Obamacare 2021 Rates for Dane County

Obamacare > Rates > Wisconsin > Dane 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 Dane County, WI.

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, 66 Plans and 2021 Rates for Dane County, Wisconsin

Below, you’ll find a summary of the 66 plans for Dane County, Wisconsin 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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Quartz

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310 | TTY: 1-800-877-8973
Toc - Plan #1 Quartz
Silver

(HMO) Quartz One Silver I302 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$376,84
$427,71
$481,60
$673,04
$1 022,74 		$665,12
$715,99
$769,88
$961,32 		$953,40
$1 004,27
$1 058,16
$1 249,60 		$1 241,68
$1 292,55
$1 346,44
$1 537,88 		$288,28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753,68
$855,42
$963,20
$1 346,08
$2 045,48 		$1 041,96
$1 143,70
$1 251,48
$1 634,36 		$1 330,24
$1 431,98
$1 539,76
$1 922,64 		$1 618,52
$1 720,26
$1 828,04
$2 210,92 		$288,28
Toc - Plan #2 Quartz
Silver

(HMO) Quartz One Silver I303 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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 		$362,86
$411,84
$463,73
$648,06
$984,80 		$640,45
$689,43
$741,32
$925,65 		$918,04
$967,02
$1 018,91
$1 203,24 		$1 195,63
$1 244,61
$1 296,50
$1 480,83 		$277,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725,72
$823,68
$927,46
$1 296,12
$1 969,60 		$1 003,31
$1 101,27
$1 205,05
$1 573,71 		$1 280,90
$1 378,86
$1 482,64
$1 851,30 		$1 558,49
$1 656,45
$1 760,23
$2 128,89 		$277,59
Toc - Plan #3 Quartz
Gold

(HMO) Quartz One Gold I402 Maintenance with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$333,17
$378,14
$425,79
$595,04
$904,21 		$588,04
$633,01
$680,66
$849,91 		$842,91
$887,88
$935,53
$1 104,78 		$1 097,78
$1 142,75
$1 190,40
$1 359,65 		$254,87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666,34
$756,28
$851,58
$1 190,08
$1 808,42 		$921,21
$1 011,15
$1 106,45
$1 444,95 		$1 176,08
$1 266,02
$1 361,32
$1 699,82 		$1 430,95
$1 520,89
$1 616,19
$1 954,69 		$254,87
Toc - Plan #4 Quartz
Gold

(HMO) Quartz One Gold I401 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$337,01
$382,50
$430,69
$601,89
$914,63 		$594,82
$640,31
$688,50
$859,70 		$852,63
$898,12
$946,31
$1 117,51 		$1 110,44
$1 155,93
$1 204,12
$1 375,32 		$257,81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674,02
$765,00
$861,38
$1 203,78
$1 829,26 		$931,83
$1 022,81
$1 119,19
$1 461,59 		$1 189,64
$1 280,62
$1 377,00
$1 719,40 		$1 447,45
$1 538,43
$1 634,81
$1 977,21 		$257,81
Toc - Plan #5 Quartz
Silver

(HMO) Quartz One Silver I301 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 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 		$376,15
$426,93
$480,72
$671,80
$1 020,87 		$663,90
$714,68
$768,47
$959,55 		$951,65
$1 002,43
$1 056,22
$1 247,30 		$1 239,40
$1 290,18
$1 343,97
$1 535,05 		$287,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752,30
$853,86
$961,44
$1 343,60
$2 041,74 		$1 040,05
$1 141,61
$1 249,19
$1 631,35 		$1 327,80
$1 429,36
$1 536,94
$1 919,10 		$1 615,55
$1 717,11
$1 824,69
$2 206,85 		$287,75
Toc - Plan #6 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I202 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 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 		$259,93
$295,02
$332,19
$464,23
$705,45 		$458,78
$493,87
$531,04
$663,08 		$657,63
$692,72
$729,89
$861,93 		$856,48
$891,57
$928,74
$1 060,78 		$198,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519,86
$590,04
$664,38
$928,46
$1 410,90 		$718,71
$788,89
$863,23
$1 127,31 		$917,56
$987,74
$1 062,08
$1 326,16 		$1 116,41
$1 186,59
$1 260,93
$1 525,01 		$198,85
Toc - Plan #7 Quartz
Gold

(HMO) Quartz One Gold I405 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$333,62
$378,66
$426,37
$595,84
$905,44 		$588,84
$633,88
$681,59
$851,06 		$844,06
$889,10
$936,81
$1 106,28 		$1 099,28
$1 144,32
$1 192,03
$1 361,50 		$255,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667,24
$757,32
$852,74
$1 191,68
$1 810,88 		$922,46
$1 012,54
$1 107,96
$1 446,90 		$1 177,68
$1 267,76
$1 363,18
$1 702,12 		$1 432,90
$1 522,98
$1 618,40
$1 957,34 		$255,22
Toc - Plan #8 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I201 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$260,86
$296,07
$333,38
$465,89
$707,97 		$460,42
$495,63
$532,94
$665,45 		$659,98
$695,19
$732,50
$865,01 		$859,54
$894,75
$932,06
$1 064,57 		$199,56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521,72
$592,14
$666,76
$931,78
$1 415,94 		$721,28
$791,70
$866,32
$1 131,34 		$920,84
$991,26
$1 065,88
$1 330,90 		$1 120,40
$1 190,82
$1 265,44
$1 530,46 		$199,56
Toc - Plan #9 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I204 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,450 $4,900 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 		$271,58
$308,24
$347,07
$485,04
$737,06 		$479,34
$516,00
$554,83
$692,80 		$687,10
$723,76
$762,59
$900,56 		$894,86
$931,52
$970,35
$1 108,32 		$207,76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543,16
$616,48
$694,14
$970,08
$1 474,12 		$750,92
$824,24
$901,90
$1 177,84 		$958,68
$1 032,00
$1 109,66
$1 385,60 		$1 166,44
$1 239,76
$1 317,42
$1 593,36 		$207,76
Toc - Plan #10 Quartz
Silver

(HMO) Quartz One Silver I302

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$362,12
$411,00
$462,78
$646,73
$982,77 		$639,13
$688,01
$739,79
$923,74 		$916,14
$965,02
$1 016,80
$1 200,75 		$1 193,15
$1 242,03
$1 293,81
$1 477,76 		$277,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724,24
$822,00
$925,56
$1 293,46
$1 965,54 		$1 001,25
$1 099,01
$1 202,57
$1 570,47 		$1 278,26
$1 376,02
$1 479,58
$1 847,48 		$1 555,27
$1 653,03
$1 756,59
$2 124,49 		$277,01
Toc - Plan #11 Quartz
Silver

(HMO) Quartz One Silver I303

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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 		$348,68
$395,75
$445,61
$622,74
$946,31 		$615,42
$662,49
$712,35
$889,48 		$882,16
$929,23
$979,09
$1 156,22 		$1 148,90
$1 195,97
$1 245,83
$1 422,96 		$266,74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697,36
$791,50
$891,22
$1 245,48
$1 892,62 		$964,10
$1 058,24
$1 157,96
$1 512,22 		$1 230,84
$1 324,98
$1 424,70
$1 778,96 		$1 497,58
$1 591,72
$1 691,44
$2 045,70 		$266,74
Toc - Plan #12 Quartz
Gold

(HMO) Quartz One Gold I402 Maintenance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$320,15
$363,36
$409,15
$571,78
$868,87 		$565,06
$608,27
$654,06
$816,69 		$809,97
$853,18
$898,97
$1 061,60 		$1 054,88
$1 098,09
$1 143,88
$1 306,51 		$244,91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640,30
$726,72
$818,30
$1 143,56
$1 737,74 		$885,21
$971,63
$1 063,21
$1 388,47 		$1 130,12
$1 216,54
$1 308,12
$1 633,38 		$1 375,03
$1 461,45
$1 553,03
$1 878,29 		$244,91
Toc - Plan #13 Quartz
Gold

(HMO) Quartz One Gold I401

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$323,84
$367,55
$413,86
$578,37
$878,88 		$571,57
$615,28
$661,59
$826,10 		$819,30
$863,01
$909,32
$1 073,83 		$1 067,03
$1 110,74
$1 157,05
$1 321,56 		$247,73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647,68
$735,10
$827,72
$1 156,74
$1 757,76 		$895,41
$982,83
$1 075,45
$1 404,47 		$1 143,14
$1 230,56
$1 323,18
$1 652,20 		$1 390,87
$1 478,29
$1 570,91
$1 899,93 		$247,73
Toc - Plan #14 Quartz
Silver

(HMO) Quartz One Silver I301

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 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 		$361,45
$410,24
$461,93
$645,55
$980,97 		$637,96
$686,75
$738,44
$922,06 		$914,47
$963,26
$1 014,95
$1 198,57 		$1 190,98
$1 239,77
$1 291,46
$1 475,08 		$276,51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722,90
$820,48
$923,86
$1 291,10
$1 961,94 		$999,41
$1 096,99
$1 200,37
$1 567,61 		$1 275,92
$1 373,50
$1 476,88
$1 844,12 		$1 552,43
$1 650,01
$1 753,39
$2 120,63 		$276,51
Toc - Plan #15 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 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 		$249,78
$283,49
$319,21
$446,09
$677,88 		$440,85
$474,56
$510,28
$637,16 		$631,92
$665,63
$701,35
$828,23 		$822,99
$856,70
$892,42
$1 019,30 		$191,07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499,56
$566,98
$638,42
$892,18
$1 355,76 		$690,63
$758,05
$829,49
$1 083,25 		$881,70
$949,12
$1 020,56
$1 274,32 		$1 072,77
$1 140,19
$1 211,63
$1 465,39 		$191,07
Toc - Plan #16 Quartz
Gold

(HMO) Quartz One Gold I405

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$320,58
$363,86
$409,70
$572,56
$870,05 		$565,82
$609,10
$654,94
$817,80 		$811,06
$854,34
$900,18
$1 063,04 		$1 056,30
$1 099,58
$1 145,42
$1 308,28 		$245,24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641,16
$727,72
$819,40
$1 145,12
$1 740,10 		$886,40
$972,96
$1 064,64
$1 390,36 		$1 131,64
$1 218,20
$1 309,88
$1 635,60 		$1 376,88
$1 463,44
$1 555,12
$1 880,84 		$245,24
Toc - Plan #17 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$250,67
$284,50
$320,35
$447,68
$680,30 		$442,43
$476,26
$512,11
$639,44 		$634,19
$668,02
$703,87
$831,20 		$825,95
$859,78
$895,63
$1 022,96 		$191,76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$501,34
$569,00
$640,70
$895,36
$1 360,60 		$693,10
$760,76
$832,46
$1 087,12 		$884,86
$952,52
$1 024,22
$1 278,88 		$1 076,62
$1 144,28
$1 215,98
$1 470,64 		$191,76
Toc - Plan #18 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,450 $4,900 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 		$260,97
$296,19
$333,51
$466,08
$708,25 		$460,61
$495,83
$533,15
$665,72 		$660,25
$695,47
$732,79
$865,36 		$859,89
$895,11
$932,43
$1 065,00 		$199,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521,94
$592,38
$667,02
$932,16
$1 416,50 		$721,58
$792,02
$866,66
$1 131,80 		$921,22
$991,66
$1 066,30
$1 331,44 		$1 120,86
$1 191,30
$1 265,94
$1 531,08 		$199,64
Toc - Plan #19 Quartz
Gold

(HMO) Quartz One Gold I404 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$6,650 $13,300 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 		$337,52
$383,08
$431,35
$602,80
$916,02 		$595,72
$641,28
$689,55
$861,00 		$853,92
$899,48
$947,75
$1 119,20 		$1 112,12
$1 157,68
$1 205,95
$1 377,40 		$258,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675,04
$766,16
$862,70
$1 205,60
$1 832,04 		$933,24
$1 024,36
$1 120,90
$1 463,80 		$1 191,44
$1 282,56
$1 379,10
$1 722,00 		$1 449,64
$1 540,76
$1 637,30
$1 980,20 		$258,20
Toc - Plan #20 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I203 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$256,75
$291,40
$328,12
$458,54
$696,80 		$453,16
$487,81
$524,53
$654,95 		$649,57
$684,22
$720,94
$851,36 		$845,98
$880,63
$917,35
$1 047,77 		$196,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$513,50
$582,80
$656,24
$917,08
$1 393,60 		$709,91
$779,21
$852,65
$1 113,49 		$906,32
$975,62
$1 049,06
$1 309,90 		$1 102,73
$1 172,03
$1 245,47
$1 506,31 		$196,41
Toc - Plan #21 Quartz
Catastrophic

(HMO) Quartz One Catastrophic I101

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$186,97
$212,21
$238,95
$333,93
$507,44 		$330,00
$355,24
$381,98
$476,96 		$473,03
$498,27
$525,01
$619,99 		$616,06
$641,30
$668,04
$763,02 		$143,03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$373,94
$424,42
$477,90
$667,86
$1 014,88 		$516,97
$567,45
$620,93
$810,89 		$660,00
$710,48
$763,96
$953,92 		$803,03
$853,51
$906,99
$1 096,95 		$143,03
Toc - Plan #22 Quartz
Silver

(HMO) Quartz One Silver I304 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$5,250 $10,500 Annual Deductible
$5,250 $10,500 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 		$373,52
$423,94
$477,35
$667,10
$1 013,72 		$659,26
$709,68
$763,09
$952,84 		$945,00
$995,42
$1 048,83
$1 238,58 		$1 230,74
$1 281,16
$1 334,57
$1 524,32 		$285,74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747,04
$847,88
$954,70
$1 334,20
$2 027,44 		$1 032,78
$1 133,62
$1 240,44
$1 619,94 		$1 318,52
$1 419,36
$1 526,18
$1 905,68 		$1 604,26
$1 705,10
$1 811,92
$2 191,42 		$285,74
Toc - Plan #23 Quartz
Gold

(HMO) Quartz One Gold I403 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$342,49
$388,72
$437,69
$611,67
$929,50 		$604,49
$650,72
$699,69
$873,67 		$866,49
$912,72
$961,69
$1 135,67 		$1 128,49
$1 174,72
$1 223,69
$1 397,67 		$262,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684,98
$777,44
$875,38
$1 223,34
$1 859,00 		$946,98
$1 039,44
$1 137,38
$1 485,34 		$1 208,98
$1 301,44
$1 399,38
$1 747,34 		$1 470,98
$1 563,44
$1 661,38
$2 009,34 		$262,00

ADVERTISEMENT

Dean Health Plan

Local: 1-800-279-1302 | Toll Free: 1-800-279-1302 | TTY: 1-800-279-1302
Toc - Plan #24 Dean Health Plan
Catastrophic

(HMO) Dean Catastrophic Safety Net

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$179,91
$204,20
$229,93
$321,33
$488,29 		$317,54
$341,83
$367,56
$458,96 		$455,17
$479,46
$505,19
$596,59 		$592,80
$617,09
$642,82
$734,22 		$137,63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$359,82
$408,40
$459,86
$642,66
$976,58 		$497,45
$546,03
$597,49
$780,29 		$635,08
$683,66
$735,12
$917,92 		$772,71
$821,29
$872,75
$1 055,55 		$137,63
Toc - Plan #25 Dean Health Plan
Silver

(HMO) Dean Silver Copay Plus 4800X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$339,10
$384,88
$433,37
$605,63
$920,32 		$598,51
$644,29
$692,78
$865,04 		$857,92
$903,70
$952,19
$1 124,45 		$1 117,33
$1 163,11
$1 211,60
$1 383,86 		$259,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678,20
$769,76
$866,74
$1 211,26
$1 840,64 		$937,61
$1 029,17
$1 126,15
$1 470,67 		$1 197,02
$1 288,58
$1 385,56
$1 730,08 		$1 456,43
$1 547,99
$1 644,97
$1 989,49 		$259,41
Toc - Plan #26 Dean Health Plan
Silver

(HMO) Dean Silver Classic 5000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$332,17
$377,02
$424,52
$593,26
$901,52 		$586,28
$631,13
$678,63
$847,37 		$840,39
$885,24
$932,74
$1 101,48 		$1 094,50
$1 139,35
$1 186,85
$1 355,59 		$254,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664,34
$754,04
$849,04
$1 186,52
$1 803,04 		$918,45
$1 008,15
$1 103,15
$1 440,63 		$1 172,56
$1 262,26
$1 357,26
$1 694,74 		$1 426,67
$1 516,37
$1 611,37
$1 948,85 		$254,11
Toc - Plan #27 Dean Health Plan
Silver

(HMO) Dean Silver Value Copay 5000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$338,26
$383,93
$432,30
$604,14
$918,05 		$597,03
$642,70
$691,07
$862,91 		$855,80
$901,47
$949,84
$1 121,68 		$1 114,57
$1 160,24
$1 208,61
$1 380,45 		$258,77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$676,52
$767,86
$864,60
$1 208,28
$1 836,10 		$935,29
$1 026,63
$1 123,37
$1 467,05 		$1 194,06
$1 285,40
$1 382,14
$1 725,82 		$1 452,83
$1 544,17
$1 640,91
$1 984,59 		$258,77
Toc - Plan #28 Dean Health Plan
Gold

(HMO) Dean Gold Value Copay 3700X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 Annual Deductible
$3,700 $7,400 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 		$323,66
$367,35
$413,63
$578,05
$878,40 		$571,26
$614,95
$661,23
$825,65 		$818,86
$862,55
$908,83
$1 073,25 		$1 066,46
$1 110,15
$1 156,43
$1 320,85 		$247,60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647,32
$734,70
$827,26
$1 156,10
$1 756,80 		$894,92
$982,30
$1 074,86
$1 403,70 		$1 142,52
$1 229,90
$1 322,46
$1 651,30 		$1 390,12
$1 477,50
$1 570,06
$1 898,90 		$247,60
Toc - Plan #29 Dean Health Plan
Bronze

(HMO) Dean Bronze Value Copay 8500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$217,27
$246,60
$277,67
$388,05
$589,68 		$383,48
$412,81
$443,88
$554,26 		$549,69
$579,02
$610,09
$720,47 		$715,90
$745,23
$776,30
$886,68 		$166,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$434,54
$493,20
$555,34
$776,10
$1 179,36 		$600,75
$659,41
$721,55
$942,31 		$766,96
$825,62
$887,76
$1 108,52 		$933,17
$991,83
$1 053,97
$1 274,73 		$166,21
Toc - Plan #30 Dean Health Plan
Silver

(HMO) Dean Silver HSA-E 4500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$324,55
$368,37
$414,78
$579,65
$880,83 		$572,83
$616,65
$663,06
$827,93 		$821,11
$864,93
$911,34
$1 076,21 		$1 069,39
$1 113,21
$1 159,62
$1 324,49 		$248,28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649,10
$736,74
$829,56
$1 159,30
$1 761,66 		$897,38
$985,02
$1 077,84
$1 407,58 		$1 145,66
$1 233,30
$1 326,12
$1 655,86 		$1 393,94
$1 481,58
$1 574,40
$1 904,14 		$248,28
Toc - Plan #31 Dean Health Plan
Gold

(HMO) Dean Gold Copay Plus 1500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,100 $10,200 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 		$334,05
$379,15
$426,91
$596,61
$906,61 		$589,60
$634,70
$682,46
$852,16 		$845,15
$890,25
$938,01
$1 107,71 		$1 100,70
$1 145,80
$1 193,56
$1 363,26 		$255,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668,10
$758,30
$853,82
$1 193,22
$1 813,22 		$923,65
$1 013,85
$1 109,37
$1 448,77 		$1 179,20
$1 269,40
$1 364,92
$1 704,32 		$1 434,75
$1 524,95
$1 620,47
$1 959,87 		$255,55
Toc - Plan #32 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze HSA-E 6850X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$230,78
$261,94
$294,94
$412,18
$626,34 		$407,33
$438,49
$471,49
$588,73 		$583,88
$615,04
$648,04
$765,28 		$760,43
$791,59
$824,59
$941,83 		$176,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$461,56
$523,88
$589,88
$824,36
$1 252,68 		$638,11
$700,43
$766,43
$1 000,91 		$814,66
$876,98
$942,98
$1 177,46 		$991,21
$1 053,53
$1 119,53
$1 354,01 		$176,55
Toc - Plan #33 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Copay Plus 8500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$223,10
$253,22
$285,13
$398,46
$605,50 		$393,77
$423,89
$455,80
$569,13 		$564,44
$594,56
$626,47
$739,80 		$735,11
$765,23
$797,14
$910,47 		$170,67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$446,20
$506,44
$570,26
$796,92
$1 211,00 		$616,87
$677,11
$740,93
$967,59 		$787,54
$847,78
$911,60
$1 138,26 		$958,21
$1 018,45
$1 082,27
$1 308,93 		$170,67
Toc - Plan #34 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Copay Plus 8500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$208,55
$236,71
$266,53
$372,48
$566,01 		$368,09
$396,25
$426,07
$532,02 		$527,63
$555,79
$585,61
$691,56 		$687,17
$715,33
$745,15
$851,10 		$159,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$417,10
$473,42
$533,06
$744,96
$1 132,02 		$576,64
$632,96
$692,60
$904,50 		$736,18
$792,50
$852,14
$1 064,04 		$895,72
$952,04
$1 011,68
$1 223,58 		$159,54
Toc - Plan #35 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Value Copay 3700X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 Annual Deductible
$3,700 $7,400 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 		$301,46
$342,15
$385,26
$538,40
$818,15 		$532,07
$572,76
$615,87
$769,01 		$762,68
$803,37
$846,48
$999,62 		$993,29
$1 033,98
$1 077,09
$1 230,23 		$230,61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602,92
$684,30
$770,52
$1 076,80
$1 636,30 		$833,53
$914,91
$1 001,13
$1 307,41 		$1 064,14
$1 145,52
$1 231,74
$1 538,02 		$1 294,75
$1 376,13
$1 462,35
$1 768,63 		$230,61
Toc - Plan #36 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Value Copay 5000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$314,97
$357,49
$402,53
$562,53
$854,82 		$555,92
$598,44
$643,48
$803,48 		$796,87
$839,39
$884,43
$1 044,43 		$1 037,82
$1 080,34
$1 125,38
$1 285,38 		$240,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629,94
$714,98
$805,06
$1 125,06
$1 709,64 		$870,89
$955,93
$1 046,01
$1 366,01 		$1 111,84
$1 196,88
$1 286,96
$1 606,96 		$1 352,79
$1 437,83
$1 527,91
$1 847,91 		$240,95
Toc - Plan #37 Dean Health Plan
Bronze

(EPO) Dean Focus Network Bronze Value Copay 8500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$203,15
$230,58
$259,63
$362,83
$551,36 		$358,56
$385,99
$415,04
$518,24 		$513,97
$541,40
$570,45
$673,65 		$669,38
$696,81
$725,86
$829,06 		$155,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$406,30
$461,16
$519,26
$725,66
$1 102,72 		$561,71
$616,57
$674,67
$881,07 		$717,12
$771,98
$830,08
$1 036,48 		$872,53
$927,39
$985,49
$1 191,89 		$155,41
Toc - Plan #38 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver HSA-E 4500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$302,29
$343,10
$386,33
$539,89
$820,42 		$533,54
$574,35
$617,58
$771,14 		$764,79
$805,60
$848,83
$1 002,39 		$996,04
$1 036,85
$1 080,08
$1 233,64 		$231,25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604,58
$686,20
$772,66
$1 079,78
$1 640,84 		$835,83
$917,45
$1 003,91
$1 311,03 		$1 067,08
$1 148,70
$1 235,16
$1 542,28 		$1 298,33
$1 379,95
$1 466,41
$1 773,53 		$231,25
Toc - Plan #39 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze HSA-E 6850X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$215,66
$244,77
$275,61
$385,16
$585,29 		$380,64
$409,75
$440,59
$550,14 		$545,62
$574,73
$605,57
$715,12 		$710,60
$739,71
$770,55
$880,10 		$164,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$431,32
$489,54
$551,22
$770,32
$1 170,58 		$596,30
$654,52
$716,20
$935,30 		$761,28
$819,50
$881,18
$1 100,28 		$926,26
$984,48
$1 046,16
$1 265,26 		$164,98

ADVERTISEMENT

Group Health Cooperative-SCW

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729 | TTY: 1-608-828-4815
Toc - Plan #40 Group Health Cooperative-SCW
Platinum

(HMO) Platinum 500 Ded/1500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$1,500 $3,000 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 		$410,67
$466,12
$524,84
$733,46
$1 114,56 		$724,84
$780,29
$839,01
$1 047,63 		$1 039,01
$1 094,46
$1 153,18
$1 361,80 		$1 353,18
$1 408,63
$1 467,35
$1 675,97 		$314,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821,34
$932,24
$1 049,68
$1 466,92
$2 229,12 		$1 135,51
$1 246,41
$1 363,85
$1 781,09 		$1 449,68
$1 560,58
$1 678,02
$2 095,26 		$1 763,85
$1 874,75
$1 992,19
$2 409,43 		$314,17
Toc - Plan #41 Group Health Cooperative-SCW
Gold

(HMO) Gold 2500 Ded/2500 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$335,75
$381,07
$429,08
$599,64
$911,21 		$592,60
$637,92
$685,93
$856,49 		$849,45
$894,77
$942,78
$1 113,34 		$1 106,30
$1 151,62
$1 199,63
$1 370,19 		$256,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671,50
$762,14
$858,16
$1 199,28
$1 822,42 		$928,35
$1 018,99
$1 115,01
$1 456,13 		$1 185,20
$1 275,84
$1 371,86
$1 712,98 		$1 442,05
$1 532,69
$1 628,71
$1 969,83 		$256,85
Toc - Plan #42 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 4000 Ded/8500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$261,83
$297,17
$334,61
$467,62
$710,59 		$462,13
$497,47
$534,91
$667,92 		$662,43
$697,77
$735,21
$868,22 		$862,73
$898,07
$935,51
$1 068,52 		$200,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523,66
$594,34
$669,22
$935,24
$1 421,18 		$723,96
$794,64
$869,52
$1 135,54 		$924,26
$994,94
$1 069,82
$1 335,84 		$1 124,56
$1 195,24
$1 270,12
$1 536,14 		$200,30
Toc - Plan #43 Group Health Cooperative-SCW
Platinum

(HMO) Select Platinum 500 Ded/1500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$1,500 $3,000 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 		$373,53
$423,96
$477,37
$667,12
$1 013,76 		$659,28
$709,71
$763,12
$952,87 		$945,03
$995,46
$1 048,87
$1 238,62 		$1 230,78
$1 281,21
$1 334,62
$1 524,37 		$285,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747,06
$847,92
$954,74
$1 334,24
$2 027,52 		$1 032,81
$1 133,67
$1 240,49
$1 619,99 		$1 318,56
$1 419,42
$1 526,24
$1 905,74 		$1 604,31
$1 705,17
$1 811,99
$2 191,49 		$285,75
Toc - Plan #44 Group Health Cooperative-SCW
Gold

(HMO) Select Gold 2500 Ded/2500 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$2,500 $5,000 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 		$305,41
$346,64
$390,31
$545,45
$828,87 		$539,05
$580,28
$623,95
$779,09 		$772,69
$813,92
$857,59
$1 012,73 		$1 006,33
$1 047,56
$1 091,23
$1 246,37 		$233,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610,82
$693,28
$780,62
$1 090,90
$1 657,74 		$844,46
$926,92
$1 014,26
$1 324,54 		$1 078,10
$1 160,56
$1 247,90
$1 558,18 		$1 311,74
$1 394,20
$1 481,54
$1 791,82 		$233,64
Toc - Plan #45 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Select Bronze 4000 Ded/8500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$238,20
$270,36
$304,42
$425,43
$646,48 		$420,43
$452,59
$486,65
$607,66 		$602,66
$634,82
$668,88
$789,89 		$784,89
$817,05
$851,11
$972,12 		$182,23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$476,40
$540,72
$608,84
$850,86
$1 292,96 		$658,63
$722,95
$791,07
$1 033,09 		$840,86
$905,18
$973,30
$1 215,32 		$1 023,09
$1 087,41
$1 155,53
$1 397,55 		$182,23
Toc - Plan #46 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 7000 Ded/7000 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$261,97
$297,33
$334,79
$467,87
$710,97 		$462,38
$497,74
$535,20
$668,28 		$662,79
$698,15
$735,61
$868,69 		$863,20
$898,56
$936,02
$1 069,10 		$200,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523,94
$594,66
$669,58
$935,74
$1 421,94 		$724,35
$795,07
$869,99
$1 136,15 		$924,76
$995,48
$1 070,40
$1 336,56 		$1 125,17
$1 195,89
$1 270,81
$1 536,97 		$200,41
Toc - Plan #47 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Select Bronze 7000 Ded/7000 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$238,33
$270,51
$304,59
$425,66
$646,83 		$420,66
$452,84
$486,92
$607,99 		$602,99
$635,17
$669,25
$790,32 		$785,32
$817,50
$851,58
$972,65 		$182,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$476,66
$541,02
$609,18
$851,32
$1 293,66 		$658,99
$723,35
$791,51
$1 033,65 		$841,32
$905,68
$973,84
$1 215,98 		$1 023,65
$1 088,01
$1 156,17
$1 398,31 		$182,33
Toc - Plan #48 Group Health Cooperative-SCW
Gold

(HMO) Gold 2500 Ded/6500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$332,25
$377,11
$424,62
$593,40
$901,73 		$586,42
$631,28
$678,79
$847,57 		$840,59
$885,45
$932,96
$1 101,74 		$1 094,76
$1 139,62
$1 187,13
$1 355,91 		$254,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664,50
$754,22
$849,24
$1 186,80
$1 803,46 		$918,67
$1 008,39
$1 103,41
$1 440,97 		$1 172,84
$1 262,56
$1 357,58
$1 695,14 		$1 427,01
$1 516,73
$1 611,75
$1 949,31 		$254,17
Toc - Plan #49 Group Health Cooperative-SCW
Gold

(HMO) Select Gold 2500 Ded/6500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$302,23
$343,04
$386,25
$539,79
$820,26 		$533,44
$574,25
$617,46
$771,00 		$764,65
$805,46
$848,67
$1 002,21 		$995,86
$1 036,67
$1 079,88
$1 233,42 		$231,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604,46
$686,08
$772,50
$1 079,58
$1 640,52 		$835,67
$917,29
$1 003,71
$1 310,79 		$1 066,88
$1 148,50
$1 234,92
$1 542,00 		$1 298,09
$1 379,71
$1 466,13
$1 773,21 		$231,21
Toc - Plan #50 Group Health Cooperative-SCW
Gold

(HMO) Select Gold Simple Choice 1600 Ded/5400 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 Annual Deductible
$5,400 $10,800 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 		$311,04
$353,04
$397,51
$555,52
$844,17 		$548,99
$590,99
$635,46
$793,47 		$786,94
$828,94
$873,41
$1 031,42 		$1 024,89
$1 066,89
$1 111,36
$1 269,37 		$237,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622,08
$706,08
$795,02
$1 111,04
$1 688,34 		$860,03
$944,03
$1 032,97
$1 348,99 		$1 097,98
$1 181,98
$1 270,92
$1 586,94 		$1 335,93
$1 419,93
$1 508,87
$1 824,89 		$237,95
Toc - Plan #51 Group Health Cooperative-SCW
Silver

(HMO) Select Silver Simple Choice 4550X Ded/7900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$334,86
$380,06
$427,95
$598,05
$908,80 		$591,03
$636,23
$684,12
$854,22 		$847,20
$892,40
$940,29
$1 110,39 		$1 103,37
$1 148,57
$1 196,46
$1 366,56 		$256,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669,72
$760,12
$855,90
$1 196,10
$1 817,60 		$925,89
$1 016,29
$1 112,07
$1 452,27 		$1 182,06
$1 272,46
$1 368,24
$1 708,44 		$1 438,23
$1 528,63
$1 624,41
$1 964,61 		$256,17
Toc - Plan #52 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Select Bronze Simple Choice 6850 Ded/8200 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 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 		$246,14
$279,37
$314,57
$439,61
$668,03 		$434,44
$467,67
$502,87
$627,91 		$622,74
$655,97
$691,17
$816,21 		$811,04
$844,27
$879,47
$1 004,51 		$188,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492,28
$558,74
$629,14
$879,22
$1 336,06 		$680,58
$747,04
$817,44
$1 067,52 		$868,88
$935,34
$1 005,74
$1 255,82 		$1 057,18
$1 123,64
$1 194,04
$1 444,12 		$188,30
Toc - Plan #53 Group Health Cooperative-SCW
Catastrophic

(HMO) Select Catastrophic 8550 Ded/8550 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$162,65
$184,60
$207,86
$290,48
$441,41 		$287,08
$309,03
$332,29
$414,91 		$411,51
$433,46
$456,72
$539,34 		$535,94
$557,89
$581,15
$663,77 		$124,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$325,30
$369,20
$415,72
$580,96
$882,82 		$449,73
$493,63
$540,15
$705,39 		$574,16
$618,06
$664,58
$829,82 		$698,59
$742,49
$789,01
$954,25 		$124,43
Toc - Plan #54 Group Health Cooperative-SCW
Gold

(HMO) Gold Simple Choice 1600 Ded/5400 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 Annual Deductible
$5,400 $10,800 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 		$341,95
$388,11
$437,01
$610,71
$928,03 		$603,54
$649,70
$698,60
$872,30 		$865,13
$911,29
$960,19
$1 133,89 		$1 126,72
$1 172,88
$1 221,78
$1 395,48 		$261,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683,90
$776,22
$874,02
$1 221,42
$1 856,06 		$945,49
$1 037,81
$1 135,61
$1 483,01 		$1 207,08
$1 299,40
$1 397,20
$1 744,60 		$1 468,67
$1 560,99
$1 658,79
$2 006,19 		$261,59
Toc - Plan #55 Group Health Cooperative-SCW
Silver

(HMO) Silver Simple Choice 4550X Ded/7900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$374,41
$424,95
$478,49
$668,69
$1 016,14 		$660,83
$711,37
$764,91
$955,11 		$947,25
$997,79
$1 051,33
$1 241,53 		$1 233,67
$1 284,21
$1 337,75
$1 527,95 		$286,42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748,82
$849,90
$956,98
$1 337,38
$2 032,28 		$1 035,24
$1 136,32
$1 243,40
$1 623,80 		$1 321,66
$1 422,74
$1 529,82
$1 910,22 		$1 608,08
$1 709,16
$1 816,24
$2 196,64 		$286,42
Toc - Plan #56 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze Simple Choice 6850 Ded/8200 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 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 		$270,56
$307,09
$345,78
$483,22
$734,30 		$477,54
$514,07
$552,76
$690,20 		$684,52
$721,05
$759,74
$897,18 		$891,50
$928,03
$966,72
$1 104,16 		$206,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541,12
$614,18
$691,56
$966,44
$1 468,60 		$748,10
$821,16
$898,54
$1 173,42 		$955,08
$1 028,14
$1 105,52
$1 380,40 		$1 162,06
$1 235,12
$1 312,50
$1 587,38 		$206,98
Toc - Plan #57 Group Health Cooperative-SCW
Platinum

(HMO) Platinum No Ded/2000 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 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 		$414,98
$471,00
$530,34
$741,15
$1 126,24 		$732,44
$788,46
$847,80
$1 058,61 		$1 049,90
$1 105,92
$1 165,26
$1 376,07 		$1 367,36
$1 423,38
$1 482,72
$1 693,53 		$317,46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829,96
$942,00
$1 060,68
$1 482,30
$2 252,48 		$1 147,42
$1 259,46
$1 378,14
$1 799,76 		$1 464,88
$1 576,92
$1 695,60
$2 117,22 		$1 782,34
$1 894,38
$2 013,06
$2 434,68 		$317,46
Toc - Plan #58 Group Health Cooperative-SCW
Platinum

(HMO) Select Platinum No Ded/2000 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 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 		$377,44
$428,39
$482,37
$674,10
$1 024,36 		$666,18
$717,13
$771,11
$962,84 		$954,92
$1 005,87
$1 059,85
$1 251,58 		$1 243,66
$1 294,61
$1 348,59
$1 540,32 		$288,74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754,88
$856,78
$964,74
$1 348,20
$2 048,72 		$1 043,62
$1 145,52
$1 253,48
$1 636,94 		$1 332,36
$1 434,26
$1 542,22
$1 925,68 		$1 621,10
$1 723,00
$1 830,96
$2 214,42 		$288,74
Toc - Plan #59 Group Health Cooperative-SCW
Bronze

(HMO) Bronze 8550 Ded/8550 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$257,16
$291,87
$328,65
$459,28
$697,92 		$453,89
$488,60
$525,38
$656,01 		$650,62
$685,33
$722,11
$852,74 		$847,35
$882,06
$918,84
$1 049,47 		$196,73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514,32
$583,74
$657,30
$918,56
$1 395,84 		$711,05
$780,47
$854,03
$1 115,29 		$907,78
$977,20
$1 050,76
$1 312,02 		$1 104,51
$1 173,93
$1 247,49
$1 508,75 		$196,73
Toc - Plan #60 Group Health Cooperative-SCW
Bronze

(HMO) Select Bronze 8550 Ded/8550 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$233,96
$265,55
$299,00
$417,85
$634,97 		$412,94
$444,53
$477,98
$596,83 		$591,92
$623,51
$656,96
$775,81 		$770,90
$802,49
$835,94
$954,79 		$178,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$467,92
$531,10
$598,00
$835,70
$1 269,94 		$646,90
$710,08
$776,98
$1 014,68 		$825,88
$889,06
$955,96
$1 193,66 		$1 004,86
$1 068,04
$1 134,94
$1 372,64 		$178,98
Toc - Plan #61 Group Health Cooperative-SCW
Silver

(HMO) Silver 4900 Ded/7900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,900 $9,800 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 		$419,99
$476,69
$536,75
$750,10
$1 139,85 		$741,28
$797,98
$858,04
$1 071,39 		$1 062,57
$1 119,27
$1 179,33
$1 392,68 		$1 383,86
$1 440,56
$1 500,62
$1 713,97 		$321,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839,98
$953,38
$1 073,50
$1 500,20
$2 279,70 		$1 161,27
$1 274,67
$1 394,79
$1 821,49 		$1 482,56
$1 595,96
$1 716,08
$2 142,78 		$1 803,85
$1 917,25
$2 037,37
$2 464,07 		$321,29
Toc - Plan #62 Group Health Cooperative-SCW
Silver

(HMO) Select Silver 4900 Ded/7900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,900 $9,800 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 		$357,12
$405,33
$456,39
$637,80
$969,20 		$630,31
$678,52
$729,58
$910,99 		$903,50
$951,71
$1 002,77
$1 184,18 		$1 176,69
$1 224,90
$1 275,96
$1 457,37 		$273,19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714,24
$810,66
$912,78
$1 275,60
$1 938,40 		$987,43
$1 083,85
$1 185,97
$1 548,79 		$1 260,62
$1 357,04
$1 459,16
$1 821,98 		$1 533,81
$1 630,23
$1 732,35
$2 095,17 		$273,19
Toc - Plan #63 Group Health Cooperative-SCW
Gold

(HMO) Gold 1500 Ded/8550 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$320,67
$363,96
$409,82
$572,71
$870,29 		$565,98
$609,27
$655,13
$818,02 		$811,29
$854,58
$900,44
$1 063,33 		$1 056,60
$1 099,89
$1 145,75
$1 308,64 		$245,31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641,34
$727,92
$819,64
$1 145,42
$1 740,58 		$886,65
$973,23
$1 064,95
$1 390,73 		$1 131,96
$1 218,54
$1 310,26
$1 636,04 		$1 377,27
$1 463,85
$1 555,57
$1 881,35 		$245,31
Toc - Plan #64 Group Health Cooperative-SCW
Silver

(HMO) Silver 8100X Ded/8150 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$389,08
$441,61
$497,25
$694,90
$1 055,97 		$686,73
$739,26
$794,90
$992,55 		$984,38
$1 036,91
$1 092,55
$1 290,20 		$1 282,03
$1 334,56
$1 390,20
$1 587,85 		$297,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778,16
$883,22
$994,50
$1 389,80
$2 111,94 		$1 075,81
$1 180,87
$1 292,15
$1 687,45 		$1 373,46
$1 478,52
$1 589,80
$1 985,10 		$1 671,11
$1 776,17
$1 887,45
$2 282,75 		$297,65
Toc - Plan #65 Group Health Cooperative-SCW
Gold

(HMO) Select Gold 1500 Ded/8550 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$291,70
$331,08
$372,79
$520,98
$791,67 		$514,85
$554,23
$595,94
$744,13 		$738,00
$777,38
$819,09
$967,28 		$961,15
$1 000,53
$1 042,24
$1 190,43 		$223,15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583,40
$662,16
$745,58
$1 041,96
$1 583,34 		$806,55
$885,31
$968,73
$1 265,11 		$1 029,70
$1 108,46
$1 191,88
$1 488,26 		$1 252,85
$1 331,61
$1 415,03
$1 711,41 		$223,15
Toc - Plan #66 Group Health Cooperative-SCW
Silver

(HMO) Select Silver 8000X Ded/8550 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$367,26
$416,84
$469,36
$655,92
$996,73 		$648,21
$697,79
$750,31
$936,87 		$929,16
$978,74
$1 031,26
$1 217,82 		$1 210,11
$1 259,69
$1 312,21
$1 498,77 		$280,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734,52
$833,68
$938,72
$1 311,84
$1 993,46 		$1 015,47
$1 114,63
$1 219,67
$1 592,79 		$1 296,42
$1 395,58
$1 500,62
$1 873,74 		$1 577,37
$1 676,53
$1 781,57
$2 154,69 		$280,95

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Dane County here.

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

Currently, there are 66 plans offered in Rating Area 2.

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