Obamacare 2021 Rates for Maricopa County

Obamacare > Rates > Arizona > Maricopa County

Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Maricopa County, AZ.

The health insurance rates listed below are for calendar year 2021.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 68 Plans and 2021 Rates for Maricopa County, Arizona

Below, you’ll find a summary of the 68 plans for Maricopa County, Arizona and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Oscar Health Plan, Inc.

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755

Toc - Plan #1 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Oscar Bronze Classic PCP Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$252,62
$286,72
$322,84
$451,17
$685,59 		$445,87
$479,97
$516,09
$644,42 		$639,12
$673,22
$709,34
$837,67 		$832,37
$866,47
$902,59
$1 030,92 		$193,25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$505,24
$573,44
$645,68
$902,34
$1 371,18 		$698,49
$766,69
$838,93
$1 095,59 		$891,74
$959,94
$1 032,18
$1 288,84 		$1 084,99
$1 153,19
$1 225,43
$1 482,09 		$193,25
Toc - Plan #2 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Oscar Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$259,01
$293,97
$331,01
$462,58
$702,94 		$457,15
$492,11
$529,15
$660,72 		$655,29
$690,25
$727,29
$858,86 		$853,43
$888,39
$925,43
$1 057,00 		$198,14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$518,02
$587,94
$662,02
$925,16
$1 405,88 		$716,16
$786,08
$860,16
$1 123,30 		$914,30
$984,22
$1 058,30
$1 321,44 		$1 112,44
$1 182,36
$1 256,44
$1 519,58 		$198,14
Toc - Plan #3 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Oscar Bronze Classic Next

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303,25
$344,18
$387,54
$541,59
$822,99 		$535,23
$576,16
$619,52
$773,57 		$767,21
$808,14
$851,50
$1 005,55 		$999,19
$1 040,12
$1 083,48
$1 237,53 		$231,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606,50
$688,36
$775,08
$1 083,18
$1 645,98 		$838,48
$920,34
$1 007,06
$1 315,16 		$1 070,46
$1 152,32
$1 239,04
$1 547,14 		$1 302,44
$1 384,30
$1 471,02
$1 779,12 		$231,98
Toc - Plan #4 Oscar Health Plan, Inc.
Silver

(HMO) Oscar Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$306,15
$347,47
$391,25
$546,77
$830,87 		$540,35
$581,67
$625,45
$780,97 		$774,55
$815,87
$859,65
$1 015,17 		$1 008,75
$1 050,07
$1 093,85
$1 249,37 		$234,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612,30
$694,94
$782,50
$1 093,54
$1 661,74 		$846,50
$929,14
$1 016,70
$1 327,74 		$1 080,70
$1 163,34
$1 250,90
$1 561,94 		$1 314,90
$1 397,54
$1 485,10
$1 796,14 		$234,20
Toc - Plan #5 Oscar Health Plan, Inc.
Silver

(HMO) Oscar Silver Saver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$298,19
$338,44
$381,08
$532,56
$809,27 		$526,30
$566,55
$609,19
$760,67 		$754,41
$794,66
$837,30
$988,78 		$982,52
$1 022,77
$1 065,41
$1 216,89 		$228,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596,38
$676,88
$762,16
$1 065,12
$1 618,54 		$824,49
$904,99
$990,27
$1 293,23 		$1 052,60
$1 133,10
$1 218,38
$1 521,34 		$1 280,71
$1 361,21
$1 446,49
$1 749,45 		$228,11
Toc - Plan #6 Oscar Health Plan, Inc.
Silver

(HMO) Oscar Silver Classic Next

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$309,52
$351,29
$395,55
$552,78
$840,01 		$546,29
$588,06
$632,32
$789,55 		$783,06
$824,83
$869,09
$1 026,32 		$1 019,83
$1 061,60
$1 105,86
$1 263,09 		$236,77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619,04
$702,58
$791,10
$1 105,56
$1 680,02 		$855,81
$939,35
$1 027,87
$1 342,33 		$1 092,58
$1 176,12
$1 264,64
$1 579,10 		$1 329,35
$1 412,89
$1 501,41
$1 815,87 		$236,77
Toc - Plan #7 Oscar Health Plan, Inc.
Catastrophic

(HMO) Oscar Secure

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$211,29
$239,81
$270,02
$377,35
$573,43 		$372,92
$401,44
$431,65
$538,98 		$534,55
$563,07
$593,28
$700,61 		$696,18
$724,70
$754,91
$862,24 		$161,63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$422,58
$479,62
$540,04
$754,70
$1 146,86 		$584,21
$641,25
$701,67
$916,33 		$745,84
$802,88
$863,30
$1 077,96 		$907,47
$964,51
$1 024,93
$1 239,59 		$161,63
Toc - Plan #8 Oscar Health Plan, Inc.
Gold

(HMO) Oscar Gold Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$396,54
$450,06
$506,77
$708,21
$1 076,19 		$699,89
$753,41
$810,12
$1 011,56 		$1 003,24
$1 056,76
$1 113,47
$1 314,91 		$1 306,59
$1 360,11
$1 416,82
$1 618,26 		$303,35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793,08
$900,12
$1 013,54
$1 416,42
$2 152,38 		$1 096,43
$1 203,47
$1 316,89
$1 719,77 		$1 399,78
$1 506,82
$1 620,24
$2 023,12 		$1 703,13
$1 810,17
$1 923,59
$2 326,47 		$303,35
Toc - Plan #9 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Oscar Bronze HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$268,24
$304,45
$342,80
$479,07
$727,99 		$473,44
$509,65
$548,00
$684,27 		$678,64
$714,85
$753,20
$889,47 		$883,84
$920,05
$958,40
$1 094,67 		$205,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536,48
$608,90
$685,60
$958,14
$1 455,98 		$741,68
$814,10
$890,80
$1 163,34 		$946,88
$1 019,30
$1 096,00
$1 368,54 		$1 152,08
$1 224,50
$1 301,20
$1 573,74 		$205,20
Toc - Plan #10 Oscar Health Plan, Inc.
Silver

(HMO) Oscar Silver Classic Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$314,49
$356,94
$401,91
$561,67
$853,51 		$555,07
$597,52
$642,49
$802,25 		$795,65
$838,10
$883,07
$1 042,83 		$1 036,23
$1 078,68
$1 123,65
$1 283,41 		$240,58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628,98
$713,88
$803,82
$1 123,34
$1 707,02 		$869,56
$954,46
$1 044,40
$1 363,92 		$1 110,14
$1 195,04
$1 284,98
$1 604,50 		$1 350,72
$1 435,62
$1 525,56
$1 845,08 		$240,58
Toc - Plan #11 Oscar Health Plan, Inc.
Silver

(HMO) Oscar Silver Classic $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$331,82
$376,61
$424,05
$592,62
$900,54 		$585,66
$630,45
$677,89
$846,46 		$839,50
$884,29
$931,73
$1 100,30 		$1 093,34
$1 138,13
$1 185,57
$1 354,14 		$253,84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663,64
$753,22
$848,10
$1 185,24
$1 801,08 		$917,48
$1 007,06
$1 101,94
$1 439,08 		$1 171,32
$1 260,90
$1 355,78
$1 692,92 		$1 425,16
$1 514,74
$1 609,62
$1 946,76 		$253,84

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-482-9045 | Toll Free: 1-877-482-9045 | TTY: 1-877-482-9045
Toc - Plan #12 UnitedHealthcare
Gold

(HMO) Value Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$477,09
$541,49
$609,72
$852,08
$1 294,81 		$842,06
$906,46
$974,69
$1 217,05 		$1 207,03
$1 271,43
$1 339,66
$1 582,02 		$1 572,00
$1 636,40
$1 704,63
$1 946,99 		$364,97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954,18
$1 082,98
$1 219,44
$1 704,16
$2 589,62 		$1 319,15
$1 447,95
$1 584,41
$2 069,13 		$1 684,12
$1 812,92
$1 949,38
$2 434,10 		$2 049,09
$2 177,89
$2 314,35
$2 799,07 		$364,97
Toc - Plan #13 UnitedHealthcare
Silver

(HMO) Value Plus Silver 3 Free Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363,97
$413,11
$465,16
$650,06
$987,83 		$642,41
$691,55
$743,60
$928,50 		$920,85
$969,99
$1 022,04
$1 206,94 		$1 199,29
$1 248,43
$1 300,48
$1 485,38 		$278,44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727,94
$826,22
$930,32
$1 300,12
$1 975,66 		$1 006,38
$1 104,66
$1 208,76
$1 578,56 		$1 284,82
$1 383,10
$1 487,20
$1 857,00 		$1 563,26
$1 661,54
$1 765,64
$2 135,44 		$278,44
Toc - Plan #14 UnitedHealthcare
Silver

(HMO) Value Silver 3 Free Visits 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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 		$365,37
$414,70
$466,95
$652,56
$991,62 		$644,88
$694,21
$746,46
$932,07 		$924,39
$973,72
$1 025,97
$1 211,58 		$1 203,90
$1 253,23
$1 305,48
$1 491,09 		$279,51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730,74
$829,40
$933,90
$1 305,12
$1 983,24 		$1 010,25
$1 108,91
$1 213,41
$1 584,63 		$1 289,76
$1 388,42
$1 492,92
$1 864,14 		$1 569,27
$1 667,93
$1 772,43
$2 143,65 		$279,51
Toc - Plan #15 UnitedHealthcare
Silver

(HMO) Value Silver 3 Free Visits 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362,01
$410,89
$462,65
$646,56
$982,51 		$638,95
$687,83
$739,59
$923,50 		$915,89
$964,77
$1 016,53
$1 200,44 		$1 192,83
$1 241,71
$1 293,47
$1 477,38 		$276,94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724,02
$821,78
$925,30
$1 293,12
$1 965,02 		$1 000,96
$1 098,72
$1 202,24
$1 570,06 		$1 277,90
$1 375,66
$1 479,18
$1 847,00 		$1 554,84
$1 652,60
$1 756,12
$2 123,94 		$276,94
Toc - Plan #16 UnitedHealthcare
Expanded Bronze

(HMO) Value Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$286,70
$325,40
$366,40
$512,05
$778,10 		$506,03
$544,73
$585,73
$731,38 		$725,36
$764,06
$805,06
$950,71 		$944,69
$983,39
$1 024,39
$1 170,04 		$219,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573,40
$650,80
$732,80
$1 024,10
$1 556,20 		$792,73
$870,13
$952,13
$1 243,43 		$1 012,06
$1 089,46
$1 171,46
$1 462,76 		$1 231,39
$1 308,79
$1 390,79
$1 682,09 		$219,33
Toc - Plan #17 UnitedHealthcare
Expanded Bronze

(HMO) Value Bronze 3 Free Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279,98
$317,78
$357,81
$500,04
$759,87 		$494,16
$531,96
$571,99
$714,22 		$708,34
$746,14
$786,17
$928,40 		$922,52
$960,32
$1 000,35
$1 142,58 		$214,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559,96
$635,56
$715,62
$1 000,08
$1 519,74 		$774,14
$849,74
$929,80
$1 214,26 		$988,32
$1 063,92
$1 143,98
$1 428,44 		$1 202,50
$1 278,10
$1 358,16
$1 642,62 		$214,18
Toc - Plan #18 UnitedHealthcare
Expanded Bronze

(HMO) Value Bronze 3 Free Telehealth Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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 		$283,34
$321,59
$362,11
$506,04
$768,98 		$500,09
$538,34
$578,86
$722,79 		$716,84
$755,09
$795,61
$939,54 		$933,59
$971,84
$1 012,36
$1 156,29 		$216,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$566,68
$643,18
$724,22
$1 012,08
$1 537,96 		$783,43
$859,93
$940,97
$1 228,83 		$1 000,18
$1 076,68
$1 157,72
$1 445,58 		$1 216,93
$1 293,43
$1 374,47
$1 662,33 		$216,75

ADVERTISEMENT

Blue Cross Blue Shield of Arizona

Local: 1-844-341-5837 | Toll Free: 1-844-341-5837 | TTY: 1-602-864-4823
Toc - Plan #19 Blue Cross Blue Shield of Arizona
Gold

(HMO) Blue EverydayHealth Gold - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 Annual Deductible
$6,750 $13,500 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 		$444,71
$504,75
$568,34
$794,25
$1 206,94 		$784,92
$844,96
$908,55
$1 134,46 		$1 125,13
$1 185,17
$1 248,76
$1 474,67 		$1 465,34
$1 525,38
$1 588,97
$1 814,88 		$340,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889,42
$1 009,50
$1 136,68
$1 588,50
$2 413,88 		$1 229,63
$1 349,71
$1 476,89
$1 928,71 		$1 569,84
$1 689,92
$1 817,10
$2 268,92 		$1 910,05
$2 030,13
$2 157,31
$2 609,13 		$340,21
Toc - Plan #20 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue EverydayHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345,81
$392,49
$441,94
$617,61
$938,51 		$610,35
$657,03
$706,48
$882,15 		$874,89
$921,57
$971,02
$1 146,69 		$1 139,43
$1 186,11
$1 235,56
$1 411,23 		$264,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691,62
$784,98
$883,88
$1 235,22
$1 877,02 		$956,16
$1 049,52
$1 148,42
$1 499,76 		$1 220,70
$1 314,06
$1 412,96
$1 764,30 		$1 485,24
$1 578,60
$1 677,50
$2 028,84 		$264,54
Toc - Plan #21 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue EverydayHealth Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281,32
$319,30
$359,53
$502,44
$763,50 		$496,53
$534,51
$574,74
$717,65 		$711,74
$749,72
$789,95
$932,86 		$926,95
$964,93
$1 005,16
$1 148,07 		$215,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562,64
$638,60
$719,06
$1 004,88
$1 527,00 		$777,85
$853,81
$934,27
$1 220,09 		$993,06
$1 069,02
$1 149,48
$1 435,30 		$1 208,27
$1 284,23
$1 364,69
$1 650,51 		$215,21
Toc - Plan #22 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue TrueHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352,11
$399,65
$450,00
$628,87
$955,63 		$621,48
$669,02
$719,37
$898,24 		$890,85
$938,39
$988,74
$1 167,61 		$1 160,22
$1 207,76
$1 258,11
$1 436,98 		$269,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704,22
$799,30
$900,00
$1 257,74
$1 911,26 		$973,59
$1 068,67
$1 169,37
$1 527,11 		$1 242,96
$1 338,04
$1 438,74
$1 796,48 		$1 512,33
$1 607,41
$1 708,11
$2 065,85 		$269,37
Toc - Plan #23 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue AdvanceHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$7,750 $15,500 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 		$320,64
$363,93
$409,78
$572,66
$870,22 		$565,93
$609,22
$655,07
$817,95 		$811,22
$854,51
$900,36
$1 063,24 		$1 056,51
$1 099,80
$1 145,65
$1 308,53 		$245,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641,28
$727,86
$819,56
$1 145,32
$1 740,44 		$886,57
$973,15
$1 064,85
$1 390,61 		$1 131,86
$1 218,44
$1 310,14
$1 635,90 		$1 377,15
$1 463,73
$1 555,43
$1 881,19 		$245,29
Toc - Plan #24 Blue Cross Blue Shield of Arizona
Catastrophic

(HMO) Blue SimpleHealth - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$239,56
$271,90
$306,16
$427,86
$650,17 		$422,83
$455,17
$489,43
$611,13 		$606,10
$638,44
$672,70
$794,40 		$789,37
$821,71
$855,97
$977,67 		$183,27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$479,12
$543,80
$612,32
$855,72
$1 300,34 		$662,39
$727,07
$795,59
$1 038,99 		$845,66
$910,34
$978,86
$1 222,26 		$1 028,93
$1 093,61
$1 162,13
$1 405,53 		$183,27
Toc - Plan #25 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue Portfolio HSA Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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 		$303,84
$344,85
$388,30
$542,65
$824,60 		$536,28
$577,29
$620,74
$775,09 		$768,72
$809,73
$853,18
$1 007,53 		$1 001,16
$1 042,17
$1 085,62
$1 239,97 		$232,44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607,68
$689,70
$776,60
$1 085,30
$1 649,20 		$840,12
$922,14
$1 009,04
$1 317,74 		$1 072,56
$1 154,58
$1 241,48
$1 550,18 		$1 305,00
$1 387,02
$1 473,92
$1 782,62 		$232,44
Toc - Plan #26 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue AdvanceHealth Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$261,72
$297,05
$334,47
$467,42
$710,29 		$461,93
$497,26
$534,68
$667,63 		$662,14
$697,47
$734,89
$867,84 		$862,35
$897,68
$935,10
$1 068,05 		$200,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523,44
$594,10
$668,94
$934,84
$1 420,58 		$723,65
$794,31
$869,15
$1 135,05 		$923,86
$994,52
$1 069,36
$1 335,26 		$1 124,07
$1 194,73
$1 269,57
$1 535,47 		$200,21

ADVERTISEMENT

Bright Health

Local: 1-800-922-7186 | Toll Free: 1-800-922-7186

Toc - Plan #27 Bright Health
Gold

(HMO) Gold 1000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$489,82
$555,95
$625,99
$874,82
$1 329,37 		$864,53
$930,66
$1 000,70
$1 249,53 		$1 239,24
$1 305,37
$1 375,41
$1 624,24 		$1 613,95
$1 680,08
$1 750,12
$1 998,95 		$374,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$979,64
$1 111,90
$1 251,98
$1 749,64
$2 658,74 		$1 354,35
$1 486,61
$1 626,69
$2 124,35 		$1 729,06
$1 861,32
$2 001,40
$2 499,06 		$2 103,77
$2 236,03
$2 376,11
$2 873,77 		$374,71
Toc - Plan #28 Bright Health
Silver

(HMO) Silver 3000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

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 		$349,17
$396,31
$446,24
$623,63
$947,66 		$616,29
$663,43
$713,36
$890,75 		$883,41
$930,55
$980,48
$1 157,87 		$1 150,53
$1 197,67
$1 247,60
$1 424,99 		$267,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698,34
$792,62
$892,48
$1 247,26
$1 895,32 		$965,46
$1 059,74
$1 159,60
$1 514,38 		$1 232,58
$1 326,86
$1 426,72
$1 781,50 		$1 499,70
$1 593,98
$1 693,84
$2 048,62 		$267,12
Toc - Plan #29 Bright Health
Silver

(HMO) Silver $0 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$365,65
$415,01
$467,30
$653,05
$992,37 		$645,37
$694,73
$747,02
$932,77 		$925,09
$974,45
$1 026,74
$1 212,49 		$1 204,81
$1 254,17
$1 306,46
$1 492,21 		$279,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731,30
$830,02
$934,60
$1 306,10
$1 984,74 		$1 011,02
$1 109,74
$1 214,32
$1 585,82 		$1 290,74
$1 389,46
$1 494,04
$1 865,54 		$1 570,46
$1 669,18
$1 773,76
$2 145,26 		$279,72
Toc - Plan #30 Bright Health
Expanded Bronze

(HMO) Bronze 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$277,35
$314,79
$354,46
$495,35
$752,73 		$489,52
$526,96
$566,63
$707,52 		$701,69
$739,13
$778,80
$919,69 		$913,86
$951,30
$990,97
$1 131,86 		$212,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554,70
$629,58
$708,92
$990,70
$1 505,46 		$766,87
$841,75
$921,09
$1 202,87 		$979,04
$1 053,92
$1 133,26
$1 415,04 		$1 191,21
$1 266,09
$1 345,43
$1 627,21 		$212,17
Toc - Plan #31 Bright Health
Expanded Bronze

(HMO) Bronze $0 Primary Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$289,32
$328,38
$369,75
$516,73
$785,22 		$510,65
$549,71
$591,08
$738,06 		$731,98
$771,04
$812,41
$959,39 		$953,31
$992,37
$1 033,74
$1 180,72 		$221,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578,64
$656,76
$739,50
$1 033,46
$1 570,44 		$799,97
$878,09
$960,83
$1 254,79 		$1 021,30
$1 099,42
$1 182,16
$1 476,12 		$1 242,63
$1 320,75
$1 403,49
$1 697,45 		$221,33
Toc - Plan #32 Bright Health
Expanded Bronze

(HMO) Bronze 7000 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$312,32
$354,49
$399,15
$557,81
$847,64 		$551,25
$593,42
$638,08
$796,74 		$790,18
$832,35
$877,01
$1 035,67 		$1 029,11
$1 071,28
$1 115,94
$1 274,60 		$238,93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624,64
$708,98
$798,30
$1 115,62
$1 695,28 		$863,57
$947,91
$1 037,23
$1 354,55 		$1 102,50
$1 186,84
$1 276,16
$1 593,48 		$1 341,43
$1 425,77
$1 515,09
$1 832,41 		$238,93
Toc - Plan #33 Bright Health
Expanded Bronze

(HMO) Bronze $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$323,73
$367,44
$413,73
$578,19
$878,61 		$571,39
$615,10
$661,39
$825,85 		$819,05
$862,76
$909,05
$1 073,51 		$1 066,71
$1 110,42
$1 156,71
$1 321,17 		$247,66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647,46
$734,88
$827,46
$1 156,38
$1 757,22 		$895,12
$982,54
$1 075,12
$1 404,04 		$1 142,78
$1 230,20
$1 322,78
$1 651,70 		$1 390,44
$1 477,86
$1 570,44
$1 899,36 		$247,66
Toc - Plan #34 Bright Health
Catastrophic

(HMO) Catastrophic 3 $0 PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$254,73
$289,12
$325,54
$454,94
$691,33 		$449,60
$483,99
$520,41
$649,81 		$644,47
$678,86
$715,28
$844,68 		$839,34
$873,73
$910,15
$1 039,55 		$194,87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$509,46
$578,24
$651,08
$909,88
$1 382,66 		$704,33
$773,11
$845,95
$1 104,75 		$899,20
$967,98
$1 040,82
$1 299,62 		$1 094,07
$1 162,85
$1 235,69
$1 494,49 		$194,87
Toc - Plan #35 Bright Health
Silver

(HMO) Silver 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340,98
$387,02
$435,78
$609,00
$925,43 		$601,83
$647,87
$696,63
$869,85 		$862,68
$908,72
$957,48
$1 130,70 		$1 123,53
$1 169,57
$1 218,33
$1 391,55 		$260,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681,96
$774,04
$871,56
$1 218,00
$1 850,86 		$942,81
$1 034,89
$1 132,41
$1 478,85 		$1 203,66
$1 295,74
$1 393,26
$1 739,70 		$1 464,51
$1 556,59
$1 654,11
$2 000,55 		$260,85
Toc - Plan #36 Bright Health
Silver

(HMO) Silver 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336,19
$381,57
$429,65
$600,43
$912,42 		$593,37
$638,75
$686,83
$857,61 		$850,55
$895,93
$944,01
$1 114,79 		$1 107,73
$1 153,11
$1 201,19
$1 371,97 		$257,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672,38
$763,14
$859,30
$1 200,86
$1 824,84 		$929,56
$1 020,32
$1 116,48
$1 458,04 		$1 186,74
$1 277,50
$1 373,66
$1 715,22 		$1 443,92
$1 534,68
$1 630,84
$1 972,40 		$257,18
Toc - Plan #37 Bright Health
Silver

(HMO) Silver $0 Primary Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$351,04
$398,43
$448,63
$626,96
$952,73 		$619,59
$666,98
$717,18
$895,51 		$888,14
$935,53
$985,73
$1 164,06 		$1 156,69
$1 204,08
$1 254,28
$1 432,61 		$268,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702,08
$796,86
$897,26
$1 253,92
$1 905,46 		$970,63
$1 065,41
$1 165,81
$1 522,47 		$1 239,18
$1 333,96
$1 434,36
$1 791,02 		$1 507,73
$1 602,51
$1 702,91
$2 059,57 		$268,55

ADVERTISEMENT

Ambetter from Arizona Complete Health

Local: 1-888-926-5057 | Toll Free: 1-888-926-5057 | TTY: 1-888-926-5180
Toc - Plan #38 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 9 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$347,29
$394,17
$443,84
$620,26
$942,54 		$612,97
$659,85
$709,52
$885,94 		$878,65
$925,53
$975,20
$1 151,62 		$1 144,33
$1 191,21
$1 240,88
$1 417,30 		$265,68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694,58
$788,34
$887,68
$1 240,52
$1 885,08 		$960,26
$1 054,02
$1 153,36
$1 506,20 		$1 225,94
$1 319,70
$1 419,04
$1 771,88 		$1 491,62
$1 585,38
$1 684,72
$2 037,56 		$265,68
Toc - Plan #39 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 4 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$323,36
$367,02
$413,26
$577,53
$877,61 		$570,73
$614,39
$660,63
$824,90 		$818,10
$861,76
$908,00
$1 072,27 		$1 065,47
$1 109,13
$1 155,37
$1 319,64 		$247,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646,72
$734,04
$826,52
$1 155,06
$1 755,22 		$894,09
$981,41
$1 073,89
$1 402,43 		$1 141,46
$1 228,78
$1 321,26
$1 649,80 		$1 388,83
$1 476,15
$1 568,63
$1 897,17 		$247,37
Toc - Plan #40 Ambetter from Arizona Complete Health
Bronze

(HMO) Ambetter Essential Care 1 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$269,30
$305,66
$344,17
$480,97
$730,89 		$475,32
$511,68
$550,19
$686,99 		$681,34
$717,70
$756,21
$893,01 		$887,36
$923,72
$962,23
$1 099,03 		$206,02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538,60
$611,32
$688,34
$961,94
$1 461,78 		$744,62
$817,34
$894,36
$1 167,96 		$950,64
$1 023,36
$1 100,38
$1 373,98 		$1 156,66
$1 229,38
$1 306,40
$1 580,00 		$206,02
Toc - Plan #41 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$277,87
$315,38
$355,12
$496,27
$754,14 		$490,44
$527,95
$567,69
$708,84 		$703,01
$740,52
$780,26
$921,41 		$915,58
$953,09
$992,83
$1 133,98 		$212,57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555,74
$630,76
$710,24
$992,54
$1 508,28 		$768,31
$843,33
$922,81
$1 205,11 		$980,88
$1 055,90
$1 135,38
$1 417,68 		$1 193,45
$1 268,47
$1 347,95
$1 630,25 		$212,57
Toc - Plan #42 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 11 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313,65
$356,00
$400,85
$560,19
$851,26 		$553,60
$595,95
$640,80
$800,14 		$793,55
$835,90
$880,75
$1 040,09 		$1 033,50
$1 075,85
$1 120,70
$1 280,04 		$239,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627,30
$712,00
$801,70
$1 120,38
$1 702,52 		$867,25
$951,95
$1 041,65
$1 360,33 		$1 107,20
$1 191,90
$1 281,60
$1 600,28 		$1 347,15
$1 431,85
$1 521,55
$1 840,23 		$239,95
Toc - Plan #43 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 12 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$308,19
$349,80
$393,87
$550,43
$836,44 		$543,96
$585,57
$629,64
$786,20 		$779,73
$821,34
$865,41
$1 021,97 		$1 015,50
$1 057,11
$1 101,18
$1 257,74 		$235,77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616,38
$699,60
$787,74
$1 100,86
$1 672,88 		$852,15
$935,37
$1 023,51
$1 336,63 		$1 087,92
$1 171,14
$1 259,28
$1 572,40 		$1 323,69
$1 406,91
$1 495,05
$1 808,17 		$235,77
Toc - Plan #44 Ambetter from Arizona Complete Health
Gold

(HMO) Ambetter Secure Care 5 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 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 		$451,30
$512,23
$576,76
$806,03
$1 224,83 		$796,55
$857,48
$922,01
$1 151,28 		$1 141,80
$1 202,73
$1 267,26
$1 496,53 		$1 487,05
$1 547,98
$1 612,51
$1 841,78 		$345,25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902,60
$1 024,46
$1 153,52
$1 612,06
$2 449,66 		$1 247,85
$1 369,71
$1 498,77
$1 957,31 		$1 593,10
$1 714,96
$1 844,02
$2 302,56 		$1 938,35
$2 060,21
$2 189,27
$2 647,81 		$345,25
Toc - Plan #45 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 29 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 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 		$305,64
$346,90
$390,61
$545,88
$829,51 		$539,46
$580,72
$624,43
$779,70 		$773,28
$814,54
$858,25
$1 013,52 		$1 007,10
$1 048,36
$1 092,07
$1 247,34 		$233,82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611,28
$693,80
$781,22
$1 091,76
$1 659,02 		$845,10
$927,62
$1 015,04
$1 325,58 		$1 078,92
$1 161,44
$1 248,86
$1 559,40 		$1 312,74
$1 395,26
$1 482,68
$1 793,22 		$233,82
Toc - Plan #46 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 25 HSA (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 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 		$320,92
$364,24
$410,13
$573,16
$870,97 		$566,42
$609,74
$655,63
$818,66 		$811,92
$855,24
$901,13
$1 064,16 		$1 057,42
$1 100,74
$1 146,63
$1 309,66 		$245,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641,84
$728,48
$820,26
$1 146,32
$1 741,94 		$887,34
$973,98
$1 065,76
$1 391,82 		$1 132,84
$1 219,48
$1 311,26
$1 637,32 		$1 378,34
$1 464,98
$1 556,76
$1 882,82 		$245,50
Toc - Plan #47 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 26 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,100 $16,200 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 		$321,62
$365,04
$411,03
$574,41
$872,87 		$567,66
$611,08
$657,07
$820,45 		$813,70
$857,12
$903,11
$1 066,49 		$1 059,74
$1 103,16
$1 149,15
$1 312,53 		$246,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643,24
$730,08
$822,06
$1 148,82
$1 745,74 		$889,28
$976,12
$1 068,10
$1 394,86 		$1 135,32
$1 222,16
$1 314,14
$1 640,90 		$1 381,36
$1 468,20
$1 560,18
$1 886,94 		$246,04
Toc - Plan #48 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 28 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$332,92
$377,87
$425,48
$594,60
$903,56 		$587,61
$632,56
$680,17
$849,29 		$842,30
$887,25
$934,86
$1 103,98 		$1 096,99
$1 141,94
$1 189,55
$1 358,67 		$254,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665,84
$755,74
$850,96
$1 189,20
$1 807,12 		$920,53
$1 010,43
$1 105,65
$1 443,89 		$1 175,22
$1 265,12
$1 360,34
$1 698,58 		$1 429,91
$1 519,81
$1 615,03
$1 953,27 		$254,69
Toc - Plan #49 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care 5 (2021)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$277,66
$315,15
$354,85
$495,90
$753,58 		$490,07
$527,56
$567,26
$708,31 		$702,48
$739,97
$779,67
$920,72 		$914,89
$952,38
$992,08
$1 133,13 		$212,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555,32
$630,30
$709,70
$991,80
$1 507,16 		$767,73
$842,71
$922,11
$1 204,21 		$980,14
$1 055,12
$1 134,52
$1 416,62 		$1 192,55
$1 267,53
$1 346,93
$1 629,03 		$212,41
Toc - Plan #50 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 12 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$322,91
$366,51
$412,68
$576,72
$876,39 		$569,94
$613,54
$659,71
$823,75 		$816,97
$860,57
$906,74
$1 070,78 		$1 064,00
$1 107,60
$1 153,77
$1 317,81 		$247,03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645,82
$733,02
$825,36
$1 153,44
$1 752,78 		$892,85
$980,05
$1 072,39
$1 400,47 		$1 139,88
$1 227,08
$1 319,42
$1 647,50 		$1 386,91
$1 474,11
$1 566,45
$1 894,53 		$247,03
Toc - Plan #51 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 9 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363,88
$413,00
$465,04
$649,89
$987,56 		$642,25
$691,37
$743,41
$928,26 		$920,62
$969,74
$1 021,78
$1 206,63 		$1 198,99
$1 248,11
$1 300,15
$1 485,00 		$278,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727,76
$826,00
$930,08
$1 299,78
$1 975,12 		$1 006,13
$1 104,37
$1 208,45
$1 578,15 		$1 284,50
$1 382,74
$1 486,82
$1 856,52 		$1 562,87
$1 661,11
$1 765,19
$2 134,89 		$278,37
Toc - Plan #52 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 4 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$7,200 $14,400 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 		$338,81
$384,55
$433,00
$605,11
$919,53 		$598,00
$643,74
$692,19
$864,30 		$857,19
$902,93
$951,38
$1 123,49 		$1 116,38
$1 162,12
$1 210,57
$1 382,68 		$259,19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677,62
$769,10
$866,00
$1 210,22
$1 839,06 		$936,81
$1 028,29
$1 125,19
$1 469,41 		$1 196,00
$1 287,48
$1 384,38
$1 728,60 		$1 455,19
$1 546,67
$1 643,57
$1 987,79 		$259,19
Toc - Plan #53 Ambetter from Arizona Complete Health
Bronze

(HMO) Ambetter Essential Care 1 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282,17
$320,26
$360,61
$503,95
$765,80 		$498,03
$536,12
$576,47
$719,81 		$713,89
$751,98
$792,33
$935,67 		$929,75
$967,84
$1 008,19
$1 151,53 		$215,86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564,34
$640,52
$721,22
$1 007,90
$1 531,60 		$780,20
$856,38
$937,08
$1 223,76 		$996,06
$1 072,24
$1 152,94
$1 439,62 		$1 211,92
$1 288,10
$1 368,80
$1 655,48 		$215,86
Toc - Plan #54 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$291,14
$330,45
$372,08
$519,98
$790,16 		$513,86
$553,17
$594,80
$742,70 		$736,58
$775,89
$817,52
$965,42 		$959,30
$998,61
$1 040,24
$1 188,14 		$222,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582,28
$660,90
$744,16
$1 039,96
$1 580,32 		$805,00
$883,62
$966,88
$1 262,68 		$1 027,72
$1 106,34
$1 189,60
$1 485,40 		$1 250,44
$1 329,06
$1 412,32
$1 708,12 		$222,72
Toc - Plan #55 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 11 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328,64
$373,00
$420,00
$586,94
$891,92 		$580,05
$624,41
$671,41
$838,35 		$831,46
$875,82
$922,82
$1 089,76 		$1 082,87
$1 127,23
$1 174,23
$1 341,17 		$251,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657,28
$746,00
$840,00
$1 173,88
$1 783,84 		$908,69
$997,41
$1 091,41
$1 425,29 		$1 160,10
$1 248,82
$1 342,82
$1 676,70 		$1 411,51
$1 500,23
$1 594,23
$1 928,11 		$251,41
Toc - Plan #56 Ambetter from Arizona Complete Health
Gold

(HMO) Ambetter Secure Care 5 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 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 		$472,86
$536,69
$604,31
$844,53
$1 283,34 		$834,60
$898,43
$966,05
$1 206,27 		$1 196,34
$1 260,17
$1 327,79
$1 568,01 		$1 558,08
$1 621,91
$1 689,53
$1 929,75 		$361,74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945,72
$1 073,38
$1 208,62
$1 689,06
$2 566,68 		$1 307,46
$1 435,12
$1 570,36
$2 050,80 		$1 669,20
$1 796,86
$1 932,10
$2 412,54 		$2 030,94
$2 158,60
$2 293,84
$2 774,28 		$361,74
Toc - Plan #57 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 25 HSA (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 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 		$336,25
$381,64
$429,72
$600,53
$912,57 		$593,48
$638,87
$686,95
$857,76 		$850,71
$896,10
$944,18
$1 114,99 		$1 107,94
$1 153,33
$1 201,41
$1 372,22 		$257,23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672,50
$763,28
$859,44
$1 201,06
$1 825,14 		$929,73
$1 020,51
$1 116,67
$1 458,29 		$1 186,96
$1 277,74
$1 373,90
$1 715,52 		$1 444,19
$1 534,97
$1 631,13
$1 972,75 		$257,23
Toc - Plan #58 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 26 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,100 $16,200 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 		$336,98
$382,47
$430,66
$601,84
$914,56 		$594,77
$640,26
$688,45
$859,63 		$852,56
$898,05
$946,24
$1 117,42 		$1 110,35
$1 155,84
$1 204,03
$1 375,21 		$257,79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$673,96
$764,94
$861,32
$1 203,68
$1 829,12 		$931,75
$1 022,73
$1 119,11
$1 461,47 		$1 189,54
$1 280,52
$1 376,90
$1 719,26 		$1 447,33
$1 538,31
$1 634,69
$1 977,05 		$257,79
Toc - Plan #59 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 28 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$348,83
$395,92
$445,80
$623,00
$946,71 		$615,68
$662,77
$712,65
$889,85 		$882,53
$929,62
$979,50
$1 156,70 		$1 149,38
$1 196,47
$1 246,35
$1 423,55 		$266,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697,66
$791,84
$891,60
$1 246,00
$1 893,42 		$964,51
$1 058,69
$1 158,45
$1 512,85 		$1 231,36
$1 325,54
$1 425,30
$1 779,70 		$1 498,21
$1 592,39
$1 692,15
$2 046,55 		$266,85
Toc - Plan #60 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care 5 (2021) + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$290,92
$330,20
$371,80
$519,59
$789,57 		$513,48
$552,76
$594,36
$742,15 		$736,04
$775,32
$816,92
$964,71 		$958,60
$997,88
$1 039,48
$1 187,27 		$222,56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581,84
$660,40
$743,60
$1 039,18
$1 579,14 		$804,40
$882,96
$966,16
$1 261,74 		$1 026,96
$1 105,52
$1 188,72
$1 484,30 		$1 249,52
$1 328,08
$1 411,28
$1 706,86 		$222,56

ADVERTISEMENT

Cigna HealthCare of Arizona, Inc

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #61 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 5000

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$337,27
$382,80
$431,03
$602,36
$915,34 		$595,28
$640,81
$689,04
$860,37 		$853,29
$898,82
$947,05
$1 118,38 		$1 111,30
$1 156,83
$1 205,06
$1 376,39 		$258,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674,54
$765,60
$862,06
$1 204,72
$1 830,68 		$932,55
$1 023,61
$1 120,07
$1 462,73 		$1 190,56
$1 281,62
$1 378,08
$1 720,74 		$1 448,57
$1 539,63
$1 636,09
$1 978,75 		$258,01
Toc - Plan #62 Cigna HealthCare of Arizona, Inc
Bronze

(HMO) Cigna Connect 7000

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$272,46
$309,24
$348,20
$486,61
$739,45 		$480,89
$517,67
$556,63
$695,04 		$689,32
$726,10
$765,06
$903,47 		$897,75
$934,53
$973,49
$1 111,90 		$208,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$544,92
$618,48
$696,40
$973,22
$1 478,90 		$753,35
$826,91
$904,83
$1 181,65 		$961,78
$1 035,34
$1 113,26
$1 390,08 		$1 170,21
$1 243,77
$1 321,69
$1 598,51 		$208,43
Toc - Plan #63 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect 8000

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$284,64
$323,07
$363,77
$508,37
$772,52 		$502,39
$540,82
$581,52
$726,12 		$720,14
$758,57
$799,27
$943,87 		$937,89
$976,32
$1 017,02
$1 161,62 		$217,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569,28
$646,14
$727,54
$1 016,74
$1 545,04 		$787,03
$863,89
$945,29
$1 234,49 		$1 004,78
$1 081,64
$1 163,04
$1 452,24 		$1 222,53
$1 299,39
$1 380,79
$1 669,99 		$217,75
Toc - Plan #64 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 3500

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$338,73
$384,46
$432,90
$604,97
$919,32 		$597,86
$643,59
$692,03
$864,10 		$856,99
$902,72
$951,16
$1 123,23 		$1 116,12
$1 161,85
$1 210,29
$1 382,36 		$259,13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677,46
$768,92
$865,80
$1 209,94
$1 838,64 		$936,59
$1 028,05
$1 124,93
$1 469,07 		$1 195,72
$1 287,18
$1 384,06
$1 728,20 		$1 454,85
$1 546,31
$1 643,19
$1 987,33 		$259,13
Toc - Plan #65 Cigna HealthCare of Arizona, Inc
Gold

(HMO) Cigna Connect 2500

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$430,57
$488,69
$550,26
$768,99
$1 168,55 		$759,95
$818,07
$879,64
$1 098,37 		$1 089,33
$1 147,45
$1 209,02
$1 427,75 		$1 418,71
$1 476,83
$1 538,40
$1 757,13 		$329,38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861,14
$977,38
$1 100,52
$1 537,98
$2 337,10 		$1 190,52
$1 306,76
$1 429,90
$1 867,36 		$1 519,90
$1 636,14
$1 759,28
$2 196,74 		$1 849,28
$1 965,52
$2 088,66
$2 526,12 		$329,38
Toc - Plan #66 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 3500 + Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340,23
$386,17
$434,82
$607,66
$923,40 		$600,51
$646,45
$695,10
$867,94 		$860,79
$906,73
$955,38
$1 128,22 		$1 121,07
$1 167,01
$1 215,66
$1 388,50 		$260,28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680,46
$772,34
$869,64
$1 215,32
$1 846,80 		$940,74
$1 032,62
$1 129,92
$1 475,60 		$1 201,02
$1 292,90
$1 390,20
$1 735,88 		$1 461,30
$1 553,18
$1 650,48
$1 996,16 		$260,28
Toc - Plan #67 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 5500

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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 		$335,37
$380,64
$428,60
$598,97
$910,19 		$591,93
$637,20
$685,16
$855,53 		$848,49
$893,76
$941,72
$1 112,09 		$1 105,05
$1 150,32
$1 198,28
$1 368,65 		$256,56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670,74
$761,28
$857,20
$1 197,94
$1 820,38 		$927,30
$1 017,84
$1 113,76
$1 454,50 		$1 183,86
$1 274,40
$1 370,32
$1 711,06 		$1 440,42
$1 530,96
$1 626,88
$1 967,62 		$256,56
Toc - Plan #68 Cigna HealthCare of Arizona, Inc
Bronze

(HMO) Cigna Connect 8550

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$271,74
$308,43
$347,29
$485,34
$737,51 		$479,62
$516,31
$555,17
$693,22 		$687,50
$724,19
$763,05
$901,10 		$895,38
$932,07
$970,93
$1 108,98 		$207,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543,48
$616,86
$694,58
$970,68
$1 475,02 		$751,36
$824,74
$902,46
$1 178,56 		$959,24
$1 032,62
$1 110,34
$1 386,44 		$1 167,12
$1 240,50
$1 318,22
$1 594,32 		$207,88

‡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 Maricopa County here.

Maricopa County is in “Rating Area 4” of Arizona.

Currently, there are 68 plans offered in Rating Area 4.

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2021 Obamacare Plans for Maricopa County, AZ

Plan Browser: 68 Plans
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