Obamacare 2021 Rates for Fond Du Lac County

Obamacare > Rates > Wisconsin > Fond Du Lac 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 Fond Du Lac 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, 69 Plans and 2021 Rates for Fond Du Lac County, Wisconsin

Below, you’ll find a summary of the 69 plans for Fond Du Lac 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 		$435,50
$494,29
$556,56
$777,80
$1 181,93 		$768,65
$827,44
$889,71
$1 110,95 		$1 101,80
$1 160,59
$1 222,86
$1 444,10 		$1 434,95
$1 493,74
$1 556,01
$1 777,25 		$333,15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871,00
$988,58
$1 113,12
$1 555,60
$2 363,86 		$1 204,15
$1 321,73
$1 446,27
$1 888,75 		$1 537,30
$1 654,88
$1 779,42
$2 221,90 		$1 870,45
$1 988,03
$2 112,57
$2 555,05 		$333,15
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 		$419,34
$475,95
$535,91
$748,94
$1 138,08 		$740,13
$796,74
$856,70
$1 069,73 		$1 060,92
$1 117,53
$1 177,49
$1 390,52 		$1 381,71
$1 438,32
$1 498,28
$1 711,31 		$320,79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838,68
$951,90
$1 071,82
$1 497,88
$2 276,16 		$1 159,47
$1 272,69
$1 392,61
$1 818,67 		$1 480,26
$1 593,48
$1 713,40
$2 139,46 		$1 801,05
$1 914,27
$2 034,19
$2 460,25 		$320,79
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 		$385,03
$437,00
$492,06
$687,65
$1 044,96 		$679,57
$731,54
$786,60
$982,19 		$974,11
$1 026,08
$1 081,14
$1 276,73 		$1 268,65
$1 320,62
$1 375,68
$1 571,27 		$294,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770,06
$874,00
$984,12
$1 375,30
$2 089,92 		$1 064,60
$1 168,54
$1 278,66
$1 669,84 		$1 359,14
$1 463,08
$1 573,20
$1 964,38 		$1 653,68
$1 757,62
$1 867,74
$2 258,92 		$294,54
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 		$389,47
$442,04
$497,73
$695,58
$1 057,00 		$687,41
$739,98
$795,67
$993,52 		$985,35
$1 037,92
$1 093,61
$1 291,46 		$1 283,29
$1 335,86
$1 391,55
$1 589,40 		$297,94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778,94
$884,08
$995,46
$1 391,16
$2 114,00 		$1 076,88
$1 182,02
$1 293,40
$1 689,10 		$1 374,82
$1 479,96
$1 591,34
$1 987,04 		$1 672,76
$1 777,90
$1 889,28
$2 284,98 		$297,94
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 		$434,70
$493,38
$555,54
$776,37
$1 179,77 		$767,24
$825,92
$888,08
$1 108,91 		$1 099,78
$1 158,46
$1 220,62
$1 441,45 		$1 432,32
$1 491,00
$1 553,16
$1 773,99 		$332,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869,40
$986,76
$1 111,08
$1 552,74
$2 359,54 		$1 201,94
$1 319,30
$1 443,62
$1 885,28 		$1 534,48
$1 651,84
$1 776,16
$2 217,82 		$1 867,02
$1 984,38
$2 108,70
$2 550,36 		$332,54
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 		$300,39
$340,94
$383,90
$536,49
$815,26 		$530,19
$570,74
$613,70
$766,29 		$759,99
$800,54
$843,50
$996,09 		$989,79
$1 030,34
$1 073,30
$1 225,89 		$229,80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600,78
$681,88
$767,80
$1 072,98
$1 630,52 		$830,58
$911,68
$997,60
$1 302,78 		$1 060,38
$1 141,48
$1 227,40
$1 532,58 		$1 290,18
$1 371,28
$1 457,20
$1 762,38 		$229,80
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 		$385,55
$437,60
$492,73
$688,59
$1 046,38 		$680,49
$732,54
$787,67
$983,53 		$975,43
$1 027,48
$1 082,61
$1 278,47 		$1 270,37
$1 322,42
$1 377,55
$1 573,41 		$294,94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771,10
$875,20
$985,46
$1 377,18
$2 092,76 		$1 066,04
$1 170,14
$1 280,40
$1 672,12 		$1 360,98
$1 465,08
$1 575,34
$1 967,06 		$1 655,92
$1 760,02
$1 870,28
$2 262,00 		$294,94
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 		$301,47
$342,16
$385,27
$538,41
$818,17 		$532,09
$572,78
$615,89
$769,03 		$762,71
$803,40
$846,51
$999,65 		$993,33
$1 034,02
$1 077,13
$1 230,27 		$230,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602,94
$684,32
$770,54
$1 076,82
$1 636,34 		$833,56
$914,94
$1 001,16
$1 307,44 		$1 064,18
$1 145,56
$1 231,78
$1 538,06 		$1 294,80
$1 376,18
$1 462,40
$1 768,68 		$230,62
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 		$313,85
$356,22
$401,10
$560,53
$851,78 		$553,94
$596,31
$641,19
$800,62 		$794,03
$836,40
$881,28
$1 040,71 		$1 034,12
$1 076,49
$1 121,37
$1 280,80 		$240,09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627,70
$712,44
$802,20
$1 121,06
$1 703,56 		$867,79
$952,53
$1 042,29
$1 361,15 		$1 107,88
$1 192,62
$1 282,38
$1 601,24 		$1 347,97
$1 432,71
$1 522,47
$1 841,33 		$240,09
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 		$418,48
$474,97
$534,81
$747,40
$1 135,74 		$738,61
$795,10
$854,94
$1 067,53 		$1 058,74
$1 115,23
$1 175,07
$1 387,66 		$1 378,87
$1 435,36
$1 495,20
$1 707,79 		$320,13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836,96
$949,94
$1 069,62
$1 494,80
$2 271,48 		$1 157,09
$1 270,07
$1 389,75
$1 814,93 		$1 477,22
$1 590,20
$1 709,88
$2 135,06 		$1 797,35
$1 910,33
$2 030,01
$2 455,19 		$320,13
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 		$402,95
$457,35
$514,97
$719,67
$1 093,60 		$711,21
$765,61
$823,23
$1 027,93 		$1 019,47
$1 073,87
$1 131,49
$1 336,19 		$1 327,73
$1 382,13
$1 439,75
$1 644,45 		$308,26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805,90
$914,70
$1 029,94
$1 439,34
$2 187,20 		$1 114,16
$1 222,96
$1 338,20
$1 747,60 		$1 422,42
$1 531,22
$1 646,46
$2 055,86 		$1 730,68
$1 839,48
$1 954,72
$2 364,12 		$308,26
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 		$369,98
$419,92
$472,83
$660,78
$1 004,12 		$653,01
$702,95
$755,86
$943,81 		$936,04
$985,98
$1 038,89
$1 226,84 		$1 219,07
$1 269,01
$1 321,92
$1 509,87 		$283,03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739,96
$839,84
$945,66
$1 321,56
$2 008,24 		$1 022,99
$1 122,87
$1 228,69
$1 604,59 		$1 306,02
$1 405,90
$1 511,72
$1 887,62 		$1 589,05
$1 688,93
$1 794,75
$2 170,65 		$283,03
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 		$374,24
$424,76
$478,28
$668,39
$1 015,68 		$660,53
$711,05
$764,57
$954,68 		$946,82
$997,34
$1 050,86
$1 240,97 		$1 233,11
$1 283,63
$1 337,15
$1 527,26 		$286,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748,48
$849,52
$956,56
$1 336,78
$2 031,36 		$1 034,77
$1 135,81
$1 242,85
$1 623,07 		$1 321,06
$1 422,10
$1 529,14
$1 909,36 		$1 607,35
$1 708,39
$1 815,43
$2 195,65 		$286,29
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 		$417,71
$474,10
$533,83
$746,03
$1 133,66 		$737,26
$793,65
$853,38
$1 065,58 		$1 056,81
$1 113,20
$1 172,93
$1 385,13 		$1 376,36
$1 432,75
$1 492,48
$1 704,68 		$319,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835,42
$948,20
$1 067,66
$1 492,06
$2 267,32 		$1 154,97
$1 267,75
$1 387,21
$1 811,61 		$1 474,52
$1 587,30
$1 706,76
$2 131,16 		$1 794,07
$1 906,85
$2 026,31
$2 450,71 		$319,55
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 		$288,65
$327,62
$368,89
$515,53
$783,39 		$509,47
$548,44
$589,71
$736,35 		$730,29
$769,26
$810,53
$957,17 		$951,11
$990,08
$1 031,35
$1 177,99 		$220,82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577,30
$655,24
$737,78
$1 031,06
$1 566,78 		$798,12
$876,06
$958,60
$1 251,88 		$1 018,94
$1 096,88
$1 179,42
$1 472,70 		$1 239,76
$1 317,70
$1 400,24
$1 693,52 		$220,82
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 		$370,48
$420,49
$473,47
$661,68
$1 005,48 		$653,90
$703,91
$756,89
$945,10 		$937,32
$987,33
$1 040,31
$1 228,52 		$1 220,74
$1 270,75
$1 323,73
$1 511,94 		$283,42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740,96
$840,98
$946,94
$1 323,36
$2 010,96 		$1 024,38
$1 124,40
$1 230,36
$1 606,78 		$1 307,80
$1 407,82
$1 513,78
$1 890,20 		$1 591,22
$1 691,24
$1 797,20
$2 173,62 		$283,42
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 		$289,68
$328,79
$370,21
$517,37
$786,19 		$511,28
$550,39
$591,81
$738,97 		$732,88
$771,99
$813,41
$960,57 		$954,48
$993,59
$1 035,01
$1 182,17 		$221,60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579,36
$657,58
$740,42
$1 034,74
$1 572,38 		$800,96
$879,18
$962,02
$1 256,34 		$1 022,56
$1 100,78
$1 183,62
$1 477,94 		$1 244,16
$1 322,38
$1 405,22
$1 699,54 		$221,60
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 		$301,59
$342,29
$385,42
$538,62
$818,49 		$532,30
$573,00
$616,13
$769,33 		$763,01
$803,71
$846,84
$1 000,04 		$993,72
$1 034,42
$1 077,55
$1 230,75 		$230,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603,18
$684,58
$770,84
$1 077,24
$1 636,98 		$833,89
$915,29
$1 001,55
$1 307,95 		$1 064,60
$1 146,00
$1 232,26
$1 538,66 		$1 295,31
$1 376,71
$1 462,97
$1 769,37 		$230,71
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 		$390,06
$442,71
$498,49
$696,63
$1 058,60 		$688,45
$741,10
$796,88
$995,02 		$986,84
$1 039,49
$1 095,27
$1 293,41 		$1 285,23
$1 337,88
$1 393,66
$1 591,80 		$298,39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780,12
$885,42
$996,98
$1 393,26
$2 117,20 		$1 078,51
$1 183,81
$1 295,37
$1 691,65 		$1 376,90
$1 482,20
$1 593,76
$1 990,04 		$1 675,29
$1 780,59
$1 892,15
$2 288,43 		$298,39
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 		$296,71
$336,76
$379,19
$529,91
$805,25 		$523,69
$563,74
$606,17
$756,89 		$750,67
$790,72
$833,15
$983,87 		$977,65
$1 017,70
$1 060,13
$1 210,85 		$226,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$593,42
$673,52
$758,38
$1 059,82
$1 610,50 		$820,40
$900,50
$985,36
$1 286,80 		$1 047,38
$1 127,48
$1 212,34
$1 513,78 		$1 274,36
$1 354,46
$1 439,32
$1 740,76 		$226,98
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 		$216,08
$245,24
$276,14
$385,90
$586,42 		$381,37
$410,53
$441,43
$551,19 		$546,66
$575,82
$606,72
$716,48 		$711,95
$741,11
$772,01
$881,77 		$165,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$432,16
$490,48
$552,28
$771,80
$1 172,84 		$597,45
$655,77
$717,57
$937,09 		$762,74
$821,06
$882,86
$1 102,38 		$928,03
$986,35
$1 048,15
$1 267,67 		$165,29
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 		$431,66
$489,92
$551,65
$770,93
$1 171,50 		$761,87
$820,13
$881,86
$1 101,14 		$1 092,08
$1 150,34
$1 212,07
$1 431,35 		$1 422,29
$1 480,55
$1 542,28
$1 761,56 		$330,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863,32
$979,84
$1 103,30
$1 541,86
$2 343,00 		$1 193,53
$1 310,05
$1 433,51
$1 872,07 		$1 523,74
$1 640,26
$1 763,72
$2 202,28 		$1 853,95
$1 970,47
$2 093,93
$2 532,49 		$330,21
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 		$395,80
$449,22
$505,82
$706,88
$1 074,18 		$698,58
$752,00
$808,60
$1 009,66 		$1 001,36
$1 054,78
$1 111,38
$1 312,44 		$1 304,14
$1 357,56
$1 414,16
$1 615,22 		$302,78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791,60
$898,44
$1 011,64
$1 413,76
$2 148,36 		$1 094,38
$1 201,22
$1 314,42
$1 716,54 		$1 397,16
$1 504,00
$1 617,20
$2 019,32 		$1 699,94
$1 806,78
$1 919,98
$2 322,10 		$302,78

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
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 		$362,57
$411,52
$463,37
$647,55
$984,02 		$639,94
$688,89
$740,74
$924,92 		$917,31
$966,26
$1 018,11
$1 202,29 		$1 194,68
$1 243,63
$1 295,48
$1 479,66 		$277,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725,14
$823,04
$926,74
$1 295,10
$1 968,04 		$1 002,51
$1 100,41
$1 204,11
$1 572,47 		$1 279,88
$1 377,78
$1 481,48
$1 849,84 		$1 557,25
$1 655,15
$1 758,85
$2 127,21 		$277,37
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 		$367,99
$417,67
$470,30
$657,24
$998,73 		$649,50
$699,18
$751,81
$938,75 		$931,01
$980,69
$1 033,32
$1 220,26 		$1 212,52
$1 262,20
$1 314,83
$1 501,77 		$281,51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735,98
$835,34
$940,60
$1 314,48
$1 997,46 		$1 017,49
$1 116,85
$1 222,11
$1 595,99 		$1 299,00
$1 398,36
$1 503,62
$1 877,50 		$1 580,51
$1 679,87
$1 785,13
$2 159,01 		$281,51
Toc - Plan #26 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 		$244,11
$277,07
$311,97
$435,98
$662,52 		$430,86
$463,82
$498,72
$622,73 		$617,61
$650,57
$685,47
$809,48 		$804,36
$837,32
$872,22
$996,23 		$186,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$488,22
$554,14
$623,94
$871,96
$1 325,04 		$674,97
$740,89
$810,69
$1 058,71 		$861,72
$927,64
$997,44
$1 245,46 		$1 048,47
$1 114,39
$1 184,19
$1 432,21 		$186,75
Toc - Plan #27 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 		$360,58
$409,26
$460,82
$644,00
$978,62 		$636,43
$685,11
$736,67
$919,85 		$912,28
$960,96
$1 012,52
$1 195,70 		$1 188,13
$1 236,81
$1 288,37
$1 471,55 		$275,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721,16
$818,52
$921,64
$1 288,00
$1 957,24 		$997,01
$1 094,37
$1 197,49
$1 563,85 		$1 272,86
$1 370,22
$1 473,34
$1 839,70 		$1 548,71
$1 646,07
$1 749,19
$2 115,55 		$275,85
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 		$351,47
$398,92
$449,18
$627,73
$953,90 		$620,35
$667,80
$718,06
$896,61 		$889,23
$936,68
$986,94
$1 165,49 		$1 158,11
$1 205,56
$1 255,82
$1 434,37 		$268,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702,94
$797,84
$898,36
$1 255,46
$1 907,80 		$971,82
$1 066,72
$1 167,24
$1 524,34 		$1 240,70
$1 335,60
$1 436,12
$1 793,22 		$1 509,58
$1 604,48
$1 705,00
$2 062,10 		$268,88
Toc - Plan #29 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 		$367,09
$416,65
$469,14
$655,62
$996,28 		$647,91
$697,47
$749,96
$936,44 		$928,73
$978,29
$1 030,78
$1 217,26 		$1 209,55
$1 259,11
$1 311,60
$1 498,08 		$280,82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734,18
$833,30
$938,28
$1 311,24
$1 992,56 		$1 015,00
$1 114,12
$1 219,10
$1 592,06 		$1 295,82
$1 394,94
$1 499,92
$1 872,88 		$1 576,64
$1 675,76
$1 780,74
$2 153,70 		$280,82
Toc - Plan #30 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 		$237,89
$270,01
$304,03
$424,88
$645,65 		$419,88
$452,00
$486,02
$606,87 		$601,87
$633,99
$668,01
$788,86 		$783,86
$815,98
$850,00
$970,85 		$181,99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$475,78
$540,02
$608,06
$849,76
$1 291,30 		$657,77
$722,01
$790,05
$1 031,75 		$839,76
$904,00
$972,04
$1 213,74 		$1 021,75
$1 085,99
$1 154,03
$1 395,73 		$181,99
Toc - Plan #31 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 		$352,41
$399,99
$450,38
$629,41
$956,45 		$622,01
$669,59
$719,98
$899,01 		$891,61
$939,19
$989,58
$1 168,61 		$1 161,21
$1 208,79
$1 259,18
$1 438,21 		$269,60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704,82
$799,98
$900,76
$1 258,82
$1 912,90 		$974,42
$1 069,58
$1 170,36
$1 528,42 		$1 244,02
$1 339,18
$1 439,96
$1 798,02 		$1 513,62
$1 608,78
$1 709,56
$2 067,62 		$269,60
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 		$252,32
$286,38
$322,46
$450,64
$684,79 		$445,34
$479,40
$515,48
$643,66 		$638,36
$672,42
$708,50
$836,68 		$831,38
$865,44
$901,52
$1 029,70 		$193,02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504,64
$572,76
$644,92
$901,28
$1 369,58 		$697,66
$765,78
$837,94
$1 094,30 		$890,68
$958,80
$1 030,96
$1 287,32 		$1 083,70
$1 151,82
$1 223,98
$1 480,34 		$193,02
Toc - Plan #33 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 		$198,02
$224,76
$253,07
$353,67
$537,43 		$349,51
$376,25
$404,56
$505,16 		$501,00
$527,74
$556,05
$656,65 		$652,49
$679,23
$707,54
$808,14 		$151,49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$396,04
$449,52
$506,14
$707,34
$1 074,86 		$547,53
$601,01
$657,63
$858,83 		$699,02
$752,50
$809,12
$1 010,32 		$850,51
$903,99
$960,61
$1 161,81 		$151,49

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-2043 | Toll Free: 1-888-560-2043

Toc - Plan #34 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395,71
$449,13
$505,72
$706,74
$1 073,96 		$698,43
$751,85
$808,44
$1 009,46 		$1 001,15
$1 054,57
$1 111,16
$1 312,18 		$1 303,87
$1 357,29
$1 413,88
$1 614,90 		$302,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791,42
$898,26
$1 011,44
$1 413,48
$2 147,92 		$1 094,14
$1 200,98
$1 314,16
$1 716,20 		$1 396,86
$1 503,70
$1 616,88
$2 018,92 		$1 699,58
$1 806,42
$1 919,60
$2 321,64 		$302,72
Toc - Plan #35 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$348,80
$395,88
$445,76
$622,95
$946,63 		$615,63
$662,71
$712,59
$889,78 		$882,46
$929,54
$979,42
$1 156,61 		$1 149,29
$1 196,37
$1 246,25
$1 423,44 		$266,83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697,60
$791,76
$891,52
$1 245,90
$1 893,26 		$964,43
$1 058,59
$1 158,35
$1 512,73 		$1 231,26
$1 325,42
$1 425,18
$1 779,56 		$1 498,09
$1 592,25
$1 692,01
$2 046,39 		$266,83
Toc - Plan #36 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$276,46
$313,78
$353,31
$493,75
$750,30 		$487,95
$525,27
$564,80
$705,24 		$699,44
$736,76
$776,29
$916,73 		$910,93
$948,25
$987,78
$1 128,22 		$211,49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552,92
$627,56
$706,62
$987,50
$1 500,60 		$764,41
$839,05
$918,11
$1 198,99 		$975,90
$1 050,54
$1 129,60
$1 410,48 		$1 187,39
$1 262,03
$1 341,09
$1 621,97 		$211,49
Toc - Plan #37 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345,11
$391,70
$441,05
$616,37
$936,63 		$609,12
$655,71
$705,06
$880,38 		$873,13
$919,72
$969,07
$1 144,39 		$1 137,14
$1 183,73
$1 233,08
$1 408,40 		$264,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690,22
$783,40
$882,10
$1 232,74
$1 873,26 		$954,23
$1 047,41
$1 146,11
$1 496,75 		$1 218,24
$1 311,42
$1 410,12
$1 760,76 		$1 482,25
$1 575,43
$1 674,13
$2 024,77 		$264,01
Toc - Plan #38 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$289,59
$328,68
$370,09
$517,20
$785,94 		$511,12
$550,21
$591,62
$738,73 		$732,65
$771,74
$813,15
$960,26 		$954,18
$993,27
$1 034,68
$1 181,79 		$221,53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579,18
$657,36
$740,18
$1 034,40
$1 571,88 		$800,71
$878,89
$961,71
$1 255,93 		$1 022,24
$1 100,42
$1 183,24
$1 477,46 		$1 243,77
$1 321,95
$1 404,77
$1 698,99 		$221,53
Toc - Plan #39 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281,56
$319,57
$359,83
$502,87
$764,16 		$496,95
$534,96
$575,22
$718,26 		$712,34
$750,35
$790,61
$933,65 		$927,73
$965,74
$1 006,00
$1 149,04 		$215,39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563,12
$639,14
$719,66
$1 005,74
$1 528,32 		$778,51
$854,53
$935,05
$1 221,13 		$993,90
$1 069,92
$1 150,44
$1 436,52 		$1 209,29
$1 285,31
$1 365,83
$1 651,91 		$215,39
Toc - Plan #40 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$398,84
$452,68
$509,72
$712,33
$1 082,45 		$703,95
$757,79
$814,83
$1 017,44 		$1 009,06
$1 062,90
$1 119,94
$1 322,55 		$1 314,17
$1 368,01
$1 425,05
$1 627,66 		$305,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797,68
$905,36
$1 019,44
$1 424,66
$2 164,90 		$1 102,79
$1 210,47
$1 324,55
$1 729,77 		$1 407,90
$1 515,58
$1 629,66
$2 034,88 		$1 713,01
$1 820,69
$1 934,77
$2 339,99 		$305,11
Toc - Plan #41 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$351,93
$399,44
$449,76
$628,54
$955,13 		$621,15
$668,66
$718,98
$897,76 		$890,37
$937,88
$988,20
$1 166,98 		$1 159,59
$1 207,10
$1 257,42
$1 436,20 		$269,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$703,86
$798,88
$899,52
$1 257,08
$1 910,26 		$973,08
$1 068,10
$1 168,74
$1 526,30 		$1 242,30
$1 337,32
$1 437,96
$1 795,52 		$1 511,52
$1 606,54
$1 707,18
$2 064,74 		$269,22
Toc - Plan #42 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279,59
$317,33
$357,31
$499,34
$758,80 		$493,47
$531,21
$571,19
$713,22 		$707,35
$745,09
$785,07
$927,10 		$921,23
$958,97
$998,95
$1 140,98 		$213,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559,18
$634,66
$714,62
$998,68
$1 517,60 		$773,06
$848,54
$928,50
$1 212,56 		$986,94
$1 062,42
$1 142,38
$1 426,44 		$1 200,82
$1 276,30
$1 356,26
$1 640,32 		$213,88
Toc - Plan #43 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$348,42
$395,46
$445,28
$622,28
$945,61 		$614,96
$662,00
$711,82
$888,82 		$881,50
$928,54
$978,36
$1 155,36 		$1 148,04
$1 195,08
$1 244,90
$1 421,90 		$266,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696,84
$790,92
$890,56
$1 244,56
$1 891,22 		$963,38
$1 057,46
$1 157,10
$1 511,10 		$1 229,92
$1 324,00
$1 423,64
$1 777,64 		$1 496,46
$1 590,54
$1 690,18
$2 044,18 		$266,54
Toc - Plan #44 Molina Healthcare
Bronze

(HMO) Core Care Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$274,01
$311,01
$350,19
$489,39
$743,67 		$483,63
$520,63
$559,81
$699,01 		$693,25
$730,25
$769,43
$908,63 		$902,87
$939,87
$979,05
$1 118,25 		$209,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548,02
$622,02
$700,38
$978,78
$1 487,34 		$757,64
$831,64
$910,00
$1 188,40 		$967,26
$1 041,26
$1 119,62
$1 398,02 		$1 176,88
$1 250,88
$1 329,24
$1 607,64 		$209,62

ADVERTISEMENT

Arise Health Plan

Local: 1-920-490-6900 | Toll Free: 1-800-332-6249 | TTY: 1-888-332-0144
Toc - Plan #45 Arise Health Plan
Bronze

(HMO) WPS HMO Bronze $8,550 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$299,32
$339,73
$382,53
$534,59
$812,35 		$528,30
$568,71
$611,51
$763,57 		$757,28
$797,69
$840,49
$992,55 		$986,26
$1 026,67
$1 069,47
$1 221,53 		$228,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598,64
$679,46
$765,06
$1 069,18
$1 624,70 		$827,62
$908,44
$994,04
$1 298,16 		$1 056,60
$1 137,42
$1 223,02
$1 527,14 		$1 285,58
$1 366,40
$1 452,00
$1 756,12 		$228,98
Toc - Plan #46 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO Bronze $6,500 with 3 Free PCP Visits | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$310,79
$352,75
$397,19
$555,07
$843,48 		$548,54
$590,50
$634,94
$792,82 		$786,29
$828,25
$872,69
$1 030,57 		$1 024,04
$1 066,00
$1 110,44
$1 268,32 		$237,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621,58
$705,50
$794,38
$1 110,14
$1 686,96 		$859,33
$943,25
$1 032,13
$1 347,89 		$1 097,08
$1 181,00
$1 269,88
$1 585,64 		$1 334,83
$1 418,75
$1 507,63
$1 823,39 		$237,75
Toc - Plan #47 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO Bronze $7,200 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$304,51
$345,62
$389,16
$543,85
$826,44 		$537,46
$578,57
$622,11
$776,80 		$770,41
$811,52
$855,06
$1 009,75 		$1 003,36
$1 044,47
$1 088,01
$1 242,70 		$232,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609,02
$691,24
$778,32
$1 087,70
$1 652,88 		$841,97
$924,19
$1 011,27
$1 320,65 		$1 074,92
$1 157,14
$1 244,22
$1 553,60 		$1 307,87
$1 390,09
$1 477,17
$1 786,55 		$232,95
Toc - Plan #48 Arise Health Plan
Silver

(HMO) WPS HMO Silver $7,500 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$7,500 $15,000 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 		$402,38
$456,70
$514,24
$718,65
$1 092,06 		$710,20
$764,52
$822,06
$1 026,47 		$1 018,02
$1 072,34
$1 129,88
$1 334,29 		$1 325,84
$1 380,16
$1 437,70
$1 642,11 		$307,82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804,76
$913,40
$1 028,48
$1 437,30
$2 184,12 		$1 112,58
$1 221,22
$1 336,30
$1 745,12 		$1 420,40
$1 529,04
$1 644,12
$2 052,94 		$1 728,22
$1 836,86
$1 951,94
$2 360,76 		$307,82
Toc - Plan #49 Arise Health Plan
Silver

(HMO) WPS HMO Silver $4,500 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403,34
$457,79
$515,47
$720,37
$1 094,66 		$711,90
$766,35
$824,03
$1 028,93 		$1 020,46
$1 074,91
$1 132,59
$1 337,49 		$1 329,02
$1 383,47
$1 441,15
$1 646,05 		$308,56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806,68
$915,58
$1 030,94
$1 440,74
$2 189,32 		$1 115,24
$1 224,14
$1 339,50
$1 749,30 		$1 423,80
$1 532,70
$1 648,06
$2 057,86 		$1 732,36
$1 841,26
$1 956,62
$2 366,42 		$308,56
Toc - Plan #50 Arise Health Plan
Silver

(HMO) WPS HMO Silver $5,000 with 3 Free PCP Visits | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$419,56
$476,20
$536,20
$749,33
$1 138,69 		$740,52
$797,16
$857,16
$1 070,29 		$1 061,48
$1 118,12
$1 178,12
$1 391,25 		$1 382,44
$1 439,08
$1 499,08
$1 712,21 		$320,96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839,12
$952,40
$1 072,40
$1 498,66
$2 277,38 		$1 160,08
$1 273,36
$1 393,36
$1 819,62 		$1 481,04
$1 594,32
$1 714,32
$2 140,58 		$1 802,00
$1 915,28
$2 035,28
$2 461,54 		$320,96
Toc - Plan #51 Arise Health Plan
Gold

(HMO) WPS HMO Gold $2,500 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$555,76
$630,79
$710,26
$992,59
$1 508,33 		$980,92
$1 055,95
$1 135,42
$1 417,75 		$1 406,08
$1 481,11
$1 560,58
$1 842,91 		$1 831,24
$1 906,27
$1 985,74
$2 268,07 		$425,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 111,52
$1 261,58
$1 420,52
$1 985,18
$3 016,66 		$1 536,68
$1 686,74
$1 845,68
$2 410,34 		$1 961,84
$2 111,90
$2 270,84
$2 835,50 		$2 387,00
$2 537,06
$2 696,00
$3 260,66 		$425,16
Toc - Plan #52 Arise Health Plan
Catastrophic

(HMO) WPS HMO Catastrophic $8,550 with 3 Free PCP Visits | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$260,22
$295,35
$332,56
$464,75
$706,24 		$459,29
$494,42
$531,63
$663,82 		$658,36
$693,49
$730,70
$862,89 		$857,43
$892,56
$929,77
$1 061,96 		$199,07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$520,44
$590,70
$665,12
$929,50
$1 412,48 		$719,51
$789,77
$864,19
$1 128,57 		$918,58
$988,84
$1 063,26
$1 327,64 		$1 117,65
$1 187,91
$1 262,33
$1 526,71 		$199,07
Toc - Plan #53 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO HDHP Bronze $7,000 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$311,17
$353,18
$397,68
$555,75
$844,52 		$549,22
$591,23
$635,73
$793,80 		$787,27
$829,28
$873,78
$1 031,85 		$1 025,32
$1 067,33
$1 111,83
$1 269,90 		$238,05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622,34
$706,36
$795,36
$1 111,50
$1 689,04 		$860,39
$944,41
$1 033,41
$1 349,55 		$1 098,44
$1 182,46
$1 271,46
$1 587,60 		$1 336,49
$1 420,51
$1 509,51
$1 825,65 		$238,05
Toc - Plan #54 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO HDHP Bronze $6,830 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$6,830 $13,660 Annual Deductible
$6,830 $13,660 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317,52
$360,39
$405,79
$567,09
$861,75 		$560,42
$603,29
$648,69
$809,99 		$803,32
$846,19
$891,59
$1 052,89 		$1 046,22
$1 089,09
$1 134,49
$1 295,79 		$242,90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635,04
$720,78
$811,58
$1 134,18
$1 723,50 		$877,94
$963,68
$1 054,48
$1 377,08 		$1 120,84
$1 206,58
$1 297,38
$1 619,98 		$1 363,74
$1 449,48
$1 540,28
$1 862,88 		$242,90
Toc - Plan #55 Arise Health Plan
Expanded Bronze

(HMO) WPS HMO HDHP Bronze $6,000 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311,82
$353,92
$398,51
$556,91
$846,28 		$550,36
$592,46
$637,05
$795,45 		$788,90
$831,00
$875,59
$1 033,99 		$1 027,44
$1 069,54
$1 114,13
$1 272,53 		$238,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623,64
$707,84
$797,02
$1 113,82
$1 692,56 		$862,18
$946,38
$1 035,56
$1 352,36 		$1 100,72
$1 184,92
$1 274,10
$1 590,90 		$1 339,26
$1 423,46
$1 512,64
$1 829,44 		$238,54
Toc - Plan #56 Arise Health Plan
Silver

(HMO) WPS HMO HDHP Silver $2,800 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$413,53
$469,36
$528,49
$738,56
$1 122,32 		$729,88
$785,71
$844,84
$1 054,91 		$1 046,23
$1 102,06
$1 161,19
$1 371,26 		$1 362,58
$1 418,41
$1 477,54
$1 687,61 		$316,35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827,06
$938,72
$1 056,98
$1 477,12
$2 244,64 		$1 143,41
$1 255,07
$1 373,33
$1 793,47 		$1 459,76
$1 571,42
$1 689,68
$2 109,82 		$1 776,11
$1 887,77
$2 006,03
$2 426,17 		$316,35
Toc - Plan #57 Arise Health Plan
Silver

(HMO) WPS HMO HDHP Silver $4,500 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$412,57
$468,27
$527,26
$736,85
$1 119,71 		$728,19
$783,89
$842,88
$1 052,47 		$1 043,81
$1 099,51
$1 158,50
$1 368,09 		$1 359,43
$1 415,13
$1 474,12
$1 683,71 		$315,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825,14
$936,54
$1 054,52
$1 473,70
$2 239,42 		$1 140,76
$1 252,16
$1 370,14
$1 789,32 		$1 456,38
$1 567,78
$1 685,76
$2 104,94 		$1 772,00
$1 883,40
$2 001,38
$2 420,56 		$315,62
Toc - Plan #58 Arise Health Plan
Silver

(HMO) WPS HMO HDHP Silver $5,500 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$391,74
$444,62
$500,64
$699,65
$1 063,18 		$691,42
$744,30
$800,32
$999,33 		$991,10
$1 043,98
$1 100,00
$1 299,01 		$1 290,78
$1 343,66
$1 399,68
$1 598,69 		$299,68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783,48
$889,24
$1 001,28
$1 399,30
$2 126,36 		$1 083,16
$1 188,92
$1 300,96
$1 698,98 		$1 382,84
$1 488,60
$1 600,64
$1 998,66 		$1 682,52
$1 788,28
$1 900,32
$2 298,34 		$299,68
Toc - Plan #59 Arise Health Plan
Bronze

(POS) WPS POS Bronze $8,550 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$320,15
$363,37
$409,15
$571,79
$868,89 		$565,06
$608,28
$654,06
$816,70 		$809,97
$853,19
$898,97
$1 061,61 		$1 054,88
$1 098,10
$1 143,88
$1 306,52 		$244,91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640,30
$726,74
$818,30
$1 143,58
$1 737,78 		$885,21
$971,65
$1 063,21
$1 388,49 		$1 130,12
$1 216,56
$1 308,12
$1 633,40 		$1 375,03
$1 461,47
$1 553,03
$1 878,31 		$244,91
Toc - Plan #60 Arise Health Plan
Expanded Bronze

(POS) WPS POS HDHP Bronze $6,000 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$333,48
$378,50
$426,19
$595,60
$905,06 		$588,59
$633,61
$681,30
$850,71 		$843,70
$888,72
$936,41
$1 105,82 		$1 098,81
$1 143,83
$1 191,52
$1 360,93 		$255,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666,96
$757,00
$852,38
$1 191,20
$1 810,12 		$922,07
$1 012,11
$1 107,49
$1 446,31 		$1 177,18
$1 267,22
$1 362,60
$1 701,42 		$1 432,29
$1 522,33
$1 617,71
$1 956,53 		$255,11

ADVERTISEMENT

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442
Toc - Plan #61 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 		$405,48
$460,21
$518,20
$724,18
$1 100,46 		$715,67
$770,40
$828,39
$1 034,37 		$1 025,86
$1 080,59
$1 138,58
$1 344,56 		$1 336,05
$1 390,78
$1 448,77
$1 654,75 		$310,19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810,96
$920,42
$1 036,40
$1 448,36
$2 200,92 		$1 121,15
$1 230,61
$1 346,59
$1 758,55 		$1 431,34
$1 540,80
$1 656,78
$2 068,74 		$1 741,53
$1 850,99
$1 966,97
$2 378,93 		$310,19
Toc - Plan #62 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 		$381,23
$432,69
$487,20
$680,86
$1 034,64 		$672,87
$724,33
$778,84
$972,50 		$964,51
$1 015,97
$1 070,48
$1 264,14 		$1 256,15
$1 307,61
$1 362,12
$1 555,78 		$291,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762,46
$865,38
$974,40
$1 361,72
$2 069,28 		$1 054,10
$1 157,02
$1 266,04
$1 653,36 		$1 345,74
$1 448,66
$1 557,68
$1 945,00 		$1 637,38
$1 740,30
$1 849,32
$2 236,64 		$291,64
Toc - Plan #63 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 		$372,86
$423,18
$476,50
$665,90
$1 011,91 		$658,09
$708,41
$761,73
$951,13 		$943,32
$993,64
$1 046,96
$1 236,36 		$1 228,55
$1 278,87
$1 332,19
$1 521,59 		$285,23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745,72
$846,36
$953,00
$1 331,80
$2 023,82 		$1 030,95
$1 131,59
$1 238,23
$1 617,03 		$1 316,18
$1 416,82
$1 523,46
$1 902,26 		$1 601,41
$1 702,05
$1 808,69
$2 187,49 		$285,23
Toc - Plan #64 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 		$389,94
$442,57
$498,33
$696,41
$1 058,26 		$688,23
$740,86
$796,62
$994,70 		$986,52
$1 039,15
$1 094,91
$1 292,99 		$1 284,81
$1 337,44
$1 393,20
$1 591,28 		$298,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779,88
$885,14
$996,66
$1 392,82
$2 116,52 		$1 078,17
$1 183,43
$1 294,95
$1 691,11 		$1 376,46
$1 481,72
$1 593,24
$1 989,40 		$1 674,75
$1 780,01
$1 891,53
$2 287,69 		$298,29
Toc - Plan #65 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 		$184,53
$209,43
$235,81
$329,55
$500,78 		$325,69
$350,59
$376,97
$470,71 		$466,85
$491,75
$518,13
$611,87 		$608,01
$632,91
$659,29
$753,03 		$141,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$369,06
$418,86
$471,62
$659,10
$1 001,56 		$510,22
$560,02
$612,78
$800,26 		$651,38
$701,18
$753,94
$941,42 		$792,54
$842,34
$895,10
$1 082,58 		$141,16
Toc - Plan #66 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 		$259,60
$294,64
$331,76
$463,64
$704,54 		$458,19
$493,23
$530,35
$662,23 		$656,78
$691,82
$728,94
$860,82 		$855,37
$890,41
$927,53
$1 059,41 		$198,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519,20
$589,28
$663,52
$927,28
$1 409,08 		$717,79
$787,87
$862,11
$1 125,87 		$916,38
$986,46
$1 060,70
$1 324,46 		$1 114,97
$1 185,05
$1 259,29
$1 523,05 		$198,59
Toc - Plan #67 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 		$276,53
$313,85
$353,39
$493,87
$750,48 		$488,07
$525,39
$564,93
$705,41 		$699,61
$736,93
$776,47
$916,95 		$911,15
$948,47
$988,01
$1 128,49 		$211,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553,06
$627,70
$706,78
$987,74
$1 500,96 		$764,60
$839,24
$918,32
$1 199,28 		$976,14
$1 050,78
$1 129,86
$1 410,82 		$1 187,68
$1 262,32
$1 341,40
$1 622,36 		$211,54
Toc - Plan #68 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 		$274,29
$311,31
$350,53
$489,87
$744,40 		$484,12
$521,14
$560,36
$699,70 		$693,95
$730,97
$770,19
$909,53 		$903,78
$940,80
$980,02
$1 119,36 		$209,83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548,58
$622,62
$701,06
$979,74
$1 488,80 		$758,41
$832,45
$910,89
$1 189,57 		$968,24
$1 042,28
$1 120,72
$1 399,40 		$1 178,07
$1 252,11
$1 330,55
$1 609,23 		$209,83
Toc - Plan #69 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 		$310,01
$351,85
$396,18
$553,65
$841,33 		$547,16
$589,00
$633,33
$790,80 		$784,31
$826,15
$870,48
$1 027,95 		$1 021,46
$1 063,30
$1 107,63
$1 265,10 		$237,15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$620,02
$703,70
$792,36
$1 107,30
$1 682,66 		$857,17
$940,85
$1 029,51
$1 344,45 		$1 094,32
$1 178,00
$1 266,66
$1 581,60 		$1 331,47
$1 415,15
$1 503,81
$1 818,75 		$237,15

‡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 Fond Du Lac County here.

Fond Du Lac County is in “Rating Area 11” of Wisconsin.

Currently, there are 69 plans offered in Rating Area 11.

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2021 Obamacare Plans for Fond Du Lac County, WI

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