Obamacare 2021 Rates for Florence County

Obamacare > Rates > Wisconsin > Florence 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 Florence 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, 40 Plans and 2021 Rates for Florence County, Wisconsin

Below, you’ll find a summary of the 40 plans for Florence 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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HealthPartners

Local: 1-952-883-5900 | Toll Free: 1-855-813-3887 | TTY: 1-952-883-6060
Toc - Plan #1 HealthPartners
Gold

(PPO) Robin Oak $1,200 w/Copay Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$406,11
$460,93
$519,01
$725,31
$1 102,18 		$716,78
$771,60
$829,68
$1 035,98 		$1 027,45
$1 082,27
$1 140,35
$1 346,65 		$1 338,12
$1 392,94
$1 451,02
$1 657,32 		$310,67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812,22
$921,86
$1 038,02
$1 450,62
$2 204,36 		$1 122,89
$1 232,53
$1 348,69
$1 761,29 		$1 433,56
$1 543,20
$1 659,36
$2 071,96 		$1 744,23
$1 853,87
$1 970,03
$2 382,63 		$310,67
Toc - Plan #2 HealthPartners
Silver

(PPO) Robin Oak $4,000 Plus Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$366,09
$415,51
$467,86
$653,84
$993,57 		$646,15
$695,57
$747,92
$933,90 		$926,21
$975,63
$1 027,98
$1 213,96 		$1 206,27
$1 255,69
$1 308,04
$1 494,02 		$280,06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732,18
$831,02
$935,72
$1 307,68
$1 987,14 		$1 012,24
$1 111,08
$1 215,78
$1 587,74 		$1 292,30
$1 391,14
$1 495,84
$1 867,80 		$1 572,36
$1 671,20
$1 775,90
$2 147,86 		$280,06
Toc - Plan #3 HealthPartners
Expanded Bronze

(PPO) Robin Oak $6,800 Plus Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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 		$290,60
$329,83
$371,39
$519,01
$788,69 		$512,91
$552,14
$593,70
$741,32 		$735,22
$774,45
$816,01
$963,63 		$957,53
$996,76
$1 038,32
$1 185,94 		$222,31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581,20
$659,66
$742,78
$1 038,02
$1 577,38 		$803,51
$881,97
$965,09
$1 260,33 		$1 025,82
$1 104,28
$1 187,40
$1 482,64 		$1 248,13
$1 326,59
$1 409,71
$1 704,95 		$222,31
Toc - Plan #4 HealthPartners
Catastrophic

(PPO) Robin Oak $8,550 Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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 		$222,87
$252,96
$284,83
$398,05
$604,87 		$393,37
$423,46
$455,33
$568,55 		$563,87
$593,96
$625,83
$739,05 		$734,37
$764,46
$796,33
$909,55 		$170,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$445,74
$505,92
$569,66
$796,10
$1 209,74 		$616,24
$676,42
$740,16
$966,60 		$786,74
$846,92
$910,66
$1 137,10 		$957,24
$1 017,42
$1 081,16
$1 307,60 		$170,50
Toc - Plan #5 HealthPartners
Silver

(PPO) Robin Oak $3,500 w/Copay P-S Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$404,17
$458,73
$516,53
$721,85
$1 096,92 		$713,36
$767,92
$825,72
$1 031,04 		$1 022,55
$1 077,11
$1 134,91
$1 340,23 		$1 331,74
$1 386,30
$1 444,10
$1 649,42 		$309,19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808,34
$917,46
$1 033,06
$1 443,70
$2 193,84 		$1 117,53
$1 226,65
$1 342,25
$1 752,89 		$1 426,72
$1 535,84
$1 651,44
$2 062,08 		$1 735,91
$1 845,03
$1 960,63
$2 371,27 		$309,19
Toc - Plan #6 HealthPartners
Silver

(PPO) Robin Oak $5,000 Plus Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$353,20
$400,88
$451,39
$630,82
$958,58 		$623,40
$671,08
$721,59
$901,02 		$893,60
$941,28
$991,79
$1 171,22 		$1 163,80
$1 211,48
$1 261,99
$1 441,42 		$270,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706,40
$801,76
$902,78
$1 261,64
$1 917,16 		$976,60
$1 071,96
$1 172,98
$1 531,84 		$1 246,80
$1 342,16
$1 443,18
$1 802,04 		$1 517,00
$1 612,36
$1 713,38
$2 072,24 		$270,20

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Security Health Plan

Local: 1-715-221-9258x19258 | Toll Free: 1-844-293-9624 | TTY: 1-877-727-2232
Toc - Plan #7 Security Health Plan
Catastrophic

(EPO) Select Protection

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$223,92
$254,14
$286,15
$399,90
$607,69 		$395,21
$425,43
$457,44
$571,19 		$566,50
$596,72
$628,73
$742,48 		$737,79
$768,01
$800,02
$913,77 		$171,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$447,84
$508,28
$572,30
$799,80
$1 215,38 		$619,13
$679,57
$743,59
$971,09 		$790,42
$850,86
$914,88
$1 142,38 		$961,71
$1 022,15
$1 086,17
$1 313,67 		$171,29
Toc - Plan #8 Security Health Plan
Bronze

(EPO) Select $8,550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$327,36
$371,54
$418,35
$584,65
$888,43 		$577,78
$621,96
$668,77
$835,07 		$828,20
$872,38
$919,19
$1 085,49 		$1 078,62
$1 122,80
$1 169,61
$1 335,91 		$250,42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654,72
$743,08
$836,70
$1 169,30
$1 776,86 		$905,14
$993,50
$1 087,12
$1 419,72 		$1 155,56
$1 243,92
$1 337,54
$1 670,14 		$1 405,98
$1 494,34
$1 587,96
$1 920,56 		$250,42
Toc - Plan #9 Security Health Plan
Silver

(EPO) Select $6,950 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,950 $13,900 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 		$496,60
$563,63
$634,64
$886,91
$1 347,75 		$876,49
$943,52
$1 014,53
$1 266,80 		$1 256,38
$1 323,41
$1 394,42
$1 646,69 		$1 636,27
$1 703,30
$1 774,31
$2 026,58 		$379,89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$993,20
$1 127,26
$1 269,28
$1 773,82
$2 695,50 		$1 373,09
$1 507,15
$1 649,17
$2 153,71 		$1 752,98
$1 887,04
$2 029,06
$2 533,60 		$2 132,87
$2 266,93
$2 408,95
$2 913,49 		$379,89
Toc - Plan #10 Security Health Plan
Silver

(EPO) Select $4,500 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$520,17
$590,38
$664,76
$929,01
$1 411,71 		$918,09
$988,30
$1 062,68
$1 326,93 		$1 316,01
$1 386,22
$1 460,60
$1 724,85 		$1 713,93
$1 784,14
$1 858,52
$2 122,77 		$397,92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 040,34
$1 180,76
$1 329,52
$1 858,02
$2 823,42 		$1 438,26
$1 578,68
$1 727,44
$2 255,94 		$1 836,18
$1 976,60
$2 125,36
$2 653,86 		$2 234,10
$2 374,52
$2 523,28
$3 051,78 		$397,92
Toc - Plan #11 Security Health Plan
Bronze

(EPO) Select $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$332,27
$377,12
$424,63
$593,42
$901,76 		$586,45
$631,30
$678,81
$847,60 		$840,63
$885,48
$932,99
$1 101,78 		$1 094,81
$1 139,66
$1 187,17
$1 355,96 		$254,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664,54
$754,24
$849,26
$1 186,84
$1 803,52 		$918,72
$1 008,42
$1 103,44
$1 441,02 		$1 172,90
$1 262,60
$1 357,62
$1 695,20 		$1 427,08
$1 516,78
$1 611,80
$1 949,38 		$254,18
Toc - Plan #12 Security Health Plan
Silver

(EPO) Select $4,800 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$505,44
$573,66
$645,94
$902,70
$1 371,73 		$892,09
$960,31
$1 032,59
$1 289,35 		$1 278,74
$1 346,96
$1 419,24
$1 676,00 		$1 665,39
$1 733,61
$1 805,89
$2 062,65 		$386,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 010,88
$1 147,32
$1 291,88
$1 805,40
$2 743,46 		$1 397,53
$1 533,97
$1 678,53
$2 192,05 		$1 784,18
$1 920,62
$2 065,18
$2 578,70 		$2 170,83
$2 307,27
$2 451,83
$2 965,35 		$386,65
Toc - Plan #13 Security Health Plan
Expanded Bronze

(EPO) Select $6,200 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 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 		$362,39
$411,30
$463,12
$647,21
$983,49 		$639,61
$688,52
$740,34
$924,43 		$916,83
$965,74
$1 017,56
$1 201,65 		$1 194,05
$1 242,96
$1 294,78
$1 478,87 		$277,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724,78
$822,60
$926,24
$1 294,42
$1 966,98 		$1 002,00
$1 099,82
$1 203,46
$1 571,64 		$1 279,22
$1 377,04
$1 480,68
$1 848,86 		$1 556,44
$1 654,26
$1 757,90
$2 126,08 		$277,22
Toc - Plan #14 Security Health Plan
Gold

(EPO) Select $3,500 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$459,61
$521,65
$587,37
$820,85
$1 247,35 		$811,20
$873,24
$938,96
$1 172,44 		$1 162,79
$1 224,83
$1 290,55
$1 524,03 		$1 514,38
$1 576,42
$1 642,14
$1 875,62 		$351,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$919,22
$1 043,30
$1 174,74
$1 641,70
$2 494,70 		$1 270,81
$1 394,89
$1 526,33
$1 993,29 		$1 622,40
$1 746,48
$1 877,92
$2 344,88 		$1 973,99
$2 098,07
$2 229,51
$2 696,47 		$351,59

ADVERTISEMENT

Aspirus Arise

Local: 1-800-332-6290 | Toll Free: 1-800-332-6290 | TTY: 1-888-332-0144
Toc - Plan #15 Aspirus Arise
Silver

(HMO) HMO Silver 7150

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$7,150 $14,300 Annual Deductible
$7,150 $14,300 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 		$470,90
$534,47
$601,81
$841,03
$1 278,02 		$831,14
$894,71
$962,05
$1 201,27 		$1 191,38
$1 254,95
$1 322,29
$1 561,51 		$1 551,62
$1 615,19
$1 682,53
$1 921,75 		$360,24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$941,80
$1 068,94
$1 203,62
$1 682,06
$2 556,04 		$1 302,04
$1 429,18
$1 563,86
$2 042,30 		$1 662,28
$1 789,42
$1 924,10
$2 402,54 		$2 022,52
$2 149,66
$2 284,34
$2 762,78 		$360,24
Toc - Plan #16 Aspirus Arise
Silver

(HMO) HMO Silver 5000 with 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$489,68
$555,79
$625,81
$874,57
$1 328,99 		$864,29
$930,40
$1 000,42
$1 249,18 		$1 238,90
$1 305,01
$1 375,03
$1 623,79 		$1 613,51
$1 679,62
$1 749,64
$1 998,40 		$374,61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$979,36
$1 111,58
$1 251,62
$1 749,14
$2 657,98 		$1 353,97
$1 486,19
$1 626,23
$2 123,75 		$1 728,58
$1 860,80
$2 000,84
$2 498,36 		$2 103,19
$2 235,41
$2 375,45
$2 872,97 		$374,61
Toc - Plan #17 Aspirus Arise
Expanded Bronze

(HMO) HMO HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$6,950 $13,900 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 		$331,29
$376,01
$423,39
$591,68
$899,12 		$584,73
$629,45
$676,83
$845,12 		$838,17
$882,89
$930,27
$1 098,56 		$1 091,61
$1 136,33
$1 183,71
$1 352,00 		$253,44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662,58
$752,02
$846,78
$1 183,36
$1 798,24 		$916,02
$1 005,46
$1 100,22
$1 436,80 		$1 169,46
$1 258,90
$1 353,66
$1 690,24 		$1 422,90
$1 512,34
$1 607,10
$1 943,68 		$253,44
Toc - Plan #18 Aspirus Arise
Silver

(HMO) HMO HDHP Silver 2800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$483,07
$548,28
$617,36
$862,76
$1 311,05 		$852,62
$917,83
$986,91
$1 232,31 		$1 222,17
$1 287,38
$1 356,46
$1 601,86 		$1 591,72
$1 656,93
$1 726,01
$1 971,41 		$369,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$966,14
$1 096,56
$1 234,72
$1 725,52
$2 622,10 		$1 335,69
$1 466,11
$1 604,27
$2 095,07 		$1 705,24
$1 835,66
$1 973,82
$2 464,62 		$2 074,79
$2 205,21
$2 343,37
$2 834,17 		$369,55
Toc - Plan #19 Aspirus Arise
Bronze

(HMO) HMO Bronze 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

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 		$317,19
$360,01
$405,37
$566,50
$860,85 		$559,84
$602,66
$648,02
$809,15 		$802,49
$845,31
$890,67
$1 051,80 		$1 045,14
$1 087,96
$1 133,32
$1 294,45 		$242,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634,38
$720,02
$810,74
$1 133,00
$1 721,70 		$877,03
$962,67
$1 053,39
$1 375,65 		$1 119,68
$1 205,32
$1 296,04
$1 618,30 		$1 362,33
$1 447,97
$1 538,69
$1 860,95 		$242,65
Toc - Plan #20 Aspirus Arise
Expanded Bronze

(HMO) HMO Bronze 6500 with 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

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 		$329,36
$373,82
$420,92
$588,24
$893,88 		$581,32
$625,78
$672,88
$840,20 		$833,28
$877,74
$924,84
$1 092,16 		$1 085,24
$1 129,70
$1 176,80
$1 344,12 		$251,96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658,72
$747,64
$841,84
$1 176,48
$1 787,76 		$910,68
$999,60
$1 093,80
$1 428,44 		$1 162,64
$1 251,56
$1 345,76
$1 680,40 		$1 414,60
$1 503,52
$1 597,72
$1 932,36 		$251,96
Toc - Plan #21 Aspirus Arise
Gold

(HMO) HMO Gold 2500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$5,000 $10,000 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 		$716,15
$812,83
$915,24
$1 279,04
$1 943,63 		$1 264,00
$1 360,68
$1 463,09
$1 826,89 		$1 811,85
$1 908,53
$2 010,94
$2 374,74 		$2 359,70
$2 456,38
$2 558,79
$2 922,59 		$547,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 432,30
$1 625,66
$1 830,48
$2 558,08
$3 887,26 		$1 980,15
$2 173,51
$2 378,33
$3 105,93 		$2 528,00
$2 721,36
$2 926,18
$3 653,78 		$3 075,85
$3 269,21
$3 474,03
$4 201,63 		$547,85
Toc - Plan #22 Aspirus Arise
Catastrophic

(HMO) HMO Catastrophic 8550 with 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

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 		$263,90
$299,53
$337,26
$471,33
$716,22 		$465,78
$501,41
$539,14
$673,21 		$667,66
$703,29
$741,02
$875,09 		$869,54
$905,17
$942,90
$1 076,97 		$201,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$527,80
$599,06
$674,52
$942,66
$1 432,44 		$729,68
$800,94
$876,40
$1 144,54 		$931,56
$1 002,82
$1 078,28
$1 346,42 		$1 133,44
$1 204,70
$1 280,16
$1 548,30 		$201,88
Toc - Plan #23 Aspirus Arise
Expanded Bronze

(HMO) HMO HDHP Bronze 6900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

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 		$331,77
$376,56
$424,00
$592,54
$900,42 		$585,57
$630,36
$677,80
$846,34 		$839,37
$884,16
$931,60
$1 100,14 		$1 093,17
$1 137,96
$1 185,40
$1 353,94 		$253,80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663,54
$753,12
$848,00
$1 185,08
$1 800,84 		$917,34
$1 006,92
$1 101,80
$1 438,88 		$1 171,14
$1 260,72
$1 355,60
$1 692,68 		$1 424,94
$1 514,52
$1 609,40
$1 946,48 		$253,80
Toc - Plan #24 Aspirus Arise
Silver

(HMO) HMO HDHP Silver 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$481,40
$546,39
$615,23
$859,78
$1 306,52 		$849,67
$914,66
$983,50
$1 228,05 		$1 217,94
$1 282,93
$1 351,77
$1 596,32 		$1 586,21
$1 651,20
$1 720,04
$1 964,59 		$368,27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$962,80
$1 092,78
$1 230,46
$1 719,56
$2 613,04 		$1 331,07
$1 461,05
$1 598,73
$2 087,83 		$1 699,34
$1 829,32
$1 967,00
$2 456,10 		$2 067,61
$2 197,59
$2 335,27
$2 824,37 		$368,27
Toc - Plan #25 Aspirus Arise
Expanded Bronze

(HMO) HMO Bronze 7200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$322,80
$366,38
$412,54
$576,52
$876,08 		$569,74
$613,32
$659,48
$823,46 		$816,68
$860,26
$906,42
$1 070,40 		$1 063,62
$1 107,20
$1 153,36
$1 317,34 		$246,94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645,60
$732,76
$825,08
$1 153,04
$1 752,16 		$892,54
$979,70
$1 072,02
$1 399,98 		$1 139,48
$1 226,64
$1 318,96
$1 646,92 		$1 386,42
$1 473,58
$1 565,90
$1 893,86 		$246,94
Toc - Plan #26 Aspirus Arise
Silver

(HMO) HMO Silver 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$471,03
$534,62
$601,98
$841,26
$1 278,38 		$831,37
$894,96
$962,32
$1 201,60 		$1 191,71
$1 255,30
$1 322,66
$1 561,94 		$1 552,05
$1 615,64
$1 683,00
$1 922,28 		$360,34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942,06
$1 069,24
$1 203,96
$1 682,52
$2 556,76 		$1 302,40
$1 429,58
$1 564,30
$2 042,86 		$1 662,74
$1 789,92
$1 924,64
$2 403,20 		$2 023,08
$2 150,26
$2 284,98
$2 763,54 		$360,34
Toc - Plan #27 Aspirus Arise
Silver

(HMO) HMO HDHP Silver 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$457,12
$518,83
$584,20
$816,42
$1 240,62 		$806,82
$868,53
$933,90
$1 166,12 		$1 156,52
$1 218,23
$1 283,60
$1 515,82 		$1 506,22
$1 567,93
$1 633,30
$1 865,52 		$349,70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$914,24
$1 037,66
$1 168,40
$1 632,84
$2 481,24 		$1 263,94
$1 387,36
$1 518,10
$1 982,54 		$1 613,64
$1 737,06
$1 867,80
$2 332,24 		$1 963,34
$2 086,76
$2 217,50
$2 681,94 		$349,70
Toc - Plan #28 Aspirus Arise
Silver

(POS) POS Silver 7150

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$7,150 $14,300 Annual Deductible
$7,150 $14,300 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 		$518,03
$587,96
$662,04
$925,20
$1 405,93 		$914,32
$984,25
$1 058,33
$1 321,49 		$1 310,61
$1 380,54
$1 454,62
$1 717,78 		$1 706,90
$1 776,83
$1 850,91
$2 114,07 		$396,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 036,06
$1 175,92
$1 324,08
$1 850,40
$2 811,86 		$1 432,35
$1 572,21
$1 720,37
$2 246,69 		$1 828,64
$1 968,50
$2 116,66
$2 642,98 		$2 224,93
$2 364,79
$2 512,95
$3 039,27 		$396,29
Toc - Plan #29 Aspirus Arise
Silver

(POS) POS Silver 5000 with 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$538,69
$611,41
$688,45
$962,10
$1 462,00 		$950,79
$1 023,51
$1 100,55
$1 374,20 		$1 362,89
$1 435,61
$1 512,65
$1 786,30 		$1 774,99
$1 847,71
$1 924,75
$2 198,40 		$412,10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 077,38
$1 222,82
$1 376,90
$1 924,20
$2 924,00 		$1 489,48
$1 634,92
$1 789,00
$2 336,30 		$1 901,58
$2 047,02
$2 201,10
$2 748,40 		$2 313,68
$2 459,12
$2 613,20
$3 160,50 		$412,10
Toc - Plan #30 Aspirus Arise
Expanded Bronze

(POS) POS HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$6,950 $13,900 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 		$364,46
$413,66
$465,78
$650,93
$989,14 		$643,27
$692,47
$744,59
$929,74 		$922,08
$971,28
$1 023,40
$1 208,55 		$1 200,89
$1 250,09
$1 302,21
$1 487,36 		$278,81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728,92
$827,32
$931,56
$1 301,86
$1 978,28 		$1 007,73
$1 106,13
$1 210,37
$1 580,67 		$1 286,54
$1 384,94
$1 489,18
$1 859,48 		$1 565,35
$1 663,75
$1 767,99
$2 138,29 		$278,81
Toc - Plan #31 Aspirus Arise
Silver

(POS) POS HDHP Silver 2800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6290

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$531,40
$603,14
$679,13
$949,08
$1 442,22 		$937,92
$1 009,66
$1 085,65
$1 355,60 		$1 344,44
$1 416,18
$1 492,17
$1 762,12 		$1 750,96
$1 822,70
$1 898,69
$2 168,64 		$406,52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 062,80
$1 206,28
$1 358,26
$1 898,16
$2 884,44 		$1 469,32
$1 612,80
$1 764,78
$2 304,68 		$1 875,84
$2 019,32
$2 171,30
$2 711,20 		$2 282,36
$2 425,84
$2 577,82
$3 117,72 		$406,52

ADVERTISEMENT

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442
Toc - Plan #32 Common Ground Healthcare Cooperative
Gold

(EPO) Envision - Gold 1800/80

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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 		$398,34
$452,11
$509,07
$711,42
$1 081,07 		$703,06
$756,83
$813,79
$1 016,14 		$1 007,78
$1 061,55
$1 118,51
$1 320,86 		$1 312,50
$1 366,27
$1 423,23
$1 625,58 		$304,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796,68
$904,22
$1 018,14
$1 422,84
$2 162,14 		$1 101,40
$1 208,94
$1 322,86
$1 727,56 		$1 406,12
$1 513,66
$1 627,58
$2 032,28 		$1 710,84
$1 818,38
$1 932,30
$2 337,00 		$304,72
Toc - Plan #33 Common Ground Healthcare Cooperative
Gold

(EPO) Envision - Gold 2000/80

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$374,52
$425,07
$478,62
$668,87
$1 016,41 		$661,02
$711,57
$765,12
$955,37 		$947,52
$998,07
$1 051,62
$1 241,87 		$1 234,02
$1 284,57
$1 338,12
$1 528,37 		$286,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749,04
$850,14
$957,24
$1 337,74
$2 032,82 		$1 035,54
$1 136,64
$1 243,74
$1 624,24 		$1 322,04
$1 423,14
$1 530,24
$1 910,74 		$1 608,54
$1 709,64
$1 816,74
$2 197,24 		$286,50
Toc - Plan #34 Common Ground Healthcare Cooperative
Silver

(EPO) Envision - Silver 4000/75

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$366,29
$415,73
$468,10
$654,17
$994,08 		$646,49
$695,93
$748,30
$934,37 		$926,69
$976,13
$1 028,50
$1 214,57 		$1 206,89
$1 256,33
$1 308,70
$1 494,77 		$280,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732,58
$831,46
$936,20
$1 308,34
$1 988,16 		$1 012,78
$1 111,66
$1 216,40
$1 588,54 		$1 292,98
$1 391,86
$1 496,60
$1 868,74 		$1 573,18
$1 672,06
$1 776,80
$2 148,94 		$280,20
Toc - Plan #35 Common Ground Healthcare Cooperative
Silver

(EPO) Envision - Silver 3000/75/Copay40

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$383,07
$434,77
$489,55
$684,14
$1 039,62 		$676,11
$727,81
$782,59
$977,18 		$969,15
$1 020,85
$1 075,63
$1 270,22 		$1 262,19
$1 313,89
$1 368,67
$1 563,26 		$293,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766,14
$869,54
$979,10
$1 368,28
$2 079,24 		$1 059,18
$1 162,58
$1 272,14
$1 661,32 		$1 352,22
$1 455,62
$1 565,18
$1 954,36 		$1 645,26
$1 748,66
$1 858,22
$2 247,40 		$293,04
Toc - Plan #36 Common Ground Healthcare Cooperative
Catastrophic

(EPO) Envision - Catastrophic 8550/100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$181,28
$205,74
$231,66
$323,74
$491,96 		$319,95
$344,41
$370,33
$462,41 		$458,62
$483,08
$509,00
$601,08 		$597,29
$621,75
$647,67
$739,75 		$138,67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$362,56
$411,48
$463,32
$647,48
$983,92 		$501,23
$550,15
$601,99
$786,15 		$639,90
$688,82
$740,66
$924,82 		$778,57
$827,49
$879,33
$1 063,49 		$138,67
Toc - Plan #37 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) Envision - Bronze 8550/100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$255,03
$289,45
$325,92
$455,47
$692,13 		$450,12
$484,54
$521,01
$650,56 		$645,21
$679,63
$716,10
$845,65 		$840,30
$874,72
$911,19
$1 040,74 		$195,09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$510,06
$578,90
$651,84
$910,94
$1 384,26 		$705,15
$773,99
$846,93
$1 106,03 		$900,24
$969,08
$1 042,02
$1 301,12 		$1 095,33
$1 164,17
$1 237,11
$1 496,21 		$195,09
Toc - Plan #38 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) Envision - Bronze 8150/ 100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$8,150 $16,300 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 		$271,66
$308,32
$347,17
$485,17
$737,26 		$479,47
$516,13
$554,98
$692,98 		$687,28
$723,94
$762,79
$900,79 		$895,09
$931,75
$970,60
$1 108,60 		$207,81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543,32
$616,64
$694,34
$970,34
$1 474,52 		$751,13
$824,45
$902,15
$1 178,15 		$958,94
$1 032,26
$1 109,96
$1 385,96 		$1 166,75
$1 240,07
$1 317,77
$1 593,77 		$207,81
Toc - Plan #39 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) Envision - HSA Bronze 7000/100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$269,46
$305,83
$344,36
$481,24
$731,29 		$475,59
$511,96
$550,49
$687,37 		$681,72
$718,09
$756,62
$893,50 		$887,85
$924,22
$962,75
$1 099,63 		$206,13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538,92
$611,66
$688,72
$962,48
$1 462,58 		$745,05
$817,79
$894,85
$1 168,61 		$951,18
$1 023,92
$1 100,98
$1 374,74 		$1 157,31
$1 230,05
$1 307,11
$1 580,87 		$206,13
Toc - Plan #40 Common Ground Healthcare Cooperative
Silver

(EPO) Envision - Silver 7000/75

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$304,55
$345,65
$389,20
$543,90
$826,51 		$537,52
$578,62
$622,17
$776,87 		$770,49
$811,59
$855,14
$1 009,84 		$1 003,46
$1 044,56
$1 088,11
$1 242,81 		$232,97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609,10
$691,30
$778,40
$1 087,80
$1 653,02 		$842,07
$924,27
$1 011,37
$1 320,77 		$1 075,04
$1 157,24
$1 244,34
$1 553,74 		$1 308,01
$1 390,21
$1 477,31
$1 786,71 		$232,97

‡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 Florence County here.

Florence County is in “Rating Area 13” of Wisconsin.

Currently, there are 40 plans offered in Rating Area 13.

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