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Cost Details

Total monthly premium (without premium assistance):

Premium assistance:

You pay

$

There must be at least one adult (aged 19 or over) ...

Cost Details

Total monthly premium (without premium assistance):

Premium assistance:

You pay

$

There must be at least one adult (aged 19 or over) ...

Issuer Name

Click on an issuer's plan to see details about the issuer

Issuer Name

Click on an issuer's plan to see details about the issuer

Platinum Plan Details

Copays in Black are Not Subject ...

Standard Benefits for Individuals

Individual Deductible

no deductible

Family Deductible

no deductible

Preventive Care Copay

no cost

Primary Care Copay

$20

Specialty Care Copay

$40

Urgent Care Copay

$40

Tier 1 Generic Brand Pharma Copay

Lab Copay

$20

X-ray Copay

$40

Emergency Copay

$150

Infrequent and High-Cost Services Copay

10%

Hospital Physician Copay

10%

Tier 2 Preferred Brand Pharma Copay

$15

Tier 3 Other Brand Pharma Copay

$25

Tier 4 Specialty Pharma Copay

10% up to $250 per script

Max Out-Of-Pocket For One

$4,000

Max Out-Of-Pocket For Family

$8,000

¹ in-network only

Gold Plan Details

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

no deductible

Family Deductible

no deductible

Preventive Care Copay

no cost

Primary Care Copay

$35

Specialty Care Copay

$55

Urgent Care Copay

$60

Tier 1 Generic Brand Pharma Copay

$15

Lab Copay

$35

X-ray Copay

$50

Emergency Copay

$250

Infrequent and High-Cost Services Copay

20%

Hospital Physician Copay

20%

Tier 2 Preferred Brand Pharma Copay

$50

Tier 3 Other Brand Pharma Copay

$70

Tier 4 Specialty Pharma Copay

20% up to $250 per script after deductible

Max Out-Of-Pocket For One

$6,200

Max Out-Of-Pocket For Family

$12,400

¹ in-network only

Silver Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

$2,250medical deductible

$250pharmacy deductible

Family Deductible

$4,500medical deductible

$500pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$45

Specialty Care Copay

$70

Urgent Care Copay

$90

Tier 1 Generic Brand Pharma Copay

$15

Lab Copay

$35

X-ray Copay

$65

Emergency Copay

$250

Infrequent and High-Cost Services Copay

20% planDetails.plansNegotiatedRate

Hospital Physician Copay

20% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$50

Tier 3 Other Brand Pharma Copay

$70

Tier 4 Specialty Pharma Copay

20% up to $250 per script after deductible

Max Out-Of-Pocket For One

$6,250

Max Out-Of-Pocket For Family

$12,500

¹ in-network only

Silver Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

$2,250medical deductible

$250pharmacy deductible

Family Deductible

$4,500medical deductible

$500pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$45

Specialty Care Copay

$70

Urgent Care Copay

$90

Tier 1 Generic Brand Pharma Copay

$15

Lab Copay

$35

X-ray Copay

$65

Emergency Copay

$250

Infrequent and High-Cost Services Copay

20% planDetails.plansNegotiatedRate

Hospital Physician Copay

20% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$50

Tier 3 Other Brand Pharma Copay

$70

Tier 4 Specialty Pharma Copay

20% up to $250 per script after deductible

Max Out-Of-Pocket For One

$6,250

Max Out-Of-Pocket For Family

$12,500

¹ in-network only

Silver 73 Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Enhanced Benefits for Individuals

Individual Deductible

$1,900medical deductible

$250pharmacy deductible

Family Deductible

$3,800medical deductible

$500pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$40

Specialty Care Copay

$55

Urgent Care Copay

$80

Tier 1 Generic Brand Pharma Copay

$15

Lab Copay

$35

X-ray Copay

$50

Emergency Copay

$250

Infrequent and High-Cost Services Copay

20% planDetails.plansNegotiatedRate

Hospital Physician Copay

20% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$45

Tier 3 Other Brand Pharma Copay

$70

Tier 4 Specialty Pharma Copay

20% up to $250 per script after deductible

Max Out-Of-Pocket For One

$5,450

Max Out-Of-Pocket For Family

$10,900

¹ in-network only

Silver 87 Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Enhanced Benefits for Individuals

Individual Deductible

$550medical deductible

$50pharmacy deductible

Family Deductible

$1,100medical deductible

$100pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$15

Specialty Care Copay

$25

Urgent Care Copay

$30

Tier 1 Generic Brand Pharma Copay

Lab Copay

$15

X-ray Copay

$25

Emergency Copay

$75

Infrequent and High-Cost Services Copay

15% planDetails.plansNegotiatedRate

Hospital Physician Copay

15% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$20

Tier 3 Other Brand Pharma Copay

$35

Tier 4 Specialty Pharma Copay

15% up to $150 per script after deductible

Max Out-Of-Pocket For One

$2,250

Max Out-Of-Pocket For Family

$4,500

¹ in-network only

Silver 94 Plan Details

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Enhanced Benefits for Individuals

Individual Deductible

$75medical deductible

Family Deductible

$150medical deductible

Preventive Care Copay

no cost

Primary Care Copay

Specialty Care Copay

Urgent Care Copay

Tier 1 Generic Brand Pharma Copay

Lab Copay

X-ray Copay

Emergency Copay

$30

Infrequent and High-Cost Services Copay

10% planDetails.plansNegotiatedRate

Hospital Physician Copay

10% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$10

Tier 3 Other Brand Pharma Copay

$15

Tier 4 Specialty Pharma Copay

10% up to $150 per script

Max Out-Of-Pocket For One

$2,250

Max Out-Of-Pocket For Family

$4,500

¹ in-network only

Bronze Plan Details

Available Plan Benefits in blue are subject to medical duductible.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

$6,000medical deductible

$500pharmacy deductible

Family Deductible

$12,000medical deductible

$1,000pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$70 2

Specialty Care Copay

$90 2

Urgent Care Copay

$120 2

Tier 1 Generic Brand Pharma Copay

100% up to $500 per script after deductible

Lab Copay

$40

X-ray Copay

100% planDetails.plansNegotiatedRate

Emergency Copay

100% planDetails.plansNegotiatedRate

Infrequent and High-Cost Services Copay

100% planDetails.plansNegotiatedRate

Hospital Physician Copay

100%

Tier 2 Preferred Brand Pharma Copay

100% up to $500 per script after deductible

Tier 3 Other Brand Pharma Copay

100% up to $500 per script after deductible

Tier 4 Specialty Pharma Copay

100% up to $500 per script after deductible

Max Out-Of-Pocket For One

$6,500

Max Out-Of-Pocket For Family

$13,000

¹ in-network only

² First 3 visits each year are not subject to the deductible

Bronze HSA Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

$4,500deductible for medical
& drugs

Family Deductible

$9,000deductible

Preventive Care Copay

no cost

Primary Care Copay

40%

Specialty Care Copay

40%

Urgent Care Copay

40%

Tier 1 Generic Brand Pharma Copay

40%

Lab Copay

40%

X-ray Copay

40%

Emergency Copay

40%

Infrequent and High-Cost Services Copay

40%

Hospital Physician Copay

40%

Tier 2 Preferred Brand Pharma Copay

40%

Tier 3 Other Brand Pharma Copay

40%

Tier 4 Specialty Pharma Copay

40%

Max Out-Of-Pocket For One

$6,500

Max Out-Of-Pocket For Family

$13,000

¹ in-network only

Platinum Plan Details

Copays in Black are Not Subject ...

Standard Benefits for Individuals

Individual Deductible

no deductible

Family Deductible

no deductible

Preventive Care Copay

no cost

Primary Care Copay

$20

Specialty Care Copay

$40

Urgent Care Copay

$40

Tier 1 Generic Brand Pharma Copay

Lab Copay

$20

X-ray Copay

$40

Emergency Copay

$150

Infrequent and High-Cost Services Copay

Hospital - $250/day up to 5 days

Hospital Physician Copay

$40

Tier 2 Preferred Brand Pharma Copay

$15

Tier 3 Other Brand Pharma Copay

$25

Tier 4 Specialty Pharma Copay

10% up to $250 per script

Max Out-Of-Pocket For One

$4,000

Max Out-Of-Pocket For Family

$8,000

¹ in-network only

Gold Plan Details

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

no deductible

Family Deductible

no deductible

Preventive Care Copay

no cost

Primary Care Copay

$35

Specialty Care Copay

$55

Urgent Care Copay

$60

Tier 1 Generic Brand Pharma Copay

$15

Lab Copay

$35

X-ray Copay

$50

Emergency Copay

$250

Infrequent and High-Cost Services Copay

Outpatient Surgery - $600
Hospital - $600/day up to 5 days

Hospital Physician Copay

$55

Tier 2 Preferred Brand Pharma Copay

$50

Tier 3 Other Brand Pharma Copay

$70

Tier 4 Specialty Pharma Copay

20% up to $250 per script after deductible

Max Out-Of-Pocket For One

$6,200

Max Out-Of-Pocket For Family

$12,400

¹ in-network only

Silver Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

$2,250medical deductible

$250pharmacy deductible

Family Deductible

$4,500medical deductible

$500pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$45

Specialty Care Copay

$70

Urgent Care Copay

$90

Tier 1 Generic Brand Pharma Copay

$15

Lab Copay

$35

X-ray Copay

$65

Emergency Copay

$250

Infrequent and High-Cost Services Copay

20% planDetails.plansNegotiatedRate

Hospital Physician Copay

20% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$50

Tier 3 Other Brand Pharma Copay

$70

Tier 4 Specialty Pharma Copay

20% up to $250 per script after deductible

Max Out-Of-Pocket For One

$6,250

Max Out-Of-Pocket For Family

$12,500

¹ in-network only

Silver Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

$2,250medical deductible

$250pharmacy deductible

Family Deductible

$4,500medical deductible

$500pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$45

Specialty Care Copay

$70

Urgent Care Copay

$90

Tier 1 Generic Brand Pharma Copay

$15

Lab Copay

$35

X-ray Copay

$65

Emergency Copay

$250

Infrequent and High-Cost Services Copay

20% planDetails.plansNegotiatedRate

Hospital Physician Copay

20% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$50

Tier 3 Other Brand Pharma Copay

$70

Tier 4 Specialty Pharma Copay

20% up to $250 per script after deductible

Max Out-Of-Pocket For One

$6,250

Max Out-Of-Pocket For Family

$12,500

¹ in-network only

Silver 73 Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Enhanced Benefits for Individuals

Individual Deductible

$1,900medical deductible

$250pharmacy deductible

Family Deductible

$3,800medical deductible

$500pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$40

Specialty Care Copay

$55

Urgent Care Copay

$80

Tier 1 Generic Brand Pharma Copay

$15

Lab Copay

$35

X-ray Copay

$50

Emergency Copay

$250

Infrequent and High-Cost Services Copay

20% planDetails.plansNegotiatedRate

Hospital Physician Copay

20% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$45

Tier 3 Other Brand Pharma Copay

$70

Tier 4 Specialty Pharma Copay

20% up to $250 per script after deductible

Max Out-Of-Pocket For One

$5,450

Max Out-Of-Pocket For Family

$10,900

¹ in-network only

Silver 87 Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Enhanced Benefits for Individuals

Individual Deductible

$550medical deductible

$50pharmacy deductible

Family Deductible

$1,100medical deductible

$100pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$15

Specialty Care Copay

$25

Urgent Care Copay

$30

Tier 1 Generic Brand Pharma Copay

Lab Copay

$15

X-ray Copay

$25

Emergency Copay

$75

Infrequent and High-Cost Services Copay

15% planDetails.plansNegotiatedRate

Hospital Physician Copay

15% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$20

Tier 3 Other Brand Pharma Copay

$35

Tier 4 Specialty Pharma Copay

15% up to $150 per script after deductible

Max Out-Of-Pocket For One

$2,250

Max Out-Of-Pocket For Family

$4,500

¹ in-network only

Silver 94 Plan Details

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Enhanced Benefits for Individuals

Individual Deductible

$75medical deductible

Family Deductible

$150medical deductible

Preventive Care Copay

no cost

Primary Care Copay

Specialty Care Copay

Urgent Care Copay

Tier 1 Generic Brand Pharma Copay

Lab Copay

X-ray Copay

Emergency Copay

$30

Infrequent and High-Cost Services Copay

10% planDetails.plansNegotiatedRate

Hospital Physician Copay

10% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

$10

Tier 3 Other Brand Pharma Copay

$15

Tier 4 Specialty Pharma Copay

10% up to $150 per script

Max Out-Of-Pocket For One

$2,250

Max Out-Of-Pocket For Family

$4,500

¹ in-network only

Bronze Plan Details

Available Plan Benefits in blue are subject to medical duductible.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

$6,000medical deductible

$500pharmacy deductible

Family Deductible

$12,000medical deductible

$1,000pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$70 2

Specialty Care Copay

$90 2

Urgent Care Copay

$120 2

Tier 1 Generic Brand Pharma Copay

100% up to $500 per script after deductible

Lab Copay

$40

X-ray Copay

100% planDetails.plansNegotiatedRate

Emergency Copay

100% planDetails.plansNegotiatedRate

Infrequent and High-Cost Services Copay

100% planDetails.plansNegotiatedRate

Hospital Physician Copay

100%

Tier 2 Preferred Brand Pharma Copay

100% up to $500 per script after deductible

Tier 3 Other Brand Pharma Copay

100% up to $500 per script after deductible

Tier 4 Specialty Pharma Copay

100% up to $500 per script after deductible

Max Out-Of-Pocket For One

$6,500

Max Out-Of-Pocket For Family

$13,000

¹ in-network only

² First 3 visits each year are not subject to the deductible

Bronze HSA Plan Details

Available Plan Benefits in blue are subject to medical deductions.

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Standard Benefits for Individuals

Individual Deductible

$4,500deductible for medical
& drugs

Family Deductible

$9,000deductible

Preventive Care Copay

no cost

Primary Care Copay

40%

Specialty Care Copay

40%

Urgent Care Copay

40%

Tier 1 Generic Brand Pharma Copay

40%

Lab Copay

40%

X-ray Copay

40%

Emergency Copay

40%

Infrequent and High-Cost Services Copay

40%

Hospital Physician Copay

40%

Tier 2 Preferred Brand Pharma Copay

40%

Tier 3 Other Brand Pharma Copay

40%

Tier 4 Specialty Pharma Copay

40%

Max Out-Of-Pocket For One

$6,500

Max Out-Of-Pocket For Family

$13,000

¹ in-network only

Family Dental HMO Plan Details

All member costs in blue are subject to deductible.

Standard Benefits for Individuals

Individual Deductible

none

Family Deductible

none

Diagnostic & Preventive

Amalgam Filling - one surface

$25

Root Canal - molar

$300

Crown - porcelain with metal

$300

Medically Necessary orthodontia

not covered

$350

Maximum out-of-pocket for one child

not applicable

$350

Maximum out-of-pocket for family

not applicable

$700

Waiting Period

none

Annual benefit limit

none

Family Dental PPO Plan Details

All member costs in blue are subject to deductible.

Standard Benefits for Individuals

Individual Deductible

$50

$65

Family Deductible

none

$130

Diagnostic & Preventive

Amalgam Filling - one surface

20%

Root Canal - molar

50%

Crown - porcelain with metal

50%

Medically Necessary orthodontia

not covered

50%

Maximum out-of-pocket for one child

not applicable

$350

Maximum out-of-pocket for family

not applicable

$700

Waiting Period

6 months waiting period

none

Annual benefit limit

$1,500

none

Family Dental HMO Plan Details

All member costs in blue are subject to deductible.

Standard Benefits for Individuals

Individual Deductible

none

Family Deductible

none

Diagnostic & Preventive

Amalgam Filling - one surface

$25

Root Canal - molar

$300

Crown - porcelain with metal

$300

Medically Necessary orthodontia

not covered

$350

Maximum out-of-pocket for one child

not applicable

$350

Maximum out-of-pocket for family

not applicable

$700

Waiting Period

none

Annual benefit limit

none

Family Dental PPO Plan Details

All member costs in blue are subject to deductible.

Standard Benefits for Individuals

Individual Deductible

$50

$65

Family Deductible

none

$130

Diagnostic & Preventive

Amalgam Filling - one surface

20%

Root Canal - molar

50%

Crown - porcelain with metal

50%

Medically Necessary orthodontia

not covered

50%

Maximum out-of-pocket for one child

not applicable

$350

Maximum out-of-pocket for family

not applicable

$700

Waiting Period

6 months waiting period

none

Annual benefit limit

$1,500

none

Metal Tiers: Platinum, Gold, Silver, and Bronze

You do not qualify for premium assistance ...

Standard Benefits for Individuals

Benefits in Blue are Subject to Deductibles

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Individual Deductible

$6,000medical deductible

$500pharmacy deductible

$2,250medical deductible

$250pharmacy deductible

no deductible

Family Deductible

$12,000medical deductible

$1,000pharmacy deductible

$4,500medical deductible

$500pharmacy deductible

no deductible

Preventive Care Copay

no cost

Primary Care Copay

$70 2

$45

$35

$20

Specialty Care Copay

$90 2

$70

$55

$40

Urgent Care Copay

$120 2

$90

$60

$40

Tier 1 Generic Brand Pharma Copay

100% up to $500 per script after deductible

$15

Lab Copay

$40

$35

$20

X-ray Copay

100% planDetails.plansNegotiatedRate

$65

$50

$40

Emergency Copay

100% planDetails.plansNegotiatedRate

$250

$150

Infrequent and High-Cost Services Copay

100% planDetails.plansNegotiatedRate

20% planDetails.plansNegotiatedRate

HMO
Outpatient Surgery - $600
Hospital - $600/day up to 5 days
PPO — 20%

HMO
Hospital - $250/day up to 5 days
PPO — 10%

Hospital Physician Copay

100%

20% planDetails.plansNegotiatedRate

HMO — $55
PPO — 20%

HMO — $40
PPO — 10%

Tier 2 Preferred Brand Pharma Copay

100% up to $500 per script after deductible

$50

$15

Tier 3 Other Brand Pharma Copay

100% up to $500 per script after deductible

$70

$25

Tier 4 Specialty Pharma Copay

100% up to $500 per script after deductible

20% up to $250 per script after deductible

10% up to $250 per script

Max Out-Of-Pocket For One

$6,500

$6,250

$6,200

$4,000

Max Out-Of-Pocket For Family

$13,000

$12,500

$12,400

$8,000

¹ in-network only

² First 3 visits each year are not subject to the deductible

Metal Tiers: Silver, and Bronze

The two options displayed below detail the ...

Standard Benefits for Individuals

Benefits in Blue are Subject to Deductibles

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Individual Deductible

$6,000medical deductible

$500pharmacy deductible

$2,250medical deductible

$250pharmacy deductible

Family Deductible

$12,000medical deductible

$1,000pharmacy deductible

$4,500medical deductible

$500pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

$70 2

$45

Specialty Care Copay

$90 2

$70

Urgent Care Copay

$120 2

$90

Tier 1 Generic Brand Pharma Copay

100% up to $500 per script after deductible

$15

Lab Copay

$40

$35

X-ray Copay

100% planDetails.plansNegotiatedRate

$65

Emergency Copay

100% planDetails.plansNegotiatedRate

$250

Infrequent and High-Cost Services Copay

100% planDetails.plansNegotiatedRate

20% planDetails.plansNegotiatedRate

Hospital Physician Copay

100%

20% planDetails.plansNegotiatedRate

Tier 2 Preferred Brand Pharma Copay

100% up to $500 per script after deductible

$50

Tier 3 Other Brand Pharma Copay

100% up to $500 per script after deductible

$70

Tier 4 Specialty Pharma Copay

100% up to $500 per script after deductible

20% up to $250 per script after deductible

Max Out-Of-Pocket For One

$6,500

$6,250

Max Out-Of-Pocket For Family

$13,000

$12,500

¹ in-network only

² First 3 visits each year are not subject to the deductible

Metal Tiers: Enhanced Silver 70, and Bronze

The two options displayed below detail the ...

Standard Benefits for Individuals

Benefits in Blue are Subject to Deductibles

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Individual Deductible

$6,000medical deductible

$500pharmacy deductible

$2,250medical deductible

$250pharmacy deductible

no deductible

Family Deductible

$12,000medical deductible

$1,000pharmacy deductible

$4,500medical deductible

$500pharmacy deductible

no deductible

Preventive Care Copay

no cost

Primary Care Copay

$70 2

$45

$35

$20

Specialty Care Copay

$90 2

$70

$55

$40

Urgent Care Copay

$120 2

$90

$60

$40

Tier 1 Generic Brand Pharma Copay

100% up to $500 per script after deductible

$15

Lab Copay

$40

$35

$20

X-ray Copay

100% planDetails.plansNegotiatedRate

$65

$50

$40

Emergency Copay

100% planDetails.plansNegotiatedRate

$250

$150

Infrequent and High-Cost Services Copay

100% planDetails.plansNegotiatedRate

20% planDetails.plansNegotiatedRate

HMO
Outpatient Surgery - $600
Hospital - $600/day up to 5 days
PPO — 20%

HMO
Hospital - $250/day up to 5 days
PPO — 10%

Hospital Physician Copay

100%

20% planDetails.plansNegotiatedRate

HMO — $55
PPO — 20%

HMO — $40
PPO — 10%

Tier 2 Preferred Brand Pharma Copay

100% up to $500 per script after deductible

$50

$15

Tier 3 Other Brand Pharma Copay

100% up to $500 per script after deductible

$70

$25

Tier 4 Specialty Pharma Copay

100% up to $500 per script after deductible

20% up to $250 per script after deductible

10% up to $250 per script

Max Out-Of-Pocket For One

$6,500

$6,250

$6,200

$4,000

Max Out-Of-Pocket For Family

$13,000

$12,500

$12,400

$8,000

¹ in-network only

² First 3 visits each year are not subject to the deductible

Metal Tiers: Platinum, Gold, Enhanced Silver 73, and Bronze

The two options displayed below detail the ...

Standard Benefits for Individuals

Benefits in Blue are Subject to Deductibles

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Individual Deductible

$6,000medical deductible

$500pharmacy deductible

$1,900medical deductible

$250pharmacy deductible

no deductible

Family Deductible

$12,000medical deductible

$1,000pharmacy deductible

$3,800medical deductible

$500pharmacy deductible

no deductible

Preventive Care Copay

no cost

Primary Care Copay

$70 2

$40

$35

$20

Specialty Care Copay

$90 2

$55

$40

Urgent Care Copay

$120 2

$80

$60

$40

Tier 1 Generic Brand Pharma Copay

100% up to $500 per script after deductible

$15

Lab Copay

$40

$35

$20

X-ray Copay

100% planDetails.plansNegotiatedRate

$50

$40

Emergency Copay

100% planDetails.plansNegotiatedRate

$250

$150

Infrequent and High-Cost Services Copay

100% planDetails.plansNegotiatedRate

20% planDetails.plansNegotiatedRate

HMO
Outpatient Surgery - $600
Hospital - $600/day up to 5 days
PPO — 20%

HMO
Hospital - $250/day up to 5 days
PPO — 10%

Hospital Physician Copay

100%

20% planDetails.plansNegotiatedRate

HMO — $55
PPO — 20%

HMO — $40
PPO — 10%

Tier 2 Preferred Brand Pharma Copay

100% up to $500 per script after deductible

$45

$50

$15

Tier 3 Other Brand Pharma Copay

100% up to $500 per script after deductible

$70

$25

Tier 4 Specialty Pharma Copay

100% up to $500 per script after deductible

20% up to $250 per script after deductible

10% up to $250 per script

Max Out-Of-Pocket For One

$6,500

$5,450

$6,200

$4,000

Max Out-Of-Pocket For Family

$13,000

$10,900

$12,400

$8,000

¹ in-network only

² First 3 visits each year are not subject to the deductible

Metal Tiers: Silver 87, and Bronze

The two options displayed below detail the ...

Standard Benefits for Individuals

Benefits in Blue are Subject to Deductibles

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Individual Deductible

$6,000medical deductible

$500pharmacy deductible

$550medical deductible

$50pharmacy deductible

no deductible

Family Deductible

$12,000medical deductible

$1,000pharmacy deductible

$1,100medical deductible

$100pharmacy deductible

no deductible

Preventive Care Copay

no cost

Primary Care Copay

$70 2

$15

$35

$20

Specialty Care Copay

$90 2

$25

$55

$40

Urgent Care Copay

$120 2

$30

$60

$40

Tier 1 Generic Brand Pharma Copay

100% up to $500 per script after deductible

$15

Lab Copay

$40

$15

$35

$20

X-ray Copay

100% planDetails.plansNegotiatedRate

$25

$50

$40

Emergency Copay

100% planDetails.plansNegotiatedRate

$75

$250

$150

Infrequent and High-Cost Services Copay

100% planDetails.plansNegotiatedRate

15% planDetails.plansNegotiatedRate

HMO
Outpatient Surgery - $600
Hospital - $600/day up to 5 days
PPO — 20%

HMO
Hospital - $250/day up to 5 days
PPO — 10%

Hospital Physician Copay

100%

15% planDetails.plansNegotiatedRate

HMO — $55
PPO — 20%

HMO — $40
PPO — 10%

Tier 2 Preferred Brand Pharma Copay

100% up to $500 per script after deductible

$20

$50

$15

Tier 3 Other Brand Pharma Copay

100% up to $500 per script after deductible

$35

$70

$25

Tier 4 Specialty Pharma Copay

100% up to $500 per script after deductible

15% up to $150 per script after deductible

20% up to $250 per script after deductible

10% up to $250 per script

Max Out-Of-Pocket For One

$6,500

$2,250

$6,200

$4,000

Max Out-Of-Pocket For Family

$13,000

$4,500

$12,400

$8,000

¹ in-network only

² First 3 visits each year are not subject to the deductible

Metal Tiers: Platinum, Gold, Enhanced Silver 94, and Bronze

The two options displayed below detail ...

Standard Benefits for Individuals

Benefits in Blue are Subject to Deductibles

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Individual Deductible

$6,000medical deductible

$500pharmacy deductible

$75medical deductible

no deductible

Family Deductible

$12,000medical deductible

$1,000pharmacy deductible

$150medical deductible

no deductible

Preventive Care Copay

no cost

Primary Care Copay

$70 2

$35

$20

Specialty Care Copay

$90 2

$55

$40

Urgent Care Copay

$120 2

$60

$40

Tier 1 Generic Brand Pharma Copay

100% up to $500 per script after deductible

$15

Lab Copay

$40

$35

$20

X-ray Copay

100% planDetails.plansNegotiatedRate

$50

$40

Emergency Copay

100% planDetails.plansNegotiatedRate

$30

$250

$150

Infrequent and High-Cost Services Copay

100% planDetails.plansNegotiatedRate

10% planDetails.plansNegotiatedRate

HMO
Outpatient Surgery - $600
Hospital - $600/day up to 5 days
PPO — 20%

HMO
Hospital - $250/day up to 5 days
PPO — 10%

Hospital Physician Copay

100%

10% planDetails.plansNegotiatedRate

HMO — $55
PPO — 20%

HMO — $40
PPO — 10%

Tier 2 Preferred Brand Pharma Copay

100% up to $500 per script after deductible

$10

$50

$15

Tier 3 Other Brand Pharma Copay

100% up to $500 per script after deductible

$15

$70

$25

Tier 4 Specialty Pharma Copay

100% up to $500 per script after deductible

10% up to $150 per script

20% up to $250 per script after deductible

10% up to $250 per script

Max Out-Of-Pocket For One

$6,500

$2,250

$6,200

$4,000

Max Out-Of-Pocket For Family

$13,000

$4,500

$12,400

$8,000

¹ in-network only

² First 3 visits each year are not subject to the deductible

Metal Tiers: Silver, and Bronze

The two options displayed below detail the ...

Standard Benefits for Individuals

Benefits in Blue are Subject to Deductibles

Copays in Black are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum

Individual Deductible

$6,850deductible for medical
& drugs

$6,000medical deductible

$500pharmacy deductible

Family Deductible

$13,700deductible

$12,000medical deductible

$1,000pharmacy deductible

Preventive Care Copay

no cost

Primary Care Copay

no cost for 3 visits 2

$70 2

Specialty Care Copay

negotiated fee

$90 2

Urgent Care Copay

no cost for 3 visits 2

$120 2

Tier 1 Generic Brand Pharma Copay

negotiated fee

100% up to $500 per script after deductible

Lab Copay

negotiated fee

$40

X-ray Copay

negotiated fee

100% planDetails.plansNegotiatedRate

Emergency Copay

negotiated fee

100% planDetails.plansNegotiatedRate

Infrequent and High-Cost Services Copay

negotiated fee

100% planDetails.plansNegotiatedRate

Hospital Physician Copay

negotiated fee

100%

Tier 2 Preferred Brand Pharma Copay

negotiated fee

100% up to $500 per script after deductible

Tier 3 Other Brand Pharma Copay

negotiated fee

100% up to $500 per script after deductible

Tier 4 Specialty Pharma Copay

negotiated fee

100% up to $500 per script after deductible

Max Out-Of-Pocket For One

$6,850

$6,500

Max Out-Of-Pocket For Family

$13,700

$13,000

¹ in-network only

² First 3 visits each year are not subject to the deductible

Your Options

Bronze/Silver Gold/Platinum Family Dental Plans

Bronze/Silver Gold/Platinum Min. Coverage Family Dental Plans

You must get a hardship exemption to purchase a minimum coverage plan if you are over 29 years old.

Bronze 60

Enhanced Silver 87

Enhanced Silver 94

Gold 80

Minimum Coverage

Dental

This plan has a substantially higher cost share when you use healthcare.

These plans offer optional dental coverage...

Understanding how Covered California helps

Total monthly premium (without premium assistance):

Premium assistance available to you:

per month

You pay:

per month

View Cost Breakdown View Plan Benefits About

These results provide an estimate only...

Quality Popup Message

Bronze 60

Enhanced Silver 70

Enhanced Silver 73

Silver 70

Platinum 90

This plan has a substantially higher cost share when you use healthcare.

Understanding how Covered California helps

Total monthly premium (without premium assistance):

Premium assistance available to you:

per month

You pay:

per month

View Cost Breakdown View Plan Benefits About

Cost Details

You pay $

Cost Details

You pay $

Issuer Name

Issuer Name

Platinum Plan Details

Standard Benefits for Individuals

Gold Plan Details

Standard Benefits for Individuals

Silver Plan Details

Standard Benefits for Individuals

Silver Plan Details

Standard Benefits for Individuals

Silver 73 Plan Details

Enhanced Benefits for Individuals

Silver 87 Plan Details

Enhanced Benefits for Individuals

Silver 94 Plan Details

Enhanced Benefits for Individuals

Bronze Plan Details

Standard Benefits for Individuals

Bronze HSA Plan Details

Standard Benefits for Individuals

Platinum Plan Details

Standard Benefits for Individuals

Gold Plan Details

Standard Benefits for Individuals

Silver Plan Details

Standard Benefits for Individuals

Silver Plan Details

Standard Benefits for Individuals

Silver 73 Plan Details

Enhanced Benefits for Individuals

Silver 87 Plan Details

Enhanced Benefits for Individuals

Silver 94 Plan Details

Enhanced Benefits for Individuals

Bronze Plan Details

Standard Benefits for Individuals

Bronze HSA Plan Details

Standard Benefits for Individuals

Family Dental HMO Plan Details

Standard Benefits for Individuals

Family Dental PPO Plan Details

Standard Benefits for Individuals

Family Dental HMO Plan Details

Standard Benefits for Individuals

Family Dental PPO Plan Details

Standard Benefits for Individuals

Standard Benefits for Individuals

Standard Benefits for Individuals

Standard Benefits for Individuals

Standard Benefits for Individuals

Standard Benefits for Individuals

Standard Benefits for Individuals

Standard Benefits for Individuals

Your Options

Bronze 60

Enhanced Silver 87

Enhanced Silver 94

Gold 80

Minimum Coverage

Dental

Understanding how Covered California helps

Bronze 60

Enhanced Silver 70

Enhanced Silver 73

Silver 70

Platinum 90

Understanding how Covered California helps

You pay

$

You pay

$