Obamacare 2023 Rates for Waushara County

Obamacare > Rates > Wisconsin > Waushara County

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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 Waushara County, WI.

The health insurance rates listed below are for calendar year 2023.

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, 131 Plans and 2023 Rates for Waushara County, Wisconsin

Below, you’ll find a summary of the 131 plans for Waushara 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

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

Waushara County Resources

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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 $1,000 w/Copay P-S Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$459.04
$521.01
$586.65
$819.85
$1,245.83 		$810.21
$872.18
$937.82
$1,171.02 		$1,161.38
$1,223.35
$1,288.99
$1,522.19 		$1,512.55
$1,574.52
$1,640.16
$1,873.36 		$351.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.08
$1,042.02
$1,173.30
$1,639.70
$2,491.66 		$1,269.25
$1,393.19
$1,524.47
$1,990.87 		$1,620.42
$1,744.36
$1,875.64
$2,342.04 		$1,971.59
$2,095.53
$2,226.81
$2,693.21 		$351.17
Toc - Plan #2 HealthPartners
Expanded Bronze

(PPO) Robin Oak $6,250 Plus Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 Annual Deductible
$9,100 $18,200 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 		$322.53
$366.07
$412.19
$576.04
$875.35 		$569.27
$612.81
$658.93
$822.78 		$816.01
$859.55
$905.67
$1,069.52 		$1,062.75
$1,106.29
$1,152.41
$1,316.26 		$246.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.06
$732.14
$824.38
$1,152.08
$1,750.70 		$891.80
$978.88
$1,071.12
$1,398.82 		$1,138.54
$1,225.62
$1,317.86
$1,645.56 		$1,385.28
$1,472.36
$1,564.60
$1,892.30 		$246.74
Toc - Plan #3 HealthPartners
Catastrophic

(PPO) Robin Oak $9,100 Catastrophic

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$243.13
$275.95
$310.72
$434.23
$659.85 		$429.12
$461.94
$496.71
$620.22 		$615.11
$647.93
$682.70
$806.21 		$801.10
$833.92
$868.69
$992.20 		$185.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.26
$551.90
$621.44
$868.46
$1,319.70 		$672.25
$737.89
$807.43
$1,054.45 		$858.24
$923.88
$993.42
$1,240.44 		$1,044.23
$1,109.87
$1,179.41
$1,426.43 		$185.99
Toc - Plan #4 HealthPartners
Silver

(PPO) Robin Oak $3,800 Plus Silver

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

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$8,700 $17,400 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 		$411.40
$466.94
$525.77
$734.76
$1,116.54 		$726.12
$781.66
$840.49
$1,049.48 		$1,040.84
$1,096.38
$1,155.21
$1,364.20 		$1,355.56
$1,411.10
$1,469.93
$1,678.92 		$314.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.80
$933.88
$1,051.54
$1,469.52
$2,233.08 		$1,137.52
$1,248.60
$1,366.26
$1,784.24 		$1,452.24
$1,563.32
$1,680.98
$2,098.96 		$1,766.96
$1,878.04
$1,995.70
$2,413.68 		$314.72
Toc - Plan #5 HealthPartners
Expanded Bronze

(PPO) Robin Oak $7,500 HSA Bronze

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

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 		$312.16
$354.30
$398.94
$557.52
$847.20 		$550.96
$593.10
$637.74
$796.32 		$789.76
$831.90
$876.54
$1,035.12 		$1,028.56
$1,070.70
$1,115.34
$1,273.92 		$238.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.32
$708.60
$797.88
$1,115.04
$1,694.40 		$863.12
$947.40
$1,036.68
$1,353.84 		$1,101.92
$1,186.20
$1,275.48
$1,592.64 		$1,340.72
$1,425.00
$1,514.28
$1,831.44 		$238.80
Toc - Plan #6 HealthPartners
Gold

(PPO) Robin Oak $2,000 w/Copay P-S Gold

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 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 		$443.24
$503.08
$566.46
$791.63
$1,202.95 		$782.32
$842.16
$905.54
$1,130.71 		$1,121.40
$1,181.24
$1,244.62
$1,469.79 		$1,460.48
$1,520.32
$1,583.70
$1,808.87 		$339.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.48
$1,006.16
$1,132.92
$1,583.26
$2,405.90 		$1,225.56
$1,345.24
$1,472.00
$1,922.34 		$1,564.64
$1,684.32
$1,811.08
$2,261.42 		$1,903.72
$2,023.40
$2,150.16
$2,600.50 		$339.08
Toc - Plan #7 HealthPartners
Silver

(PPO) Robin Oak $5,800 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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$412.61
$468.31
$527.32
$736.92
$1,119.82 		$728.26
$783.96
$842.97
$1,052.57 		$1,043.91
$1,099.61
$1,158.62
$1,368.22 		$1,359.56
$1,415.26
$1,474.27
$1,683.87 		$315.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.22
$936.62
$1,054.64
$1,473.84
$2,239.64 		$1,140.87
$1,252.27
$1,370.29
$1,789.49 		$1,456.52
$1,567.92
$1,685.94
$2,105.14 		$1,772.17
$1,883.57
$2,001.59
$2,420.79 		$315.65
Toc - Plan #8 HealthPartners
Expanded Bronze

(PPO) Robin Oak $7,500 w/Copay P-S Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$324.82
$368.67
$415.12
$580.13
$881.56 		$573.31
$617.16
$663.61
$828.62 		$821.80
$865.65
$912.10
$1,077.11 		$1,070.29
$1,114.14
$1,160.59
$1,325.60 		$248.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.64
$737.34
$830.24
$1,160.26
$1,763.12 		$898.13
$985.83
$1,078.73
$1,408.75 		$1,146.62
$1,234.32
$1,327.22
$1,657.24 		$1,395.11
$1,482.81
$1,575.71
$1,905.73 		$248.49
Toc - Plan #9 HealthPartners
Silver

(PPO) Robin Oak $3,500 HSA 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
$7,300 $14,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.83
$462.89
$521.21
$728.38
$1,106.85 		$719.82
$774.88
$833.20
$1,040.37 		$1,031.81
$1,086.87
$1,145.19
$1,352.36 		$1,343.80
$1,398.86
$1,457.18
$1,664.35 		$311.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.66
$925.78
$1,042.42
$1,456.76
$2,213.70 		$1,127.65
$1,237.77
$1,354.41
$1,768.75 		$1,439.64
$1,549.76
$1,666.40
$2,080.74 		$1,751.63
$1,861.75
$1,978.39
$2,392.73 		$311.99
Toc - Plan #10 HealthPartners
Silver

(PPO) Robin Select $3,800 Plus Silver

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

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$8,700 $17,400 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 		$366.17
$415.60
$467.97
$653.98
$993.79 		$646.29
$695.72
$748.09
$934.10 		$926.41
$975.84
$1,028.21
$1,214.22 		$1,206.53
$1,255.96
$1,308.33
$1,494.34 		$280.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.34
$831.20
$935.94
$1,307.96
$1,987.58 		$1,012.46
$1,111.32
$1,216.06
$1,588.08 		$1,292.58
$1,391.44
$1,496.18
$1,868.20 		$1,572.70
$1,671.56
$1,776.30
$2,148.32 		$280.12
Toc - Plan #11 HealthPartners
Silver

(PPO) Robin Select $5,800 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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$367.22
$416.79
$469.31
$655.85
$996.64 		$648.14
$697.71
$750.23
$936.77 		$929.06
$978.63
$1,031.15
$1,217.69 		$1,209.98
$1,259.55
$1,312.07
$1,498.61 		$280.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.44
$833.58
$938.62
$1,311.70
$1,993.28 		$1,015.36
$1,114.50
$1,219.54
$1,592.62 		$1,296.28
$1,395.42
$1,500.46
$1,873.54 		$1,577.20
$1,676.34
$1,781.38
$2,154.46 		$280.92
Toc - Plan #12 HealthPartners
Expanded Bronze

(PPO) Robin Select $6,250 Plus Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 Annual Deductible
$9,100 $18,200 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 		$287.04
$325.79
$366.84
$512.65
$779.03 		$506.63
$545.38
$586.43
$732.24 		$726.22
$764.97
$806.02
$951.83 		$945.81
$984.56
$1,025.61
$1,171.42 		$219.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.08
$651.58
$733.68
$1,025.30
$1,558.06 		$793.67
$871.17
$953.27
$1,244.89 		$1,013.26
$1,090.76
$1,172.86
$1,464.48 		$1,232.85
$1,310.35
$1,392.45
$1,684.07 		$219.59
Toc - Plan #13 HealthPartners
Expanded Bronze

(PPO) Robin Select $7,500 w/Copay P-S Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$289.10
$328.13
$369.47
$516.33
$784.62 		$510.26
$549.29
$590.63
$737.49 		$731.42
$770.45
$811.79
$958.65 		$952.58
$991.61
$1,032.95
$1,179.81 		$221.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.20
$656.26
$738.94
$1,032.66
$1,569.24 		$799.36
$877.42
$960.10
$1,253.82 		$1,020.52
$1,098.58
$1,181.26
$1,474.98 		$1,241.68
$1,319.74
$1,402.42
$1,696.14 		$221.16
Toc - Plan #14 HealthPartners
Silver

(PPO) Robin Select $3,500 HSA 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
$7,300 $14,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.95
$411.95
$463.85
$648.23
$985.05 		$640.61
$689.61
$741.51
$925.89 		$918.27
$967.27
$1,019.17
$1,203.55 		$1,195.93
$1,244.93
$1,296.83
$1,481.21 		$277.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.90
$823.90
$927.70
$1,296.46
$1,970.10 		$1,003.56
$1,101.56
$1,205.36
$1,574.12 		$1,281.22
$1,379.22
$1,483.02
$1,851.78 		$1,558.88
$1,656.88
$1,760.68
$2,129.44 		$277.66
Toc - Plan #15 HealthPartners
Expanded Bronze

(PPO) Robin Select $7,500 HSA Bronze

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

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 		$277.84
$315.35
$355.08
$496.22
$754.06 		$490.39
$527.90
$567.63
$708.77 		$702.94
$740.45
$780.18
$921.32 		$915.49
$953.00
$992.73
$1,133.87 		$212.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.68
$630.70
$710.16
$992.44
$1,508.12 		$768.23
$843.25
$922.71
$1,204.99 		$980.78
$1,055.80
$1,135.26
$1,417.54 		$1,193.33
$1,268.35
$1,347.81
$1,630.09 		$212.55
Toc - Plan #16 HealthPartners
Catastrophic

(PPO) Robin Select $9,100 Catastrophic

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$216.38
$245.59
$276.53
$386.45
$587.26 		$381.91
$411.12
$442.06
$551.98 		$547.44
$576.65
$607.59
$717.51 		$712.97
$742.18
$773.12
$883.04 		$165.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$432.76
$491.18
$553.06
$772.90
$1,174.52 		$598.29
$656.71
$718.59
$938.43 		$763.82
$822.24
$884.12
$1,103.96 		$929.35
$987.77
$1,049.65
$1,269.49 		$165.53

ADVERTISEMENT

Quartz

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310 | TTY: 1-800-877-8973
Toc - Plan #17 Quartz
Silver

(HMO) QUARTZ ONE SILVER I303 with Dental & Vision

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
$9,000 $18,000 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 		$512.03
$581.15
$654.37
$914.49
$1,389.65 		$903.73
$972.85
$1,046.07
$1,306.19 		$1,295.43
$1,364.55
$1,437.77
$1,697.89 		$1,687.13
$1,756.25
$1,829.47
$2,089.59 		$391.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,024.06
$1,162.30
$1,308.74
$1,828.98
$2,779.30 		$1,415.76
$1,554.00
$1,700.44
$2,220.68 		$1,807.46
$1,945.70
$2,092.14
$2,612.38 		$2,199.16
$2,337.40
$2,483.84
$3,004.08 		$391.70
Toc - Plan #18 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$537.22
$609.74
$686.56
$959.46
$1,458.00 		$948.19
$1,020.71
$1,097.53
$1,370.43 		$1,359.16
$1,431.68
$1,508.50
$1,781.40 		$1,770.13
$1,842.65
$1,919.47
$2,192.37 		$410.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,074.44
$1,219.48
$1,373.12
$1,918.92
$2,916.00 		$1,485.41
$1,630.45
$1,784.09
$2,329.89 		$1,896.38
$2,041.42
$2,195.06
$2,740.86 		$2,307.35
$2,452.39
$2,606.03
$3,151.83 		$410.97
Toc - Plan #19 Quartz
Silver

(HMO) Quartz One Silver I309 Standard with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$562.65
$638.61
$719.07
$1,004.89
$1,527.03 		$993.08
$1,069.04
$1,149.50
$1,435.32 		$1,423.51
$1,499.47
$1,579.93
$1,865.75 		$1,853.94
$1,929.90
$2,010.36
$2,296.18 		$430.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,125.30
$1,277.22
$1,438.14
$2,009.78
$3,054.06 		$1,555.73
$1,707.65
$1,868.57
$2,440.21 		$1,986.16
$2,138.08
$2,299.00
$2,870.64 		$2,416.59
$2,568.51
$2,729.43
$3,301.07 		$430.43
Toc - Plan #20 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I201 with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$380.83
$432.23
$486.69
$680.15
$1,033.55 		$672.16
$723.56
$778.02
$971.48 		$963.49
$1,014.89
$1,069.35
$1,262.81 		$1,254.82
$1,306.22
$1,360.68
$1,554.14 		$291.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.66
$864.46
$973.38
$1,360.30
$2,067.10 		$1,052.99
$1,155.79
$1,264.71
$1,651.63 		$1,344.32
$1,447.12
$1,556.04
$1,942.96 		$1,635.65
$1,738.45
$1,847.37
$2,234.29 		$291.33
Toc - Plan #21 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I202 with Dental & Vision

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
$9,000 $18,000 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 		$384.60
$436.51
$491.51
$686.88
$1,043.78 		$678.81
$730.72
$785.72
$981.09 		$973.02
$1,024.93
$1,079.93
$1,275.30 		$1,267.23
$1,319.14
$1,374.14
$1,569.51 		$294.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.20
$873.02
$983.02
$1,373.76
$2,087.56 		$1,063.41
$1,167.23
$1,277.23
$1,667.97 		$1,357.62
$1,461.44
$1,571.44
$1,962.18 		$1,651.83
$1,755.65
$1,865.65
$2,256.39 		$294.21
Toc - Plan #22 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 with Dental & Vision

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
$9,000 $18,000 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 		$403.14
$457.56
$515.20
$719.99
$1,094.10 		$711.54
$765.96
$823.60
$1,028.39 		$1,019.94
$1,074.36
$1,132.00
$1,336.79 		$1,328.34
$1,382.76
$1,440.40
$1,645.19 		$308.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.28
$915.12
$1,030.40
$1,439.98
$2,188.20 		$1,114.68
$1,223.52
$1,338.80
$1,748.38 		$1,423.08
$1,531.92
$1,647.20
$2,056.78 		$1,731.48
$1,840.32
$1,955.60
$2,365.18 		$308.40
Toc - Plan #23 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$399.02
$452.88
$509.94
$712.64
$1,082.92 		$704.26
$758.12
$815.18
$1,017.88 		$1,009.50
$1,063.36
$1,120.42
$1,323.12 		$1,314.74
$1,368.60
$1,425.66
$1,628.36 		$305.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.04
$905.76
$1,019.88
$1,425.28
$2,165.84 		$1,103.28
$1,211.00
$1,325.12
$1,730.52 		$1,408.52
$1,516.24
$1,630.36
$2,035.76 		$1,713.76
$1,821.48
$1,935.60
$2,341.00 		$305.24
Toc - Plan #24 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I206 Standard with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$415.44
$471.52
$530.93
$741.97
$1,127.50 		$733.25
$789.33
$848.74
$1,059.78 		$1,051.06
$1,107.14
$1,166.55
$1,377.59 		$1,368.87
$1,424.95
$1,484.36
$1,695.40 		$317.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.88
$943.04
$1,061.86
$1,483.94
$2,255.00 		$1,148.69
$1,260.85
$1,379.67
$1,801.75 		$1,466.50
$1,578.66
$1,697.48
$2,119.56 		$1,784.31
$1,896.47
$2,015.29
$2,437.37 		$317.81
Toc - Plan #25 Quartz
Gold

(HMO) Tiered Choice Plus Gold I407 Maintenance with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$520.83
$591.13
$665.61
$930.19
$1,413.51 		$919.26
$989.56
$1,064.04
$1,328.62 		$1,317.69
$1,387.99
$1,462.47
$1,727.05 		$1,716.12
$1,786.42
$1,860.90
$2,125.48 		$398.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,041.66
$1,182.26
$1,331.22
$1,860.38
$2,827.02 		$1,440.09
$1,580.69
$1,729.65
$2,258.81 		$1,838.52
$1,979.12
$2,128.08
$2,657.24 		$2,236.95
$2,377.55
$2,526.51
$3,055.67 		$398.43
Toc - Plan #26 Quartz
Gold

(HMO) Tiered Choice Plus Gold I406 with Dental & Vision

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
$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 		$455.81
$517.33
$582.51
$814.06
$1,237.05 		$804.50
$866.02
$931.20
$1,162.75 		$1,153.19
$1,214.71
$1,279.89
$1,511.44 		$1,501.88
$1,563.40
$1,628.58
$1,860.13 		$348.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.62
$1,034.66
$1,165.02
$1,628.12
$2,474.10 		$1,260.31
$1,383.35
$1,513.71
$1,976.81 		$1,609.00
$1,732.04
$1,862.40
$2,325.50 		$1,957.69
$2,080.73
$2,211.09
$2,674.19 		$348.69
Toc - Plan #27 Quartz
Gold

(HMO) Tiered Choice Plus Gold I409 with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$3,600 $7,200 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 		$464.85
$527.60
$594.07
$830.21
$1,261.59 		$820.46
$883.21
$949.68
$1,185.82 		$1,176.07
$1,238.82
$1,305.29
$1,541.43 		$1,531.68
$1,594.43
$1,660.90
$1,897.04 		$355.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.70
$1,055.20
$1,188.14
$1,660.42
$2,523.18 		$1,285.31
$1,410.81
$1,543.75
$2,016.03 		$1,640.92
$1,766.42
$1,899.36
$2,371.64 		$1,996.53
$2,122.03
$2,254.97
$2,727.25 		$355.61
Toc - Plan #28 Quartz
Silver

(HMO) Tiered Choice Plus Silver I305 with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$489.70
$555.81
$625.83
$874.60
$1,329.04 		$864.32
$930.43
$1,000.45
$1,249.22 		$1,238.94
$1,305.05
$1,375.07
$1,623.84 		$1,613.56
$1,679.67
$1,749.69
$1,998.46 		$374.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$979.40
$1,111.62
$1,251.66
$1,749.20
$2,658.08 		$1,354.02
$1,486.24
$1,626.28
$2,123.82 		$1,728.64
$1,860.86
$2,000.90
$2,498.44 		$2,103.26
$2,235.48
$2,375.52
$2,873.06 		$374.62
Toc - Plan #29 Quartz
Gold

(HMO) Quartz One Gold I410 Standard with Dental & Vision

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
$8,700 $17,400 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 		$513.96
$583.34
$656.84
$917.93
$1,394.88 		$907.14
$976.52
$1,050.02
$1,311.11 		$1,300.32
$1,369.70
$1,443.20
$1,704.29 		$1,693.50
$1,762.88
$1,836.38
$2,097.47 		$393.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,027.92
$1,166.68
$1,313.68
$1,835.86
$2,789.76 		$1,421.10
$1,559.86
$1,706.86
$2,229.04 		$1,814.28
$1,953.04
$2,100.04
$2,622.22 		$2,207.46
$2,346.22
$2,493.22
$3,015.40 		$393.18
Toc - Plan #30 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
$8,000 $16,000 Annual Deductible
$9,000 $18,000 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 		$489.33
$555.39
$625.36
$873.94
$1,328.04 		$863.67
$929.73
$999.70
$1,248.28 		$1,238.01
$1,304.07
$1,374.04
$1,622.62 		$1,612.35
$1,678.41
$1,748.38
$1,996.96 		$374.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$978.66
$1,110.78
$1,250.72
$1,747.88
$2,656.08 		$1,353.00
$1,485.12
$1,625.06
$2,122.22 		$1,727.34
$1,859.46
$1,999.40
$2,496.56 		$2,101.68
$2,233.80
$2,373.74
$2,870.90 		$374.34
Toc - Plan #31 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $18,000 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 		$513.40
$582.70
$656.12
$916.93
$1,393.36 		$906.15
$975.45
$1,048.87
$1,309.68 		$1,298.90
$1,368.20
$1,441.62
$1,702.43 		$1,691.65
$1,760.95
$1,834.37
$2,095.18 		$392.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,026.80
$1,165.40
$1,312.24
$1,833.86
$2,786.72 		$1,419.55
$1,558.15
$1,704.99
$2,226.61 		$1,812.30
$1,950.90
$2,097.74
$2,619.36 		$2,205.05
$2,343.65
$2,490.49
$3,012.11 		$392.75
Toc - Plan #32 Quartz
Silver

(HMO) Quartz One Silver I309 Standard

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$537.71
$610.29
$687.19
$960.34
$1,459.33 		$949.05
$1,021.63
$1,098.53
$1,371.68 		$1,360.39
$1,432.97
$1,509.87
$1,783.02 		$1,771.73
$1,844.31
$1,921.21
$2,194.36 		$411.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,075.42
$1,220.58
$1,374.38
$1,920.68
$2,918.66 		$1,486.76
$1,631.92
$1,785.72
$2,332.02 		$1,898.10
$2,043.26
$2,197.06
$2,743.36 		$2,309.44
$2,454.60
$2,608.40
$3,154.70 		$411.34
Toc - Plan #33 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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$363.94
$413.07
$465.11
$649.99
$987.73 		$642.35
$691.48
$743.52
$928.40 		$920.76
$969.89
$1,021.93
$1,206.81 		$1,199.17
$1,248.30
$1,300.34
$1,485.22 		$278.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.88
$826.14
$930.22
$1,299.98
$1,975.46 		$1,006.29
$1,104.55
$1,208.63
$1,578.39 		$1,284.70
$1,382.96
$1,487.04
$1,856.80 		$1,563.11
$1,661.37
$1,765.45
$2,135.21 		$278.41
Toc - Plan #34 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
$8,000 $16,000 Annual Deductible
$9,000 $18,000 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 		$367.55
$417.16
$469.72
$656.43
$997.50 		$648.72
$698.33
$750.89
$937.60 		$929.89
$979.50
$1,032.06
$1,218.77 		$1,211.06
$1,260.67
$1,313.23
$1,499.94 		$281.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.10
$834.32
$939.44
$1,312.86
$1,995.00 		$1,016.27
$1,115.49
$1,220.61
$1,594.03 		$1,297.44
$1,396.66
$1,501.78
$1,875.20 		$1,578.61
$1,677.83
$1,782.95
$2,156.37 		$281.17
Toc - Plan #35 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
$3,000 $6,000 Annual Deductible
$9,000 $18,000 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 		$385.26
$437.27
$492.36
$688.07
$1,045.59 		$679.98
$731.99
$787.08
$982.79 		$974.70
$1,026.71
$1,081.80
$1,277.51 		$1,269.42
$1,321.43
$1,376.52
$1,572.23 		$294.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.52
$874.54
$984.72
$1,376.14
$2,091.18 		$1,065.24
$1,169.26
$1,279.44
$1,670.86 		$1,359.96
$1,463.98
$1,574.16
$1,965.58 		$1,654.68
$1,758.70
$1,868.88
$2,260.30 		$294.72
Toc - Plan #36 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$381.33
$432.80
$487.33
$681.04
$1,034.91 		$673.04
$724.51
$779.04
$972.75 		$964.75
$1,016.22
$1,070.75
$1,264.46 		$1,256.46
$1,307.93
$1,362.46
$1,556.17 		$291.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.66
$865.60
$974.66
$1,362.08
$2,069.82 		$1,054.37
$1,157.31
$1,266.37
$1,653.79 		$1,346.08
$1,449.02
$1,558.08
$1,945.50 		$1,637.79
$1,740.73
$1,849.79
$2,237.21 		$291.71
Toc - Plan #37 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I206 Standard

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$397.03
$450.62
$507.39
$709.08
$1,077.51 		$700.75
$754.34
$811.11
$1,012.80 		$1,004.47
$1,058.06
$1,114.83
$1,316.52 		$1,308.19
$1,361.78
$1,418.55
$1,620.24 		$303.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.06
$901.24
$1,014.78
$1,418.16
$2,155.02 		$1,097.78
$1,204.96
$1,318.50
$1,721.88 		$1,401.50
$1,508.68
$1,622.22
$2,025.60 		$1,705.22
$1,812.40
$1,925.94
$2,329.32 		$303.72
Toc - Plan #38 Quartz
Gold

(HMO) Tiered Choice Plus Gold I407 Maintenance

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$497.74
$564.93
$636.10
$888.95
$1,350.85 		$878.51
$945.70
$1,016.87
$1,269.72 		$1,259.28
$1,326.47
$1,397.64
$1,650.49 		$1,640.05
$1,707.24
$1,778.41
$2,031.26 		$380.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$995.48
$1,129.86
$1,272.20
$1,777.90
$2,701.70 		$1,376.25
$1,510.63
$1,652.97
$2,158.67 		$1,757.02
$1,891.40
$2,033.74
$2,539.44 		$2,137.79
$2,272.17
$2,414.51
$2,920.21 		$380.77
Toc - Plan #39 Quartz
Gold

(HMO) Tiered Choice Plus Gold I406

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
$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 		$435.60
$494.40
$556.69
$777.97
$1,182.20 		$768.83
$827.63
$889.92
$1,111.20 		$1,102.06
$1,160.86
$1,223.15
$1,444.43 		$1,435.29
$1,494.09
$1,556.38
$1,777.66 		$333.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.20
$988.80
$1,113.38
$1,555.94
$2,364.40 		$1,204.43
$1,322.03
$1,446.61
$1,889.17 		$1,537.66
$1,655.26
$1,779.84
$2,222.40 		$1,870.89
$1,988.49
$2,113.07
$2,555.63 		$333.23
Toc - Plan #40 Quartz
Gold

(HMO) Tiered Choice Plus Gold I409

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$3,600 $7,200 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 		$444.24
$504.21
$567.73
$793.40
$1,205.66 		$784.08
$844.05
$907.57
$1,133.24 		$1,123.92
$1,183.89
$1,247.41
$1,473.08 		$1,463.76
$1,523.73
$1,587.25
$1,812.92 		$339.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.48
$1,008.42
$1,135.46
$1,586.80
$2,411.32 		$1,228.32
$1,348.26
$1,475.30
$1,926.64 		$1,568.16
$1,688.10
$1,815.14
$2,266.48 		$1,908.00
$2,027.94
$2,154.98
$2,606.32 		$339.84
Toc - Plan #41 Quartz
Silver

(HMO) Tiered Choice Plus Silver I305

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$467.99
$531.16
$598.08
$835.82
$1,270.11 		$826.00
$889.17
$956.09
$1,193.83 		$1,184.01
$1,247.18
$1,314.10
$1,551.84 		$1,542.02
$1,605.19
$1,672.11
$1,909.85 		$358.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$935.98
$1,062.32
$1,196.16
$1,671.64
$2,540.22 		$1,293.99
$1,420.33
$1,554.17
$2,029.65 		$1,652.00
$1,778.34
$1,912.18
$2,387.66 		$2,010.01
$2,136.35
$2,270.19
$2,745.67 		$358.01
Toc - Plan #42 Quartz
Gold

(HMO) Quartz One Gold I410 Standard

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
$8,700 $17,400 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 		$491.17
$557.48
$627.72
$877.23
$1,333.03 		$866.91
$933.22
$1,003.46
$1,252.97 		$1,242.65
$1,308.96
$1,379.20
$1,628.71 		$1,618.39
$1,684.70
$1,754.94
$2,004.45 		$375.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$982.34
$1,114.96
$1,255.44
$1,754.46
$2,666.06 		$1,358.08
$1,490.70
$1,631.18
$2,130.20 		$1,733.82
$1,866.44
$2,006.92
$2,505.94 		$2,109.56
$2,242.18
$2,382.66
$2,881.68 		$375.74
Toc - Plan #43 Quartz
Gold

(HMO) Tiered Choice Plus Gold I408 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 		$461.19
$523.44
$589.39
$823.67
$1,251.65 		$814.00
$876.25
$942.20
$1,176.48 		$1,166.81
$1,229.06
$1,295.01
$1,529.29 		$1,519.62
$1,581.87
$1,647.82
$1,882.10 		$352.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.38
$1,046.88
$1,178.78
$1,647.34
$2,503.30 		$1,275.19
$1,399.69
$1,531.59
$2,000.15 		$1,628.00
$1,752.50
$1,884.40
$2,352.96 		$1,980.81
$2,105.31
$2,237.21
$2,705.77 		$352.81
Toc - Plan #44 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I203

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 		$382.47
$434.09
$488.79
$683.08
$1,038.00 		$675.05
$726.67
$781.37
$975.66 		$967.63
$1,019.25
$1,073.95
$1,268.24 		$1,260.21
$1,311.83
$1,366.53
$1,560.82 		$292.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.94
$868.18
$977.58
$1,366.16
$2,076.00 		$1,057.52
$1,160.76
$1,270.16
$1,658.74 		$1,350.10
$1,453.34
$1,562.74
$1,951.32 		$1,642.68
$1,745.92
$1,855.32
$2,243.90 		$292.58
Toc - Plan #45 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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$281.95
$320.00
$360.32
$503.55
$765.19 		$497.64
$535.69
$576.01
$719.24 		$713.33
$751.38
$791.70
$934.93 		$929.02
$967.07
$1,007.39
$1,150.62 		$215.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.90
$640.00
$720.64
$1,007.10
$1,530.38 		$779.59
$855.69
$936.33
$1,222.79 		$995.28
$1,071.38
$1,152.02
$1,438.48 		$1,210.97
$1,287.07
$1,367.71
$1,654.17 		$215.69
Toc - Plan #46 Quartz
Silver

(HMO) Tiered Choice Plus Silver I310 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
$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 		$514.65
$584.12
$657.71
$919.15
$1,396.74 		$908.35
$977.82
$1,051.41
$1,312.85 		$1,302.05
$1,371.52
$1,445.11
$1,706.55 		$1,695.75
$1,765.22
$1,838.81
$2,100.25 		$393.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,029.30
$1,168.24
$1,315.42
$1,838.30
$2,793.48 		$1,423.00
$1,561.94
$1,709.12
$2,232.00 		$1,816.70
$1,955.64
$2,102.82
$2,625.70 		$2,210.40
$2,349.34
$2,496.52
$3,019.40 		$393.70
Toc - Plan #47 Quartz
Silver

(HMO) Tiered Choice Plus Silver I311 HSA

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
$4,400 $8,800 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 		$504.51
$572.61
$644.75
$901.04
$1,369.22 		$890.45
$958.55
$1,030.69
$1,286.98 		$1,276.39
$1,344.49
$1,416.63
$1,672.92 		$1,662.33
$1,730.43
$1,802.57
$2,058.86 		$385.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,009.02
$1,145.22
$1,289.50
$1,802.08
$2,738.44 		$1,394.96
$1,531.16
$1,675.44
$2,188.02 		$1,780.90
$1,917.10
$2,061.38
$2,573.96 		$2,166.84
$2,303.04
$2,447.32
$2,959.90 		$385.94
Toc - Plan #48 Quartz
Silver

(HMO) QUARTZ ONE SILVER I303 with Vision

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
$9,000 $18,000 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 		$495.02
$561.84
$632.63
$884.09
$1,343.46 		$873.70
$940.52
$1,011.31
$1,262.77 		$1,252.38
$1,319.20
$1,389.99
$1,641.45 		$1,631.06
$1,697.88
$1,768.67
$2,020.13 		$378.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$990.04
$1,123.68
$1,265.26
$1,768.18
$2,686.92 		$1,368.72
$1,502.36
$1,643.94
$2,146.86 		$1,747.40
$1,881.04
$2,022.62
$2,525.54 		$2,126.08
$2,259.72
$2,401.30
$2,904.22 		$378.68
Toc - Plan #49 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $18,000 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 		$519.36
$589.47
$663.74
$927.58
$1,409.54 		$916.67
$986.78
$1,061.05
$1,324.89 		$1,313.98
$1,384.09
$1,458.36
$1,722.20 		$1,711.29
$1,781.40
$1,855.67
$2,119.51 		$397.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,038.72
$1,178.94
$1,327.48
$1,855.16
$2,819.08 		$1,436.03
$1,576.25
$1,724.79
$2,252.47 		$1,833.34
$1,973.56
$2,122.10
$2,649.78 		$2,230.65
$2,370.87
$2,519.41
$3,047.09 		$397.31
Toc - Plan #50 Quartz
Silver

(HMO) Quartz One Silver I309 Standard with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$543.96
$617.38
$695.17
$971.49
$1,476.28 		$960.08
$1,033.50
$1,111.29
$1,387.61 		$1,376.20
$1,449.62
$1,527.41
$1,803.73 		$1,792.32
$1,865.74
$1,943.53
$2,219.85 		$416.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,087.92
$1,234.76
$1,390.34
$1,942.98
$2,952.56 		$1,504.04
$1,650.88
$1,806.46
$2,359.10 		$1,920.16
$2,067.00
$2,222.58
$2,775.22 		$2,336.28
$2,483.12
$2,638.70
$3,191.34 		$416.12
Toc - Plan #51 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I201 with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$368.17
$417.87
$470.52
$657.55
$999.20 		$649.82
$699.52
$752.17
$939.20 		$931.47
$981.17
$1,033.82
$1,220.85 		$1,213.12
$1,262.82
$1,315.47
$1,502.50 		$281.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.34
$835.74
$941.04
$1,315.10
$1,998.40 		$1,017.99
$1,117.39
$1,222.69
$1,596.75 		$1,299.64
$1,399.04
$1,504.34
$1,878.40 		$1,581.29
$1,680.69
$1,785.99
$2,160.05 		$281.65
Toc - Plan #52 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I202 with Vision

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
$9,000 $18,000 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 		$371.81
$422.00
$475.17
$664.05
$1,009.09 		$656.24
$706.43
$759.60
$948.48 		$940.67
$990.86
$1,044.03
$1,232.91 		$1,225.10
$1,275.29
$1,328.46
$1,517.34 		$284.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.62
$844.00
$950.34
$1,328.10
$2,018.18 		$1,028.05
$1,128.43
$1,234.77
$1,612.53 		$1,312.48
$1,412.86
$1,519.20
$1,896.96 		$1,596.91
$1,697.29
$1,803.63
$2,181.39 		$284.43
Toc - Plan #53 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 with Vision

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
$9,000 $18,000 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 		$389.74
$442.35
$498.08
$696.07
$1,057.74 		$687.89
$740.50
$796.23
$994.22 		$986.04
$1,038.65
$1,094.38
$1,292.37 		$1,284.19
$1,336.80
$1,392.53
$1,590.52 		$298.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.48
$884.70
$996.16
$1,392.14
$2,115.48 		$1,077.63
$1,182.85
$1,294.31
$1,690.29 		$1,375.78
$1,481.00
$1,592.46
$1,988.44 		$1,673.93
$1,779.15
$1,890.61
$2,286.59 		$298.15
Toc - Plan #54 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$385.76
$437.83
$492.99
$688.95
$1,046.93 		$680.86
$732.93
$788.09
$984.05 		$975.96
$1,028.03
$1,083.19
$1,279.15 		$1,271.06
$1,323.13
$1,378.29
$1,574.25 		$295.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.52
$875.66
$985.98
$1,377.90
$2,093.86 		$1,066.62
$1,170.76
$1,281.08
$1,673.00 		$1,361.72
$1,465.86
$1,576.18
$1,968.10 		$1,656.82
$1,760.96
$1,871.28
$2,263.20 		$295.10
Toc - Plan #55 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I206 Standard with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$401.64
$455.85
$513.29
$717.31
$1,090.03 		$708.89
$763.10
$820.54
$1,024.56 		$1,016.14
$1,070.35
$1,127.79
$1,331.81 		$1,323.39
$1,377.60
$1,435.04
$1,639.06 		$307.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.28
$911.70
$1,026.58
$1,434.62
$2,180.06 		$1,110.53
$1,218.95
$1,333.83
$1,741.87 		$1,417.78
$1,526.20
$1,641.08
$2,049.12 		$1,725.03
$1,833.45
$1,948.33
$2,356.37 		$307.25
Toc - Plan #56 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I203 with Vision

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 		$386.91
$439.14
$494.46
$691.01
$1,050.06 		$682.89
$735.12
$790.44
$986.99 		$978.87
$1,031.10
$1,086.42
$1,282.97 		$1,274.85
$1,327.08
$1,382.40
$1,578.95 		$295.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.82
$878.28
$988.92
$1,382.02
$2,100.12 		$1,069.80
$1,174.26
$1,284.90
$1,678.00 		$1,365.78
$1,470.24
$1,580.88
$1,973.98 		$1,661.76
$1,766.22
$1,876.86
$2,269.96 		$295.98
Toc - Plan #57 Quartz
Gold

(HMO) Tiered Choice Plus Gold I407 Maintenance with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$503.52
$571.49
$643.49
$899.28
$1,366.54 		$888.71
$956.68
$1,028.68
$1,284.47 		$1,273.90
$1,341.87
$1,413.87
$1,669.66 		$1,659.09
$1,727.06
$1,799.06
$2,054.85 		$385.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,007.04
$1,142.98
$1,286.98
$1,798.56
$2,733.08 		$1,392.23
$1,528.17
$1,672.17
$2,183.75 		$1,777.42
$1,913.36
$2,057.36
$2,568.94 		$2,162.61
$2,298.55
$2,442.55
$2,954.13 		$385.19
Toc - Plan #58 Quartz
Gold

(HMO) Tiered Choice Plus Gold I406 with Vision

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
$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 		$440.66
$500.14
$563.15
$787.01
$1,195.93 		$777.76
$837.24
$900.25
$1,124.11 		$1,114.86
$1,174.34
$1,237.35
$1,461.21 		$1,451.96
$1,511.44
$1,574.45
$1,798.31 		$337.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.32
$1,000.28
$1,126.30
$1,574.02
$2,391.86 		$1,218.42
$1,337.38
$1,463.40
$1,911.12 		$1,555.52
$1,674.48
$1,800.50
$2,248.22 		$1,892.62
$2,011.58
$2,137.60
$2,585.32 		$337.10
Toc - Plan #59 Quartz
Gold

(HMO) Tiered Choice Plus Gold I409 with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$3,600 $7,200 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 		$449.40
$510.06
$574.33
$802.62
$1,219.66 		$793.19
$853.85
$918.12
$1,146.41 		$1,136.98
$1,197.64
$1,261.91
$1,490.20 		$1,480.77
$1,541.43
$1,605.70
$1,833.99 		$343.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.80
$1,020.12
$1,148.66
$1,605.24
$2,439.32 		$1,242.59
$1,363.91
$1,492.45
$1,949.03 		$1,586.38
$1,707.70
$1,836.24
$2,292.82 		$1,930.17
$2,051.49
$2,180.03
$2,636.61 		$343.79
Toc - Plan #60 Quartz
Silver

(HMO) Tiered Choice Plus Silver I305 with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$473.43
$537.33
$605.03
$845.53
$1,284.87 		$835.60
$899.50
$967.20
$1,207.70 		$1,197.77
$1,261.67
$1,329.37
$1,569.87 		$1,559.94
$1,623.84
$1,691.54
$1,932.04 		$362.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$946.86
$1,074.66
$1,210.06
$1,691.06
$2,569.74 		$1,309.03
$1,436.83
$1,572.23
$2,053.23 		$1,671.20
$1,799.00
$1,934.40
$2,415.40 		$2,033.37
$2,161.17
$2,296.57
$2,777.57 		$362.17
Toc - Plan #61 Quartz
Gold

(HMO) Tiered Choice Plus Gold I408 HSA with Vision

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 		$466.55
$529.52
$596.24
$833.24
$1,266.19 		$823.45
$886.42
$953.14
$1,190.14 		$1,180.35
$1,243.32
$1,310.04
$1,547.04 		$1,537.25
$1,600.22
$1,666.94
$1,903.94 		$356.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$933.10
$1,059.04
$1,192.48
$1,666.48
$2,532.38 		$1,290.00
$1,415.94
$1,549.38
$2,023.38 		$1,646.90
$1,772.84
$1,906.28
$2,380.28 		$2,003.80
$2,129.74
$2,263.18
$2,737.18 		$356.90
Toc - Plan #62 Quartz
Silver

(HMO) Tiered Choice Plus Silver I310 HSA with Vision

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
$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 		$520.63
$590.91
$665.35
$929.83
$1,412.97 		$918.91
$989.19
$1,063.63
$1,328.11 		$1,317.19
$1,387.47
$1,461.91
$1,726.39 		$1,715.47
$1,785.75
$1,860.19
$2,124.67 		$398.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,041.26
$1,181.82
$1,330.70
$1,859.66
$2,825.94 		$1,439.54
$1,580.10
$1,728.98
$2,257.94 		$1,837.82
$1,978.38
$2,127.26
$2,656.22 		$2,236.10
$2,376.66
$2,525.54
$3,054.50 		$398.28
Toc - Plan #63 Quartz
Silver

(HMO) Tiered Choice Plus Silver I311 HSA with Vision

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
$4,400 $8,800 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 		$510.37
$579.26
$652.24
$911.51
$1,385.12 		$900.80
$969.69
$1,042.67
$1,301.94 		$1,291.23
$1,360.12
$1,433.10
$1,692.37 		$1,681.66
$1,750.55
$1,823.53
$2,082.80 		$390.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,020.74
$1,158.52
$1,304.48
$1,823.02
$2,770.24 		$1,411.17
$1,548.95
$1,694.91
$2,213.45 		$1,801.60
$1,939.38
$2,085.34
$2,603.88 		$2,192.03
$2,329.81
$2,475.77
$2,994.31 		$390.43
Toc - Plan #64 Quartz
Gold

(HMO) Quartz One Gold I410 Standard with Vision

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
$8,700 $17,400 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 		$496.88
$563.95
$635.01
$887.42
$1,348.52 		$876.99
$944.06
$1,015.12
$1,267.53 		$1,257.10
$1,324.17
$1,395.23
$1,647.64 		$1,637.21
$1,704.28
$1,775.34
$2,027.75 		$380.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$993.76
$1,127.90
$1,270.02
$1,774.84
$2,697.04 		$1,373.87
$1,508.01
$1,650.13
$2,154.95 		$1,753.98
$1,888.12
$2,030.24
$2,535.06 		$2,134.09
$2,268.23
$2,410.35
$2,915.17 		$380.11

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #65 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
$1,900 $3,800 Annual Deductible
$9,100 $18,200 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 		$449.08
$509.71
$573.93
$802.06
$1,218.81 		$792.63
$853.26
$917.48
$1,145.61 		$1,136.18
$1,196.81
$1,261.03
$1,489.16 		$1,479.73
$1,540.36
$1,604.58
$1,832.71 		$343.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.16
$1,019.42
$1,147.86
$1,604.12
$2,437.62 		$1,241.71
$1,362.97
$1,491.41
$1,947.67 		$1,585.26
$1,706.52
$1,834.96
$2,291.22 		$1,928.81
$2,050.07
$2,178.51
$2,634.77 		$343.55
Toc - Plan #66 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
$2,500 $5,000 Annual Deductible
$9,100 $18,200 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 		$376.98
$427.87
$481.78
$673.28
$1,023.12 		$665.37
$716.26
$770.17
$961.67 		$953.76
$1,004.65
$1,058.56
$1,250.06 		$1,242.15
$1,293.04
$1,346.95
$1,538.45 		$288.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.96
$855.74
$963.56
$1,346.56
$2,046.24 		$1,042.35
$1,144.13
$1,251.95
$1,634.95 		$1,330.74
$1,432.52
$1,540.34
$1,923.34 		$1,619.13
$1,720.91
$1,828.73
$2,211.73 		$288.39
Toc - Plan #67 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 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 		$458.76
$520.69
$586.29
$819.34
$1,245.06 		$809.71
$871.64
$937.24
$1,170.29 		$1,160.66
$1,222.59
$1,288.19
$1,521.24 		$1,511.61
$1,573.54
$1,639.14
$1,872.19 		$350.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.52
$1,041.38
$1,172.58
$1,638.68
$2,490.12 		$1,268.47
$1,392.33
$1,523.53
$1,989.63 		$1,619.42
$1,743.28
$1,874.48
$2,340.58 		$1,970.37
$2,094.23
$2,225.43
$2,691.53 		$350.95
Toc - Plan #68 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$387.69
$440.03
$495.47
$692.42
$1,052.19 		$684.27
$736.61
$792.05
$989.00 		$980.85
$1,033.19
$1,088.63
$1,285.58 		$1,277.43
$1,329.77
$1,385.21
$1,582.16 		$296.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.38
$880.06
$990.94
$1,384.84
$2,104.38 		$1,071.96
$1,176.64
$1,287.52
$1,681.42 		$1,368.54
$1,473.22
$1,584.10
$1,978.00 		$1,665.12
$1,769.80
$1,880.68
$2,274.58 		$296.58
Toc - Plan #69 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
$1,900 $3,800 Annual Deductible
$9,100 $18,200 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 		$453.33
$514.52
$579.35
$809.64
$1,230.33 		$800.12
$861.31
$926.14
$1,156.43 		$1,146.91
$1,208.10
$1,272.93
$1,503.22 		$1,493.70
$1,554.89
$1,619.72
$1,850.01 		$346.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$906.66
$1,029.04
$1,158.70
$1,619.28
$2,460.66 		$1,253.45
$1,375.83
$1,505.49
$1,966.07 		$1,600.24
$1,722.62
$1,852.28
$2,312.86 		$1,947.03
$2,069.41
$2,199.07
$2,659.65 		$346.79
Toc - Plan #70 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
$2,500 $5,000 Annual Deductible
$9,100 $18,200 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 		$387.27
$439.55
$494.93
$691.66
$1,051.05 		$683.53
$735.81
$791.19
$987.92 		$979.79
$1,032.07
$1,087.45
$1,284.18 		$1,276.05
$1,328.33
$1,383.71
$1,580.44 		$296.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.54
$879.10
$989.86
$1,383.32
$2,102.10 		$1,070.80
$1,175.36
$1,286.12
$1,679.58 		$1,367.06
$1,471.62
$1,582.38
$1,975.84 		$1,663.32
$1,767.88
$1,878.64
$2,272.10 		$296.26

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1813 | Toll Free: 1-855-748-1813

Toc - Plan #71 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$337.56
$383.13
$431.40
$602.88
$916.14 		$595.79
$641.36
$689.63
$861.11 		$854.02
$899.59
$947.86
$1,119.34 		$1,112.25
$1,157.82
$1,206.09
$1,377.57 		$258.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.12
$766.26
$862.80
$1,205.76
$1,832.28 		$933.35
$1,024.49
$1,121.03
$1,463.99 		$1,191.58
$1,282.72
$1,379.26
$1,722.22 		$1,449.81
$1,540.95
$1,637.49
$1,980.45 		$258.23
Toc - Plan #72 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,100 $18,200 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 		$327.30
$371.49
$418.29
$584.56
$888.29 		$577.68
$621.87
$668.67
$834.94 		$828.06
$872.25
$919.05
$1,085.32 		$1,078.44
$1,122.63
$1,169.43
$1,335.70 		$250.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.60
$742.98
$836.58
$1,169.12
$1,776.58 		$904.98
$993.36
$1,086.96
$1,419.50 		$1,155.36
$1,243.74
$1,337.34
$1,669.88 		$1,405.74
$1,494.12
$1,587.72
$1,920.26 		$250.38
Toc - Plan #73 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 6550 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$6,550 $13,100 Annual Deductible
$9,100 $18,200 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 		$321.43
$364.82
$410.79
$574.07
$872.36 		$567.32
$610.71
$656.68
$819.96 		$813.21
$856.60
$902.57
$1,065.85 		$1,059.10
$1,102.49
$1,148.46
$1,311.74 		$245.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.86
$729.64
$821.58
$1,148.14
$1,744.72 		$888.75
$975.53
$1,067.47
$1,394.03 		$1,134.64
$1,221.42
$1,313.36
$1,639.92 		$1,380.53
$1,467.31
$1,559.25
$1,885.81 		$245.89
Toc - Plan #74 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$304.67
$345.80
$389.37
$544.14
$826.87 		$537.74
$578.87
$622.44
$777.21 		$770.81
$811.94
$855.51
$1,010.28 		$1,003.88
$1,045.01
$1,088.58
$1,243.35 		$233.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.34
$691.60
$778.74
$1,088.28
$1,653.74 		$842.41
$924.67
$1,011.81
$1,321.35 		$1,075.48
$1,157.74
$1,244.88
$1,554.42 		$1,308.55
$1,390.81
$1,477.95
$1,787.49 		$233.07
Toc - Plan #75 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$320.77
$364.07
$409.94
$572.90
$870.57 		$566.16
$609.46
$655.33
$818.29 		$811.55
$854.85
$900.72
$1,063.68 		$1,056.94
$1,100.24
$1,146.11
$1,309.07 		$245.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.54
$728.14
$819.88
$1,145.80
$1,741.14 		$886.93
$973.53
$1,065.27
$1,391.19 		$1,132.32
$1,218.92
$1,310.66
$1,636.58 		$1,377.71
$1,464.31
$1,556.05
$1,881.97 		$245.39
Toc - Plan #76 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Preferred/Broad 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$416.09
$472.26
$531.76
$743.14
$1,129.27 		$734.40
$790.57
$850.07
$1,061.45 		$1,052.71
$1,108.88
$1,168.38
$1,379.76 		$1,371.02
$1,427.19
$1,486.69
$1,698.07 		$318.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.18
$944.52
$1,063.52
$1,486.28
$2,258.54 		$1,150.49
$1,262.83
$1,381.83
$1,804.59 		$1,468.80
$1,581.14
$1,700.14
$2,122.90 		$1,787.11
$1,899.45
$2,018.45
$2,441.21 		$318.31
Toc - Plan #77 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 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 		$401.73
$455.96
$513.41
$717.49
$1,090.30 		$709.05
$763.28
$820.73
$1,024.81 		$1,016.37
$1,070.60
$1,128.05
$1,332.13 		$1,323.69
$1,377.92
$1,435.37
$1,639.45 		$307.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.46
$911.92
$1,026.82
$1,434.98
$2,180.60 		$1,110.78
$1,219.24
$1,334.14
$1,742.30 		$1,418.10
$1,526.56
$1,641.46
$2,049.62 		$1,725.42
$1,833.88
$1,948.78
$2,356.94 		$307.32
Toc - Plan #78 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,250 $14,500 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 		$406.56
$461.45
$519.58
$726.12
$1,103.40 		$717.58
$772.47
$830.60
$1,037.14 		$1,028.60
$1,083.49
$1,141.62
$1,348.16 		$1,339.62
$1,394.51
$1,452.64
$1,659.18 		$311.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.12
$922.90
$1,039.16
$1,452.24
$2,206.80 		$1,124.14
$1,233.92
$1,350.18
$1,763.26 		$1,435.16
$1,544.94
$1,661.20
$2,074.28 		$1,746.18
$1,855.96
$1,972.22
$2,385.30 		$311.02
Toc - Plan #79 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 5300 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 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 		$399.37
$453.28
$510.39
$713.27
$1,083.89 		$704.89
$758.80
$815.91
$1,018.79 		$1,010.41
$1,064.32
$1,121.43
$1,324.31 		$1,315.93
$1,369.84
$1,426.95
$1,629.83 		$305.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.74
$906.56
$1,020.78
$1,426.54
$2,167.78 		$1,104.26
$1,212.08
$1,326.30
$1,732.06 		$1,409.78
$1,517.60
$1,631.82
$2,037.58 		$1,715.30
$1,823.12
$1,937.34
$2,343.10 		$305.52
Toc - Plan #80 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$305.11
$346.30
$389.93
$544.93
$828.07 		$538.52
$579.71
$623.34
$778.34 		$771.93
$813.12
$856.75
$1,011.75 		$1,005.34
$1,046.53
$1,090.16
$1,245.16 		$233.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.22
$692.60
$779.86
$1,089.86
$1,656.14 		$843.63
$926.01
$1,013.27
$1,323.27 		$1,077.04
$1,159.42
$1,246.68
$1,556.68 		$1,310.45
$1,392.83
$1,480.09
$1,790.09 		$233.41
Toc - Plan #81 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$331.63
$376.40
$423.82
$592.29
$900.04 		$585.33
$630.10
$677.52
$845.99 		$839.03
$883.80
$931.22
$1,099.69 		$1,092.73
$1,137.50
$1,184.92
$1,353.39 		$253.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663.26
$752.80
$847.64
$1,184.58
$1,800.08 		$916.96
$1,006.50
$1,101.34
$1,438.28 		$1,170.66
$1,260.20
$1,355.04
$1,691.98 		$1,424.36
$1,513.90
$1,608.74
$1,945.68 		$253.70
Toc - Plan #82 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$395.97
$449.43
$506.05
$707.20
$1,074.66 		$698.89
$752.35
$808.97
$1,010.12 		$1,001.81
$1,055.27
$1,111.89
$1,313.04 		$1,304.73
$1,358.19
$1,414.81
$1,615.96 		$302.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.94
$898.86
$1,012.10
$1,414.40
$2,149.32 		$1,094.86
$1,201.78
$1,315.02
$1,717.32 		$1,397.78
$1,504.70
$1,617.94
$2,020.24 		$1,700.70
$1,807.62
$1,920.86
$2,323.16 		$302.92
Toc - Plan #83 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Preferred/Broad 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 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 		$416.39
$472.60
$532.15
$743.67
$1,130.08 		$734.93
$791.14
$850.69
$1,062.21 		$1,053.47
$1,109.68
$1,169.23
$1,380.75 		$1,372.01
$1,428.22
$1,487.77
$1,699.29 		$318.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.78
$945.20
$1,064.30
$1,487.34
$2,260.16 		$1,151.32
$1,263.74
$1,382.84
$1,805.88 		$1,469.86
$1,582.28
$1,701.38
$2,124.42 		$1,788.40
$1,900.82
$2,019.92
$2,442.96 		$318.54

ADVERTISEMENT

Aspirus Health Plan

Local: 1-866-631-4611 | Toll Free: 1-866-631-4611 | TTY: 1-866-631-8597
Toc - Plan #84 Aspirus Health Plan
Silver

(HMO) HMO Silver 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$413.77
$469.63
$528.80
$739.00
$1,122.98 		$730.31
$786.17
$845.34
$1,055.54 		$1,046.85
$1,102.71
$1,161.88
$1,372.08 		$1,363.39
$1,419.25
$1,478.42
$1,688.62 		$316.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.54
$939.26
$1,057.60
$1,478.00
$2,245.96 		$1,144.08
$1,255.80
$1,374.14
$1,794.54 		$1,460.62
$1,572.34
$1,690.68
$2,111.08 		$1,777.16
$1,888.88
$2,007.22
$2,427.62 		$316.54
Toc - Plan #85 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$305.69
$346.96
$390.67
$545.96
$829.64 		$539.54
$580.81
$624.52
$779.81 		$773.39
$814.66
$858.37
$1,013.66 		$1,007.24
$1,048.51
$1,092.22
$1,247.51 		$233.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.38
$693.92
$781.34
$1,091.92
$1,659.28 		$845.23
$927.77
$1,015.19
$1,325.77 		$1,079.08
$1,161.62
$1,249.04
$1,559.62 		$1,312.93
$1,395.47
$1,482.89
$1,793.47 		$233.85
Toc - Plan #86 Aspirus Health Plan
Bronze

(HMO) HMO Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$281.10
$319.04
$359.24
$502.04
$762.89 		$496.14
$534.08
$574.28
$717.08 		$711.18
$749.12
$789.32
$932.12 		$926.22
$964.16
$1,004.36
$1,147.16 		$215.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.20
$638.08
$718.48
$1,004.08
$1,525.78 		$777.24
$853.12
$933.52
$1,219.12 		$992.28
$1,068.16
$1,148.56
$1,434.16 		$1,207.32
$1,283.20
$1,363.60
$1,649.20 		$215.04
Toc - Plan #87 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze 6500 with 3 Free PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$302.46
$343.29
$386.54
$540.18
$820.86 		$533.84
$574.67
$617.92
$771.56 		$765.22
$806.05
$849.30
$1,002.94 		$996.60
$1,037.43
$1,080.68
$1,234.32 		$231.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.92
$686.58
$773.08
$1,080.36
$1,641.72 		$836.30
$917.96
$1,004.46
$1,311.74 		$1,067.68
$1,149.34
$1,235.84
$1,543.12 		$1,299.06
$1,380.72
$1,467.22
$1,774.50 		$231.38
Toc - Plan #88 Aspirus Health Plan
Gold

(HMO) HMO Gold 2800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$380.39
$431.74
$486.13
$679.37
$1,032.37 		$671.39
$722.74
$777.13
$970.37 		$962.39
$1,013.74
$1,068.13
$1,261.37 		$1,253.39
$1,304.74
$1,359.13
$1,552.37 		$291.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.78
$863.48
$972.26
$1,358.74
$2,064.74 		$1,051.78
$1,154.48
$1,263.26
$1,649.74 		$1,342.78
$1,445.48
$1,554.26
$1,940.74 		$1,633.78
$1,736.48
$1,845.26
$2,231.74 		$291.00
Toc - Plan #89 Aspirus Health Plan
Catastrophic

(HMO) HMO Catastrophic 9100 with 3 Free PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$204.60
$232.23
$261.48
$365.42
$555.30 		$361.12
$388.75
$418.00
$521.94 		$517.64
$545.27
$574.52
$678.46 		$674.16
$701.79
$731.04
$834.98 		$156.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$409.20
$464.46
$522.96
$730.84
$1,110.60 		$565.72
$620.98
$679.48
$887.36 		$722.24
$777.50
$836.00
$1,043.88 		$878.76
$934.02
$992.52
$1,200.40 		$156.52
Toc - Plan #90 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 6900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$304.48
$345.58
$389.12
$543.80
$826.35 		$537.40
$578.50
$622.04
$776.72 		$770.32
$811.42
$854.96
$1,009.64 		$1,003.24
$1,044.34
$1,087.88
$1,242.56 		$232.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.96
$691.16
$778.24
$1,087.60
$1,652.70 		$841.88
$924.08
$1,011.16
$1,320.52 		$1,074.80
$1,157.00
$1,244.08
$1,553.44 		$1,307.72
$1,389.92
$1,477.00
$1,786.36 		$232.92
Toc - Plan #91 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$299.55
$339.99
$382.83
$535.00
$812.99 		$528.71
$569.15
$611.99
$764.16 		$757.87
$798.31
$841.15
$993.32 		$987.03
$1,027.47
$1,070.31
$1,222.48 		$229.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.10
$679.98
$765.66
$1,070.00
$1,625.98 		$828.26
$909.14
$994.82
$1,299.16 		$1,057.42
$1,138.30
$1,223.98
$1,528.32 		$1,286.58
$1,367.46
$1,453.14
$1,757.48 		$229.16
Toc - Plan #92 Aspirus Health Plan
Silver

(HMO) HMO Silver 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$412.73
$468.44
$527.46
$737.13
$1,120.14 		$728.47
$784.18
$843.20
$1,052.87 		$1,044.21
$1,099.92
$1,158.94
$1,368.61 		$1,359.95
$1,415.66
$1,474.68
$1,684.35 		$315.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.46
$936.88
$1,054.92
$1,474.26
$2,240.28 		$1,141.20
$1,252.62
$1,370.66
$1,790.00 		$1,456.94
$1,568.36
$1,686.40
$2,105.74 		$1,772.68
$1,884.10
$2,002.14
$2,421.48 		$315.74
Toc - Plan #93 Aspirus Health Plan
Silver

(HMO) HMO HDHP Silver 5400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$419.75
$476.41
$536.44
$749.67
$1,139.20 		$740.86
$797.52
$857.55
$1,070.78 		$1,061.97
$1,118.63
$1,178.66
$1,391.89 		$1,383.08
$1,439.74
$1,499.77
$1,713.00 		$321.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.50
$952.82
$1,072.88
$1,499.34
$2,278.40 		$1,160.61
$1,273.93
$1,393.99
$1,820.45 		$1,481.72
$1,595.04
$1,715.10
$2,141.56 		$1,802.83
$1,916.15
$2,036.21
$2,462.67 		$321.11
Toc - Plan #94 Aspirus Health Plan
Gold

(HMO) HMO Gold 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 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 		$379.94
$431.23
$485.56
$678.57
$1,031.15 		$670.59
$721.88
$776.21
$969.22 		$961.24
$1,012.53
$1,066.86
$1,259.87 		$1,251.89
$1,303.18
$1,357.51
$1,550.52 		$290.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$759.88
$862.46
$971.12
$1,357.14
$2,062.30 		$1,050.53
$1,153.11
$1,261.77
$1,647.79 		$1,341.18
$1,443.76
$1,552.42
$1,938.44 		$1,631.83
$1,734.41
$1,843.07
$2,229.09 		$290.65
Toc - Plan #95 Aspirus Health Plan
Silver

(POS) POS Silver 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$472.52
$536.30
$603.87
$843.91
$1,282.41 		$833.99
$897.77
$965.34
$1,205.38 		$1,195.46
$1,259.24
$1,326.81
$1,566.85 		$1,556.93
$1,620.71
$1,688.28
$1,928.32 		$361.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945.04
$1,072.60
$1,207.74
$1,687.82
$2,564.82 		$1,306.51
$1,434.07
$1,569.21
$2,049.29 		$1,667.98
$1,795.54
$1,930.68
$2,410.76 		$2,029.45
$2,157.01
$2,292.15
$2,772.23 		$361.47
Toc - Plan #96 Aspirus Health Plan
Expanded Bronze

(POS) POS HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$336.44
$381.86
$429.97
$600.88
$913.09 		$593.81
$639.23
$687.34
$858.25 		$851.18
$896.60
$944.71
$1,115.62 		$1,108.55
$1,153.97
$1,202.08
$1,372.99 		$257.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.88
$763.72
$859.94
$1,201.76
$1,826.18 		$930.25
$1,021.09
$1,117.31
$1,459.13 		$1,187.62
$1,278.46
$1,374.68
$1,716.50 		$1,444.99
$1,535.83
$1,632.05
$1,973.87 		$257.37
Toc - Plan #97 Aspirus Health Plan
Expanded Bronze

(POS) POS Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$432.64
$491.04
$552.91
$772.69
$1,174.17 		$763.61
$822.01
$883.88
$1,103.66 		$1,094.58
$1,152.98
$1,214.85
$1,434.63 		$1,425.55
$1,483.95
$1,545.82
$1,765.60 		$330.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$865.28
$982.08
$1,105.82
$1,545.38
$2,348.34 		$1,196.25
$1,313.05
$1,436.79
$1,876.35 		$1,527.22
$1,644.02
$1,767.76
$2,207.32 		$1,858.19
$1,974.99
$2,098.73
$2,538.29 		$330.97

ADVERTISEMENT

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442
Toc - Plan #98 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$283.96
$322.29
$362.89
$507.14
$770.65 		$501.19
$539.52
$580.12
$724.37 		$718.42
$756.75
$797.35
$941.60 		$935.65
$973.98
$1,014.58
$1,158.83 		$217.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.92
$644.58
$725.78
$1,014.28
$1,541.30 		$785.15
$861.81
$943.01
$1,231.51 		$1,002.38
$1,079.04
$1,160.24
$1,448.74 		$1,219.61
$1,296.27
$1,377.47
$1,665.97 		$217.23
Toc - Plan #99 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Copay Silver $0 Ded - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$403.17
$457.58
$515.23
$720.04
$1,094.17 		$711.58
$765.99
$823.64
$1,028.45 		$1,019.99
$1,074.40
$1,132.05
$1,336.86 		$1,328.40
$1,382.81
$1,440.46
$1,645.27 		$308.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.34
$915.16
$1,030.46
$1,440.08
$2,188.34 		$1,114.75
$1,223.57
$1,338.87
$1,748.49 		$1,423.16
$1,531.98
$1,647.28
$2,056.90 		$1,731.57
$1,840.39
$1,955.69
$2,365.31 		$308.41
Toc - Plan #100 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$434.51
$493.15
$555.29
$776.01
$1,179.22 		$766.90
$825.54
$887.68
$1,108.40 		$1,099.29
$1,157.93
$1,220.07
$1,440.79 		$1,431.68
$1,490.32
$1,552.46
$1,773.18 		$332.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869.02
$986.30
$1,110.58
$1,552.02
$2,358.44 		$1,201.41
$1,318.69
$1,442.97
$1,884.41 		$1,533.80
$1,651.08
$1,775.36
$2,216.80 		$1,866.19
$1,983.47
$2,107.75
$2,549.19 		$332.39
Toc - Plan #101 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $3000 - Envision Network

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
$9,100 $18,200 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 		$374.80
$425.39
$478.98
$669.38
$1,017.18 		$661.52
$712.11
$765.70
$956.10 		$948.24
$998.83
$1,052.42
$1,242.82 		$1,234.96
$1,285.55
$1,339.14
$1,529.54 		$286.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.60
$850.78
$957.96
$1,338.76
$2,034.36 		$1,036.32
$1,137.50
$1,244.68
$1,625.48 		$1,323.04
$1,424.22
$1,531.40
$1,912.20 		$1,609.76
$1,710.94
$1,818.12
$2,198.92 		$286.72
Toc - Plan #102 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $1800 - Envision Network

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
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.52
$465.93
$524.63
$733.18
$1,114.13 		$724.56
$779.97
$838.67
$1,047.22 		$1,038.60
$1,094.01
$1,152.71
$1,361.26 		$1,352.64
$1,408.05
$1,466.75
$1,675.30 		$314.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.04
$931.86
$1,049.26
$1,466.36
$2,228.26 		$1,135.08
$1,245.90
$1,363.30
$1,780.40 		$1,449.12
$1,559.94
$1,677.34
$2,094.44 		$1,763.16
$1,873.98
$1,991.38
$2,408.48 		$314.04
Toc - Plan #103 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $4000 - Envision Network

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
$9,100 $18,200 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 		$369.84
$419.76
$472.65
$660.52
$1,003.73 		$652.76
$702.68
$755.57
$943.44 		$935.68
$985.60
$1,038.49
$1,226.36 		$1,218.60
$1,268.52
$1,321.41
$1,509.28 		$282.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.68
$839.52
$945.30
$1,321.04
$2,007.46 		$1,022.60
$1,122.44
$1,228.22
$1,603.96 		$1,305.52
$1,405.36
$1,511.14
$1,886.88 		$1,588.44
$1,688.28
$1,794.06
$2,169.80 		$282.92
Toc - Plan #104 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5000 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,100 $18,200 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 		$316.41
$359.11
$404.35
$565.08
$858.70 		$558.45
$601.15
$646.39
$807.12 		$800.49
$843.19
$888.43
$1,049.16 		$1,042.53
$1,085.23
$1,130.47
$1,291.20 		$242.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.82
$718.22
$808.70
$1,130.16
$1,717.40 		$874.86
$960.26
$1,050.74
$1,372.20 		$1,116.90
$1,202.30
$1,292.78
$1,614.24 		$1,358.94
$1,444.34
$1,534.82
$1,856.28 		$242.04
Toc - Plan #105 Common Ground Healthcare Cooperative
Catastrophic

(EPO) CGHC Catastrophic $9100 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$186.10
$211.21
$237.83
$332.36
$505.05 		$328.46
$353.57
$380.19
$474.72 		$470.82
$495.93
$522.55
$617.08 		$613.18
$638.29
$664.91
$759.44 		$142.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$372.20
$422.42
$475.66
$664.72
$1,010.10 		$514.56
$564.78
$618.02
$807.08 		$656.92
$707.14
$760.38
$949.44 		$799.28
$849.50
$902.74
$1,091.80 		$142.36
Toc - Plan #106 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $9100 ($35 PCP Copay) - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$266.02
$301.92
$339.96
$475.09
$721.95 		$469.52
$505.42
$543.46
$678.59 		$673.02
$708.92
$746.96
$882.09 		$876.52
$912.42
$950.46
$1,085.59 		$203.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$532.04
$603.84
$679.92
$950.18
$1,443.90 		$735.54
$807.34
$883.42
$1,153.68 		$939.04
$1,010.84
$1,086.92
$1,357.18 		$1,142.54
$1,214.34
$1,290.42
$1,560.68 		$203.50
Toc - Plan #107 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $8150 - Envision Network

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
$9,100 $18,200 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 		$276.09
$313.35
$352.83
$493.07
$749.27 		$487.29
$524.55
$564.03
$704.27 		$698.49
$735.75
$775.23
$915.47 		$909.69
$946.95
$986.43
$1,126.67 		$211.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552.18
$626.70
$705.66
$986.14
$1,498.54 		$763.38
$837.90
$916.86
$1,197.34 		$974.58
$1,049.10
$1,128.06
$1,408.54 		$1,185.78
$1,260.30
$1,339.26
$1,619.74 		$211.20
Toc - Plan #108 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network

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

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 		$274.64
$311.70
$350.97
$490.48
$745.34 		$484.73
$521.79
$561.06
$700.57 		$694.82
$731.88
$771.15
$910.66 		$904.91
$941.97
$981.24
$1,120.75 		$210.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.28
$623.40
$701.94
$980.96
$1,490.68 		$759.37
$833.49
$912.03
$1,191.05 		$969.46
$1,043.58
$1,122.12
$1,401.14 		$1,179.55
$1,253.67
$1,332.21
$1,611.23 		$210.09
Toc - Plan #109 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $3000 - Envision Network

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
$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 		$436.43
$495.34
$557.75
$779.45
$1,184.45 		$770.29
$829.20
$891.61
$1,113.31 		$1,104.15
$1,163.06
$1,225.47
$1,447.17 		$1,438.01
$1,496.92
$1,559.33
$1,781.03 		$333.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$872.86
$990.68
$1,115.50
$1,558.90
$2,368.90 		$1,206.72
$1,324.54
$1,449.36
$1,892.76 		$1,540.58
$1,658.40
$1,783.22
$2,226.62 		$1,874.44
$1,992.26
$2,117.08
$2,560.48 		$333.86
Toc - Plan #110 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3000 - Envision Network

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
$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 		$423.24
$480.36
$540.88
$755.88
$1,148.63 		$747.01
$804.13
$864.65
$1,079.65 		$1,070.78
$1,127.90
$1,188.42
$1,403.42 		$1,394.55
$1,451.67
$1,512.19
$1,727.19 		$323.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.48
$960.72
$1,081.76
$1,511.76
$2,297.26 		$1,170.25
$1,284.49
$1,405.53
$1,835.53 		$1,494.02
$1,608.26
$1,729.30
$2,159.30 		$1,817.79
$1,932.03
$2,053.07
$2,483.07 		$323.77
Toc - Plan #111 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $6000 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 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 		$272.65
$309.44
$348.43
$486.93
$739.93 		$481.22
$518.01
$557.00
$695.50 		$689.79
$726.58
$765.57
$904.07 		$898.36
$935.15
$974.14
$1,112.64 		$208.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$545.30
$618.88
$696.86
$973.86
$1,479.86 		$753.87
$827.45
$905.43
$1,182.43 		$962.44
$1,036.02
$1,114.00
$1,391.00 		$1,171.01
$1,244.59
$1,322.57
$1,599.57 		$208.57
Toc - Plan #112 Common Ground Healthcare Cooperative
Bronze

(EPO) Bronze Standard Plan - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$264.09
$299.74
$337.50
$471.65
$716.72 		$466.11
$501.76
$539.52
$673.67 		$668.13
$703.78
$741.54
$875.69 		$870.15
$905.80
$943.56
$1,077.71 		$202.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$528.18
$599.48
$675.00
$943.30
$1,433.44 		$730.20
$801.50
$877.02
$1,145.32 		$932.22
$1,003.52
$1,079.04
$1,347.34 		$1,134.24
$1,205.54
$1,281.06
$1,549.36 		$202.02
Toc - Plan #113 Common Ground Healthcare Cooperative
Silver

(EPO) Silver Standard Plan - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$319.59
$362.72
$408.42
$570.77
$867.34 		$564.07
$607.20
$652.90
$815.25 		$808.55
$851.68
$897.38
$1,059.73 		$1,053.03
$1,096.16
$1,141.86
$1,304.21 		$244.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.18
$725.44
$816.84
$1,141.54
$1,734.68 		$883.66
$969.92
$1,061.32
$1,386.02 		$1,128.14
$1,214.40
$1,305.80
$1,630.50 		$1,372.62
$1,458.88
$1,550.28
$1,874.98 		$244.48
Toc - Plan #114 Common Ground Healthcare Cooperative
Gold

(EPO) Gold Standard Plan - Envision Network

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
$8,700 $17,400 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 		$382.09
$433.66
$488.30
$682.40
$1,036.97 		$674.38
$725.95
$780.59
$974.69 		$966.67
$1,018.24
$1,072.88
$1,266.98 		$1,258.96
$1,310.53
$1,365.17
$1,559.27 		$292.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.18
$867.32
$976.60
$1,364.80
$2,073.94 		$1,056.47
$1,159.61
$1,268.89
$1,657.09 		$1,348.76
$1,451.90
$1,561.18
$1,949.38 		$1,641.05
$1,744.19
$1,853.47
$2,241.67 		$292.29
Toc - Plan #115 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5650 - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 Annual Deductible
$9,100 $18,200 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 		$316.20
$358.87
$404.09
$564.71
$858.13 		$558.08
$600.75
$645.97
$806.59 		$799.96
$842.63
$887.85
$1,048.47 		$1,041.84
$1,084.51
$1,129.73
$1,290.35 		$241.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.40
$717.74
$808.18
$1,129.42
$1,716.26 		$874.28
$959.62
$1,050.06
$1,371.30 		$1,116.16
$1,201.50
$1,291.94
$1,613.18 		$1,358.04
$1,443.38
$1,533.82
$1,855.06 		$241.88
Toc - Plan #116 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $1800 - Envision Network (Vision Exam + Allergy Test)

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
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$413.44
$469.25
$528.37
$738.39
$1,122.06 		$729.72
$785.53
$844.65
$1,054.67 		$1,046.00
$1,101.81
$1,160.93
$1,370.95 		$1,362.28
$1,418.09
$1,477.21
$1,687.23 		$316.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.88
$938.50
$1,056.74
$1,476.78
$2,244.12 		$1,143.16
$1,254.78
$1,373.02
$1,793.06 		$1,459.44
$1,571.06
$1,689.30
$2,109.34 		$1,775.72
$1,887.34
$2,005.58
$2,425.62 		$316.28
Toc - Plan #117 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $2000 - Envision Network (Vision Exam + Allergy Test)

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
$8,700 $17,400 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 		$384.62
$436.54
$491.54
$686.92
$1,043.84 		$678.85
$730.77
$785.77
$981.15 		$973.08
$1,025.00
$1,080.00
$1,275.38 		$1,267.31
$1,319.23
$1,374.23
$1,569.61 		$294.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.24
$873.08
$983.08
$1,373.84
$2,087.68 		$1,063.47
$1,167.31
$1,277.31
$1,668.07 		$1,357.70
$1,461.54
$1,571.54
$1,962.30 		$1,651.93
$1,755.77
$1,865.77
$2,256.53 		$294.23
Toc - Plan #118 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $3000 - Envision Network (Vision Exam + Allergy Test)

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
$9,100 $18,200 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 		$377.69
$428.67
$482.68
$674.54
$1,025.03 		$666.62
$717.60
$771.61
$963.47 		$955.55
$1,006.53
$1,060.54
$1,252.40 		$1,244.48
$1,295.46
$1,349.47
$1,541.33 		$288.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.38
$857.34
$965.36
$1,349.08
$2,050.06 		$1,044.31
$1,146.27
$1,254.29
$1,638.01 		$1,333.24
$1,435.20
$1,543.22
$1,926.94 		$1,622.17
$1,724.13
$1,832.15
$2,215.87 		$288.93
Toc - Plan #119 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $4000 - Envision Network (Vision Exam + Allergy Test)

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
$9,100 $18,200 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 		$372.74
$423.04
$476.34
$665.69
$1,011.58 		$657.87
$708.17
$761.47
$950.82 		$943.00
$993.30
$1,046.60
$1,235.95 		$1,228.13
$1,278.43
$1,331.73
$1,521.08 		$285.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.48
$846.08
$952.68
$1,331.38
$2,023.16 		$1,030.61
$1,131.21
$1,237.81
$1,616.51 		$1,315.74
$1,416.34
$1,522.94
$1,901.64 		$1,600.87
$1,701.47
$1,808.07
$2,186.77 		$285.13
Toc - Plan #120 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5650 (Vision Exam + Allergy Test) - Envision Network

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

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 Annual Deductible
$9,100 $18,200 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 		$319.05
$362.11
$407.73
$569.81
$865.87 		$563.12
$606.18
$651.80
$813.88 		$807.19
$850.25
$895.87
$1,057.95 		$1,051.26
$1,094.32
$1,139.94
$1,302.02 		$244.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.10
$724.22
$815.46
$1,139.62
$1,731.74 		$882.17
$968.29
$1,059.53
$1,383.69 		$1,126.24
$1,212.36
$1,303.60
$1,627.76 		$1,370.31
$1,456.43
$1,547.67
$1,871.83 		$244.07
Toc - Plan #121 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5000 - Envision Network (Vision Exam + Allergy Test)

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,100 $18,200 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 		$319.26
$362.35
$408.00
$570.18
$866.44 		$563.49
$606.58
$652.23
$814.41 		$807.72
$850.81
$896.46
$1,058.64 		$1,051.95
$1,095.04
$1,140.69
$1,302.87 		$244.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.52
$724.70
$816.00
$1,140.36
$1,732.88 		$882.75
$968.93
$1,060.23
$1,384.59 		$1,126.98
$1,213.16
$1,304.46
$1,628.82 		$1,371.21
$1,457.39
$1,548.69
$1,873.05 		$244.23
Toc - Plan #122 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $9100 - Envision Network (Vision Exam + Allergy Test)

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$266.92
$302.94
$341.11
$476.70
$724.39 		$471.11
$507.13
$545.30
$680.89 		$675.30
$711.32
$749.49
$885.08 		$879.49
$915.51
$953.68
$1,089.27 		$204.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$533.84
$605.88
$682.22
$953.40
$1,448.78 		$738.03
$810.07
$886.41
$1,157.59 		$942.22
$1,014.26
$1,090.60
$1,361.78 		$1,146.41
$1,218.45
$1,294.79
$1,565.97 		$204.19
Toc - Plan #123 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $9100 ($35 PCP Copay) - Envision Network (Vision Exam + Allergy Test)

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$268.84
$305.13
$343.57
$480.14
$729.62 		$474.50
$510.79
$549.23
$685.80 		$680.16
$716.45
$754.89
$891.46 		$885.82
$922.11
$960.55
$1,097.12 		$205.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$537.68
$610.26
$687.14
$960.28
$1,459.24 		$743.34
$815.92
$892.80
$1,165.94 		$949.00
$1,021.58
$1,098.46
$1,371.60 		$1,154.66
$1,227.24
$1,304.12
$1,577.26 		$205.66
Toc - Plan #124 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $8150 - Envision Network (Vision Exam + Allergy Test)

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
$9,100 $18,200 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 		$278.92
$316.56
$356.45
$498.14
$756.96 		$492.29
$529.93
$569.82
$711.51 		$705.66
$743.30
$783.19
$924.88 		$919.03
$956.67
$996.56
$1,138.25 		$213.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.84
$633.12
$712.90
$996.28
$1,513.92 		$771.21
$846.49
$926.27
$1,209.65 		$984.58
$1,059.86
$1,139.64
$1,423.02 		$1,197.95
$1,273.23
$1,353.01
$1,636.39 		$213.37
Toc - Plan #125 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $6000 - Envision Network (Vision Exam + Allergy Test)

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 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 		$275.47
$312.65
$352.04
$491.97
$747.60 		$486.20
$523.38
$562.77
$702.70 		$696.93
$734.11
$773.50
$913.43 		$907.66
$944.84
$984.23
$1,124.16 		$210.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.94
$625.30
$704.08
$983.94
$1,495.20 		$761.67
$836.03
$914.81
$1,194.67 		$972.40
$1,046.76
$1,125.54
$1,405.40 		$1,183.13
$1,257.49
$1,336.27
$1,616.13 		$210.73
Toc - Plan #126 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network (Vision Exam + Allergy Test)

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

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 		$277.46
$314.91
$354.58
$495.53
$753.00 		$489.71
$527.16
$566.83
$707.78 		$701.96
$739.41
$779.08
$920.03 		$914.21
$951.66
$991.33
$1,132.28 		$212.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.92
$629.82
$709.16
$991.06
$1,506.00 		$767.17
$842.07
$921.41
$1,203.31 		$979.42
$1,054.32
$1,133.66
$1,415.56 		$1,191.67
$1,266.57
$1,345.91
$1,627.81 		$212.25
Toc - Plan #127 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3000 - Envision Network (Vision Exam + Allergy Test)

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
$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 		$426.16
$483.69
$544.63
$761.11
$1,156.58 		$752.17
$809.70
$870.64
$1,087.12 		$1,078.18
$1,135.71
$1,196.65
$1,413.13 		$1,404.19
$1,461.72
$1,522.66
$1,739.14 		$326.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.32
$967.38
$1,089.26
$1,522.22
$2,313.16 		$1,178.33
$1,293.39
$1,415.27
$1,848.23 		$1,504.34
$1,619.40
$1,741.28
$2,174.24 		$1,830.35
$1,945.41
$2,067.29
$2,500.25 		$326.01
Toc - Plan #128 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $3000 - Envision Network (Vision Exam + Allergy Test)

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
$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 		$439.37
$498.67
$561.50
$784.70
$1,192.42 		$775.48
$834.78
$897.61
$1,120.81 		$1,111.59
$1,170.89
$1,233.72
$1,456.92 		$1,447.70
$1,507.00
$1,569.83
$1,793.03 		$336.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.74
$997.34
$1,123.00
$1,569.40
$2,384.84 		$1,214.85
$1,333.45
$1,459.11
$1,905.51 		$1,550.96
$1,669.56
$1,795.22
$2,241.62 		$1,887.07
$2,005.67
$2,131.33
$2,577.73 		$336.11
Toc - Plan #129 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded - Envision Network (Vision Exam + Allergy Test)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$286.80
$325.51
$366.52
$512.21
$778.35 		$506.19
$544.90
$585.91
$731.60 		$725.58
$764.29
$805.30
$950.99 		$944.97
$983.68
$1,024.69
$1,170.38 		$219.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.60
$651.02
$733.04
$1,024.42
$1,556.70 		$792.99
$870.41
$952.43
$1,243.81 		$1,012.38
$1,089.80
$1,171.82
$1,463.20 		$1,231.77
$1,309.19
$1,391.21
$1,682.59 		$219.39
Toc - Plan #130 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Copay Silver $0 Ded - Envision Network (Vision Exam + Allergy Test)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$406.08
$460.89
$518.95
$725.23
$1,102.06 		$716.72
$771.53
$829.59
$1,035.87 		$1,027.36
$1,082.17
$1,140.23
$1,346.51 		$1,338.00
$1,392.81
$1,450.87
$1,657.15 		$310.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.16
$921.78
$1,037.90
$1,450.46
$2,204.12 		$1,122.80
$1,232.42
$1,348.54
$1,761.10 		$1,433.44
$1,543.06
$1,659.18
$2,071.74 		$1,744.08
$1,853.70
$1,969.82
$2,382.38 		$310.64
Toc - Plan #131 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network (Vision Exam + Allergy Test)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$437.44
$496.48
$559.03
$781.24
$1,187.17 		$772.07
$831.11
$893.66
$1,115.87 		$1,106.70
$1,165.74
$1,228.29
$1,450.50 		$1,441.33
$1,500.37
$1,562.92
$1,785.13 		$334.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.88
$992.96
$1,118.06
$1,562.48
$2,374.34 		$1,209.51
$1,327.59
$1,452.69
$1,897.11 		$1,544.14
$1,662.22
$1,787.32
$2,231.74 		$1,878.77
$1,996.85
$2,121.95
$2,566.37 		$334.63

‡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 Waushara County here.

Waushara County is in “Rating Area 15” of Wisconsin.

Currently, there are 131 plans offered in Rating Area 15.

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2023 Obamacare Plans for Waushara County, WI

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