1 803,34
$1 877,22
$1 955,48
$2 233,50 		$418,68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 094,60
$1 242,36
$1 398,88
$1 954,92
$2 970,70 		$1 513,28
$1 661,04
$1 817,56
$2 373,60 		$1 931,96
$2 079,72
$2 236,24
$2 792,28 		$2 350,64
$2 498,40
$2 654,92
$3 210,96 		$418,68
Toc - Plan #8 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279,06
$316,72
$356,63
$498,39
$757,35 		$492,54
$530,20
$570,11
$711,87 		$706,02
$743,68
$783,59
$925,35 		$919,50
$957,16
$997,07
$1 138,83 		$213,48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558,12
$633,44
$713,26
$996,78
$1 514,70 		$771,60
$846,92
$926,74
$1 210,26 		$985,08
$1 060,40
$1 140,22
$1 423,74 		$1 198,56
$1 273,88
$1 353,70
$1 637,22 		$213,48
Toc - Plan #9 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$433,87
$492,43
$554,47
$774,87
$1 177,50 		$765,77
$824,33
$886,37
$1 106,77 		$1 097,67
$1 156,23
$1 218,27
$1 438,67 		$1 429,57
$1 488,13
$1 550,17
$1 770,57 		$331,90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867,74
$984,86
$1 108,94
$1 549,74
$2 355,00 		$1 199,64
$1 316,76
$1 440,84
$1 881,64 		$1 531,54
$1 648,66
$1 772,74
$2 213,54 		$1 863,44
$1 980,56
$2 104,64
$2 545,44 		$331,90
Toc - Plan #10 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$574,38
$651,92
$734,06
$1 025,84
$1 558,87 		$1 013,78
$1 091,32
$1 173,46
$1 465,24 		$1 453,18
$1 530,72
$1 612,86
$1 904,64 		$1 892,58
$1 970,12
$2 052,26
$2 344,04 		$439,40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 148,76
$1 303,84
$1 468,12
$2 051,68
$3 117,74 		$1 588,16
$1 743,24
$1 907,52
$2 491,08 		$2 027,56
$2 182,64
$2 346,92
$2 930,48 		$2 466,96
$2 622,04
$2 786,32
$3 369,88 		$439,40
Toc - Plan #11 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$700,54
$795,11
$895,28
$1 251,15
$1 901,25 		$1 236,45
$1 331,02
$1 431,19
$1 787,06 		$1 772,36
$1 866,93
$1 967,10
$2 322,97 		$2 308,27
$2 402,84
$2 503,01
$2 858,88 		$535,91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 401,08
$1 590,22
$1 790,56
$2 502,30
$3 802,50 		$1 936,99
$2 126,13
$2 326,47
$3 038,21 		$2 472,90
$2 662,04
$2 862,38
$3 574,12 		$3 008,81
$3 197,95
$3 398,29
$4 110,03 		$535,91
Toc - Plan #12 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$276,08
$313,35
$352,83
$493,07
$749,27 		$487,28
$524,55
$564,03
$704,27 		$698,48
$735,75
$775,23
$915,47 		$909,68
$946,95
$986,43
$1 126,67 		$211,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552,16
$626,70
$705,66
$986,14
$1 498,54 		$763,36
$837,90
$916,86
$1 197,34 		$974,56
$1 049,10
$1 128,06
$1 408,54 		$1 185,76
$1 260,30
$1 339,26
$1 619,74 		$211,20
Toc - Plan #13 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1000 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$541,64
$614,76
$692,21
$967,36
$1 470,00 		$955,99
$1 029,11
$1 106,56
$1 381,71 		$1 370,34
$1 443,46
$1 520,91
$1 796,06 		$1 784,69
$1 857,81
$1 935,26
$2 210,41 		$414,35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 083,28
$1 229,52
$1 384,42
$1 934,72
$2 940,00 		$1 497,63
$1 643,87
$1 798,77
$2 349,07 		$1 911,98
$2 058,22
$2 213,12
$2 763,42 		$2 326,33
$2 472,57
$2 627,47
$3 177,77 		$414,35
Toc - Plan #14 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$444,90
$504,95
$568,57
$794,58
$1 207,44 		$785,24
$845,29
$908,91
$1 134,92 		$1 125,58
$1 185,63
$1 249,25
$1 475,26 		$1 465,92
$1 525,97
$1 589,59
$1 815,60 		$340,34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889,80
$1 009,90
$1 137,14
$1 589,16
$2 414,88 		$1 230,14
$1 350,24
$1 477,48
$1 929,50 		$1 570,48
$1 690,58
$1 817,82
$2 269,84 		$1 910,82
$2 030,92
$2 158,16
$2 610,18 		$340,34
Toc - Plan #15 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$335,26
$380,52
$428,46
$598,77
$909,89 		$591,73
$636,99
$684,93
$855,24 		$848,20
$893,46
$941,40
$1 111,71 		$1 104,67
$1 149,93
$1 197,87
$1 368,18 		$256,47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670,52
$761,04
$856,92
$1 197,54
$1 819,78 		$926,99
$1 017,51
$1 113,39
$1 454,01 		$1 183,46
$1 273,98
$1 369,86
$1 710,48 		$1 439,93
$1 530,45
$1 626,33
$1 966,95 		$256,47
Toc - Plan #16 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$215,69
$244,80
$275,65
$385,21
$585,37 		$380,69
$409,80
$440,65
$550,21 		$545,69
$574,80
$605,65
$715,21 		$710,69
$739,80
$770,65
$880,21 		$165,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$431,38
$489,60
$551,30
$770,42
$1 170,74 		$596,38
$654,60
$716,30
$935,42 		$761,38
$819,60
$881,30
$1 100,42 		$926,38
$984,60
$1 046,30
$1 265,42 		$165,00
Toc - Plan #17 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$495,48
$562,37
$633,22
$884,93
$1 344,73 		$874,52
$941,41
$1 012,26
$1 263,97 		$1 253,56
$1 320,45
$1 391,30
$1 643,01 		$1 632,60
$1 699,49
$1 770,34
$2 022,05 		$379,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$990,96
$1 124,74
$1 266,44
$1 769,86
$2 689,46 		$1 370,00
$1 503,78
$1 645,48
$2 148,90 		$1 749,04
$1 882,82
$2 024,52
$2 527,94 		$2 128,08
$2 261,86
$2 403,56
$2 906,98 		$379,04
Toc - Plan #18 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$387,10
$439,35
$494,71
$691,35
$1 050,57 		$683,23
$735,48
$790,84
$987,48 		$979,36
$1 031,61
$1 086,97
$1 283,61 		$1 275,49
$1 327,74
$1 383,10
$1 579,74 		$296,13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774,20
$878,70
$989,42
$1 382,70
$2 101,14 		$1 070,33
$1 174,83
$1 285,55
$1 678,83 		$1 366,46
$1 470,96
$1 581,68
$1 974,96 		$1 662,59
$1 767,09
$1 877,81
$2 271,09 		$296,13
Toc - Plan #19 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$490,22
$556,39
$626,49
$875,52
$1 330,44 		$865,23
$931,40
$1 001,50
$1 250,53 		$1 240,24
$1 306,41
$1 376,51
$1 625,54 		$1 615,25
$1 681,42
$1 751,52
$2 000,55 		$375,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$980,44
$1 112,78
$1 252,98
$1 751,04
$2 660,88 		$1 355,45
$1 487,79
$1 627,99
$2 126,05 		$1 730,46
$1 862,80
$2 003,00
$2 501,06 		$2 105,47
$2 237,81
$2 378,01
$2 876,07 		$375,01
Toc - Plan #20 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382,98
$434,68
$489,45
$684,00
$1 039,41 		$675,96
$727,66
$782,43
$976,98 		$968,94
$1 020,64
$1 075,41
$1 269,96 		$1 261,92
$1 313,62
$1 368,39
$1 562,94 		$292,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765,96
$869,36
$978,90
$1 368,00
$2 078,82 		$1 058,94
$1 162,34
$1 271,88
$1 660,98 		$1 351,92
$1 455,32
$1 564,86
$1 953,96 		$1 644,90
$1 748,30
$1 857,84
$2 246,94 		$292,98
Toc - Plan #21 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$435,58
$494,37
$556,66
$777,93
$1 182,14 		$768,79
$827,58
$889,87
$1 111,14 		$1 102,00
$1 160,79
$1 223,08
$1 444,35 		$1 435,21
$1 494,00
$1 556,29
$1 777,56 		$333,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871,16
$988,74
$1 113,32
$1 555,86
$2 364,28 		$1 204,37
$1 321,95
$1 446,53
$1 889,07 		$1 537,58
$1 655,16
$1 779,74
$2 222,28 		$1 870,79
$1 988,37
$2 112,95
$2 555,49 		$333,21
Toc - Plan #22 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340,30
$386,23
$434,89
$607,76
$923,55 		$600,62
$646,55
$695,21
$868,08 		$860,94
$906,87
$955,53
$1 128,40 		$1 121,26
$1 167,19
$1 215,85
$1 388,72 		$260,32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680,60
$772,46
$869,78
$1 215,52
$1 847,10 		$940,92
$1 032,78
$1 130,10
$1 475,84 		$1 201,24
$1 293,10
$1 390,42
$1 736,16 		$1 461,56
$1 553,42
$1 650,74
$1 996,48 		$260,32
Toc - Plan #23 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$430,86
$489,02
$550,64
$769,51
$1 169,35 		$760,47
$818,63
$880,25
$1 099,12 		$1 090,08
$1 148,24
$1 209,86
$1 428,73 		$1 419,69
$1 477,85
$1 539,47
$1 758,34 		$329,61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861,72
$978,04
$1 101,28
$1 539,02
$2 338,70 		$1 191,33
$1 307,65
$1 430,89
$1 868,63 		$1 520,94
$1 637,26
$1 760,50
$2 198,24 		$1 850,55
$1 966,87
$2 090,11
$2 527,85 		$329,61
Toc - Plan #24 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336,61
$382,05
$430,18
$601,18
$913,55 		$594,11
$639,55
$687,68
$858,68 		$851,61
$897,05
$945,18
$1 116,18 		$1 109,11
$1 154,55
$1 202,68
$1 373,68 		$257,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$673,22
$764,10
$860,36
$1 202,36
$1 827,10 		$930,72
$1 021,60
$1 117,86
$1 459,86 		$1 188,22
$1 279,10
$1 375,36
$1 717,36 		$1 445,72
$1 536,60
$1 632,86
$1 974,86 		$257,50
Toc - Plan #25 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze Standard Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,650 $13,300 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324,61
$368,42
$414,84
$579,74
$880,97 		$572,93
$616,74
$663,16
$828,06 		$821,25
$865,06
$911,48
$1 076,38 		$1 069,57
$1 113,38
$1 159,80
$1 324,70 		$248,32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649,22
$736,84
$829,68
$1 159,48
$1 761,94 		$897,54
$985,16
$1 078,00
$1 407,80 		$1 145,86
$1 233,48
$1 326,32
$1 656,12 		$1 394,18
$1 481,80
$1 574,64
$1 904,44 		$248,32
Toc - Plan #26 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361,01
$409,74
$461,36
$644,75
$979,76 		$637,18
$685,91
$737,53
$920,92 		$913,35
$962,08
$1 013,70
$1 197,09 		$1 189,52
$1 238,25
$1 289,87
$1 473,26 		$276,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722,02
$819,48
$922,72
$1 289,50
$1 959,52 		$998,19
$1 095,65
$1 198,89
$1 565,67 		$1 274,36
$1 371,82
$1 475,06
$1 841,84 		$1 550,53
$1 647,99
$1 751,23
$2 118,01 		$276,17
Toc - Plan #27 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282,04
$320,11
$360,44
$503,71
$765,44 		$497,80
$535,87
$576,20
$719,47 		$713,56
$751,63
$791,96
$935,23 		$929,32
$967,39
$1 007,72
$1 150,99 		$215,76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564,08
$640,22
$720,88
$1 007,42
$1 530,88 		$779,84
$855,98
$936,64
$1 223,18 		$995,60
$1 071,74
$1 152,40
$1 438,94 		$1 211,36
$1 287,50
$1 368,16
$1 654,70 		$215,76
Toc - Plan #28 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$356,97
$405,15
$456,20
$637,54
$968,80 		$630,05
$678,23
$729,28
$910,62 		$903,13
$951,31
$1 002,36
$1 183,70 		$1 176,21
$1 224,39
$1 275,44
$1 456,78 		$273,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713,94
$810,30
$912,40
$1 275,08
$1 937,60 		$987,02
$1 083,38
$1 185,48
$1 548,16 		$1 260,10
$1 356,46
$1 458,56
$1 821,24 		$1 533,18
$1 629,54
$1 731,64
$2 094,32 		$273,08
Toc - Plan #29 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$278,88
$316,53
$356,41
$498,08
$756,87 		$492,22
$529,87
$569,75
$711,42 		$705,56
$743,21
$783,09
$924,76 		$918,90
$956,55
$996,43
$1 138,10 		$213,34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557,76
$633,06
$712,82
$996,16
$1 513,74 		$771,10
$846,40
$926,16
$1 209,50 		$984,44
$1 059,74
$1 139,50
$1 422,84 		$1 197,78
$1 273,08
$1 352,84
$1 636,18 		$213,34
Toc - Plan #30 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$351,38
$398,82
$449,06
$627,56
$953,65 		$620,19
$667,63
$717,87
$896,37 		$889,00
$936,44
$986,68
$1 165,18 		$1 157,81
$1 205,25
$1 255,49
$1 433,99 		$268,81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702,76
$797,64
$898,12
$1 255,12
$1 907,30 		$971,57
$1 066,45
$1 166,93
$1 523,93 		$1 240,38
$1 335,26
$1 435,74
$1 792,74 		$1 509,19
$1 604,07
$1 704,55
$2 061,55 		$268,81
Toc - Plan #31 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$274,52
$311,58
$350,83
$490,28
$745,04 		$484,52
$521,58
$560,83
$700,28 		$694,52
$731,58
$770,83
$910,28 		$904,52
$941,58
$980,83
$1 120,28 		$210,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549,04
$623,16
$701,66
$980,56
$1 490,08 		$759,04
$833,16
$911,66
$1 190,56 		$969,04
$1 043,16
$1 121,66
$1 400,56 		$1 179,04
$1 253,16
$1 331,66
$1 610,56 		$210,00
Toc - Plan #32 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$347,52
$394,43
$444,12
$620,66
$943,15 		$613,37
$660,28
$709,97
$886,51 		$879,22
$926,13
$975,82
$1 152,36 		$1 145,07
$1 191,98
$1 241,67
$1 418,21 		$265,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$695,04
$788,86
$888,24
$1 241,32
$1 886,30 		$960,89
$1 054,71
$1 154,09
$1 507,17 		$1 226,74
$1 320,56
$1 419,94
$1 773,02 		$1 492,59
$1 586,41
$1 685,79
$2 038,87 		$265,85
Toc - Plan #33 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$271,50
$308,15
$346,97
$484,89
$736,84 		$479,19
$515,84
$554,66
$692,58 		$686,88
$723,53
$762,35
$900,27 		$894,57
$931,22
$970,04
$1 107,96 		$207,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543,00
$616,30
$693,94
$969,78
$1 473,68 		$750,69
$823,99
$901,63
$1 177,47 		$958,38
$1 031,68
$1 109,32
$1 385,16 		$1 166,07
$1 239,37
$1 317,01
$1 592,85 		$207,69
Toc - Plan #34 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$365,61
$414,96
$467,25
$652,97
$992,26 		$645,30
$694,65
$746,94
$932,66 		$924,99
$974,34
$1 026,63
$1 212,35 		$1 204,68
$1 254,03
$1 306,32
$1 492,04 		$279,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731,22
$829,92
$934,50
$1 305,94
$1 984,52 		$1 010,91
$1 109,61
$1 214,19
$1 585,63 		$1 290,60
$1 389,30
$1 493,88
$1 865,32 		$1 570,29
$1 668,99
$1 773,57
$2 145,01 		$279,69
Toc - Plan #35 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$285,64
$324,19
$365,04
$510,14
$775,20 		$504,15
$542,70
$583,55
$728,65 		$722,66
$761,21
$802,06
$947,16 		$941,17
$979,72
$1 020,57
$1 165,67 		$218,51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571,28
$648,38
$730,08
$1 020,28
$1 550,40 		$789,79
$866,89
$948,59
$1 238,79 		$1 008,30
$1 085,40
$1 167,10
$1 457,30 		$1 226,81
$1 303,91
$1 385,61
$1 675,81 		$218,51
Toc - Plan #36 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361,93
$410,79
$462,55
$646,41
$982,28 		$638,81
$687,67
$739,43
$923,29 		$915,69
$964,55
$1 016,31
$1 200,17 		$1 192,57
$1 241,43
$1 293,19
$1 477,05 		$276,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723,86
$821,58
$925,10
$1 292,82
$1 964,56 		$1 000,74
$1 098,46
$1 201,98
$1 569,70 		$1 277,62
$1 375,34
$1 478,86
$1 846,58 		$1 554,50
$1 652,22
$1 755,74
$2 123,46 		$276,88
Toc - Plan #37 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282,76
$320,93
$361,36
$505,00
$767,40 		$499,07
$537,24
$577,67
$721,31 		$715,38
$753,55
$793,98
$937,62 		$931,69
$969,86
$1 010,29
$1 153,93 		$216,31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565,52
$641,86
$722,72
$1 010,00
$1 534,80 		$781,83
$858,17
$939,03
$1 226,31 		$998,14
$1 074,48
$1 155,34
$1 442,62 		$1 214,45
$1 290,79
$1 371,65
$1 658,93 		$216,31

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1808 | Toll Free: 1-855-748-1808

Toc - Plan #38 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354,68
$402,56
$453,28
$633,46
$962,60 		$626,01
$673,89
$724,61
$904,79 		$897,34
$945,22
$995,94
$1 176,12 		$1 168,67
$1 216,55
$1 267,27
$1 447,45 		$271,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709,36
$805,12
$906,56
$1 266,92
$1 925,20 		$980,69
$1 076,45
$1 177,89
$1 538,25 		$1 252,02
$1 347,78
$1 449,22
$1 809,58 		$1 523,35
$1 619,11
$1 720,55
$2 080,91 		$271,33
Toc - Plan #39 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X HMO 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336,18
$381,56
$429,64
$600,42
$912,39 		$593,36
$638,74
$686,82
$857,60 		$850,54
$895,92
$944,00
$1 114,78 		$1 107,72
$1 153,10
$1 201,18
$1 371,96 		$257,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672,36
$763,12
$859,28
$1 200,84
$1 824,78 		$929,54
$1 020,30
$1 116,46
$1 458,02 		$1 186,72
$1 277,48
$1 373,64
$1 715,20 		$1 443,90
$1 534,66
$1 630,82
$1 972,38 		$257,18
Toc - Plan #40 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 4000 Online Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$471,27
$534,89
$602,28
$841,69
$1 279,03 		$831,79
$895,41
$962,80
$1 202,21 		$1 192,31
$1 255,93
$1 323,32
$1 562,73 		$1 552,83
$1 616,45
$1 683,84
$1 923,25 		$360,52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942,54
$1 069,78
$1 204,56
$1 683,38
$2 558,06 		$1 303,06
$1 430,30
$1 565,08
$2 043,90 		$1 663,58
$1 790,82
$1 925,60
$2 404,42 		$2 024,10
$2 151,34
$2 286,12
$2 764,94 		$360,52
Toc - Plan #41 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway X HMO 2500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$2,500 $7,500 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$517,28
$587,11
$661,08
$923,86
$1 403,90 		$913,00
$982,83
$1 056,80
$1 319,58 		$1 308,72
$1 378,55
$1 452,52
$1 715,30 		$1 704,44
$1 774,27
$1 848,24
$2 111,02 		$395,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 034,56
$1 174,22
$1 322,16
$1 847,72
$2 807,80 		$1 430,28
$1 569,94
$1 717,88
$2 243,44 		$1 826,00
$1 965,66
$2 113,60
$2 639,16 		$2 221,72
$2 361,38
$2 509,32
$3 034,88 		$395,72
Toc - Plan #42 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6850 0 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360,20
$408,83
$460,34
$643,32
$977,58 		$635,75
$684,38
$735,89
$918,87 		$911,30
$959,93
$1 011,44
$1 194,42 		$1 186,85
$1 235,48
$1 286,99
$1 469,97 		$275,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720,40
$817,66
$920,68
$1 286,64
$1 955,16 		$995,95
$1 093,21
$1 196,23
$1 562,19 		$1 271,50
$1 368,76
$1 471,78
$1 837,74 		$1 547,05
$1 644,31
$1 747,33
$2 113,29 		$275,55
Toc - Plan #43 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3200 10 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$474,54
$538,60
$606,46
$847,53
$1 287,90 		$837,56
$901,62
$969,48
$1 210,55 		$1 200,58
$1 264,64
$1 332,50
$1 573,57 		$1 563,60
$1 627,66
$1 695,52
$1 936,59 		$363,02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$949,08
$1 077,20
$1 212,92
$1 695,06
$2 575,80 		$1 312,10
$1 440,22
$1 575,94
$2 058,08 		$1 675,12
$1 803,24
$1 938,96
$2 421,10 		$2 038,14
$2 166,26
$2 301,98
$2 784,12 		$363,02
Toc - Plan #44 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$484,60
$550,02
$619,32
$865,50
$1 315,20 		$855,32
$920,74
$990,04
$1 236,22 		$1 226,04
$1 291,46
$1 360,76
$1 606,94 		$1 596,76
$1 662,18
$1 731,48
$1 977,66 		$370,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969,20
$1 100,04
$1 238,64
$1 731,00
$2 630,40 		$1 339,92
$1 470,76
$1 609,36
$2 101,72 		$1 710,64
$1 841,48
$1 980,08
$2 472,44 		$2 081,36
$2 212,20
$2 350,80
$2 843,16 		$370,72
Toc - Plan #45 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000 20 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359,15
$407,64
$458,99
$641,44
$974,73 		$633,90
$682,39
$733,74
$916,19 		$908,65
$957,14
$1 008,49
$1 190,94 		$1 183,40
$1 231,89
$1 283,24
$1 465,69 		$274,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718,30
$815,28
$917,98
$1 282,88
$1 949,46 		$993,05
$1 090,03
$1 192,73
$1 557,63 		$1 267,80
$1 364,78
$1 467,48
$1 832,38 		$1 542,55
$1 639,53
$1 742,23
$2 107,13 		$274,75
Toc - Plan #46 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 6100 0 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$6,100 $12,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$439,78
$499,15
$562,04
$785,45
$1 193,56 		$776,21
$835,58
$898,47
$1 121,88 		$1 112,64
$1 172,01
$1 234,90
$1 458,31 		$1 449,07
$1 508,44
$1 571,33
$1 794,74 		$336,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879,56
$998,30
$1 124,08
$1 570,90
$2 387,12 		$1 215,99
$1 334,73
$1 460,51
$1 907,33 		$1 552,42
$1 671,16
$1 796,94
$2 243,76 		$1 888,85
$2 007,59
$2 133,37
$2 580,19 		$336,43
Toc - Plan #47 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$469,96
$533,40
$600,61
$839,35
$1 275,47 		$829,48
$892,92
$960,13
$1 198,87 		$1 189,00
$1 252,44
$1 319,65
$1 558,39 		$1 548,52
$1 611,96
$1 679,17
$1 917,91 		$359,52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939,92
$1 066,80
$1 201,22
$1 678,70
$2 550,94 		$1 299,44
$1 426,32
$1 560,74
$2 038,22 		$1 658,96
$1 785,84
$1 920,26
$2 397,74 		$2 018,48
$2 145,36
$2 279,78
$2 757,26 		$359,52
Toc - Plan #48 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$488,30
$554,22
$624,05
$872,10
$1 325,25 		$861,85
$927,77
$997,60
$1 245,65 		$1 235,40
$1 301,32
$1 371,15
$1 619,20 		$1 608,95
$1 674,87
$1 744,70
$1 992,75 		$373,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$976,60
$1 108,44
$1 248,10
$1 744,20
$2 650,50 		$1 350,15
$1 481,99
$1 621,65
$2 117,75 		$1 723,70
$1 855,54
$1 995,20
$2 491,30 		$2 097,25
$2 229,09
$2 368,75
$2 864,85 		$373,55
Toc - Plan #49 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$448,30
$508,82
$572,93
$800,66
$1 216,69 		$791,25
$851,77
$915,88
$1 143,61 		$1 134,20
$1 194,72
$1 258,83
$1 486,56 		$1 477,15
$1 537,67
$1 601,78
$1 829,51 		$342,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896,60
$1 017,64
$1 145,86
$1 601,32
$2 433,38 		$1 239,55
$1 360,59
$1 488,81
$1 944,27 		$1 582,50
$1 703,54
$1 831,76
$2 287,22 		$1 925,45
$2 046,49
$2 174,71
$2 630,17 		$342,95
Toc - Plan #50 Anthem Blue Cross and Blue Shield
Catastrophic

(HMO) Anthem Catastrophic Pathway X HMO 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$269,36
$305,72
$344,24
$481,08
$731,04 		$475,42
$511,78
$550,30
$687,14 		$681,48
$717,84
$756,36
$893,20 		$887,54
$923,90
$962,42
$1 099,26 		$206,06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538,72
$611,44
$688,48
$962,16
$1 462,08 		$744,78
$817,50
$894,54
$1 168,22 		$950,84
$1 023,56
$1 100,60
$1 374,28 		$1 156,90
$1 229,62
$1 306,66
$1 580,34 		$206,06
Toc - Plan #51 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 2600

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$2,600 $5,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$500,44
$568,00
$639,56
$893,79
$1 358,19 		$883,28
$950,84
$1 022,40
$1 276,63 		$1 266,12
$1 333,68
$1 405,24
$1 659,47 		$1 648,96
$1 716,52
$1 788,08
$2 042,31 		$382,84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 000,88
$1 136,00
$1 279,12
$1 787,58
$2 716,38 		$1 383,72
$1 518,84
$1 661,96
$2 170,42 		$1 766,56
$1 901,68
$2 044,80
$2 553,26 		$2 149,40
$2 284,52
$2 427,64
$2 936,10 		$382,84
Toc - Plan #52 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 6900 25

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$436,85
$495,82
$558,29
$780,21
$1 185,61 		$771,04
$830,01
$892,48
$1 114,40 		$1 105,23
$1 164,20
$1 226,67
$1 448,59 		$1 439,42
$1 498,39
$1 560,86
$1 782,78 		$334,19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$873,70
$991,64
$1 116,58
$1 560,42
$2 371,22 		$1 207,89
$1 325,83
$1 450,77
$1 894,61 		$1 542,08
$1 660,02
$1 784,96
$2 228,80 		$1 876,27
$1 994,21
$2 119,15
$2 562,99 		$334,19
Toc - Plan #53 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5500 Online Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366,01
$415,42
$467,76
$653,69
$993,35 		$646,01
$695,42
$747,76
$933,69 		$926,01
$975,42
$1 027,76
$1 213,69 		$1 206,01
$1 255,42
$1 307,76
$1 493,69 		$280,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732,02
$830,84
$935,52
$1 307,38
$1 986,70 		$1 012,02
$1 110,84
$1 215,52
$1 587,38 		$1 292,02
$1 390,84
$1 495,52
$1 867,38 		$1 572,02
$1 670,84
$1 775,52
$2 147,38 		$280,00
Toc - Plan #54 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$347,25
$394,13
$443,79
$620,19
$942,44 		$612,90
$659,78
$709,44
$885,84 		$878,55
$925,43
$975,09
$1 151,49 		$1 144,20
$1 191,08
$1 240,74
$1 417,14 		$265,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694,50
$788,26
$887,58
$1 240,38
$1 884,88 		$960,15
$1 053,91
$1 153,23
$1 506,03 		$1 225,80
$1 319,56
$1 418,88
$1 771,68 		$1 491,45
$1 585,21
$1 684,53
$2 037,33 		$265,65

ADVERTISEMENT

Oscar Insurance Corporation of Ohio

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755

Toc - Plan #55 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Oscar Bronze Simple

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,300 $14,600 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319,95
$363,13
$408,88
$571,41
$868,32 		$564,70
$607,88
$653,63
$816,16 		$809,45
$852,63
$898,38
$1 060,91 		$1 054,20
$1 097,38
$1 143,13
$1 305,66 		$244,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639,90
$726,26
$817,76
$1 142,82
$1 736,64 		$884,65
$971,01
$1 062,51
$1 387,57 		$1 129,40
$1 215,76
$1 307,26
$1 632,32 		$1 374,15
$1 460,51
$1 552,01
$1 877,07 		$244,75
Toc - Plan #56 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Oscar Bronze Classic PCP Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$329,05
$373,46
$420,51
$587,66
$893,00 		$580,76
$625,17
$672,22
$839,37 		$832,47
$876,88
$923,93
$1 091,08 		$1 084,18
$1 128,59
$1 175,64
$1 342,79 		$251,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658,10
$746,92
$841,02
$1 175,32
$1 786,00 		$909,81
$998,63
$1 092,73
$1 427,03 		$1 161,52
$1 250,34
$1 344,44
$1 678,74 		$1 413,23
$1 502,05
$1 596,15
$1 930,45 		$251,71
Toc - Plan #57 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Oscar Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321,98
$365,43
$411,47
$575,03
$873,82 		$568,28
$611,73
$657,77
$821,33 		$814,58
$858,03
$904,07
$1 067,63 		$1 060,88
$1 104,33
$1 150,37
$1 313,93 		$246,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643,96
$730,86
$822,94
$1 150,06
$1 747,64 		$890,26
$977,16
$1 069,24
$1 396,36 		$1 136,56
$1 223,46
$1 315,54
$1 642,66 		$1 382,86
$1 469,76
$1 561,84
$1 888,96 		$246,30
Toc - Plan #58 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Oscar Bronze Classic Next

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383,24
$434,97
$489,77
$684,45
$1 040,09 		$676,41
$728,14
$782,94
$977,62 		$969,58
$1 021,31
$1 076,11
$1 270,79 		$1 262,75
$1 314,48
$1 369,28
$1 563,96 		$293,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766,48
$869,94
$979,54
$1 368,90
$2 080,18 		$1 059,65
$1 163,11
$1 272,71
$1 662,07 		$1 352,82
$1 456,28
$1 565,88
$1 955,24 		$1 645,99
$1 749,45
$1 859,05
$2 248,41 		$293,17
Toc - Plan #59 Oscar Insurance Corporation of Ohio
Silver

(HMO) Oscar Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382,82
$434,49
$489,23
$683,70
$1 038,95 		$675,67
$727,34
$782,08
$976,55 		$968,52
$1 020,19
$1 074,93
$1 269,40 		$1 261,37
$1 313,04
$1 367,78
$1 562,25 		$292,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765,64
$868,98
$978,46
$1 367,40
$2 077,90 		$1 058,49
$1 161,83
$1 271,31
$1 660,25 		$1 351,34
$1 454,68
$1 564,16
$1 953,10 		$1 644,19
$1 747,53
$1 857,01
$2 245,95 		$292,85
Toc - Plan #60 Oscar Insurance Corporation of Ohio
Silver

(HMO) Oscar Silver Saver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375,46
$426,13
$479,82
$670,55
$1 018,96 		$662,68
$713,35
$767,04
$957,77 		$949,90
$1 000,57
$1 054,26
$1 244,99 		$1 237,12
$1 287,79
$1 341,48
$1 532,21 		$287,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750,92
$852,26
$959,64
$1 341,10
$2 037,92 		$1 038,14
$1 139,48
$1 246,86
$1 628,32 		$1 325,36
$1 426,70
$1 534,08
$1 915,54 		$1 612,58
$1 713,92
$1 821,30
$2 202,76 		$287,22
Toc - Plan #61 Oscar Insurance Corporation of Ohio
Silver

(HMO) Oscar Silver Classic Next

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$388,68
$441,15
$496,73
$694,17
$1 054,86 		$686,02
$738,49
$794,07
$991,51 		$983,36
$1 035,83
$1 091,41
$1 288,85 		$1 280,70
$1 333,17
$1 388,75
$1 586,19 		$297,34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777,36
$882,30
$993,46
$1 388,34
$2 109,72 		$1 074,70
$1 179,64
$1 290,80
$1 685,68 		$1 372,04
$1 476,98
$1 588,14
$1 983,02 		$1 669,38
$1 774,32
$1 885,48
$2 280,36 		$297,34
Toc - Plan #62 Oscar Insurance Corporation of Ohio
Catastrophic

(HMO) Oscar Secure

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$224,67
$254,99
$287,12
$401,25
$609,73 		$396,54
$426,86
$458,99
$573,12 		$568,41
$598,73
$630,86
$744,99 		$740,28
$770,60
$802,73
$916,86 		$171,87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$449,34
$509,98
$574,24
$802,50
$1 219,46 		$621,21
$681,85
$746,11
$974,37 		$793,08
$853,72
$917,98
$1 146,24 		$964,95
$1 025,59
$1 089,85
$1 318,11 		$171,87
Toc - Plan #63 Oscar Insurance Corporation of Ohio
Gold

(HMO) Oscar Gold Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$445,13
$505,21
$568,87
$794,99
$1 208,06 		$785,65
$845,73
$909,39
$1 135,51 		$1 126,17
$1 186,25
$1 249,91
$1 476,03 		$1 466,69
$1 526,77
$1 590,43
$1 816,55 		$340,52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890,26
$1 010,42
$1 137,74
$1 589,98
$2 416,12 		$1 230,78
$1 350,94
$1 478,26
$1 930,50 		$1 571,30
$1 691,46
$1 818,78
$2 271,02 		$1 911,82
$2 031,98
$2 159,30
$2 611,54 		$340,52
Toc - Plan #64 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Oscar Bronze HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$344,52
$391,01
$440,28
$615,29
$934,99 		$608,07
$654,56
$703,83
$878,84 		$871,62
$918,11
$967,38
$1 142,39 		$1 135,17
$1 181,66
$1 230,93
$1 405,94 		$263,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689,04
$782,02
$880,56
$1 230,58
$1 869,98 		$952,59
$1 045,57
$1 144,11
$1 494,13 		$1 216,14
$1 309,12
$1 407,66
$1 757,68 		$1 479,69
$1 572,67
$1 671,21
$2 021,23 		$263,55
Toc - Plan #65 Oscar Insurance Corporation of Ohio
Silver

(HMO) Oscar Silver Classic Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$392,23
$445,17
$501,25
$700,50
$1 064,48 		$692,28
$745,22
$801,30
$1 000,55 		$992,33
$1 045,27
$1 101,35
$1 300,60 		$1 292,38
$1 345,32
$1 401,40
$1 600,65 		$300,05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784,46
$890,34
$1 002,50
$1 401,00
$2 128,96 		$1 084,51
$1 190,39
$1 302,55
$1 701,05 		$1 384,56
$1 490,44
$1 602,60
$2 001,10 		$1 684,61
$1 790,49
$1 902,65
$2 301,15 		$300,05
Toc - Plan #66 Oscar Insurance Corporation of Ohio
Silver

(HMO) Oscar Silver Classic $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$419,44
$476,05
$536,03
$749,10
$1 138,32 		$740,30
$796,91
$856,89
$1 069,96 		$1 061,16
$1 117,77
$1 177,75
$1 390,82 		$1 382,02
$1 438,63
$1 498,61
$1 711,68 		$320,86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838,88
$952,10
$1 072,06
$1 498,20
$2 276,64 		$1 159,74
$1 272,96
$1 392,92
$1 819,06 		$1 480,60
$1 593,82
$1 713,78
$2 139,92 		$1 801,46
$1 914,68
$2 034,64
$2 460,78 		$320,86

ADVERTISEMENT

MedMutual

Local: 1-888-308-0357 | Toll Free: 1-888-308-0357

Toc - Plan #67 MedMutual
Gold

(HMO) Market HMO 2000 - NE Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$504,79
$572,94
$645,13
$901,56
$1 370,01 		$890,96
$959,11
$1 031,30
$1 287,73 		$1 277,13
$1 345,28
$1 417,47
$1 673,90 		$1 663,30
$1 731,45
$1 803,64
$2 060,07 		$386,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 009,58
$1 145,88
$1 290,26
$1 803,12
$2 740,02 		$1 395,75
$1 532,05
$1 676,43
$2 189,29 		$1 781,92
$1 918,22
$2 062,60
$2 575,46 		$2 168,09
$2 304,39
$2 448,77
$2 961,63 		$386,17
Toc - Plan #68 MedMutual
Silver

(HMO) Market HMO 3000 - NE Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393,30
$446,39
$502,63
$702,43
$1 067,40 		$694,17
$747,26
$803,50
$1 003,30 		$995,04
$1 048,13
$1 104,37
$1 304,17 		$1 295,91
$1 349,00
$1 405,24
$1 605,04 		$300,87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786,60
$892,78
$1 005,26
$1 404,86
$2 134,80 		$1 087,47
$1 193,65
$1 306,13
$1 705,73 		$1 388,34
$1 494,52
$1 607,00
$2 006,60 		$1 689,21
$1 795,39
$1 907,87
$2 307,47 		$300,87
Toc - Plan #69 MedMutual
Silver

(HMO) Market HMO 4000 HSA - NE Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$391,77
$444,66
$500,68
$699,70
$1 063,27 		$691,48
$744,37
$800,39
$999,41 		$991,19
$1 044,08
$1 100,10
$1 299,12 		$1 290,90
$1 343,79
$1 399,81
$1 598,83 		$299,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783,54
$889,32
$1 001,36
$1 399,40
$2 126,54 		$1 083,25
$1 189,03
$1 301,07
$1 699,11 		$1 382,96
$1 488,74
$1 600,78
$1 998,82 		$1 682,67
$1 788,45
$1 900,49
$2 298,53 		$299,71
Toc - Plan #70 MedMutual
Silver

(HMO) Market HMO 6500 - NE Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407,31
$462,30
$520,54
$727,45
$1 105,44 		$718,90
$773,89
$832,13
$1 039,04 		$1 030,49
$1 085,48
$1 143,72
$1 350,63 		$1 342,08
$1 397,07
$1 455,31
$1 662,22 		$311,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814,62
$924,60
$1 041,08
$1 454,90
$2 210,88 		$1 126,21
$1 236,19
$1 352,67
$1 766,49 		$1 437,80
$1 547,78
$1 664,26
$2 078,08 		$1 749,39
$1 859,37
$1 975,85
$2 389,67 		$311,59
Toc - Plan #71 MedMutual
Expanded Bronze

(HMO) Market HMO 5850 HSA - NE Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$5,850 $11,700 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$323,84
$367,55
$413,86
$578,37
$878,89 		$571,57
$615,28
$661,59
$826,10 		$819,30
$863,01
$909,32
$1 073,83 		$1 067,03
$1 110,74
$1 157,05
$1 321,56 		$247,73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647,68
$735,10
$827,72
$1 156,74
$1 757,78 		$895,41
$982,83
$1 075,45
$1 404,47 		$1 143,14
$1 230,56
$1 323,18
$1 652,20 		$1 390,87
$1 478,29
$1 570,91
$1 899,93 		$247,73
Toc - Plan #72 MedMutual
Expanded Bronze

(HMO) Market HMO 7000 HSA - NE Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302,21
$343,00
$386,22
$539,74
$820,19 		$533,40
$574,19
$617,41
$770,93 		$764,59
$805,38
$848,60
$1 002,12 		$995,78
$1 036,57
$1 079,79
$1 233,31 		$231,19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604,42
$686,00
$772,44
$1 079,48
$1 640,38 		$835,61
$917,19
$1 003,63
$1 310,67 		$1 066,80
$1 148,38
$1 234,82
$1 541,86 		$1 297,99
$1 379,57
$1 466,01
$1 773,05 		$231,19
Toc - Plan #73 MedMutual
Bronze

(HMO) Market HMO 8500 - NE Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$290,63
$329,87
$371,43
$519,07
$788,77 		$512,96
$552,20
$593,76
$741,40 		$735,29
$774,53
$816,09
$963,73 		$957,62
$996,86
$1 038,42
$1 186,06 		$222,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581,26
$659,74
$742,86
$1 038,14
$1 577,54 		$803,59
$882,07
$965,19
$1 260,47 		$1 025,92
$1 104,40
$1 187,52
$1 482,80 		$1 248,25
$1 326,73
$1 409,85
$1 705,13 		$222,33
Toc - Plan #74 MedMutual
Expanded Bronze

(HMO) Market HMO $0 Deductible - NE Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336,94
$382,42
$430,60
$601,77
$914,44 		$594,70
$640,18
$688,36
$859,53 		$852,46
$897,94
$946,12
$1 117,29 		$1 110,22
$1 155,70
$1 203,88
$1 375,05 		$257,76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$673,88
$764,84
$861,20
$1 203,54
$1 828,88 		$931,64
$1 022,60
$1 118,96
$1 461,30 		$1 189,40
$1 280,36
$1 376,72
$1 719,06 		$1 447,16
$1 538,12
$1 634,48
$1 976,82 		$257,76
Toc - Plan #75 MedMutual
Catastrophic

(HMO) Market HMO Young Adult Essentials - NE Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$182,18
$206,77
$232,82
$325,37
$494,43 		$321,55
$346,14
$372,19
$464,74 		$460,92
$485,51
$511,56
$604,11 		$600,29
$624,88
$650,93
$743,48 		$139,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$364,36
$413,54
$465,64
$650,74
$988,86 		$503,73
$552,91
$605,01
$790,11 		$643,10
$692,28
$744,38
$929,48 		$782,47
$831,65
$883,75
$1 068,85 		$139,37

‡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 Tuscarawas County here.

Tuscarawas County is in “Rating Area 16” of Ohio.

Currently, there are 75 plans offered in Rating Area 16.

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