Obamacare 2021 Rates for Utah County

Obamacare > Rates > Utah > Utah 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 Utah County, UT.

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, 69 Plans and 2021 Rates for Utah County, Utah

Below, you’ll find a summary of the 69 plans for Utah County, Utah 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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Molina Healthcare

Local: 1-801-858-0400 | Toll Free: 1-888-858-3973

Toc - Plan #1 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$308,52
$428,84
$456,30
$656,22
$925,56 		$553,18
$673,50
$700,96
$900,88 		$797,84
$918,16
$945,62
$1 145,54 		$1 042,50
$1 162,82
$1 190,28
$1 390,20 		$244,66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617,04
$857,68
$912,60
$1 312,44
$1 851,12 		$861,70
$1 102,34
$1 157,26
$1 557,10 		$1 106,36
$1 347,00
$1 401,92
$1 801,76 		$1 351,02
$1 591,66
$1 646,58
$2 046,42 		$244,66
Toc - Plan #2 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$318,09
$442,14
$470,45
$676,57
$954,26 		$570,33
$694,38
$722,69
$928,81 		$822,57
$946,62
$974,93
$1 181,05 		$1 074,81
$1 198,86
$1 227,17
$1 433,29 		$252,24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636,18
$884,28
$940,90
$1 353,14
$1 908,52 		$888,42
$1 136,52
$1 193,14
$1 605,38 		$1 140,66
$1 388,76
$1 445,38
$1 857,62 		$1 392,90
$1 641,00
$1 697,62
$2 109,86 		$252,24
Toc - Plan #3 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$218,54
$303,77
$323,22
$464,84
$655,62 		$391,84
$477,07
$496,52
$638,14 		$565,14
$650,37
$669,82
$811,44 		$738,44
$823,67
$843,12
$984,74 		$173,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$437,08
$607,54
$646,44
$929,68
$1 311,24 		$610,38
$780,84
$819,74
$1 102,98 		$783,68
$954,14
$993,04
$1 276,28 		$956,98
$1 127,44
$1 166,34
$1 449,58 		$173,30
Toc - Plan #4 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$305,81
$425,08
$452,30
$650,47
$917,43 		$548,32
$667,59
$694,81
$892,98 		$790,83
$910,10
$937,32
$1 135,49 		$1 033,34
$1 152,61
$1 179,83
$1 378,00 		$242,51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611,62
$850,16
$904,60
$1 300,94
$1 834,86 		$854,13
$1 092,67
$1 147,11
$1 543,45 		$1 096,64
$1 335,18
$1 389,62
$1 785,96 		$1 339,15
$1 577,69
$1 632,13
$2 028,47 		$242,51
Toc - Plan #5 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$228,62
$317,79
$338,13
$486,28
$685,86 		$409,92
$499,09
$519,43
$667,58 		$591,22
$680,39
$700,73
$848,88 		$772,52
$861,69
$882,03
$1 030,18 		$181,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$457,24
$635,58
$676,26
$972,56
$1 371,72 		$638,54
$816,88
$857,56
$1 153,86 		$819,84
$998,18
$1 038,86
$1 335,16 		$1 001,14
$1 179,48
$1 220,16
$1 516,46 		$181,30
Toc - Plan #6 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$222,46
$309,22
$329,02
$473,17
$667,38 		$398,87
$485,63
$505,43
$649,58 		$575,28
$662,04
$681,84
$825,99 		$751,69
$838,45
$858,25
$1 002,40 		$176,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$444,92
$618,44
$658,04
$946,34
$1 334,76 		$621,33
$794,85
$834,45
$1 122,75 		$797,74
$971,26
$1 010,86
$1 299,16 		$974,15
$1 147,67
$1 187,27
$1 475,57 		$176,41
Toc - Plan #7 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$312,20
$433,96
$461,75
$664,05
$936,60 		$559,78
$681,54
$709,33
$911,63 		$807,36
$929,12
$956,91
$1 159,21 		$1 054,94
$1 176,70
$1 204,49
$1 406,79 		$247,58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624,40
$867,92
$923,50
$1 328,10
$1 873,20 		$871,98
$1 115,50
$1 171,08
$1 575,68 		$1 119,56
$1 363,08
$1 418,66
$1 823,26 		$1 367,14
$1 610,66
$1 666,24
$2 070,84 		$247,58
Toc - Plan #8 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$321,77
$447,26
$475,90
$684,40
$965,31 		$576,93
$702,42
$731,06
$939,56 		$832,09
$957,58
$986,22
$1 194,72 		$1 087,25
$1 212,74
$1 241,38
$1 449,88 		$255,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643,54
$894,52
$951,80
$1 368,80
$1 930,62 		$898,70
$1 149,68
$1 206,96
$1 623,96 		$1 153,86
$1 404,84
$1 462,12
$1 879,12 		$1 409,02
$1 660,00
$1 717,28
$2 134,28 		$255,16
Toc - Plan #9 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$222,22
$308,89
$328,67
$472,67
$666,66 		$398,44
$485,11
$504,89
$648,89 		$574,66
$661,33
$681,11
$825,11 		$750,88
$837,55
$857,33
$1 001,33 		$176,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$444,44
$617,78
$657,34
$945,34
$1 333,32 		$620,66
$794,00
$833,56
$1 121,56 		$796,88
$970,22
$1 009,78
$1 297,78 		$973,10
$1 146,44
$1 186,00
$1 474,00 		$176,22
Toc - Plan #10 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$314,81
$437,58
$465,60
$669,59
$944,42 		$564,45
$687,22
$715,24
$919,23 		$814,09
$936,86
$964,88
$1 168,87 		$1 063,73
$1 186,50
$1 214,52
$1 418,51 		$249,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629,62
$875,16
$931,20
$1 339,18
$1 888,84 		$879,26
$1 124,80
$1 180,84
$1 588,82 		$1 128,90
$1 374,44
$1 430,48
$1 838,46 		$1 378,54
$1 624,08
$1 680,12
$2 088,10 		$249,64
Toc - Plan #11 Molina Healthcare
Bronze

(HMO) Core Care Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$216,67
$301,17
$320,45
$460,85
$650,00 		$388,49
$472,99
$492,27
$632,67 		$560,31
$644,81
$664,09
$804,49 		$732,13
$816,63
$835,91
$976,31 		$171,82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$433,34
$602,34
$640,90
$921,70
$1 300,00 		$605,16
$774,16
$812,72
$1 093,52 		$776,98
$945,98
$984,54
$1 265,34 		$948,80
$1 117,80
$1 156,36
$1 437,16 		$171,82

ADVERTISEMENT

Regence BlueCross BlueShield of Utah

Local: 1-888-231-8424 | Toll Free: 1-888-231-8424

Toc - Plan #12 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 3500 EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$323,02
$449,00
$477,75
$687,07
$969,06 		$579,18
$705,16
$733,91
$943,23 		$835,34
$961,32
$990,07
$1 199,39 		$1 091,50
$1 217,48
$1 246,23
$1 455,55 		$256,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646,04
$898,00
$955,50
$1 374,14
$1 938,12 		$902,20
$1 154,16
$1 211,66
$1 630,30 		$1 158,36
$1 410,32
$1 467,82
$1 886,46 		$1 414,52
$1 666,48
$1 723,98
$2 142,62 		$256,16
Toc - Plan #13 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze HDHP 5700 EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 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 		$236,82
$329,18
$350,26
$503,72
$710,46 		$424,62
$516,98
$538,06
$691,52 		$612,42
$704,78
$725,86
$879,32 		$800,22
$892,58
$913,66
$1 067,12 		$187,80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$473,64
$658,36
$700,52
$1 007,44
$1 420,92 		$661,44
$846,16
$888,32
$1 195,24 		$849,24
$1 033,96
$1 076,12
$1 383,04 		$1 037,04
$1 221,76
$1 263,92
$1 570,84 		$187,80
Toc - Plan #14 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze Essential 7500 EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$235,82
$327,78
$348,77
$501,58
$707,45 		$422,82
$514,78
$535,77
$688,58 		$609,82
$701,78
$722,77
$875,58 		$796,82
$888,78
$909,77
$1 062,58 		$187,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$471,64
$655,56
$697,54
$1 003,16
$1 414,90 		$658,64
$842,56
$884,54
$1 190,16 		$845,64
$1 029,56
$1 071,54
$1 377,16 		$1 032,64
$1 216,56
$1 258,54
$1 564,16 		$187,00
Toc - Plan #15 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze Care on Demand 8000 EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$225,00
$312,76
$332,78
$478,58
$675,00 		$403,43
$491,19
$511,21
$657,01 		$581,86
$669,62
$689,64
$835,44 		$760,29
$848,05
$868,07
$1 013,87 		$178,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$450,00
$625,52
$665,56
$957,16
$1 350,00 		$628,43
$803,95
$843,99
$1 135,59 		$806,86
$982,38
$1 022,42
$1 314,02 		$985,29
$1 160,81
$1 200,85
$1 492,45 		$178,43
Toc - Plan #16 Regence BlueCross BlueShield of Utah
Gold

(EPO) Gold 1200 EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$385,03
$535,19
$569,46
$818,96
$1 155,09 		$690,36
$840,52
$874,79
$1 124,29 		$995,69
$1 145,85
$1 180,12
$1 429,62 		$1 301,02
$1 451,18
$1 485,45
$1 734,95 		$305,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770,06
$1 070,38
$1 138,92
$1 637,92
$2 310,18 		$1 075,39
$1 375,71
$1 444,25
$1 943,25 		$1 380,72
$1 681,04
$1 749,58
$2 248,58 		$1 686,05
$1 986,37
$2 054,91
$2 553,91 		$305,33
Toc - Plan #17 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver Care on Demand 4000 EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$315,63
$438,73
$466,82
$671,35
$946,89 		$565,93
$689,03
$717,12
$921,65 		$816,23
$939,33
$967,42
$1 171,95 		$1 066,53
$1 189,63
$1 217,72
$1 422,25 		$250,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631,26
$877,46
$933,64
$1 342,70
$1 893,78 		$881,56
$1 127,76
$1 183,94
$1 593,00 		$1 131,86
$1 378,06
$1 434,24
$1 843,30 		$1 382,16
$1 628,36
$1 684,54
$2 093,60 		$250,30
Toc - Plan #18 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 5000 EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$308,28
$428,51
$455,95
$655,71
$924,84 		$552,75
$672,98
$700,42
$900,18 		$797,22
$917,45
$944,89
$1 144,65 		$1 041,69
$1 161,92
$1 189,36
$1 389,12 		$244,47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616,56
$857,02
$911,90
$1 311,42
$1 849,68 		$861,03
$1 101,49
$1 156,37
$1 555,89 		$1 105,50
$1 345,96
$1 400,84
$1 800,36 		$1 349,97
$1 590,43
$1 645,31
$2 044,83 		$244,47

ADVERTISEMENT

BridgeSpan Health Company

Local: 1-855-857-9945 | Toll Free: 1-855-857-9945 | TTY: 1-800-735-2900
Toc - Plan #19 BridgeSpan Health Company
Silver

(HMO) BridgeSpan Silver Essential 4000 HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9945

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 		$341,97
$475,34
$505,77
$727,37
$1 025,91 		$613,15
$746,52
$776,95
$998,55 		$884,33
$1 017,70
$1 048,13
$1 269,73 		$1 155,51
$1 288,88
$1 319,31
$1 540,91 		$271,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683,94
$950,68
$1 011,54
$1 454,74
$2 051,82 		$955,12
$1 221,86
$1 282,72
$1 725,92 		$1 226,30
$1 493,04
$1 553,90
$1 997,10 		$1 497,48
$1 764,22
$1 825,08
$2 268,28 		$271,18
Toc - Plan #20 BridgeSpan Health Company
Gold

(HMO) Gold Essential 1200 HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9945

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$384,83
$534,91
$569,16
$818,53
$1 154,48 		$690,00
$840,08
$874,33
$1 123,70 		$995,17
$1 145,25
$1 179,50
$1 428,87 		$1 300,34
$1 450,42
$1 484,67
$1 734,04 		$305,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769,66
$1 069,82
$1 138,32
$1 637,06
$2 308,96 		$1 074,83
$1 374,99
$1 443,49
$1 942,23 		$1 380,00
$1 680,16
$1 748,66
$2 247,40 		$1 685,17
$1 985,33
$2 053,83
$2 552,57 		$305,17
Toc - Plan #21 BridgeSpan Health Company
Expanded Bronze

(HMO) Bronze Care on Demand 8000 HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9945

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 		$229,90
$319,56
$340,02
$488,99
$689,70 		$412,21
$501,87
$522,33
$671,30 		$594,52
$684,18
$704,64
$853,61 		$776,83
$866,49
$886,95
$1 035,92 		$182,31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$459,80
$639,12
$680,04
$977,98
$1 379,40 		$642,11
$821,43
$862,35
$1 160,29 		$824,42
$1 003,74
$1 044,66
$1 342,60 		$1 006,73
$1 186,05
$1 226,97
$1 524,91 		$182,31

ADVERTISEMENT

University of Utah Health Plans

Local: 1-801-587-6480x1 | Toll Free: 1-888-271-5870 | TTY: 1-800-346-4128
Toc - Plan #22 University of Utah Health Plans
Gold

(EPO) Healthy Premier Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$537,90
$747,68
$795,55
$1 144,11
$1 613,70 		$964,45
$1 174,23
$1 222,10
$1 570,66 		$1 391,00
$1 600,78
$1 648,65
$1 997,21 		$1 817,55
$2 027,33
$2 075,20
$2 423,76 		$426,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 075,80
$1 495,36
$1 591,10
$2 288,22
$3 227,40 		$1 502,35
$1 921,91
$2 017,65
$2 714,77 		$1 928,90
$2 348,46
$2 444,20
$3 141,32 		$2 355,45
$2 775,01
$2 870,75
$3 567,87 		$426,55
Toc - Plan #23 University of Utah Health Plans
Silver

(EPO) Healthy Premier Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$412,91
$573,95
$610,70
$878,27
$1 238,73 		$740,35
$901,39
$938,14
$1 205,71 		$1 067,79
$1 228,83
$1 265,58
$1 533,15 		$1 395,23
$1 556,27
$1 593,02
$1 860,59 		$327,44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825,82
$1 147,90
$1 221,40
$1 756,54
$2 477,46 		$1 153,26
$1 475,34
$1 548,84
$2 083,98 		$1 480,70
$1 802,78
$1 876,28
$2 411,42 		$1 808,14
$2 130,22
$2 203,72
$2 738,86 		$327,44
Toc - Plan #24 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

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 		$255,65
$355,35
$378,11
$543,77
$766,95 		$458,38
$558,08
$580,84
$746,50 		$661,11
$760,81
$783,57
$949,23 		$863,84
$963,54
$986,30
$1 151,96 		$202,73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$511,30
$710,70
$756,22
$1 087,54
$1 533,90 		$714,03
$913,43
$958,95
$1 290,27 		$916,76
$1 116,16
$1 161,68
$1 493,00 		$1 119,49
$1 318,89
$1 364,41
$1 695,73 		$202,73
Toc - Plan #25 University of Utah Health Plans
Gold

(EPO) Healthy Preferred Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$476,02
$661,66
$704,03
$1 012,49
$1 428,05 		$853,50
$1 039,14
$1 081,51
$1 389,97 		$1 230,98
$1 416,62
$1 458,99
$1 767,45 		$1 608,46
$1 794,10
$1 836,47
$2 144,93 		$377,48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952,04
$1 323,32
$1 408,06
$2 024,98
$2 856,10 		$1 329,52
$1 700,80
$1 785,54
$2 402,46 		$1 707,00
$2 078,28
$2 163,02
$2 779,94 		$2 084,48
$2 455,76
$2 540,50
$3 157,42 		$377,48
Toc - Plan #26 University of Utah Health Plans
Silver

(EPO) Healthy Preferred Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$365,41
$507,92
$540,44
$777,23
$1 096,23 		$655,18
$797,69
$830,21
$1 067,00 		$944,95
$1 087,46
$1 119,98
$1 356,77 		$1 234,72
$1 377,23
$1 409,75
$1 646,54 		$289,77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730,82
$1 015,84
$1 080,88
$1 554,46
$2 192,46 		$1 020,59
$1 305,61
$1 370,65
$1 844,23 		$1 310,36
$1 595,38
$1 660,42
$2 134,00 		$1 600,13
$1 885,15
$1 950,19
$2 423,77 		$289,77
Toc - Plan #27 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Preferred Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

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 		$226,24
$314,47
$334,61
$481,21
$678,71 		$405,65
$493,88
$514,02
$660,62 		$585,06
$673,29
$693,43
$840,03 		$764,47
$852,70
$872,84
$1 019,44 		$179,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452,48
$628,94
$669,22
$962,42
$1 357,42 		$631,89
$808,35
$848,63
$1 141,83 		$811,30
$987,76
$1 028,04
$1 321,24 		$990,71
$1 167,17
$1 207,45
$1 500,65 		$179,41
Toc - Plan #28 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$307,30
$427,15
$454,50
$653,63
$921,90 		$550,99
$670,84
$698,19
$897,32 		$794,68
$914,53
$941,88
$1 141,01 		$1 038,37
$1 158,22
$1 185,57
$1 384,70 		$243,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614,60
$854,30
$909,00
$1 307,26
$1 843,80 		$858,29
$1 097,99
$1 152,69
$1 550,95 		$1 101,98
$1 341,68
$1 396,38
$1 794,64 		$1 345,67
$1 585,37
$1 640,07
$2 038,33 		$243,69
Toc - Plan #29 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Preferred Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$271,95
$378,01
$402,21
$578,43
$815,84 		$487,60
$593,66
$617,86
$794,08 		$703,25
$809,31
$833,51
$1 009,73 		$918,90
$1 024,96
$1 049,16
$1 225,38 		$215,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543,90
$756,02
$804,42
$1 156,86
$1 631,68 		$759,55
$971,67
$1 020,07
$1 372,51 		$975,20
$1 187,32
$1 235,72
$1 588,16 		$1 190,85
$1 402,97
$1 451,37
$1 803,81 		$215,65
Toc - Plan #30 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Expanded Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

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 		$307,30
$427,15
$454,50
$653,63
$921,90 		$550,99
$670,84
$698,19
$897,32 		$794,68
$914,53
$941,88
$1 141,01 		$1 038,37
$1 158,22
$1 185,57
$1 384,70 		$243,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614,60
$854,30
$909,00
$1 307,26
$1 843,80 		$858,29
$1 097,99
$1 152,69
$1 550,95 		$1 101,98
$1 341,68
$1 396,38
$1 794,64 		$1 345,67
$1 585,37
$1 640,07
$2 038,33 		$243,69
Toc - Plan #31 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Preferred Expanded Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

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 		$271,95
$378,01
$402,21
$578,43
$815,84 		$487,60
$593,66
$617,86
$794,08 		$703,25
$809,31
$833,51
$1 009,73 		$918,90
$1 024,96
$1 049,16
$1 225,38 		$215,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543,90
$756,02
$804,42
$1 156,86
$1 631,68 		$759,55
$971,67
$1 020,07
$1 372,51 		$975,20
$1 187,32
$1 235,72
$1 588,16 		$1 190,85
$1 402,97
$1 451,37
$1 803,81 		$215,65
Toc - Plan #32 University of Utah Health Plans
Silver

(EPO) Healthy Premier Silver 2300

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$413,48
$574,74
$611,54
$879,47
$1 240,44 		$741,37
$902,63
$939,43
$1 207,36 		$1 069,26
$1 230,52
$1 267,32
$1 535,25 		$1 397,15
$1 558,41
$1 595,21
$1 863,14 		$327,89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826,96
$1 149,48
$1 223,08
$1 758,94
$2 480,88 		$1 154,85
$1 477,37
$1 550,97
$2 086,83 		$1 482,74
$1 805,26
$1 878,86
$2 414,72 		$1 810,63
$2 133,15
$2 206,75
$2 742,61 		$327,89
Toc - Plan #33 University of Utah Health Plans
Silver

(EPO) Healthy Preferred Silver 2300

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$365,91
$508,62
$541,18
$778,30
$1 097,73 		$656,08
$798,79
$831,35
$1 068,47 		$946,25
$1 088,96
$1 121,52
$1 358,64 		$1 236,42
$1 379,13
$1 411,69
$1 648,81 		$290,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731,82
$1 017,24
$1 082,36
$1 556,60
$2 195,46 		$1 021,99
$1 307,41
$1 372,53
$1 846,77 		$1 312,16
$1 597,58
$1 662,70
$2 136,94 		$1 602,33
$1 887,75
$1 952,87
$2 427,11 		$290,17
Toc - Plan #34 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Bronze w.3 Copays Before Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$257,35
$357,72
$380,62
$547,39
$772,05 		$461,43
$561,80
$584,70
$751,47 		$665,51
$765,88
$788,78
$955,55 		$869,59
$969,96
$992,86
$1 159,63 		$204,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514,70
$715,44
$761,24
$1 094,78
$1 544,10 		$718,78
$919,52
$965,32
$1 298,86 		$922,86
$1 123,60
$1 169,40
$1 502,94 		$1 126,94
$1 327,68
$1 373,48
$1 707,02 		$204,08
Toc - Plan #35 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Preferred Bronze w.3 Copays Before Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$227,75
$316,57
$336,84
$484,41
$683,24 		$408,35
$497,17
$517,44
$665,01 		$588,95
$677,77
$698,04
$845,61 		$769,55
$858,37
$878,64
$1 026,21 		$180,60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$455,50
$633,14
$673,68
$968,82
$1 366,48 		$636,10
$813,74
$854,28
$1 149,42 		$816,70
$994,34
$1 034,88
$1 330,02 		$997,30
$1 174,94
$1 215,48
$1 510,62 		$180,60

ADVERTISEMENT

SelectHealth

Local: 1-801-442-5038 | Toll Free: 1-800-538-5038

Toc - Plan #36 SelectHealth
Silver

(HMO) Med Silver 2500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$364,27
$506,33
$538,75
$774,80
$1 092,81 		$653,14
$795,20
$827,62
$1 063,67 		$942,01
$1 084,07
$1 116,49
$1 352,54 		$1 230,88
$1 372,94
$1 405,36
$1 641,41 		$288,87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728,54
$1 012,66
$1 077,50
$1 549,60
$2 185,62 		$1 017,41
$1 301,53
$1 366,37
$1 838,47 		$1 306,28
$1 590,40
$1 655,24
$2 127,34 		$1 595,15
$1 879,27
$1 944,11
$2 416,21 		$288,87
Toc - Plan #37 SelectHealth
Gold

(HMO) Med Gold 1500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$449,20
$624,39
$664,37
$955,46
$1 347,60 		$805,42
$980,61
$1 020,59
$1 311,68 		$1 161,64
$1 336,83
$1 376,81
$1 667,90 		$1 517,86
$1 693,05
$1 733,03
$2 024,12 		$356,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898,40
$1 248,78
$1 328,74
$1 910,92
$2 695,20 		$1 254,62
$1 605,00
$1 684,96
$2 267,14 		$1 610,84
$1 961,22
$2 041,18
$2 623,36 		$1 967,06
$2 317,44
$2 397,40
$2 979,58 		$356,22
Toc - Plan #38 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 7800 - no deductible for one urgent care and all PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$228,92
$318,19
$338,57
$486,91
$686,75 		$410,45
$499,72
$520,10
$668,44 		$591,98
$681,25
$701,63
$849,97 		$773,51
$862,78
$883,16
$1 031,50 		$181,53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$457,84
$636,38
$677,14
$973,82
$1 373,50 		$639,37
$817,91
$858,67
$1 155,35 		$820,90
$999,44
$1 040,20
$1 336,88 		$1 002,43
$1 180,97
$1 221,73
$1 518,41 		$181,53
Toc - Plan #39 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 6900 HSA Qualified

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$230,73
$320,72
$341,26
$490,77
$692,19 		$413,70
$503,69
$524,23
$673,74 		$596,67
$686,66
$707,20
$856,71 		$779,64
$869,63
$890,17
$1 039,68 		$182,97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$461,46
$641,44
$682,52
$981,54
$1 384,38 		$644,43
$824,41
$865,49
$1 164,51 		$827,40
$1 007,38
$1 048,46
$1 347,48 		$1 010,37
$1 190,35
$1 231,43
$1 530,45 		$182,97
Toc - Plan #40 SelectHealth
Catastrophic

(HMO) Med Catastrophic 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$191,22
$265,79
$282,81
$406,72
$573,66 		$342,86
$417,43
$434,45
$558,36 		$494,50
$569,07
$586,09
$710,00 		$646,14
$720,71
$737,73
$861,64 		$151,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$382,44
$531,58
$565,62
$813,44
$1 147,32 		$534,08
$683,22
$717,26
$965,08 		$685,72
$834,86
$868,90
$1 116,72 		$837,36
$986,50
$1 020,54
$1 268,36 		$151,64
Toc - Plan #41 SelectHealth
Gold

(HMO) Value Gold 1500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$397,56
$552,60
$587,99
$845,60
$1 192,67 		$712,82
$867,86
$903,25
$1 160,86 		$1 028,08
$1 183,12
$1 218,51
$1 476,12 		$1 343,34
$1 498,38
$1 533,77
$1 791,38 		$315,26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795,12
$1 105,20
$1 175,98
$1 691,20
$2 385,34 		$1 110,38
$1 420,46
$1 491,24
$2 006,46 		$1 425,64
$1 735,72
$1 806,50
$2 321,72 		$1 740,90
$2 050,98
$2 121,76
$2 636,98 		$315,26
Toc - Plan #42 SelectHealth
Silver

(HMO) Value Silver 2500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$322,39
$448,12
$476,81
$685,72
$967,16 		$578,04
$703,77
$732,46
$941,37 		$833,69
$959,42
$988,11
$1 197,02 		$1 089,34
$1 215,07
$1 243,76
$1 452,67 		$255,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644,78
$896,24
$953,62
$1 371,44
$1 934,32 		$900,43
$1 151,89
$1 209,27
$1 627,09 		$1 156,08
$1 407,54
$1 464,92
$1 882,74 		$1 411,73
$1 663,19
$1 720,57
$2 138,39 		$255,65
Toc - Plan #43 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 7800 - no deductible for one urgent care and all PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$202,60
$281,61
$299,64
$430,92
$607,79 		$363,26
$442,27
$460,30
$591,58 		$523,92
$602,93
$620,96
$752,24 		$684,58
$763,59
$781,62
$912,90 		$160,66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$405,20
$563,22
$599,28
$861,84
$1 215,58 		$565,86
$723,88
$759,94
$1 022,50 		$726,52
$884,54
$920,60
$1 183,16 		$887,18
$1 045,20
$1 081,26
$1 343,82 		$160,66
Toc - Plan #44 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 6900 HSA Qualified

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$204,21
$283,85
$302,02
$434,34
$612,62 		$366,14
$445,78
$463,95
$596,27 		$528,07
$607,71
$625,88
$758,20 		$690,00
$769,64
$787,81
$920,13 		$161,93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$408,42
$567,70
$604,04
$868,68
$1 225,24 		$570,35
$729,63
$765,97
$1 030,61 		$732,28
$891,56
$927,90
$1 192,54 		$894,21
$1 053,49
$1 089,83
$1 354,47 		$161,93
Toc - Plan #45 SelectHealth
Catastrophic

(HMO) Value Catastrophic 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$169,23
$235,23
$250,30
$359,96
$507,69 		$303,43
$369,43
$384,50
$494,16 		$437,63
$503,63
$518,70
$628,36 		$571,83
$637,83
$652,90
$762,56 		$134,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$338,46
$470,46
$500,60
$719,92
$1 015,38 		$472,66
$604,66
$634,80
$854,12 		$606,86
$738,86
$769,00
$988,32 		$741,06
$873,06
$903,20
$1 122,52 		$134,20
Toc - Plan #46 SelectHealth
Silver

(HMO) Value Silver 3000 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$347,31
$482,76
$513,67
$738,73
$1 041,93 		$622,73
$758,18
$789,09
$1 014,15 		$898,15
$1 033,60
$1 064,51
$1 289,57 		$1 173,57
$1 309,02
$1 339,93
$1 564,99 		$275,42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694,62
$965,52
$1 027,34
$1 477,46
$2 083,86 		$970,04
$1 240,94
$1 302,76
$1 752,88 		$1 245,46
$1 516,36
$1 578,18
$2 028,30 		$1 520,88
$1 791,78
$1 853,60
$2 303,72 		$275,42
Toc - Plan #47 SelectHealth
Silver

(HMO) Med Silver 3000 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$392,43
$545,48
$580,40
$834,70
$1 177,29 		$703,63
$856,68
$891,60
$1 145,90 		$1 014,83
$1 167,88
$1 202,80
$1 457,10 		$1 326,03
$1 479,08
$1 514,00
$1 768,30 		$311,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784,86
$1 090,96
$1 160,80
$1 669,40
$2 354,58 		$1 096,06
$1 402,16
$1 472,00
$1 980,60 		$1 407,26
$1 713,36
$1 783,20
$2 291,80 		$1 718,46
$2 024,56
$2 094,40
$2 603,00 		$311,20
Toc - Plan #48 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 5900 HSA Qualified

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$256,86
$357,04
$379,90
$546,35
$770,58 		$460,55
$560,73
$583,59
$750,04 		$664,24
$764,42
$787,28
$953,73 		$867,93
$968,11
$990,97
$1 157,42 		$203,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$513,72
$714,08
$759,80
$1 092,70
$1 541,16 		$717,41
$917,77
$963,49
$1 296,39 		$921,10
$1 121,46
$1 167,18
$1 500,08 		$1 124,79
$1 325,15
$1 370,87
$1 703,77 		$203,69
Toc - Plan #49 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 5900 HSA Qualified

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$290,23
$403,43
$429,26
$617,33
$870,69 		$520,39
$633,59
$659,42
$847,49 		$750,55
$863,75
$889,58
$1 077,65 		$980,71
$1 093,91
$1 119,74
$1 307,81 		$230,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580,46
$806,86
$858,52
$1 234,66
$1 741,38 		$810,62
$1 037,02
$1 088,68
$1 464,82 		$1 040,78
$1 267,18
$1 318,84
$1 694,98 		$1 270,94
$1 497,34
$1 549,00
$1 925,14 		$230,16
Toc - Plan #50 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 5300 Copay Plan - no deductible for one urgent care and all PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 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 		$250,43
$348,10
$370,39
$532,67
$751,29 		$449,02
$546,69
$568,98
$731,26 		$647,61
$745,28
$767,57
$929,85 		$846,20
$943,87
$966,16
$1 128,44 		$198,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$500,86
$696,20
$740,78
$1 065,34
$1 502,58 		$699,45
$894,79
$939,37
$1 263,93 		$898,04
$1 093,38
$1 137,96
$1 462,52 		$1 096,63
$1 291,97
$1 336,55
$1 661,11 		$198,59
Toc - Plan #51 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 5300 Copay Plan - no deductible for one urgent care and all PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 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 		$282,97
$393,32
$418,51
$601,87
$848,90 		$507,36
$617,71
$642,90
$826,26 		$731,75
$842,10
$867,29
$1 050,65 		$956,14
$1 066,49
$1 091,68
$1 275,04 		$224,39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565,94
$786,64
$837,02
$1 203,74
$1 697,80 		$790,33
$1 011,03
$1 061,41
$1 428,13 		$1 014,72
$1 235,42
$1 285,80
$1 652,52 		$1 239,11
$1 459,81
$1 510,19
$1 876,91 		$224,39
Toc - Plan #52 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 8550 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$248,82
$345,87
$368,01
$529,25
$746,46 		$446,14
$543,19
$565,33
$726,57 		$643,46
$740,51
$762,65
$923,89 		$840,78
$937,83
$959,97
$1 121,21 		$197,32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$497,64
$691,74
$736,02
$1 058,50
$1 492,92 		$694,96
$889,06
$933,34
$1 255,82 		$892,28
$1 086,38
$1 130,66
$1 453,14 		$1 089,60
$1 283,70
$1 327,98
$1 650,46 		$197,32
Toc - Plan #53 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 8550 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$281,15
$390,80
$415,82
$598,01
$843,45 		$504,10
$613,75
$638,77
$820,96 		$727,05
$836,70
$861,72
$1 043,91 		$950,00
$1 059,65
$1 084,67
$1 266,86 		$222,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562,30
$781,60
$831,64
$1 196,02
$1 686,90 		$785,25
$1 004,55
$1 054,59
$1 418,97 		$1 008,20
$1 227,50
$1 277,54
$1 641,92 		$1 231,15
$1 450,45
$1 500,49
$1 864,87 		$222,95
Toc - Plan #54 SelectHealth
Expanded Bronze

(HMO) Med Benchmark Expanded Bronze 6800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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 		$219,42
$304,99
$324,52
$466,70
$658,25 		$393,42
$478,99
$498,52
$640,70 		$567,42
$652,99
$672,52
$814,70 		$741,42
$826,99
$846,52
$988,70 		$174,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$438,84
$609,98
$649,04
$933,40
$1 316,50 		$612,84
$783,98
$823,04
$1 107,40 		$786,84
$957,98
$997,04
$1 281,40 		$960,84
$1 131,98
$1 171,04
$1 455,40 		$174,00
Toc - Plan #55 SelectHealth
Expanded Bronze

(HMO) Value Benchmark Expanded Bronze 6800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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 		$194,19
$269,92
$287,21
$413,04
$582,57 		$348,18
$423,91
$441,20
$567,03 		$502,17
$577,90
$595,19
$721,02 		$656,16
$731,89
$749,18
$875,01 		$153,99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$388,38
$539,84
$574,42
$826,08
$1 165,14 		$542,37
$693,83
$728,41
$980,07 		$696,36
$847,82
$882,40
$1 134,06 		$850,35
$1 001,81
$1 036,39
$1 288,05 		$153,99
Toc - Plan #56 SelectHealth
Expanded Bronze

(HMO) Value Benchmark Expanded Bronze 3800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 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 		$229,54
$319,06
$339,49
$488,24
$688,62 		$411,57
$501,09
$521,52
$670,27 		$593,60
$683,12
$703,55
$852,30 		$775,63
$865,15
$885,58
$1 034,33 		$182,03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$459,08
$638,12
$678,98
$976,48
$1 377,24 		$641,11
$820,15
$861,01
$1 158,51 		$823,14
$1 002,18
$1 043,04
$1 340,54 		$1 005,17
$1 184,21
$1 225,07
$1 522,57 		$182,03
Toc - Plan #57 SelectHealth
Expanded Bronze

(HMO) Med Benchmark Expanded Bronze 3800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 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 		$259,36
$360,52
$383,60
$551,67
$778,08 		$465,04
$566,20
$589,28
$757,35 		$670,72
$771,88
$794,96
$963,03 		$876,40
$977,56
$1 000,64
$1 168,71 		$205,68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$518,72
$721,04
$767,20
$1 103,34
$1 556,16 		$724,40
$926,72
$972,88
$1 309,02 		$930,08
$1 132,40
$1 178,56
$1 514,70 		$1 135,76
$1 338,08
$1 384,24
$1 720,38 		$205,68
Toc - Plan #58 SelectHealth
Bronze

(HMO) Value Benchmark Bronze 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$187,75
$260,97
$277,68
$399,34
$563,24 		$336,63
$409,85
$426,56
$548,22 		$485,51
$558,73
$575,44
$697,10 		$634,39
$707,61
$724,32
$845,98 		$148,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$375,50
$521,94
$555,36
$798,68
$1 126,48 		$524,38
$670,82
$704,24
$947,56 		$673,26
$819,70
$853,12
$1 096,44 		$822,14
$968,58
$1 002,00
$1 245,32 		$148,88
Toc - Plan #59 SelectHealth
Bronze

(HMO) Med Benchmark Bronze 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$212,14
$294,87
$313,75
$451,22
$636,41 		$380,36
$463,09
$481,97
$619,44 		$548,58
$631,31
$650,19
$787,66 		$716,80
$799,53
$818,41
$955,88 		$168,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$424,28
$589,74
$627,50
$902,44
$1 272,82 		$592,50
$757,96
$795,72
$1 070,66 		$760,72
$926,18
$963,94
$1 238,88 		$928,94
$1 094,40
$1 132,16
$1 407,10 		$168,22
Toc - Plan #60 SelectHealth
Silver

(HMO) Value Benchmark Silver 6500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$311,59
$433,10
$460,83
$662,74
$934,76 		$558,68
$680,19
$707,92
$909,83 		$805,77
$927,28
$955,01
$1 156,92 		$1 052,86
$1 174,37
$1 202,10
$1 404,01 		$247,09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623,18
$866,20
$921,66
$1 325,48
$1 869,52 		$870,27
$1 113,29
$1 168,75
$1 572,57 		$1 117,36
$1 360,38
$1 415,84
$1 819,66 		$1 364,45
$1 607,47
$1 662,93
$2 066,75 		$247,09
Toc - Plan #61 SelectHealth
Silver

(HMO) Med Benchmark Silver 6500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$352,06
$489,37
$520,70
$748,84
$1 056,18 		$631,25
$768,56
$799,89
$1 028,03 		$910,44
$1 047,75
$1 079,08
$1 307,22 		$1 189,63
$1 326,94
$1 358,27
$1 586,41 		$279,19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704,12
$978,74
$1 041,40
$1 497,68
$2 112,36 		$983,31
$1 257,93
$1 320,59
$1 776,87 		$1 262,50
$1 537,12
$1 599,78
$2 056,06 		$1 541,69
$1 816,31
$1 878,97
$2 335,25 		$279,19

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #62 Cigna Healthcare
Bronze

(EPO) Cigna Connect 7000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$247,48
$344,00
$366,03
$526,40
$742,44 		$443,73
$540,25
$562,28
$722,65 		$639,98
$736,50
$758,53
$918,90 		$836,23
$932,75
$954,78
$1 115,15 		$196,25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494,96
$688,00
$732,06
$1 052,80
$1 484,88 		$691,21
$884,25
$928,31
$1 249,05 		$887,46
$1 080,50
$1 124,56
$1 445,30 		$1 083,71
$1 276,75
$1 320,81
$1 641,55 		$196,25
Toc - Plan #63 Cigna Healthcare
Bronze

(EPO) Cigna Connect 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$254,29
$353,47
$376,10
$540,88
$762,87 		$455,94
$555,12
$577,75
$742,53 		$657,59
$756,77
$779,40
$944,18 		$859,24
$958,42
$981,05
$1 145,83 		$201,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$508,58
$706,94
$752,20
$1 081,76
$1 525,74 		$710,23
$908,59
$953,85
$1 283,41 		$911,88
$1 110,24
$1 155,50
$1 485,06 		$1 113,53
$1 311,89
$1 357,15
$1 686,71 		$201,65
Toc - Plan #64 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$264,02
$366,99
$390,49
$561,57
$792,06 		$473,39
$576,36
$599,86
$770,94 		$682,76
$785,73
$809,23
$980,31 		$892,13
$995,10
$1 018,60
$1 189,68 		$209,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$528,04
$733,98
$780,98
$1 123,14
$1 584,12 		$737,41
$943,35
$990,35
$1 332,51 		$946,78
$1 152,72
$1 199,72
$1 541,88 		$1 156,15
$1 362,09
$1 409,09
$1 751,25 		$209,37
Toc - Plan #65 Cigna Healthcare
Silver

(EPO) Cigna Connect 1750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 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 		$315,47
$438,50
$466,58
$671,00
$946,41 		$565,64
$688,67
$716,75
$921,17 		$815,81
$938,84
$966,92
$1 171,34 		$1 065,98
$1 189,01
$1 217,09
$1 421,51 		$250,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630,94
$877,00
$933,16
$1 342,00
$1 892,82 		$881,11
$1 127,17
$1 183,33
$1 592,17 		$1 131,28
$1 377,34
$1 433,50
$1 842,34 		$1 381,45
$1 627,51
$1 683,67
$2 092,51 		$250,17
Toc - Plan #66 Cigna Healthcare
Silver

(EPO) Cigna Connect 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$318,78
$443,11
$471,48
$678,05
$956,34 		$571,58
$695,91
$724,28
$930,85 		$824,38
$948,71
$977,08
$1 183,65 		$1 077,18
$1 201,51
$1 229,88
$1 436,45 		$252,80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637,56
$886,22
$942,96
$1 356,10
$1 912,68 		$890,36
$1 139,02
$1 195,76
$1 608,90 		$1 143,16
$1 391,82
$1 448,56
$1 861,70 		$1 395,96
$1 644,62
$1 701,36
$2 114,50 		$252,80
Toc - Plan #67 Cigna Healthcare
Gold

(EPO) Cigna Connect 1800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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 		$380,32
$528,65
$562,49
$808,94
$1 140,96 		$681,91
$830,24
$864,08
$1 110,53 		$983,50
$1 131,83
$1 165,67
$1 412,12 		$1 285,09
$1 433,42
$1 467,26
$1 713,71 		$301,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760,64
$1 057,30
$1 124,98
$1 617,88
$2 281,92 		$1 062,23
$1 358,89
$1 426,57
$1 919,47 		$1 363,82
$1 660,48
$1 728,16
$2 221,06 		$1 665,41
$1 962,07
$2 029,75
$2 522,65 		$301,59
Toc - Plan #68 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500 Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$319,72
$444,41
$472,87
$680,05
$959,16 		$573,26
$697,95
$726,41
$933,59 		$826,80
$951,49
$979,95
$1 187,13 		$1 080,34
$1 205,03
$1 233,49
$1 440,67 		$253,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639,44
$888,82
$945,74
$1 360,10
$1 918,32 		$892,98
$1 142,36
$1 199,28
$1 613,64 		$1 146,52
$1 395,90
$1 452,82
$1 867,18 		$1 400,06
$1 649,44
$1 706,36
$2 120,72 		$253,54
Toc - Plan #69 Cigna Healthcare
Silver

(EPO) Cigna Connect 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$313,38
$435,60
$463,49
$666,56
$940,14 		$561,89
$684,11
$712,00
$915,07 		$810,40
$932,62
$960,51
$1 163,58 		$1 058,91
$1 181,13
$1 209,02
$1 412,09 		$248,51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626,76
$871,20
$926,98
$1 333,12
$1 880,28 		$875,27
$1 119,71
$1 175,49
$1 581,63 		$1 123,78
$1 368,22
$1 424,00
$1 830,14 		$1 372,29
$1 616,73
$1 672,51
$2 078,65 		$248,51

‡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 Utah County here.

Utah County is in “Rating Area 4” of Utah.

Currently, there are 69 plans offered in Rating Area 4.

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2021 Obamacare Plans for Utah County, UT

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