Obamacare 2021 Rates for Clarendon County

Obamacare > Rates > South Carolina > Clarendon 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 Clarendon County, SC.

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, 52 Plans and 2021 Rates for Clarendon County, South Carolina

Below, you’ll find a summary of the 52 plans for Clarendon County, South Carolina 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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BlueCross BlueShield of South Carolina

Local: 1-855-404-6752 | Toll Free: 1-855-404-6752 | TTY: 1-855-889-4325
Toc - Plan #1 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,500 $9,000 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 		$393,01
$446,07
$502,27
$701,92
$1 066,64 		$693,67
$746,73
$802,93
$1 002,58 		$994,33
$1 047,39
$1 103,59
$1 303,24 		$1 294,99
$1 348,05
$1 404,25
$1 603,90 		$300,66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786,02
$892,14
$1 004,54
$1 403,84
$2 133,28 		$1 086,68
$1 192,80
$1 305,20
$1 704,50 		$1 387,34
$1 493,46
$1 605,86
$2 005,16 		$1 688,00
$1 794,12
$1 906,52
$2 305,82 		$300,66
Toc - Plan #2 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$8,150 $16,300 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 		$409,81
$465,14
$523,74
$731,93
$1 112,24 		$723,32
$778,65
$837,25
$1 045,44 		$1 036,83
$1 092,16
$1 150,76
$1 358,95 		$1 350,34
$1 405,67
$1 464,27
$1 672,46 		$313,51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819,62
$930,28
$1 047,48
$1 463,86
$2 224,48 		$1 133,13
$1 243,79
$1 360,99
$1 777,37 		$1 446,64
$1 557,30
$1 674,50
$2 090,88 		$1 760,15
$1 870,81
$1 988,01
$2 404,39 		$313,51
Toc - Plan #3 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 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 		$390,44
$443,15
$498,99
$697,33
$1 059,66 		$689,13
$741,84
$797,68
$996,02 		$987,82
$1 040,53
$1 096,37
$1 294,71 		$1 286,51
$1 339,22
$1 395,06
$1 593,40 		$298,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780,88
$886,30
$997,98
$1 394,66
$2 119,32 		$1 079,57
$1 184,99
$1 296,67
$1 693,35 		$1 378,26
$1 483,68
$1 595,36
$1 992,04 		$1 676,95
$1 782,37
$1 894,05
$2 290,73 		$298,69
Toc - Plan #4 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$246,68
$279,98
$315,26
$440,57
$669,49 		$435,39
$468,69
$503,97
$629,28 		$624,10
$657,40
$692,68
$817,99 		$812,81
$846,11
$881,39
$1 006,70 		$188,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$493,36
$559,96
$630,52
$881,14
$1 338,98 		$682,07
$748,67
$819,23
$1 069,85 		$870,78
$937,38
$1 007,94
$1 258,56 		$1 059,49
$1 126,09
$1 196,65
$1 447,27 		$188,71
Toc - Plan #5 BlueCross BlueShield of South Carolina
Bronze

(EPO) BlueEssentials Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$246,16
$279,39
$314,59
$439,64
$668,08 		$434,47
$467,70
$502,90
$627,95 		$622,78
$656,01
$691,21
$816,26 		$811,09
$844,32
$879,52
$1 004,57 		$188,31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492,32
$558,78
$629,18
$879,28
$1 336,16 		$680,63
$747,09
$817,49
$1 067,59 		$868,94
$935,40
$1 005,80
$1 255,90 		$1 057,25
$1 123,71
$1 194,11
$1 444,21 		$188,31
Toc - Plan #6 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$5,600 $11,200 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 		$383,72
$435,53
$490,40
$685,33
$1 041,42 		$677,27
$729,08
$783,95
$978,88 		$970,82
$1 022,63
$1 077,50
$1 272,43 		$1 264,37
$1 316,18
$1 371,05
$1 565,98 		$293,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767,44
$871,06
$980,80
$1 370,66
$2 082,84 		$1 060,99
$1 164,61
$1 274,35
$1 664,21 		$1 354,54
$1 458,16
$1 567,90
$1 957,76 		$1 648,09
$1 751,71
$1 861,45
$2 251,31 		$293,55
Toc - Plan #7 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials HD Gold 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$3,000 $6,000 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 		$391,16
$443,96
$499,90
$698,61
$1 061,60 		$690,39
$743,19
$799,13
$997,84 		$989,62
$1 042,42
$1 098,36
$1 297,07 		$1 288,85
$1 341,65
$1 397,59
$1 596,30 		$299,23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782,32
$887,92
$999,80
$1 397,22
$2 123,20 		$1 081,55
$1 187,15
$1 299,03
$1 696,45 		$1 380,78
$1 486,38
$1 598,26
$1 995,68 		$1 680,01
$1 785,61
$1 897,49
$2 294,91 		$299,23
Toc - Plan #8 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials HD Silver 6

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$4,300 $8,600 Annual Deductible
$4,300 $8,600 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 		$412,64
$468,35
$527,36
$736,98
$1 119,91 		$728,31
$784,02
$843,03
$1 052,65 		$1 043,98
$1 099,69
$1 158,70
$1 368,32 		$1 359,65
$1 415,36
$1 474,37
$1 683,99 		$315,67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825,28
$936,70
$1 054,72
$1 473,96
$2 239,82 		$1 140,95
$1 252,37
$1 370,39
$1 789,63 		$1 456,62
$1 568,04
$1 686,06
$2 105,30 		$1 772,29
$1 883,71
$2 001,73
$2 420,97 		$315,67
Toc - Plan #9 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials HD Bronze 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 Annual Deductible
$6,900 $13,800 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 		$257,36
$292,10
$328,90
$459,64
$698,46 		$454,24
$488,98
$525,78
$656,52 		$651,12
$685,86
$722,66
$853,40 		$848,00
$882,74
$919,54
$1 050,28 		$196,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514,72
$584,20
$657,80
$919,28
$1 396,92 		$711,60
$781,08
$854,68
$1 116,16 		$908,48
$977,96
$1 051,56
$1 313,04 		$1 105,36
$1 174,84
$1 248,44
$1 509,92 		$196,88
Toc - Plan #10 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 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 		$248,60
$282,17
$317,72
$444,01
$674,71 		$438,78
$472,35
$507,90
$634,19 		$628,96
$662,53
$698,08
$824,37 		$819,14
$852,71
$888,26
$1 014,55 		$190,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$497,20
$564,34
$635,44
$888,02
$1 349,42 		$687,38
$754,52
$825,62
$1 078,20 		$877,56
$944,70
$1 015,80
$1 268,38 		$1 067,74
$1 134,88
$1 205,98
$1 458,56 		$190,18
Toc - Plan #11 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials HD Bronze 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$257,48
$292,23
$329,05
$459,85
$698,79 		$454,45
$489,20
$526,02
$656,82 		$651,42
$686,17
$722,99
$853,79 		$848,39
$883,14
$919,96
$1 050,76 		$196,97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514,96
$584,46
$658,10
$919,70
$1 397,58 		$711,93
$781,43
$855,07
$1 116,67 		$908,90
$978,40
$1 052,04
$1 313,64 		$1 105,87
$1 175,37
$1 249,01
$1 510,61 		$196,97
Toc - Plan #12 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 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 		$377,96
$428,98
$483,03
$675,03
$1 025,77 		$667,10
$718,12
$772,17
$964,17 		$956,24
$1 007,26
$1 061,31
$1 253,31 		$1 245,38
$1 296,40
$1 350,45
$1 542,45 		$289,14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755,92
$857,96
$966,06
$1 350,06
$2 051,54 		$1 045,06
$1 147,10
$1 255,20
$1 639,20 		$1 334,20
$1 436,24
$1 544,34
$1 928,34 		$1 623,34
$1 725,38
$1 833,48
$2 217,48 		$289,14
Toc - Plan #13 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$5,250 $10,500 Annual Deductible
$7,900 $15,800 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 		$398,56
$452,37
$509,36
$711,83
$1 081,70 		$703,46
$757,27
$814,26
$1 016,73 		$1 008,36
$1 062,17
$1 119,16
$1 321,63 		$1 313,26
$1 367,07
$1 424,06
$1 626,53 		$304,90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797,12
$904,74
$1 018,72
$1 423,66
$2 163,40 		$1 102,02
$1 209,64
$1 323,62
$1 728,56 		$1 406,92
$1 514,54
$1 628,52
$2 033,46 		$1 711,82
$1 819,44
$1 933,42
$2 338,36 		$304,90
Toc - Plan #14 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 9

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,850 $15,700 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 		$395,39
$448,76
$505,30
$706,16
$1 073,08 		$697,86
$751,23
$807,77
$1 008,63 		$1 000,33
$1 053,70
$1 110,24
$1 311,10 		$1 302,80
$1 356,17
$1 412,71
$1 613,57 		$302,47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790,78
$897,52
$1 010,60
$1 412,32
$2 146,16 		$1 093,25
$1 199,99
$1 313,07
$1 714,79 		$1 395,72
$1 502,46
$1 615,54
$2 017,26 		$1 698,19
$1 804,93
$1 918,01
$2 319,73 		$302,47
Toc - Plan #15 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,300 $16,600 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 		$396,88
$450,46
$507,21
$708,82
$1 077,13 		$700,49
$754,07
$810,82
$1 012,43 		$1 004,10
$1 057,68
$1 114,43
$1 316,04 		$1 307,71
$1 361,29
$1 418,04
$1 619,65 		$303,61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793,76
$900,92
$1 014,42
$1 417,64
$2 154,26 		$1 097,37
$1 204,53
$1 318,03
$1 721,25 		$1 400,98
$1 508,14
$1 621,64
$2 024,86 		$1 704,59
$1 811,75
$1 925,25
$2 328,47 		$303,61
Toc - Plan #16 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$7,350 $14,700 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 		$403,06
$457,47
$515,11
$719,86
$1 093,90 		$711,40
$765,81
$823,45
$1 028,20 		$1 019,74
$1 074,15
$1 131,79
$1 336,54 		$1 328,08
$1 382,49
$1 440,13
$1 644,88 		$308,34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806,12
$914,94
$1 030,22
$1 439,72
$2 187,80 		$1 114,46
$1 223,28
$1 338,56
$1 748,06 		$1 422,80
$1 531,62
$1 646,90
$2 056,40 		$1 731,14
$1 839,96
$1 955,24
$2 364,74 		$308,34
Toc - Plan #17 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$5,500 $11,000 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 		$383,79
$435,60
$490,48
$685,44
$1 041,60 		$677,39
$729,20
$784,08
$979,04 		$970,99
$1 022,80
$1 077,68
$1 272,64 		$1 264,59
$1 316,40
$1 371,28
$1 566,24 		$293,60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767,58
$871,20
$980,96
$1 370,88
$2 083,20 		$1 061,18
$1 164,80
$1 274,56
$1 664,48 		$1 354,78
$1 458,40
$1 568,16
$1 958,08 		$1 648,38
$1 752,00
$1 861,76
$2 251,68 		$293,60
Toc - Plan #18 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials HD Silver 13

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$5,750 $11,500 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 		$389,17
$441,71
$497,36
$695,06
$1 056,21 		$686,88
$739,42
$795,07
$992,77 		$984,59
$1 037,13
$1 092,78
$1 290,48 		$1 282,30
$1 334,84
$1 390,49
$1 588,19 		$297,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778,34
$883,42
$994,72
$1 390,12
$2 112,42 		$1 076,05
$1 181,13
$1 292,43
$1 687,83 		$1 373,76
$1 478,84
$1 590,14
$1 985,54 		$1 671,47
$1 776,55
$1 887,85
$2 283,25 		$297,71
Toc - Plan #19 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 14

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$376,35
$427,16
$480,98
$672,17
$1 021,42 		$664,26
$715,07
$768,89
$960,08 		$952,17
$1 002,98
$1 056,80
$1 247,99 		$1 240,08
$1 290,89
$1 344,71
$1 535,90 		$287,91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752,70
$854,32
$961,96
$1 344,34
$2 042,84 		$1 040,61
$1 142,23
$1 249,87
$1 632,25 		$1 328,52
$1 430,14
$1 537,78
$1 920,16 		$1 616,43
$1 718,05
$1 825,69
$2 208,07 		$287,91
Toc - Plan #20 BlueCross BlueShield of South Carolina
Catastrophic

(EPO) BlueEssentials Catastrophic 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$163,55
$185,63
$209,02
$292,11
$443,89 		$288,67
$310,75
$334,14
$417,23 		$413,79
$435,87
$459,26
$542,35 		$538,91
$560,99
$584,38
$667,47 		$125,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$327,10
$371,26
$418,04
$584,22
$887,78 		$452,22
$496,38
$543,16
$709,34 		$577,34
$621,50
$668,28
$834,46 		$702,46
$746,62
$793,40
$959,58 		$125,12

ADVERTISEMENT

Molina Healthcare

Local: 1-855-885-3176 | Toll Free: 1-800-659-8331 | TTY: 1-800-659-8331
Toc - Plan #21 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

Annual Out of Pocket Expenses:

Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 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 		$417,59
$473,97
$533,69
$745,82
$1 133,35 		$737,05
$793,43
$853,15
$1 065,28 		$1 056,51
$1 112,89
$1 172,61
$1 384,74 		$1 375,97
$1 432,35
$1 492,07
$1 704,20 		$319,46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835,18
$947,94
$1 067,38
$1 491,64
$2 266,70 		$1 154,64
$1 267,40
$1 386,84
$1 811,10 		$1 474,10
$1 586,86
$1 706,30
$2 130,56 		$1 793,56
$1 906,32
$2 025,76
$2 450,02 		$319,46
Toc - Plan #22 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

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 		$376,94
$427,82
$481,73
$673,21
$1 023,01 		$665,30
$716,18
$770,09
$961,57 		$953,66
$1 004,54
$1 058,45
$1 249,93 		$1 242,02
$1 292,90
$1 346,81
$1 538,29 		$288,36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753,88
$855,64
$963,46
$1 346,42
$2 046,02 		$1 042,24
$1 144,00
$1 251,82
$1 634,78 		$1 330,60
$1 432,36
$1 540,18
$1 923,14 		$1 618,96
$1 720,72
$1 828,54
$2 211,50 		$288,36
Toc - Plan #23 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$272,47
$309,25
$348,21
$486,63
$739,48 		$480,91
$517,69
$556,65
$695,07 		$689,35
$726,13
$765,09
$903,51 		$897,79
$934,57
$973,53
$1 111,95 		$208,44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$544,94
$618,50
$696,42
$973,26
$1 478,96 		$753,38
$826,94
$904,86
$1 181,70 		$961,82
$1 035,38
$1 113,30
$1 390,14 		$1 170,26
$1 243,82
$1 321,74
$1 598,58 		$208,44
Toc - Plan #24 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 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 		$372,65
$422,96
$476,25
$665,56
$1 011,39 		$657,73
$708,04
$761,33
$950,64 		$942,81
$993,12
$1 046,41
$1 235,72 		$1 227,89
$1 278,20
$1 331,49
$1 520,80 		$285,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745,30
$845,92
$952,50
$1 331,12
$2 022,78 		$1 030,38
$1 131,00
$1 237,58
$1 616,20 		$1 315,46
$1 416,08
$1 522,66
$1 901,28 		$1 600,54
$1 701,16
$1 807,74
$2 186,36 		$285,08
Toc - Plan #25 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

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 		$284,87
$323,32
$364,06
$508,77
$773,13 		$502,79
$541,24
$581,98
$726,69 		$720,71
$759,16
$799,90
$944,61 		$938,63
$977,08
$1 017,82
$1 162,53 		$217,92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569,74
$646,64
$728,12
$1 017,54
$1 546,26 		$787,66
$864,56
$946,04
$1 235,46 		$1 005,58
$1 082,48
$1 163,96
$1 453,38 		$1 223,50
$1 300,40
$1 381,88
$1 671,30 		$217,92
Toc - Plan #26 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

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 		$277,12
$314,53
$354,16
$494,94
$752,11 		$489,12
$526,53
$566,16
$706,94 		$701,12
$738,53
$778,16
$918,94 		$913,12
$950,53
$990,16
$1 130,94 		$212,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554,24
$629,06
$708,32
$989,88
$1 504,22 		$766,24
$841,06
$920,32
$1 201,88 		$978,24
$1 053,06
$1 132,32
$1 413,88 		$1 190,24
$1 265,06
$1 344,32
$1 625,88 		$212,00
Toc - Plan #27 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

Annual Out of Pocket Expenses:

Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 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 		$421,11
$477,96
$538,18
$752,11
$1 142,90 		$743,26
$800,11
$860,33
$1 074,26 		$1 065,41
$1 122,26
$1 182,48
$1 396,41 		$1 387,56
$1 444,41
$1 504,63
$1 718,56 		$322,15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842,22
$955,92
$1 076,36
$1 504,22
$2 285,80 		$1 164,37
$1 278,07
$1 398,51
$1 826,37 		$1 486,52
$1 600,22
$1 720,66
$2 148,52 		$1 808,67
$1 922,37
$2 042,81
$2 470,67 		$322,15
Toc - Plan #28 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

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 		$380,49
$431,86
$486,27
$679,55
$1 032,65 		$671,56
$722,93
$777,34
$970,62 		$962,63
$1 014,00
$1 068,41
$1 261,69 		$1 253,70
$1 305,07
$1 359,48
$1 552,76 		$291,07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760,98
$863,72
$972,54
$1 359,10
$2 065,30 		$1 052,05
$1 154,79
$1 263,61
$1 650,17 		$1 343,12
$1 445,86
$1 554,68
$1 941,24 		$1 634,19
$1 736,93
$1 845,75
$2 232,31 		$291,07
Toc - Plan #29 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$275,76
$312,98
$352,42
$492,50
$748,40 		$486,71
$523,93
$563,37
$703,45 		$697,66
$734,88
$774,32
$914,40 		$908,61
$945,83
$985,27
$1 125,35 		$210,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551,52
$625,96
$704,84
$985,00
$1 496,80 		$762,47
$836,91
$915,79
$1 195,95 		$973,42
$1 047,86
$1 126,74
$1 406,90 		$1 184,37
$1 258,81
$1 337,69
$1 617,85 		$210,95
Toc - Plan #30 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$8,150 $16,300 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 		$376,71
$427,57
$481,44
$672,81
$1 022,40 		$664,90
$715,76
$769,63
$961,00 		$953,09
$1 003,95
$1 057,82
$1 249,19 		$1 241,28
$1 292,14
$1 346,01
$1 537,38 		$288,19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753,42
$855,14
$962,88
$1 345,62
$2 044,80 		$1 041,61
$1 143,33
$1 251,07
$1 633,81 		$1 329,80
$1 431,52
$1 539,26
$1 922,00 		$1 617,99
$1 719,71
$1 827,45
$2 210,19 		$288,19
Toc - Plan #31 Molina Healthcare
Bronze

(HMO) Core Care Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-659-8331

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$269,84
$306,27
$344,85
$481,93
$732,34 		$476,27
$512,70
$551,28
$688,36 		$682,70
$719,13
$757,71
$894,79 		$889,13
$925,56
$964,14
$1 101,22 		$206,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539,68
$612,54
$689,70
$963,86
$1 464,68 		$746,11
$818,97
$896,13
$1 170,29 		$952,54
$1 025,40
$1 102,56
$1 376,72 		$1 158,97
$1 231,83
$1 308,99
$1 583,15 		$206,43

ADVERTISEMENT

Ambetter from Absolute Total Care

Local: 1-833-270-5443 | Toll Free: 1-833-270-5443

Toc - Plan #32 Ambetter from Absolute Total Care
Bronze

(HMO) Ambetter Essential Care 1 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,300 $16,600 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 		$267,76
$303,90
$342,19
$478,20
$726,68 		$472,59
$508,73
$547,02
$683,03 		$677,42
$713,56
$751,85
$887,86 		$882,25
$918,39
$956,68
$1 092,69 		$204,83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$535,52
$607,80
$684,38
$956,40
$1 453,36 		$740,35
$812,63
$889,21
$1 161,23 		$945,18
$1 017,46
$1 094,04
$1 366,06 		$1 150,01
$1 222,29
$1 298,87
$1 570,89 		$204,83
Toc - Plan #33 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 11 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$365,14
$414,42
$466,64
$652,12
$990,97 		$644,47
$693,75
$745,97
$931,45 		$923,80
$973,08
$1 025,30
$1 210,78 		$1 203,13
$1 252,41
$1 304,63
$1 490,11 		$279,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730,28
$828,84
$933,28
$1 304,24
$1 981,94 		$1 009,61
$1 108,17
$1 212,61
$1 583,57 		$1 288,94
$1 387,50
$1 491,94
$1 862,90 		$1 568,27
$1 666,83
$1 771,27
$2 142,23 		$279,33
Toc - Plan #34 Ambetter from Absolute Total Care
Gold

(HMO) Ambetter Secure Care 5 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 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 		$426,81
$484,42
$545,45
$762,27
$1 158,34 		$753,31
$810,92
$871,95
$1 088,77 		$1 079,81
$1 137,42
$1 198,45
$1 415,27 		$1 406,31
$1 463,92
$1 524,95
$1 741,77 		$326,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853,62
$968,84
$1 090,90
$1 524,54
$2 316,68 		$1 180,12
$1 295,34
$1 417,40
$1 851,04 		$1 506,62
$1 621,84
$1 743,90
$2 177,54 		$1 833,12
$1 948,34
$2 070,40
$2 504,04 		$326,50
Toc - Plan #35 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 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 		$288,87
$327,85
$369,16
$515,90
$783,95 		$509,84
$548,82
$590,13
$736,87 		$730,81
$769,79
$811,10
$957,84 		$951,78
$990,76
$1 032,07
$1 178,81 		$220,97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577,74
$655,70
$738,32
$1 031,80
$1 567,90 		$798,71
$876,67
$959,29
$1 252,77 		$1 019,68
$1 097,64
$1 180,26
$1 473,74 		$1 240,65
$1 318,61
$1 401,23
$1 694,71 		$220,97
Toc - Plan #36 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 12 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 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 		$357,84
$406,14
$457,31
$639,08
$971,15 		$631,58
$679,88
$731,05
$912,82 		$905,32
$953,62
$1 004,79
$1 186,56 		$1 179,06
$1 227,36
$1 278,53
$1 460,30 		$273,74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715,68
$812,28
$914,62
$1 278,16
$1 942,30 		$989,42
$1 086,02
$1 188,36
$1 551,90 		$1 263,16
$1 359,76
$1 462,10
$1 825,64 		$1 536,90
$1 633,50
$1 735,84
$2 099,38 		$273,74
Toc - Plan #37 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Essential Care 5 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 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 		$290,98
$330,25
$371,86
$519,68
$789,70 		$513,57
$552,84
$594,45
$742,27 		$736,16
$775,43
$817,04
$964,86 		$958,75
$998,02
$1 039,63
$1 187,45 		$222,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581,96
$660,50
$743,72
$1 039,36
$1 579,40 		$804,55
$883,09
$966,31
$1 261,95 		$1 027,14
$1 105,68
$1 188,90
$1 484,54 		$1 249,73
$1 328,27
$1 411,49
$1 707,13 		$222,59
Toc - Plan #38 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Essential Care 10 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,400 $16,800 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 		$276,63
$313,97
$353,52
$494,05
$750,76 		$488,25
$525,59
$565,14
$705,67 		$699,87
$737,21
$776,76
$917,29 		$911,49
$948,83
$988,38
$1 128,91 		$211,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553,26
$627,94
$707,04
$988,10
$1 501,52 		$764,88
$839,56
$918,66
$1 199,72 		$976,50
$1 051,18
$1 130,28
$1 411,34 		$1 188,12
$1 262,80
$1 341,90
$1 622,96 		$211,62
Toc - Plan #39 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 29 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,400 $16,800 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 		$354,48
$402,32
$453,01
$633,08
$962,03 		$625,65
$673,49
$724,18
$904,25 		$896,82
$944,66
$995,35
$1 175,42 		$1 167,99
$1 215,83
$1 266,52
$1 446,59 		$271,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708,96
$804,64
$906,02
$1 266,16
$1 924,06 		$980,13
$1 075,81
$1 177,19
$1 537,33 		$1 251,30
$1 346,98
$1 448,36
$1 808,50 		$1 522,47
$1 618,15
$1 719,53
$2 079,67 		$271,17
Toc - Plan #40 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 25 HSA (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 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 		$371,39
$421,51
$474,62
$663,28
$1 007,91 		$655,49
$705,61
$758,72
$947,38 		$939,59
$989,71
$1 042,82
$1 231,48 		$1 223,69
$1 273,81
$1 326,92
$1 515,58 		$284,10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742,78
$843,02
$949,24
$1 326,56
$2 015,82 		$1 026,88
$1 127,12
$1 233,34
$1 610,66 		$1 310,98
$1 411,22
$1 517,44
$1 894,76 		$1 595,08
$1 695,32
$1 801,54
$2 178,86 		$284,10
Toc - Plan #41 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 27 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 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 		$392,20
$445,13
$501,22
$700,45
$1 064,40 		$692,22
$745,15
$801,24
$1 000,47 		$992,24
$1 045,17
$1 101,26
$1 300,49 		$1 292,26
$1 345,19
$1 401,28
$1 600,51 		$300,02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784,40
$890,26
$1 002,44
$1 400,90
$2 128,80 		$1 084,42
$1 190,28
$1 302,46
$1 700,92 		$1 384,44
$1 490,30
$1 602,48
$2 000,94 		$1 684,46
$1 790,32
$1 902,50
$2 300,96 		$300,02
Toc - Plan #42 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 28 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$396,07
$449,53
$506,16
$707,36
$1 074,90 		$699,05
$752,51
$809,14
$1 010,34 		$1 002,03
$1 055,49
$1 112,12
$1 313,32 		$1 305,01
$1 358,47
$1 415,10
$1 616,30 		$302,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792,14
$899,06
$1 012,32
$1 414,72
$2 149,80 		$1 095,12
$1 202,04
$1 315,30
$1 717,70 		$1 398,10
$1 505,02
$1 618,28
$2 020,68 		$1 701,08
$1 808,00
$1 921,26
$2 323,66 		$302,98
Toc - Plan #43 Ambetter from Absolute Total Care
Gold

(HMO) Ambetter Secure Care 5 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 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 		$445,16
$505,25
$568,90
$795,04
$1 208,14 		$785,70
$845,79
$909,44
$1 135,58 		$1 126,24
$1 186,33
$1 249,98
$1 476,12 		$1 466,78
$1 526,87
$1 590,52
$1 816,66 		$340,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890,32
$1 010,50
$1 137,80
$1 590,08
$2 416,28 		$1 230,86
$1 351,04
$1 478,34
$1 930,62 		$1 571,40
$1 691,58
$1 818,88
$2 271,16 		$1 911,94
$2 032,12
$2 159,42
$2 611,70 		$340,54
Toc - Plan #44 Ambetter from Absolute Total Care
Bronze

(HMO) Ambetter Essential Care 1 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,300 $16,600 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 		$279,27
$316,96
$356,90
$498,76
$757,92 		$492,91
$530,60
$570,54
$712,40 		$706,55
$744,24
$784,18
$926,04 		$920,19
$957,88
$997,82
$1 139,68 		$213,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558,54
$633,92
$713,80
$997,52
$1 515,84 		$772,18
$847,56
$927,44
$1 211,16 		$985,82
$1 061,20
$1 141,08
$1 424,80 		$1 199,46
$1 274,84
$1 354,72
$1 638,44 		$213,64
Toc - Plan #45 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 11 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$380,84
$432,24
$486,70
$680,16
$1 033,57 		$672,17
$723,57
$778,03
$971,49 		$963,50
$1 014,90
$1 069,36
$1 262,82 		$1 254,83
$1 306,23
$1 360,69
$1 554,15 		$291,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761,68
$864,48
$973,40
$1 360,32
$2 067,14 		$1 053,01
$1 155,81
$1 264,73
$1 651,65 		$1 344,34
$1 447,14
$1 556,06
$1 942,98 		$1 635,67
$1 738,47
$1 847,39
$2 234,31 		$291,33
Toc - Plan #46 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 12 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 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 		$373,22
$423,60
$476,97
$666,56
$1 012,90 		$658,73
$709,11
$762,48
$952,07 		$944,24
$994,62
$1 047,99
$1 237,58 		$1 229,75
$1 280,13
$1 333,50
$1 523,09 		$285,51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746,44
$847,20
$953,94
$1 333,12
$2 025,80 		$1 031,95
$1 132,71
$1 239,45
$1 618,63 		$1 317,46
$1 418,22
$1 524,96
$1 904,14 		$1 602,97
$1 703,73
$1 810,47
$2 189,65 		$285,51
Toc - Plan #47 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 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 		$301,28
$341,95
$385,03
$538,07
$817,66 		$531,75
$572,42
$615,50
$768,54 		$762,22
$802,89
$845,97
$999,01 		$992,69
$1 033,36
$1 076,44
$1 229,48 		$230,47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602,56
$683,90
$770,06
$1 076,14
$1 635,32 		$833,03
$914,37
$1 000,53
$1 306,61 		$1 063,50
$1 144,84
$1 231,00
$1 537,08 		$1 293,97
$1 375,31
$1 461,47
$1 767,55 		$230,47
Toc - Plan #48 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Essential Care 5 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 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 		$303,49
$344,45
$387,85
$542,02
$823,65 		$535,65
$576,61
$620,01
$774,18 		$767,81
$808,77
$852,17
$1 006,34 		$999,97
$1 040,93
$1 084,33
$1 238,50 		$232,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606,98
$688,90
$775,70
$1 084,04
$1 647,30 		$839,14
$921,06
$1 007,86
$1 316,20 		$1 071,30
$1 153,22
$1 240,02
$1 548,36 		$1 303,46
$1 385,38
$1 472,18
$1 780,52 		$232,16
Toc - Plan #49 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Essential Care 10 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,400 $16,800 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 		$288,53
$327,47
$368,72
$515,29
$783,03 		$509,24
$548,18
$589,43
$736,00 		$729,95
$768,89
$810,14
$956,71 		$950,66
$989,60
$1 030,85
$1 177,42 		$220,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577,06
$654,94
$737,44
$1 030,58
$1 566,06 		$797,77
$875,65
$958,15
$1 251,29 		$1 018,48
$1 096,36
$1 178,86
$1 472,00 		$1 239,19
$1 317,07
$1 399,57
$1 692,71 		$220,71
Toc - Plan #50 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 25 HSA (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 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 		$387,35
$439,63
$495,02
$691,79
$1 051,24 		$683,67
$735,95
$791,34
$988,11 		$979,99
$1 032,27
$1 087,66
$1 284,43 		$1 276,31
$1 328,59
$1 383,98
$1 580,75 		$296,32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774,70
$879,26
$990,04
$1 383,58
$2 102,48 		$1 071,02
$1 175,58
$1 286,36
$1 679,90 		$1 367,34
$1 471,90
$1 582,68
$1 976,22 		$1 663,66
$1 768,22
$1 879,00
$2 272,54 		$296,32
Toc - Plan #51 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 27 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 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 		$409,06
$464,27
$522,76
$730,56
$1 110,16 		$721,98
$777,19
$835,68
$1 043,48 		$1 034,90
$1 090,11
$1 148,60
$1 356,40 		$1 347,82
$1 403,03
$1 461,52
$1 669,32 		$312,92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818,12
$928,54
$1 045,52
$1 461,12
$2 220,32 		$1 131,04
$1 241,46
$1 358,44
$1 774,04 		$1 443,96
$1 554,38
$1 671,36
$2 086,96 		$1 756,88
$1 867,30
$1 984,28
$2 399,88 		$312,92
Toc - Plan #52 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 28 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$413,10
$468,85
$527,92
$737,77
$1 121,11 		$729,11
$784,86
$843,93
$1 053,78 		$1 045,12
$1 100,87
$1 159,94
$1 369,79 		$1 361,13
$1 416,88
$1 475,95
$1 685,80 		$316,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826,20
$937,70
$1 055,84
$1 475,54
$2 242,22 		$1 142,21
$1 253,71
$1 371,85
$1 791,55 		$1 458,22
$1 569,72
$1 687,86
$2 107,56 		$1 774,23
$1 885,73
$2 003,87
$2 423,57 		$316,01

‡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 Clarendon County here.

Clarendon County is in “Rating Area 14” of South Carolina.

Currently, there are 52 plans offered in Rating Area 14.

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2021 Obamacare Plans for Clarendon County, SC

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