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Bright HealthCare

Local: 1-855-521-9335 | Toll Free: 1-855-521-9335

Toc - Plan #1 Bright HealthCare
Gold

(EPO) Gold 1000 ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.15
$451.90
$508.83
$711.09
$1,080.57
$702.73
$756.48
$813.41
$1,015.67
$1,007.31
$1,061.06
$1,117.99
$1,320.25
$1,311.89
$1,365.64
$1,422.57
$1,624.83
$304.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.30
$903.80
$1,017.66
$1,422.18
$2,161.14
$1,100.88
$1,208.38
$1,322.24
$1,726.76
$1,405.46
$1,512.96
$1,626.82
$2,031.34
$1,710.04
$1,817.54
$1,931.40
$2,335.92
$304.58
Toc - Plan #2 Bright HealthCare
Silver

(EPO) Silver 5000 ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386.90
$439.13
$494.45
$691.00
$1,050.04
$682.88
$735.11
$790.43
$986.98
$978.86
$1,031.09
$1,086.41
$1,282.96
$1,274.84
$1,327.07
$1,382.39
$1,578.94
$295.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$773.80
$878.26
$988.90
$1,382.00
$2,100.08
$1,069.78
$1,174.24
$1,284.88
$1,677.98
$1,365.76
$1,470.22
$1,580.86
$1,973.96
$1,661.74
$1,766.20
$1,876.84
$2,269.94
$295.98
Toc - Plan #3 Bright HealthCare
Silver

(EPO) Silver 3000 ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.54
$448.94
$505.50
$706.44
$1,073.50
$698.13
$751.53
$808.09
$1,009.03
$1,000.72
$1,054.12
$1,110.68
$1,311.62
$1,303.31
$1,356.71
$1,413.27
$1,614.21
$302.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.08
$897.88
$1,011.00
$1,412.88
$2,147.00
$1,093.67
$1,200.47
$1,313.59
$1,715.47
$1,396.26
$1,503.06
$1,616.18
$2,018.06
$1,698.85
$1,805.65
$1,918.77
$2,320.65
$302.59
Toc - Plan #4 Bright HealthCare
Silver

(EPO) Silver $0 Deductible ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$430.88
$489.05
$550.66
$769.55
$1,169.41
$760.50
$818.67
$880.28
$1,099.17
$1,090.12
$1,148.29
$1,209.90
$1,428.79
$1,419.74
$1,477.91
$1,539.52
$1,758.41
$329.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$861.76
$978.10
$1,101.32
$1,539.10
$2,338.82
$1,191.38
$1,307.72
$1,430.94
$1,868.72
$1,521.00
$1,637.34
$1,760.56
$2,198.34
$1,850.62
$1,966.96
$2,090.18
$2,527.96
$329.62
Toc - Plan #5 Bright HealthCare
Silver

(EPO) Silver 6700 ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.67
$449.08
$505.66
$706.66
$1,073.84
$698.35
$751.76
$808.34
$1,009.34
$1,001.03
$1,054.44
$1,111.02
$1,312.02
$1,303.71
$1,357.12
$1,413.70
$1,614.70
$302.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.34
$898.16
$1,011.32
$1,413.32
$2,147.68
$1,094.02
$1,200.84
$1,314.00
$1,716.00
$1,396.70
$1,503.52
$1,616.68
$2,018.68
$1,699.38
$1,806.20
$1,919.36
$2,321.36
$302.68
Toc - Plan #6 Bright HealthCare
Expanded Bronze

(EPO) Bronze 8700 + $0 Mental Health ($0 Telehealth + $0 Primary Care + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$279.08
$316.76
$356.67
$498.44
$757.43
$492.58
$530.26
$570.17
$711.94
$706.08
$743.76
$783.67
$925.44
$919.58
$957.26
$997.17
$1,138.94
$213.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$558.16
$633.52
$713.34
$996.88
$1,514.86
$771.66
$847.02
$926.84
$1,210.38
$985.16
$1,060.52
$1,140.34
$1,423.88
$1,198.66
$1,274.02
$1,353.84
$1,637.38
$213.50
Toc - Plan #7 Bright HealthCare
Expanded Bronze

(EPO) Bronze 5300 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$7,050 $14,100 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
$308.07
$349.66
$393.72
$550.22
$836.11
$543.75
$585.34
$629.40
$785.90
$779.43
$821.02
$865.08
$1,021.58
$1,015.11
$1,056.70
$1,100.76
$1,257.26
$235.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$616.14
$699.32
$787.44
$1,100.44
$1,672.22
$851.82
$935.00
$1,023.12
$1,336.12
$1,087.50
$1,170.68
$1,258.80
$1,571.80
$1,323.18
$1,406.36
$1,494.48
$1,807.48
$235.68
Toc - Plan #8 Bright HealthCare
Expanded Bronze

(EPO) Bronze 7200 ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.67
$329.91
$371.47
$519.13
$788.87
$513.03
$552.27
$593.83
$741.49
$735.39
$774.63
$816.19
$963.85
$957.75
$996.99
$1,038.55
$1,186.21
$222.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$581.34
$659.82
$742.94
$1,038.26
$1,577.74
$803.70
$882.18
$965.30
$1,260.62
$1,026.06
$1,104.54
$1,187.66
$1,482.98
$1,248.42
$1,326.90
$1,410.02
$1,705.34
$222.36
Toc - Plan #9 Bright HealthCare
Expanded Bronze

(EPO) Bronze $0 Medical Deductible ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.36
$368.15
$414.53
$579.31
$880.32
$572.50
$616.29
$662.67
$827.45
$820.64
$864.43
$910.81
$1,075.59
$1,068.78
$1,112.57
$1,158.95
$1,323.73
$248.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.72
$736.30
$829.06
$1,158.62
$1,760.64
$896.86
$984.44
$1,077.20
$1,406.76
$1,145.00
$1,232.58
$1,325.34
$1,654.90
$1,393.14
$1,480.72
$1,573.48
$1,903.04
$248.14
Toc - Plan #10 Bright HealthCare
Catastrophic

(EPO) Catastrophic 8700 ($0 Primary Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$205.23
$232.93
$262.28
$366.53
$556.98
$362.23
$389.93
$419.28
$523.53
$519.23
$546.93
$576.28
$680.53
$676.23
$703.93
$733.28
$837.53
$157.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$410.46
$465.86
$524.56
$733.06
$1,113.96
$567.46
$622.86
$681.56
$890.06
$724.46
$779.86
$838.56
$1,047.06
$881.46
$936.86
$995.56
$1,204.06
$157.00
Toc - Plan #11 Bright HealthCare
Gold

(EPO) Super Gold 10 + Adult Dental ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.83
$433.38
$487.98
$681.95
$1,036.29
$673.93
$725.48
$780.08
$974.05
$966.03
$1,017.58
$1,072.18
$1,266.15
$1,258.13
$1,309.68
$1,364.28
$1,558.25
$292.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.66
$866.76
$975.96
$1,363.90
$2,072.58
$1,055.76
$1,158.86
$1,268.06
$1,656.00
$1,347.86
$1,450.96
$1,560.16
$1,948.10
$1,639.96
$1,743.06
$1,852.26
$2,240.20
$292.10
Toc - Plan #12 Bright HealthCare
Silver

(EPO) Super Silver 50 + Adult Dental ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$371.11
$421.21
$474.28
$662.80
$1,007.19
$655.01
$705.11
$758.18
$946.70
$938.91
$989.01
$1,042.08
$1,230.60
$1,222.81
$1,272.91
$1,325.98
$1,514.50
$283.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.22
$842.42
$948.56
$1,325.60
$2,014.38
$1,026.12
$1,126.32
$1,232.46
$1,609.50
$1,310.02
$1,410.22
$1,516.36
$1,893.40
$1,593.92
$1,694.12
$1,800.26
$2,177.30
$283.90
Toc - Plan #13 Bright HealthCare
Silver

(EPO) Super Silver 30 + Adult Dental ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$379.35
$430.56
$484.81
$677.52
$1,029.55
$669.55
$720.76
$775.01
$967.72
$959.75
$1,010.96
$1,065.21
$1,257.92
$1,249.95
$1,301.16
$1,355.41
$1,548.12
$290.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.70
$861.12
$969.62
$1,355.04
$2,059.10
$1,048.90
$1,151.32
$1,259.82
$1,645.24
$1,339.10
$1,441.52
$1,550.02
$1,935.44
$1,629.30
$1,731.72
$1,840.22
$2,225.64
$290.20
Toc - Plan #14 Bright HealthCare
Silver

(EPO) Super Silver $0 Deductible + Adult Dental ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription Li

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413.02
$468.77
$527.84
$737.65
$1,120.93
$728.98
$784.73
$843.80
$1,053.61
$1,044.94
$1,100.69
$1,159.76
$1,369.57
$1,360.90
$1,416.65
$1,475.72
$1,685.53
$315.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.04
$937.54
$1,055.68
$1,475.30
$2,241.86
$1,142.00
$1,253.50
$1,371.64
$1,791.26
$1,457.96
$1,569.46
$1,687.60
$2,107.22
$1,773.92
$1,885.42
$2,003.56
$2,423.18
$315.96
Toc - Plan #15 Bright HealthCare
Silver

(EPO) Super Silver 67 + Adult Dental ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescripti

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$379.47
$430.69
$484.96
$677.73
$1,029.87
$669.76
$720.98
$775.25
$968.02
$960.05
$1,011.27
$1,065.54
$1,258.31
$1,250.34
$1,301.56
$1,355.83
$1,548.60
$290.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.94
$861.38
$969.92
$1,355.46
$2,059.74
$1,049.23
$1,151.67
$1,260.21
$1,645.75
$1,339.52
$1,441.96
$1,550.50
$1,936.04
$1,629.81
$1,732.25
$1,840.79
$2,226.33
$290.29
Toc - Plan #16 Bright HealthCare
Expanded Bronze

(EPO) Super Bronze 87 + $0 Mental Health + Adult Dental ($0 Telehealth + $0 Primary Care + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$268.39
$304.62
$343.00
$479.34
$728.41
$473.71
$509.94
$548.32
$684.66
$679.03
$715.26
$753.64
$889.98
$884.35
$920.58
$958.96
$1,095.30
$205.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$536.78
$609.24
$686.00
$958.68
$1,456.82
$742.10
$814.56
$891.32
$1,164.00
$947.42
$1,019.88
$1,096.64
$1,369.32
$1,152.74
$1,225.20
$1,301.96
$1,574.64
$205.32
Toc - Plan #17 Bright HealthCare
Expanded Bronze

(EPO) Super Bronze 72 + Adult Dental ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$279.43
$317.15
$357.11
$499.06
$758.36
$493.19
$530.91
$570.87
$712.82
$706.95
$744.67
$784.63
$926.58
$920.71
$958.43
$998.39
$1,140.34
$213.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$558.86
$634.30
$714.22
$998.12
$1,516.72
$772.62
$848.06
$927.98
$1,211.88
$986.38
$1,061.82
$1,141.74
$1,425.64
$1,200.14
$1,275.58
$1,355.50
$1,639.40
$213.76
Toc - Plan #18 Bright HealthCare
Expanded Bronze

(EPO) Super Bronze $0 Medical Deductible + Adult Dental ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Hea

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$311.53
$353.59
$398.13
$556.39
$845.49
$549.85
$591.91
$636.45
$794.71
$788.17
$830.23
$874.77
$1,033.03
$1,026.49
$1,068.55
$1,113.09
$1,271.35
$238.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$623.06
$707.18
$796.26
$1,112.78
$1,690.98
$861.38
$945.50
$1,034.58
$1,351.10
$1,099.70
$1,183.82
$1,272.90
$1,589.42
$1,338.02
$1,422.14
$1,511.22
$1,827.74
$238.32
Toc - Plan #19 Bright HealthCare
Catastrophic

(EPO) Super Catastrophic 87 + Adult Dental ($0 Primary Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$198.02
$224.75
$253.07
$353.66
$537.42
$349.50
$376.23
$404.55
$505.14
$500.98
$527.71
$556.03
$656.62
$652.46
$679.19
$707.51
$808.10
$151.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$396.04
$449.50
$506.14
$707.32
$1,074.84
$547.52
$600.98
$657.62
$858.80
$699.00
$752.46
$809.10
$1,010.28
$850.48
$903.94
$960.58
$1,161.76
$151.48
Toc - Plan #20 Bright HealthCare
Expanded Bronze

(EPO) Bronze 7200 + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$294.83
$334.63
$376.79
$526.57
$800.17
$520.38
$560.18
$602.34
$752.12
$745.93
$785.73
$827.89
$977.67
$971.48
$1,011.28
$1,053.44
$1,203.22
$225.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$589.66
$669.26
$753.58
$1,053.14
$1,600.34
$815.21
$894.81
$979.13
$1,278.69
$1,040.76
$1,120.36
$1,204.68
$1,504.24
$1,266.31
$1,345.91
$1,430.23
$1,729.79
$225.55
Toc - Plan #21 Bright HealthCare
Silver

(EPO) Silver 6700 + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Presc

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$399.83
$453.81
$510.98
$714.10
$1,085.14
$705.70
$759.68
$816.85
$1,019.97
$1,011.57
$1,065.55
$1,122.72
$1,325.84
$1,317.44
$1,371.42
$1,428.59
$1,631.71
$305.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$799.66
$907.62
$1,021.96
$1,428.20
$2,170.28
$1,105.53
$1,213.49
$1,327.83
$1,734.07
$1,411.40
$1,519.36
$1,633.70
$2,039.94
$1,717.27
$1,825.23
$1,939.57
$2,345.81
$305.87
Toc - Plan #22 Bright HealthCare
Gold

(EPO) Gold $0 Deductible + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription L

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$431.15
$489.35
$551.01
$770.03
$1,170.13
$760.98
$819.18
$880.84
$1,099.86
$1,090.81
$1,149.01
$1,210.67
$1,429.69
$1,420.64
$1,478.84
$1,540.50
$1,759.52
$329.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$862.30
$978.70
$1,102.02
$1,540.06
$2,340.26
$1,192.13
$1,308.53
$1,431.85
$1,869.89
$1,521.96
$1,638.36
$1,761.68
$2,199.72
$1,851.79
$1,968.19
$2,091.51
$2,529.55
$329.83
Toc - Plan #23 Bright HealthCare
Silver

(EPO) Super Silver 50 ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$368.63
$418.39
$471.10
$658.37
$1,000.45
$650.63
$700.39
$753.10
$940.37
$932.63
$982.39
$1,035.10
$1,222.37
$1,214.63
$1,264.39
$1,317.10
$1,504.37
$282.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737.26
$836.78
$942.20
$1,316.74
$2,000.90
$1,019.26
$1,118.78
$1,224.20
$1,598.74
$1,301.26
$1,400.78
$1,506.20
$1,880.74
$1,583.26
$1,682.78
$1,788.20
$2,162.74
$282.00
Toc - Plan #24 Bright HealthCare
Expanded Bronze

(EPO) Super Bronze 87 + $0 Mental Health ($0 Telehealth + $0 Primary Care + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$265.90
$301.80
$339.83
$474.90
$721.66
$469.32
$505.22
$543.25
$678.32
$672.74
$708.64
$746.67
$881.74
$876.16
$912.06
$950.09
$1,085.16
$203.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$531.80
$603.60
$679.66
$949.80
$1,443.32
$735.22
$807.02
$883.08
$1,153.22
$938.64
$1,010.44
$1,086.50
$1,356.64
$1,142.06
$1,213.86
$1,289.92
$1,560.06
$203.42
Toc - Plan #25 Bright HealthCare
Gold

(EPO) Super Gold Ded + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.98
$466.47
$525.24
$734.02
$1,115.41
$725.38
$780.87
$839.64
$1,048.42
$1,039.78
$1,095.27
$1,154.04
$1,362.82
$1,354.18
$1,409.67
$1,468.44
$1,677.22
$314.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.96
$932.94
$1,050.48
$1,468.04
$2,230.82
$1,136.36
$1,247.34
$1,364.88
$1,782.44
$1,450.76
$1,561.74
$1,679.28
$2,096.84
$1,765.16
$1,876.14
$1,993.68
$2,411.24
$314.40
Toc - Plan #26 Bright HealthCare
Expanded Bronze

(EPO) Bronze 8700 ($25 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$274.20
$311.21
$350.42
$489.71
$744.17
$483.96
$520.97
$560.18
$699.47
$693.72
$730.73
$769.94
$909.23
$903.48
$940.49
$979.70
$1,118.99
$209.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$548.40
$622.42
$700.84
$979.42
$1,488.34
$758.16
$832.18
$910.60
$1,189.18
$967.92
$1,041.94
$1,120.36
$1,398.94
$1,177.68
$1,251.70
$1,330.12
$1,608.70
$209.76
Toc - Plan #27 Bright HealthCare
Silver

(EPO) Silver 4000 ($35 Primary Care + $15 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.90
$417.57
$470.18
$657.07
$998.49
$649.35
$699.02
$751.63
$938.52
$930.80
$980.47
$1,033.08
$1,219.97
$1,212.25
$1,261.92
$1,314.53
$1,501.42
$281.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.80
$835.14
$940.36
$1,314.14
$1,996.98
$1,017.25
$1,116.59
$1,221.81
$1,595.59
$1,298.70
$1,398.04
$1,503.26
$1,877.04
$1,580.15
$1,679.49
$1,784.71
$2,158.49
$281.45
Toc - Plan #28 Bright HealthCare
Expanded Bronze

(EPO) Super Bronze 72 + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$281.10
$319.05
$359.25
$502.05
$762.92
$496.15
$534.10
$574.30
$717.10
$711.20
$749.15
$789.35
$932.15
$926.25
$964.20
$1,004.40
$1,147.20
$215.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$562.20
$638.10
$718.50
$1,004.10
$1,525.84
$777.25
$853.15
$933.55
$1,219.15
$992.30
$1,068.20
$1,148.60
$1,434.20
$1,207.35
$1,283.25
$1,363.65
$1,649.25
$215.05
Toc - Plan #29 Bright HealthCare
Expanded Bronze

(EPO) Super Bronze 87 ($25 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$261.25
$296.51
$333.87
$466.59
$709.02
$461.10
$496.36
$533.72
$666.44
$660.95
$696.21
$733.57
$866.29
$860.80
$896.06
$933.42
$1,066.14
$199.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$522.50
$593.02
$667.74
$933.18
$1,418.04
$722.35
$792.87
$867.59
$1,133.03
$922.20
$992.72
$1,067.44
$1,332.88
$1,122.05
$1,192.57
$1,267.29
$1,532.73
$199.85
Toc - Plan #30 Bright HealthCare
Silver

(EPO) Super Silver 40 ($35 Primary Care + $15 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$350.53
$397.85
$447.98
$626.04
$951.34
$618.68
$666.00
$716.13
$894.19
$886.83
$934.15
$984.28
$1,162.34
$1,154.98
$1,202.30
$1,252.43
$1,430.49
$268.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$701.06
$795.70
$895.96
$1,252.08
$1,902.68
$969.21
$1,063.85
$1,164.11
$1,520.23
$1,237.36
$1,332.00
$1,432.26
$1,788.38
$1,505.51
$1,600.15
$1,700.41
$2,056.53
$268.15
Toc - Plan #31 Bright HealthCare
Silver

(EPO) Super Silver 67 + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 P

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.14
$432.60
$487.10
$680.72
$1,034.43
$672.72
$724.18
$778.68
$972.30
$964.30
$1,015.76
$1,070.26
$1,263.88
$1,255.88
$1,307.34
$1,361.84
$1,555.46
$291.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.28
$865.20
$974.20
$1,361.44
$2,068.86
$1,053.86
$1,156.78
$1,265.78
$1,653.02
$1,345.44
$1,448.36
$1,557.36
$1,944.60
$1,637.02
$1,739.94
$1,848.94
$2,236.18
$291.58
Toc - Plan #32 Bright HealthCare
Expanded Bronze

(EPO) Super Bronze $0 Medical Deductible ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescr

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$309.04
$350.76
$394.96
$551.95
$838.75
$545.46
$587.18
$631.38
$788.37
$781.88
$823.60
$867.80
$1,024.79
$1,018.30
$1,060.02
$1,104.22
$1,261.21
$236.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$618.08
$701.52
$789.92
$1,103.90
$1,677.50
$854.50
$937.94
$1,026.34
$1,340.32
$1,090.92
$1,174.36
$1,262.76
$1,576.74
$1,327.34
$1,410.78
$1,499.18
$1,813.16
$236.42
Toc - Plan #33 Bright HealthCare
Silver

(EPO) Super Silver 50 + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription Lis

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.79
$423.12
$476.42
$665.80
$1,011.75
$657.97
$708.30
$761.60
$950.98
$943.15
$993.48
$1,046.78
$1,236.16
$1,228.33
$1,278.66
$1,331.96
$1,521.34
$285.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$745.58
$846.24
$952.84
$1,331.60
$2,023.50
$1,030.76
$1,131.42
$1,238.02
$1,616.78
$1,315.94
$1,416.60
$1,523.20
$1,901.96
$1,601.12
$1,701.78
$1,808.38
$2,187.14
$285.18
Toc - Plan #34 Bright HealthCare
Expanded Bronze

(EPO) Super Bronze 87 + $0 MH + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$270.07
$306.53
$345.15
$482.34
$732.96
$476.67
$513.13
$551.75
$688.94
$683.27
$719.73
$758.35
$895.54
$889.87
$926.33
$964.95
$1,102.14
$206.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$540.14
$613.06
$690.30
$964.68
$1,465.92
$746.74
$819.66
$896.90
$1,171.28
$953.34
$1,026.26
$1,103.50
$1,377.88
$1,159.94
$1,232.86
$1,310.10
$1,584.48
$206.60
Toc - Plan #35 Bright HealthCare
Expanded Bronze

(EPO) Super Bronze $0 Medical Ded + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental H

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$313.21
$355.49
$400.28
$559.39
$850.04
$552.81
$595.09
$639.88
$798.99
$792.41
$834.69
$879.48
$1,038.59
$1,032.01
$1,074.29
$1,119.08
$1,278.19
$239.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$626.42
$710.98
$800.56
$1,118.78
$1,700.08
$866.02
$950.58
$1,040.16
$1,358.38
$1,105.62
$1,190.18
$1,279.76
$1,597.98
$1,345.22
$1,429.78
$1,519.36
$1,837.58
$239.60

ADVERTISEMENT

Florida Blue (BlueCross BlueShield FL)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771

Toc - Plan #36 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1423 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 Annual Deductible
$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$773.72
$878.17
$988.81
$1,381.86
$2,099.88
$1,365.62
$1,470.07
$1,580.71
$1,973.76
$1,957.52
$2,061.97
$2,172.61
$2,565.66
$2,549.42
$2,653.87
$2,764.51
$3,157.56
$591.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,547.44
$1,756.34
$1,977.62
$2,763.72
$4,199.76
$2,139.34
$2,348.24
$2,569.52
$3,355.62
$2,731.24
$2,940.14
$3,161.42
$3,947.52
$3,323.14
$3,532.04
$3,753.32
$4,539.42
$591.90
Toc - Plan #37 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueOptions Bronze 1419 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$482.73
$547.90
$616.93
$862.16
$1,310.13
$852.02
$917.19
$986.22
$1,231.45
$1,221.31
$1,286.48
$1,355.51
$1,600.74
$1,590.60
$1,655.77
$1,724.80
$1,970.03
$369.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$965.46
$1,095.80
$1,233.86
$1,724.32
$2,620.26
$1,334.75
$1,465.09
$1,603.15
$2,093.61
$1,704.04
$1,834.38
$1,972.44
$2,462.90
$2,073.33
$2,203.67
$2,341.73
$2,832.19
$369.29
Toc - Plan #38 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1431 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$5,600 $11,200 Annual Deductible
$7,800 $15,600 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
$791.76
$898.65
$1,011.87
$1,414.08
$2,148.84
$1,397.46
$1,504.35
$1,617.57
$2,019.78
$2,003.16
$2,110.05
$2,223.27
$2,625.48
$2,608.86
$2,715.75
$2,828.97
$3,231.18
$605.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,583.52
$1,797.30
$2,023.74
$2,828.16
$4,297.68
$2,189.22
$2,403.00
$2,629.44
$3,433.86
$2,794.92
$3,008.70
$3,235.14
$4,039.56
$3,400.62
$3,614.40
$3,840.84
$4,645.26
$605.70
Toc - Plan #39 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueOptions Platinum 1418 ($0 Virtual Visits /Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$4,250 $8,500 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
$964.54
$1,094.75
$1,232.68
$1,722.67
$2,617.76
$1,702.41
$1,832.62
$1,970.55
$2,460.54
$2,440.28
$2,570.49
$2,708.42
$3,198.41
$3,178.15
$3,308.36
$3,446.29
$3,936.28
$737.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,929.08
$2,189.50
$2,465.36
$3,445.34
$5,235.52
$2,666.95
$2,927.37
$3,203.23
$4,183.21
$3,404.82
$3,665.24
$3,941.10
$4,921.08
$4,142.69
$4,403.11
$4,678.97
$5,658.95
$737.87
Toc - Plan #40 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 1416 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$518.67
$588.69
$662.86
$926.34
$1,407.67
$915.45
$985.47
$1,059.64
$1,323.12
$1,312.23
$1,382.25
$1,456.42
$1,719.90
$1,709.01
$1,779.03
$1,853.20
$2,116.68
$396.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,037.34
$1,177.38
$1,325.72
$1,852.68
$2,815.34
$1,434.12
$1,574.16
$1,722.50
$2,249.46
$1,830.90
$1,970.94
$2,119.28
$2,646.24
$2,227.68
$2,367.72
$2,516.06
$3,043.02
$396.78
Toc - Plan #41 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueOptions Platinum 1424 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 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
$1,017.54
$1,154.91
$1,300.42
$1,817.33
$2,761.60
$1,795.96
$1,933.33
$2,078.84
$2,595.75
$2,574.38
$2,711.75
$2,857.26
$3,374.17
$3,352.80
$3,490.17
$3,635.68
$4,152.59
$778.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,035.08
$2,309.82
$2,600.84
$3,634.66
$5,523.20
$2,813.50
$3,088.24
$3,379.26
$4,413.08
$3,591.92
$3,866.66
$4,157.68
$5,191.50
$4,370.34
$4,645.08
$4,936.10
$5,969.92
$778.42
Toc - Plan #42 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1410 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$715.04
$811.57
$913.82
$1,277.06
$1,940.62
$1,262.05
$1,358.58
$1,460.83
$1,824.07
$1,809.06
$1,905.59
$2,007.84
$2,371.08
$2,356.07
$2,452.60
$2,554.85
$2,918.09
$547.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,430.08
$1,623.14
$1,827.64
$2,554.12
$3,881.24
$1,977.09
$2,170.15
$2,374.65
$3,101.13
$2,524.10
$2,717.16
$2,921.66
$3,648.14
$3,071.11
$3,264.17
$3,468.67
$4,195.15
$547.01
Toc - Plan #43 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1505 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$816.26
$926.46
$1,043.18
$1,457.84
$2,215.33
$1,440.70
$1,550.90
$1,667.62
$2,082.28
$2,065.14
$2,175.34
$2,292.06
$2,706.72
$2,689.58
$2,799.78
$2,916.50
$3,331.16
$624.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,632.52
$1,852.92
$2,086.36
$2,915.68
$4,430.66
$2,256.96
$2,477.36
$2,710.80
$3,540.12
$2,881.40
$3,101.80
$3,335.24
$4,164.56
$3,505.84
$3,726.24
$3,959.68
$4,789.00
$624.44
Toc - Plan #44 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze (HSA) 1705 (Rewards $$$ / $4 Condition Care Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$504.29
$572.37
$644.48
$900.66
$1,368.64
$890.07
$958.15
$1,030.26
$1,286.44
$1,275.85
$1,343.93
$1,416.04
$1,672.22
$1,661.63
$1,729.71
$1,801.82
$2,058.00
$385.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,008.58
$1,144.74
$1,288.96
$1,801.32
$2,737.28
$1,394.36
$1,530.52
$1,674.74
$2,187.10
$1,780.14
$1,916.30
$2,060.52
$2,572.88
$2,165.92
$2,302.08
$2,446.30
$2,958.66
$385.78
Toc - Plan #45 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1706S ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 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
$786.46
$892.63
$1,005.10
$1,404.62
$2,134.45
$1,388.10
$1,494.27
$1,606.74
$2,006.26
$1,989.74
$2,095.91
$2,208.38
$2,607.90
$2,591.38
$2,697.55
$2,810.02
$3,209.54
$601.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,572.92
$1,785.26
$2,010.20
$2,809.24
$4,268.90
$2,174.56
$2,386.90
$2,611.84
$3,410.88
$2,776.20
$2,988.54
$3,213.48
$4,012.52
$3,377.84
$3,590.18
$3,815.12
$4,614.16
$601.64
Toc - Plan #46 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 1707S ($0 Virtual Visits / $30 PCP Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$518.01
$587.94
$662.02
$925.17
$1,405.88
$914.29
$984.22
$1,058.30
$1,321.45
$1,310.57
$1,380.50
$1,454.58
$1,717.73
$1,706.85
$1,776.78
$1,850.86
$2,114.01
$396.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,036.02
$1,175.88
$1,324.04
$1,850.34
$2,811.76
$1,432.30
$1,572.16
$1,720.32
$2,246.62
$1,828.58
$1,968.44
$2,116.60
$2,642.90
$2,224.86
$2,364.72
$2,512.88
$3,039.18
$396.28
Toc - Plan #47 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1805 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$788.56
$895.02
$1,007.78
$1,408.37
$2,140.15
$1,391.81
$1,498.27
$1,611.03
$2,011.62
$1,995.06
$2,101.52
$2,214.28
$2,614.87
$2,598.31
$2,704.77
$2,817.53
$3,218.12
$603.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,577.12
$1,790.04
$2,015.56
$2,816.74
$4,280.30
$2,180.37
$2,393.29
$2,618.81
$3,419.99
$2,783.62
$2,996.54
$3,222.06
$4,023.24
$3,386.87
$3,599.79
$3,825.31
$4,626.49
$603.25
Toc - Plan #48 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 2119 ($0 Deductible / $30 PCP Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$552.00
$626.52
$705.46
$985.87
$1,498.13
$974.28
$1,048.80
$1,127.74
$1,408.15
$1,396.56
$1,471.08
$1,550.02
$1,830.43
$1,818.84
$1,893.36
$1,972.30
$2,252.71
$422.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,104.00
$1,253.04
$1,410.92
$1,971.74
$2,996.26
$1,526.28
$1,675.32
$1,833.20
$2,394.02
$1,948.56
$2,097.60
$2,255.48
$2,816.30
$2,370.84
$2,519.88
$2,677.76
$3,238.58
$422.28
Toc - Plan #49 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1456 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 Annual Deductible
$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$503.37
$571.32
$643.31
$899.02
$1,366.15
$888.45
$956.40
$1,028.39
$1,284.10
$1,273.53
$1,341.48
$1,413.47
$1,669.18
$1,658.61
$1,726.56
$1,798.55
$2,054.26
$385.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,006.74
$1,142.64
$1,286.62
$1,798.04
$2,732.30
$1,391.82
$1,527.72
$1,671.70
$2,183.12
$1,776.90
$1,912.80
$2,056.78
$2,568.20
$2,161.98
$2,297.88
$2,441.86
$2,953.28
$385.08
Toc - Plan #50 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueSelect Bronze 1452 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$362.44
$411.37
$463.20
$647.32
$983.66
$639.71
$688.64
$740.47
$924.59
$916.98
$965.91
$1,017.74
$1,201.86
$1,194.25
$1,243.18
$1,295.01
$1,479.13
$277.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.88
$822.74
$926.40
$1,294.64
$1,967.32
$1,002.15
$1,100.01
$1,203.67
$1,571.91
$1,279.42
$1,377.28
$1,480.94
$1,849.18
$1,556.69
$1,654.55
$1,758.21
$2,126.45
$277.27
Toc - Plan #51 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1464 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$5,600 $11,200 Annual Deductible
$7,800 $15,600 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
$515.12
$584.66
$658.32
$920.00
$1,398.04
$909.19
$978.73
$1,052.39
$1,314.07
$1,303.26
$1,372.80
$1,446.46
$1,708.14
$1,697.33
$1,766.87
$1,840.53
$2,102.21
$394.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,030.24
$1,169.32
$1,316.64
$1,840.00
$2,796.08
$1,424.31
$1,563.39
$1,710.71
$2,234.07
$1,818.38
$1,957.46
$2,104.78
$2,628.14
$2,212.45
$2,351.53
$2,498.85
$3,022.21
$394.07
Toc - Plan #52 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1451 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$4,250 $8,500 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
$629.33
$714.29
$804.28
$1,123.98
$1,708.00
$1,110.77
$1,195.73
$1,285.72
$1,605.42
$1,592.21
$1,677.17
$1,767.16
$2,086.86
$2,073.65
$2,158.61
$2,248.60
$2,568.30
$481.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,258.66
$1,428.58
$1,608.56
$2,247.96
$3,416.00
$1,740.10
$1,910.02
$2,090.00
$2,729.40
$2,221.54
$2,391.46
$2,571.44
$3,210.84
$2,702.98
$2,872.90
$3,052.88
$3,692.28
$481.44
Toc - Plan #53 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389.40
$441.97
$497.65
$695.47
$1,056.83
$687.29
$739.86
$795.54
$993.36
$985.18
$1,037.75
$1,093.43
$1,291.25
$1,283.07
$1,335.64
$1,391.32
$1,589.14
$297.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.80
$883.94
$995.30
$1,390.94
$2,113.66
$1,076.69
$1,181.83
$1,293.19
$1,688.83
$1,374.58
$1,479.72
$1,591.08
$1,986.72
$1,672.47
$1,777.61
$1,888.97
$2,284.61
$297.89
Toc - Plan #54 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 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
$663.46
$753.03
$847.90
$1,184.94
$1,800.63
$1,171.01
$1,260.58
$1,355.45
$1,692.49
$1,678.56
$1,768.13
$1,863.00
$2,200.04
$2,186.11
$2,275.68
$2,370.55
$2,707.59
$507.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,326.92
$1,506.06
$1,695.80
$2,369.88
$3,601.26
$1,834.47
$2,013.61
$2,203.35
$2,877.43
$2,342.02
$2,521.16
$2,710.90
$3,384.98
$2,849.57
$3,028.71
$3,218.45
$3,892.53
$507.55
Toc - Plan #55 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1443 ($0 Labs / $0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$465.22
$528.02
$594.55
$830.88
$1,262.61
$821.11
$883.91
$950.44
$1,186.77
$1,177.00
$1,239.80
$1,306.33
$1,542.66
$1,532.89
$1,595.69
$1,662.22
$1,898.55
$355.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$930.44
$1,056.04
$1,189.10
$1,661.76
$2,525.22
$1,286.33
$1,411.93
$1,544.99
$2,017.65
$1,642.22
$1,767.82
$1,900.88
$2,373.54
$1,998.11
$2,123.71
$2,256.77
$2,729.43
$355.89
Toc - Plan #56 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1535 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$540.14
$613.06
$690.30
$964.69
$1,465.94
$953.35
$1,026.27
$1,103.51
$1,377.90
$1,366.56
$1,439.48
$1,516.72
$1,791.11
$1,779.77
$1,852.69
$1,929.93
$2,204.32
$413.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,080.28
$1,226.12
$1,380.60
$1,929.38
$2,931.88
$1,493.49
$1,639.33
$1,793.81
$2,342.59
$1,906.70
$2,052.54
$2,207.02
$2,755.80
$2,319.91
$2,465.75
$2,620.23
$3,169.01
$413.21
Toc - Plan #57 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$378.59
$429.70
$483.84
$676.16
$1,027.49
$668.21
$719.32
$773.46
$965.78
$957.83
$1,008.94
$1,063.08
$1,255.40
$1,247.45
$1,298.56
$1,352.70
$1,545.02
$289.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.18
$859.40
$967.68
$1,352.32
$2,054.98
$1,046.80
$1,149.02
$1,257.30
$1,641.94
$1,336.42
$1,438.64
$1,546.92
$1,931.56
$1,626.04
$1,728.26
$1,836.54
$2,221.18
$289.62
Toc - Plan #58 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1736S ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 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
$511.68
$580.76
$653.93
$913.86
$1,388.70
$903.12
$972.20
$1,045.37
$1,305.30
$1,294.56
$1,363.64
$1,436.81
$1,696.74
$1,686.00
$1,755.08
$1,828.25
$2,088.18
$391.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,023.36
$1,161.52
$1,307.86
$1,827.72
$2,777.40
$1,414.80
$1,552.96
$1,699.30
$2,219.16
$1,806.24
$1,944.40
$2,090.74
$2,610.60
$2,197.68
$2,335.84
$2,482.18
$3,002.04
$391.44
Toc - Plan #59 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1737S ($0 Virtual Visits / $40 PCP Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.93
$441.44
$497.05
$694.63
$1,055.56
$686.46
$738.97
$794.58
$992.16
$983.99
$1,036.50
$1,092.11
$1,289.69
$1,281.52
$1,334.03
$1,389.64
$1,587.22
$297.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.86
$882.88
$994.10
$1,389.26
$2,111.12
$1,075.39
$1,180.41
$1,291.63
$1,686.79
$1,372.92
$1,477.94
$1,589.16
$1,984.32
$1,670.45
$1,775.47
$1,886.69
$2,281.85
$297.53
Toc - Plan #60 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1835 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$522.63
$593.19
$667.92
$933.42
$1,418.42
$922.44
$993.00
$1,067.73
$1,333.23
$1,322.25
$1,392.81
$1,467.54
$1,733.04
$1,722.06
$1,792.62
$1,867.35
$2,132.85
$399.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,045.26
$1,186.38
$1,335.84
$1,866.84
$2,836.84
$1,445.07
$1,586.19
$1,735.65
$2,266.65
$1,844.88
$1,986.00
$2,135.46
$2,666.46
$2,244.69
$2,385.81
$2,535.27
$3,066.27
$399.81
Toc - Plan #61 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2139 ($0 Deductible / $50 PCP Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414.04
$469.94
$529.14
$739.48
$1,123.70
$730.78
$786.68
$845.88
$1,056.22
$1,047.52
$1,103.42
$1,162.62
$1,372.96
$1,364.26
$1,420.16
$1,479.36
$1,689.70
$316.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$828.08
$939.88
$1,058.28
$1,478.96
$2,247.40
$1,144.82
$1,256.62
$1,375.02
$1,795.70
$1,461.56
$1,573.36
$1,691.76
$2,112.44
$1,778.30
$1,890.10
$2,008.50
$2,429.18
$316.74

ADVERTISEMENT

AvMed

Local: 1-800-477-8768 | Toll Free: 

Toc - Plan #62 AvMed
Gold

(HMO) AvMed Entrust Gold 125 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,700 $9,400 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
$388.47
$440.91
$496.46
$693.81
$1,054.31
$685.65
$738.09
$793.64
$990.99
$982.83
$1,035.27
$1,090.82
$1,288.17
$1,280.01
$1,332.45
$1,388.00
$1,585.35
$297.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.94
$881.82
$992.92
$1,387.62
$2,108.62
$1,074.12
$1,179.00
$1,290.10
$1,684.80
$1,371.30
$1,476.18
$1,587.28
$1,981.98
$1,668.48
$1,773.36
$1,884.46
$2,279.16
$297.18
Toc - Plan #63 AvMed
Silver

(HMO) AvMed Entrust Silver 300 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$379.10
$430.28
$484.49
$677.08
$1,028.88
$669.11
$720.29
$774.50
$967.09
$959.12
$1,010.30
$1,064.51
$1,257.10
$1,249.13
$1,300.31
$1,354.52
$1,547.11
$290.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.20
$860.56
$968.98
$1,354.16
$2,057.76
$1,048.21
$1,150.57
$1,258.99
$1,644.17
$1,338.22
$1,440.58
$1,549.00
$1,934.18
$1,628.23
$1,730.59
$1,839.01
$2,224.19
$290.01
Toc - Plan #64 AvMed
Silver

(HMO) AvMed Entrust Silver 350 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$356.95
$405.14
$456.19
$637.52
$968.77
$630.02
$678.21
$729.26
$910.59
$903.09
$951.28
$1,002.33
$1,183.66
$1,176.16
$1,224.35
$1,275.40
$1,456.73
$273.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.90
$810.28
$912.38
$1,275.04
$1,937.54
$986.97
$1,083.35
$1,185.45
$1,548.11
$1,260.04
$1,356.42
$1,458.52
$1,821.18
$1,533.11
$1,629.49
$1,731.59
$2,094.25
$273.07
Toc - Plan #65 AvMed
Silver

(HMO) AvMed Entrust Silver 500 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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
$358.16
$406.51
$457.73
$639.68
$972.05
$632.15
$680.50
$731.72
$913.67
$906.14
$954.49
$1,005.71
$1,187.66
$1,180.13
$1,228.48
$1,279.70
$1,461.65
$273.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716.32
$813.02
$915.46
$1,279.36
$1,944.10
$990.31
$1,087.01
$1,189.45
$1,553.35
$1,264.30
$1,361.00
$1,463.44
$1,827.34
$1,538.29
$1,634.99
$1,737.43
$2,101.33
$273.99
Toc - Plan #66 AvMed
Silver

(HMO) AvMed Entrust Silver 550 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$353.01
$400.67
$451.15
$630.48
$958.08
$623.06
$670.72
$721.20
$900.53
$893.11
$940.77
$991.25
$1,170.58
$1,163.16
$1,210.82
$1,261.30
$1,440.63
$270.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.02
$801.34
$902.30
$1,260.96
$1,916.16
$976.07
$1,071.39
$1,172.35
$1,531.01
$1,246.12
$1,341.44
$1,442.40
$1,801.06
$1,516.17
$1,611.49
$1,712.45
$2,071.11
$270.05
Toc - Plan #67 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 600 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$286.05
$324.66
$365.57
$510.88
$776.33
$504.88
$543.49
$584.40
$729.71
$723.71
$762.32
$803.23
$948.54
$942.54
$981.15
$1,022.06
$1,167.37
$218.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$572.10
$649.32
$731.14
$1,021.76
$1,552.66
$790.93
$868.15
$949.97
$1,240.59
$1,009.76
$1,086.98
$1,168.80
$1,459.42
$1,228.59
$1,305.81
$1,387.63
$1,678.25
$218.83
Toc - Plan #68 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 650 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$273.59
$310.52
$349.65
$488.63
$742.52
$482.89
$519.82
$558.95
$697.93
$692.19
$729.12
$768.25
$907.23
$901.49
$938.42
$977.55
$1,116.53
$209.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$547.18
$621.04
$699.30
$977.26
$1,485.04
$756.48
$830.34
$908.60
$1,186.56
$965.78
$1,039.64
$1,117.90
$1,395.86
$1,175.08
$1,248.94
$1,327.20
$1,605.16
$209.30
Toc - Plan #69 AvMed
Catastrophic

(HMO) AvMed Entrust Catastrophic 100 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$251.91
$285.92
$321.94
$449.91
$683.68
$444.62
$478.63
$514.65
$642.62
$637.33
$671.34
$707.36
$835.33
$830.04
$864.05
$900.07
$1,028.04
$192.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$503.82
$571.84
$643.88
$899.82
$1,367.36
$696.53
$764.55
$836.59
$1,092.53
$889.24
$957.26
$1,029.30
$1,285.24
$1,081.95
$1,149.97
$1,222.01
$1,477.95
$192.71
Toc - Plan #70 AvMed
Gold

(HMO) AvMed Entrust Gold 125 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,700 $9,400 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
$392.47
$445.45
$501.58
$700.95
$1,065.16
$692.71
$745.69
$801.82
$1,001.19
$992.95
$1,045.93
$1,102.06
$1,301.43
$1,293.19
$1,346.17
$1,402.30
$1,601.67
$300.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.94
$890.90
$1,003.16
$1,401.90
$2,130.32
$1,085.18
$1,191.14
$1,303.40
$1,702.14
$1,385.42
$1,491.38
$1,603.64
$2,002.38
$1,685.66
$1,791.62
$1,903.88
$2,302.62
$300.24
Toc - Plan #71 AvMed
Silver

(HMO) AvMed Entrust Silver 300 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$383.11
$434.83
$489.61
$684.23
$1,039.76
$676.19
$727.91
$782.69
$977.31
$969.27
$1,020.99
$1,075.77
$1,270.39
$1,262.35
$1,314.07
$1,368.85
$1,563.47
$293.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.22
$869.66
$979.22
$1,368.46
$2,079.52
$1,059.30
$1,162.74
$1,272.30
$1,661.54
$1,352.38
$1,455.82
$1,565.38
$1,954.62
$1,645.46
$1,748.90
$1,858.46
$2,247.70
$293.08
Toc - Plan #72 AvMed
Silver

(HMO) AvMed Entrust Silver 350 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$360.95
$409.68
$461.30
$644.66
$979.62
$637.08
$685.81
$737.43
$920.79
$913.21
$961.94
$1,013.56
$1,196.92
$1,189.34
$1,238.07
$1,289.69
$1,473.05
$276.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.90
$819.36
$922.60
$1,289.32
$1,959.24
$998.03
$1,095.49
$1,198.73
$1,565.45
$1,274.16
$1,371.62
$1,474.86
$1,841.58
$1,550.29
$1,647.75
$1,750.99
$2,117.71
$276.13
Toc - Plan #73 AvMed
Silver

(HMO) AvMed Entrust Silver 500 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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
$362.16
$411.05
$462.84
$646.82
$982.90
$639.21
$688.10
$739.89
$923.87
$916.26
$965.15
$1,016.94
$1,200.92
$1,193.31
$1,242.20
$1,293.99
$1,477.97
$277.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.32
$822.10
$925.68
$1,293.64
$1,965.80
$1,001.37
$1,099.15
$1,202.73
$1,570.69
$1,278.42
$1,376.20
$1,479.78
$1,847.74
$1,555.47
$1,653.25
$1,756.83
$2,124.79
$277.05
Toc - Plan #74 AvMed
Silver

(HMO) AvMed Entrust Silver 550 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$357.01
$405.21
$456.26
$637.62
$968.93
$630.12
$678.32
$729.37
$910.73
$903.23
$951.43
$1,002.48
$1,183.84
$1,176.34
$1,224.54
$1,275.59
$1,456.95
$273.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714.02
$810.42
$912.52
$1,275.24
$1,937.86
$987.13
$1,083.53
$1,185.63
$1,548.35
$1,260.24
$1,356.64
$1,458.74
$1,821.46
$1,533.35
$1,629.75
$1,731.85
$2,094.57
$273.11
Toc - Plan #75 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 625 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,350 $16,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.98
$406.31
$457.50
$639.36
$971.56
$631.84
$680.17
$731.36
$913.22
$905.70
$954.03
$1,005.22
$1,187.08
$1,179.56
$1,227.89
$1,279.08
$1,460.94
$273.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.96
$812.62
$915.00
$1,278.72
$1,943.12
$989.82
$1,086.48
$1,188.86
$1,552.58
$1,263.68
$1,360.34
$1,462.72
$1,826.44
$1,537.54
$1,634.20
$1,736.58
$2,100.30
$273.86

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770

Toc - Plan #76 Ambetter from Sunshine Health
Bronze

(EPO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 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
$301.83
$342.57
$385.73
$539.06
$819.15
$532.72
$573.46
$616.62
$769.95
$763.61
$804.35
$847.51
$1,000.84
$994.50
$1,035.24
$1,078.40
$1,231.73
$230.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$603.66
$685.14
$771.46
$1,078.12
$1,638.30
$834.55
$916.03
$1,002.35
$1,309.01
$1,065.44
$1,146.92
$1,233.24
$1,539.90
$1,296.33
$1,377.81
$1,464.13
$1,770.79
$230.89
Toc - Plan #77 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$421.79
$478.72
$539.03
$753.29
$1,144.70
$744.45
$801.38
$861.69
$1,075.95
$1,067.11
$1,124.04
$1,184.35
$1,398.61
$1,389.77
$1,446.70
$1,507.01
$1,721.27
$322.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$843.58
$957.44
$1,078.06
$1,506.58
$2,289.40
$1,166.24
$1,280.10
$1,400.72
$1,829.24
$1,488.90
$1,602.76
$1,723.38
$2,151.90
$1,811.56
$1,925.42
$2,046.04
$2,474.56
$322.66
Toc - Plan #78 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$429.00
$486.90
$548.25
$766.17
$1,164.28
$757.18
$815.08
$876.43
$1,094.35
$1,085.36
$1,143.26
$1,204.61
$1,422.53
$1,413.54
$1,471.44
$1,532.79
$1,750.71
$328.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.00
$973.80
$1,096.50
$1,532.34
$2,328.56
$1,186.18
$1,301.98
$1,424.68
$1,860.52
$1,514.36
$1,630.16
$1,752.86
$2,188.70
$1,842.54
$1,958.34
$2,081.04
$2,516.88
$328.18
Toc - Plan #79 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$331.91
$376.70
$424.16
$592.77
$900.77
$585.81
$630.60
$678.06
$846.67
$839.71
$884.50
$931.96
$1,100.57
$1,093.61
$1,138.40
$1,185.86
$1,354.47
$253.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$663.82
$753.40
$848.32
$1,185.54
$1,801.54
$917.72
$1,007.30
$1,102.22
$1,439.44
$1,171.62
$1,261.20
$1,356.12
$1,693.34
$1,425.52
$1,515.10
$1,610.02
$1,947.24
$253.90
Toc - Plan #80 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$415.97
$472.11
$531.59
$742.90
$1,128.91
$734.18
$790.32
$849.80
$1,061.11
$1,052.39
$1,108.53
$1,168.01
$1,379.32
$1,370.60
$1,426.74
$1,486.22
$1,697.53
$318.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$831.94
$944.22
$1,063.18
$1,485.80
$2,257.82
$1,150.15
$1,262.43
$1,381.39
$1,804.01
$1,468.36
$1,580.64
$1,699.60
$2,122.22
$1,786.57
$1,898.85
$2,017.81
$2,440.43
$318.21
Toc - Plan #81 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 24

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.29
$487.24
$548.63
$766.70
$1,165.08
$757.69
$815.64
$877.03
$1,095.10
$1,086.09
$1,144.04
$1,205.43
$1,423.50
$1,414.49
$1,472.44
$1,533.83
$1,751.90
$328.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.58
$974.48
$1,097.26
$1,533.40
$2,330.16
$1,186.98
$1,302.88
$1,425.66
$1,861.80
$1,515.38
$1,631.28
$1,754.06
$2,190.20
$1,843.78
$1,959.68
$2,082.46
$2,518.60
$328.40
Toc - Plan #82 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 29

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 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
$411.12
$466.61
$525.39
$734.23
$1,115.74
$725.62
$781.11
$839.89
$1,048.73
$1,040.12
$1,095.61
$1,154.39
$1,363.23
$1,354.62
$1,410.11
$1,468.89
$1,677.73
$314.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.24
$933.22
$1,050.78
$1,468.46
$2,231.48
$1,136.74
$1,247.72
$1,365.28
$1,782.96
$1,451.24
$1,562.22
$1,679.78
$2,097.46
$1,765.74
$1,876.72
$1,994.28
$2,411.96
$314.50
Toc - Plan #83 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328.32
$372.63
$419.58
$586.36
$891.04
$579.48
$623.79
$670.74
$837.52
$830.64
$874.95
$921.90
$1,088.68
$1,081.80
$1,126.11
$1,173.06
$1,339.84
$251.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.64
$745.26
$839.16
$1,172.72
$1,782.08
$907.80
$996.42
$1,090.32
$1,423.88
$1,158.96
$1,247.58
$1,341.48
$1,675.04
$1,410.12
$1,498.74
$1,592.64
$1,926.20
$251.16
Toc - Plan #84 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 22

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351.10
$398.48
$448.69
$627.04
$952.85
$619.68
$667.06
$717.27
$895.62
$888.26
$935.64
$985.85
$1,164.20
$1,156.84
$1,204.22
$1,254.43
$1,432.78
$268.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.20
$796.96
$897.38
$1,254.08
$1,905.70
$970.78
$1,065.54
$1,165.96
$1,522.66
$1,239.36
$1,334.12
$1,434.54
$1,791.24
$1,507.94
$1,602.70
$1,703.12
$2,059.82
$268.58
Toc - Plan #85 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care: $1,500 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.71
$409.40
$460.98
$644.22
$978.95
$636.65
$685.34
$736.92
$920.16
$912.59
$961.28
$1,012.86
$1,196.10
$1,188.53
$1,237.22
$1,288.80
$1,472.04
$275.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.42
$818.80
$921.96
$1,288.44
$1,957.90
$997.36
$1,094.74
$1,197.90
$1,564.38
$1,273.30
$1,370.68
$1,473.84
$1,840.32
$1,549.24
$1,646.62
$1,749.78
$2,116.26
$275.94
Toc - Plan #86 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.73
$434.39
$489.12
$683.54
$1,038.70
$675.51
$727.17
$781.90
$976.32
$968.29
$1,019.95
$1,074.68
$1,269.10
$1,261.07
$1,312.73
$1,367.46
$1,561.88
$292.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.46
$868.78
$978.24
$1,367.08
$2,077.40
$1,058.24
$1,161.56
$1,271.02
$1,659.86
$1,351.02
$1,454.34
$1,563.80
$1,952.64
$1,643.80
$1,747.12
$1,856.58
$2,245.42
$292.78
Toc - Plan #87 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$6,100 $12,200 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
$394.62
$447.89
$504.32
$704.78
$1,070.98
$696.50
$749.77
$806.20
$1,006.66
$998.38
$1,051.65
$1,108.08
$1,308.54
$1,300.26
$1,353.53
$1,409.96
$1,610.42
$301.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$789.24
$895.78
$1,008.64
$1,409.56
$2,141.96
$1,091.12
$1,197.66
$1,310.52
$1,711.44
$1,393.00
$1,499.54
$1,612.40
$2,013.32
$1,694.88
$1,801.42
$1,914.28
$2,315.20
$301.88
Toc - Plan #88 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.47
$448.84
$505.40
$706.29
$1,073.27
$698.00
$751.37
$807.93
$1,008.82
$1,000.53
$1,053.90
$1,110.46
$1,311.35
$1,303.06
$1,356.43
$1,412.99
$1,613.88
$302.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$790.94
$897.68
$1,010.80
$1,412.58
$2,146.54
$1,093.47
$1,200.21
$1,313.33
$1,715.11
$1,396.00
$1,502.74
$1,615.86
$2,017.64
$1,698.53
$1,805.27
$1,918.39
$2,320.17
$302.53
Toc - Plan #89 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$402.05
$456.31
$513.80
$718.04
$1,091.13
$709.61
$763.87
$821.36
$1,025.60
$1,017.17
$1,071.43
$1,128.92
$1,333.16
$1,324.73
$1,378.99
$1,436.48
$1,640.72
$307.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$804.10
$912.62
$1,027.60
$1,436.08
$2,182.26
$1,111.66
$1,220.18
$1,335.16
$1,743.64
$1,419.22
$1,527.74
$1,642.72
$2,051.20
$1,726.78
$1,835.30
$1,950.28
$2,358.76
$307.56
Toc - Plan #90 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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
$401.20
$455.36
$512.73
$716.53
$1,088.84
$708.11
$762.27
$819.64
$1,023.44
$1,015.02
$1,069.18
$1,126.55
$1,330.35
$1,321.93
$1,376.09
$1,433.46
$1,637.26
$306.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802.40
$910.72
$1,025.46
$1,433.06
$2,177.68
$1,109.31
$1,217.63
$1,332.37
$1,739.97
$1,416.22
$1,524.54
$1,639.28
$2,046.88
$1,723.13
$1,831.45
$1,946.19
$2,353.79
$306.91
Toc - Plan #91 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$343.74
$390.14
$439.29
$613.91
$932.89
$606.70
$653.10
$702.25
$876.87
$869.66
$916.06
$965.21
$1,139.83
$1,132.62
$1,179.02
$1,228.17
$1,402.79
$262.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.48
$780.28
$878.58
$1,227.82
$1,865.78
$950.44
$1,043.24
$1,141.54
$1,490.78
$1,213.40
$1,306.20
$1,404.50
$1,753.74
$1,476.36
$1,569.16
$1,667.46
$2,016.70
$262.96
Toc - Plan #92 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 12 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$430.80
$488.95
$550.55
$769.39
$1,169.17
$760.36
$818.51
$880.11
$1,098.95
$1,089.92
$1,148.07
$1,209.67
$1,428.51
$1,419.48
$1,477.63
$1,539.23
$1,758.07
$329.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$861.60
$977.90
$1,101.10
$1,538.78
$2,338.34
$1,191.16
$1,307.46
$1,430.66
$1,868.34
$1,520.72
$1,637.02
$1,760.22
$2,197.90
$1,850.28
$1,966.58
$2,089.78
$2,527.46
$329.56
Toc - Plan #93 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$444.30
$504.27
$567.80
$793.50
$1,205.80
$784.18
$844.15
$907.68
$1,133.38
$1,124.06
$1,184.03
$1,247.56
$1,473.26
$1,463.94
$1,523.91
$1,587.44
$1,813.14
$339.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.60
$1,008.54
$1,135.60
$1,587.00
$2,411.60
$1,228.48
$1,348.42
$1,475.48
$1,926.88
$1,568.36
$1,688.30
$1,815.36
$2,266.76
$1,908.24
$2,028.18
$2,155.24
$2,606.64
$339.88
Toc - Plan #94 Ambetter from Sunshine Health
Bronze

(EPO) Ambetter Essential Care 1 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 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
$312.60
$354.79
$399.49
$558.28
$848.36
$551.73
$593.92
$638.62
$797.41
$790.86
$833.05
$877.75
$1,036.54
$1,029.99
$1,072.18
$1,116.88
$1,275.67
$239.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625.20
$709.58
$798.98
$1,116.56
$1,696.72
$864.33
$948.71
$1,038.11
$1,355.69
$1,103.46
$1,187.84
$1,277.24
$1,594.82
$1,342.59
$1,426.97
$1,516.37
$1,833.95
$239.13
Toc - Plan #95 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 24 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.60
$504.62
$568.19
$794.05
$1,206.63
$784.71
$844.73
$908.30
$1,134.16
$1,124.82
$1,184.84
$1,248.41
$1,474.27
$1,464.93
$1,524.95
$1,588.52
$1,814.38
$340.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$889.20
$1,009.24
$1,136.38
$1,588.10
$2,413.26
$1,229.31
$1,349.35
$1,476.49
$1,928.21
$1,569.42
$1,689.46
$1,816.60
$2,268.32
$1,909.53
$2,029.57
$2,156.71
$2,608.43
$340.11
Toc - Plan #96 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 11 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$436.83
$495.79
$558.26
$780.16
$1,185.53
$771.00
$829.96
$892.43
$1,114.33
$1,105.17
$1,164.13
$1,226.60
$1,448.50
$1,439.34
$1,498.30
$1,560.77
$1,782.67
$334.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.66
$991.58
$1,116.52
$1,560.32
$2,371.06
$1,207.83
$1,325.75
$1,450.69
$1,894.49
$1,542.00
$1,659.92
$1,784.86
$2,228.66
$1,876.17
$1,994.09
$2,119.03
$2,562.83
$334.17
Toc - Plan #97 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.03
$385.92
$434.55
$607.28
$922.81
$600.15
$646.04
$694.67
$867.40
$860.27
$906.16
$954.79
$1,127.52
$1,120.39
$1,166.28
$1,214.91
$1,387.64
$260.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.06
$771.84
$869.10
$1,214.56
$1,845.62
$940.18
$1,031.96
$1,129.22
$1,474.68
$1,200.30
$1,292.08
$1,389.34
$1,734.80
$1,460.42
$1,552.20
$1,649.46
$1,994.92
$260.12
Toc - Plan #98 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 22 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.62
$412.70
$464.69
$649.40
$986.83
$641.78
$690.86
$742.85
$927.56
$919.94
$969.02
$1,021.01
$1,205.72
$1,198.10
$1,247.18
$1,299.17
$1,483.88
$278.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.24
$825.40
$929.38
$1,298.80
$1,973.66
$1,005.40
$1,103.56
$1,207.54
$1,576.96
$1,283.56
$1,381.72
$1,485.70
$1,855.12
$1,561.72
$1,659.88
$1,763.86
$2,133.28
$278.16
Toc - Plan #99 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care: $1,500 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.58
$424.00
$477.42
$667.19
$1,013.86
$659.36
$709.78
$763.20
$952.97
$945.14
$995.56
$1,048.98
$1,238.75
$1,230.92
$1,281.34
$1,334.76
$1,524.53
$285.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.16
$848.00
$954.84
$1,334.38
$2,027.72
$1,032.94
$1,133.78
$1,240.62
$1,620.16
$1,318.72
$1,419.56
$1,526.40
$1,905.94
$1,604.50
$1,705.34
$1,812.18
$2,191.72
$285.78
Toc - Plan #100 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.38
$449.88
$506.56
$707.92
$1,075.75
$699.60
$753.10
$809.78
$1,011.14
$1,002.82
$1,056.32
$1,113.00
$1,314.36
$1,306.04
$1,359.54
$1,416.22
$1,617.58
$303.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.76
$899.76
$1,013.12
$1,415.84
$2,151.50
$1,095.98
$1,202.98
$1,316.34
$1,719.06
$1,399.20
$1,506.20
$1,619.56
$2,022.28
$1,702.42
$1,809.42
$1,922.78
$2,325.50
$303.22
Toc - Plan #101 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 31 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.57
$464.85
$523.42
$731.48
$1,111.55
$722.88
$778.16
$836.73
$1,044.79
$1,036.19
$1,091.47
$1,150.04
$1,358.10
$1,349.50
$1,404.78
$1,463.35
$1,671.41
$313.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$819.14
$929.70
$1,046.84
$1,462.96
$2,223.10
$1,132.45
$1,243.01
$1,360.15
$1,776.27
$1,445.76
$1,556.32
$1,673.46
$2,089.58
$1,759.07
$1,869.63
$1,986.77
$2,402.89
$313.31
Toc - Plan #102 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 32 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.39
$472.59
$532.13
$743.65
$1,130.05
$734.92
$791.12
$850.66
$1,062.18
$1,053.45
$1,109.65
$1,169.19
$1,380.71
$1,371.98
$1,428.18
$1,487.72
$1,699.24
$318.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.78
$945.18
$1,064.26
$1,487.30
$2,260.10
$1,151.31
$1,263.71
$1,382.79
$1,805.83
$1,469.84
$1,582.24
$1,701.32
$2,124.36
$1,788.37
$1,900.77
$2,019.85
$2,442.89
$318.53
Toc - Plan #103 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 20 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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
$415.51
$471.60
$531.01
$742.09
$1,127.67
$733.37
$789.46
$848.87
$1,059.95
$1,051.23
$1,107.32
$1,166.73
$1,377.81
$1,369.09
$1,425.18
$1,484.59
$1,695.67
$317.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$831.02
$943.20
$1,062.02
$1,484.18
$2,255.34
$1,148.88
$1,261.06
$1,379.88
$1,802.04
$1,466.74
$1,578.92
$1,697.74
$2,119.90
$1,784.60
$1,896.78
$2,015.60
$2,437.76
$317.86
Toc - Plan #104 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 29 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 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
$425.78
$483.25
$544.13
$760.42
$1,155.53
$751.49
$808.96
$869.84
$1,086.13
$1,077.20
$1,134.67
$1,195.55
$1,411.84
$1,402.91
$1,460.38
$1,521.26
$1,737.55
$325.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$851.56
$966.50
$1,088.26
$1,520.84
$2,311.06
$1,177.27
$1,292.21
$1,413.97
$1,846.55
$1,502.98
$1,617.92
$1,739.68
$2,172.26
$1,828.69
$1,943.63
$2,065.39
$2,497.97
$325.71

ADVERTISEMENT

Florida Blue HMO (a BlueCross BlueShield FL company)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771

Toc - Plan #105 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 2151 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 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
$772.01
$876.23
$986.63
$1,378.81
$2,095.24
$1,362.60
$1,466.82
$1,577.22
$1,969.40
$1,953.19
$2,057.41
$2,167.81
$2,559.99
$2,543.78
$2,648.00
$2,758.40
$3,150.58
$590.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,544.02
$1,752.46
$1,973.26
$2,757.62
$4,190.48
$2,134.61
$2,343.05
$2,563.85
$3,348.21
$2,725.20
$2,933.64
$3,154.44
$3,938.80
$3,315.79
$3,524.23
$3,745.03
$4,529.39
$590.59
Toc - Plan #106 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2153 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$456.23
$517.82
$583.06
$814.83
$1,238.21
$805.25
$866.84
$932.08
$1,163.85
$1,154.27
$1,215.86
$1,281.10
$1,512.87
$1,503.29
$1,564.88
$1,630.12
$1,861.89
$349.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$912.46
$1,035.64
$1,166.12
$1,629.66
$2,476.42
$1,261.48
$1,384.66
$1,515.14
$1,978.68
$1,610.50
$1,733.68
$1,864.16
$2,327.70
$1,959.52
$2,082.70
$2,213.18
$2,676.72
$349.02
Toc - Plan #107 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) BlueCare Bronze 2154 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412.16
$467.80
$526.74
$736.12
$1,118.60
$727.46
$783.10
$842.04
$1,051.42
$1,042.76
$1,098.40
$1,157.34
$1,366.72
$1,358.06
$1,413.70
$1,472.64
$1,682.02
$315.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$824.32
$935.60
$1,053.48
$1,472.24
$2,237.20
$1,139.62
$1,250.90
$1,368.78
$1,787.54
$1,454.92
$1,566.20
$1,684.08
$2,102.84
$1,770.22
$1,881.50
$1,999.38
$2,418.14
$315.30
Toc - Plan #108 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 2156 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$664.09
$753.74
$848.71
$1,186.06
$1,802.34
$1,172.12
$1,261.77
$1,356.74
$1,694.09
$1,680.15
$1,769.80
$1,864.77
$2,202.12
$2,188.18
$2,277.83
$2,372.80
$2,710.15
$508.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,328.18
$1,507.48
$1,697.42
$2,372.12
$3,604.68
$1,836.21
$2,015.51
$2,205.45
$2,880.15
$2,344.24
$2,523.54
$2,713.48
$3,388.18
$2,852.27
$3,031.57
$3,221.51
$3,896.21
$508.03
Toc - Plan #109 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 2157 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$552.66
$627.27
$706.30
$987.05
$1,499.92
$975.44
$1,050.05
$1,129.08
$1,409.83
$1,398.22
$1,472.83
$1,551.86
$1,832.61
$1,821.00
$1,895.61
$1,974.64
$2,255.39
$422.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,105.32
$1,254.54
$1,412.60
$1,974.10
$2,999.84
$1,528.10
$1,677.32
$1,835.38
$2,396.88
$1,950.88
$2,100.10
$2,258.16
$2,819.66
$2,373.66
$2,522.88
$2,680.94
$3,242.44
$422.78
Toc - Plan #110 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2159 ($0 Deductible / $50 PCP Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$495.90
$562.85
$633.76
$885.68
$1,345.87
$875.26
$942.21
$1,013.12
$1,265.04
$1,254.62
$1,321.57
$1,392.48
$1,644.40
$1,633.98
$1,700.93
$1,771.84
$2,023.76
$379.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$991.80
$1,125.70
$1,267.52
$1,771.36
$2,691.74
$1,371.16
$1,505.06
$1,646.88
$2,150.72
$1,750.52
$1,884.42
$2,026.24
$2,530.08
$2,129.88
$2,263.78
$2,405.60
$2,909.44
$379.36
Toc - Plan #111 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.09
$358.76
$403.96
$564.54
$857.87
$557.90
$600.57
$645.77
$806.35
$799.71
$842.38
$887.58
$1,048.16
$1,041.52
$1,084.19
$1,129.39
$1,289.97
$241.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.18
$717.52
$807.92
$1,129.08
$1,715.74
$873.99
$959.33
$1,049.73
$1,370.89
$1,115.80
$1,201.14
$1,291.54
$1,612.70
$1,357.61
$1,442.95
$1,533.35
$1,854.51
$241.81
Toc - Plan #112 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1602 ($0 Labs / $0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$280.96
$318.89
$359.07
$501.79
$762.53
$495.89
$533.82
$574.00
$716.72
$710.82
$748.75
$788.93
$931.65
$925.75
$963.68
$1,003.86
$1,146.58
$214.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$561.92
$637.78
$718.14
$1,003.58
$1,525.06
$776.85
$852.71
$933.07
$1,218.51
$991.78
$1,067.64
$1,148.00
$1,433.44
$1,206.71
$1,282.57
$1,362.93
$1,648.37
$214.93
Toc - Plan #113 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1603 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$401.63
$455.85
$513.28
$717.31
$1,090.02
$708.88
$763.10
$820.53
$1,024.56
$1,016.13
$1,070.35
$1,127.78
$1,331.81
$1,323.38
$1,377.60
$1,435.03
$1,639.06
$307.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.26
$911.70
$1,026.56
$1,434.62
$2,180.04
$1,110.51
$1,218.95
$1,333.81
$1,741.87
$1,417.76
$1,526.20
$1,641.06
$2,049.12
$1,725.01
$1,833.45
$1,948.31
$2,356.37
$307.25
Toc - Plan #114 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1604 ($0 Labs / $0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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
$380.11
$431.42
$485.78
$678.88
$1,031.62
$670.89
$722.20
$776.56
$969.66
$961.67
$1,012.98
$1,067.34
$1,260.44
$1,252.45
$1,303.76
$1,358.12
$1,551.22
$290.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.22
$862.84
$971.56
$1,357.76
$2,063.24
$1,051.00
$1,153.62
$1,262.34
$1,648.54
$1,341.78
$1,444.40
$1,553.12
$1,939.32
$1,632.56
$1,735.18
$1,843.90
$2,230.10
$290.78
Toc - Plan #115 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 1605 ($0 Labs / $0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$940 $1,880 Annual Deductible
$4,700 $9,400 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
$422.07
$479.05
$539.41
$753.82
$1,145.50
$744.95
$801.93
$862.29
$1,076.70
$1,067.83
$1,124.81
$1,185.17
$1,399.58
$1,390.71
$1,447.69
$1,508.05
$1,722.46
$322.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$844.14
$958.10
$1,078.82
$1,507.64
$2,291.00
$1,167.02
$1,280.98
$1,401.70
$1,830.52
$1,489.90
$1,603.86
$1,724.58
$2,153.40
$1,812.78
$1,926.74
$2,047.46
$2,476.28
$322.88
Toc - Plan #116 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1710 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

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
$413.14
$468.91
$527.99
$737.87
$1,121.26
$729.19
$784.96
$844.04
$1,053.92
$1,045.24
$1,101.01
$1,160.09
$1,369.97
$1,361.29
$1,417.06
$1,476.14
$1,686.02
$316.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.28
$937.82
$1,055.98
$1,475.74
$2,242.52
$1,142.33
$1,253.87
$1,372.03
$1,791.79
$1,458.38
$1,569.92
$1,688.08
$2,107.84
$1,774.43
$1,885.97
$2,004.13
$2,423.89
$316.05
Toc - Plan #117 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1711S ($0 Virtual Visits / $60 PCP Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$314.29
$356.72
$401.66
$561.32
$852.98
$554.72
$597.15
$642.09
$801.75
$795.15
$837.58
$882.52
$1,042.18
$1,035.58
$1,078.01
$1,122.95
$1,282.61
$240.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$628.58
$713.44
$803.32
$1,122.64
$1,705.96
$869.01
$953.87
$1,043.75
$1,363.07
$1,109.44
$1,194.30
$1,284.18
$1,603.50
$1,349.87
$1,434.73
$1,524.61
$1,843.93
$240.43
Toc - Plan #118 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1712S ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$3,950 $7,900 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.89
$464.09
$522.56
$730.28
$1,109.73
$721.69
$776.89
$835.36
$1,043.08
$1,034.49
$1,089.69
$1,148.16
$1,355.88
$1,347.29
$1,402.49
$1,460.96
$1,668.68
$312.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$817.78
$928.18
$1,045.12
$1,460.56
$2,219.46
$1,130.58
$1,240.98
$1,357.92
$1,773.36
$1,443.38
$1,553.78
$1,670.72
$2,086.16
$1,756.18
$1,866.58
$1,983.52
$2,398.96
$312.80
Toc - Plan #119 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2017 ($0 Labs / $0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.52
$423.95
$477.36
$667.11
$1,013.73
$659.26
$709.69
$763.10
$952.85
$945.00
$995.43
$1,048.84
$1,238.59
$1,230.74
$1,281.17
$1,334.58
$1,524.33
$285.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.04
$847.90
$954.72
$1,334.22
$2,027.46
$1,032.78
$1,133.64
$1,240.46
$1,619.96
$1,318.52
$1,419.38
$1,526.20
$1,905.70
$1,604.26
$1,705.12
$1,811.94
$2,191.44
$285.74
Toc - Plan #120 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2127 ($0 Labs / $0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$365.17
$414.47
$466.69
$652.19
$991.07
$644.53
$693.83
$746.05
$931.55
$923.89
$973.19
$1,025.41
$1,210.91
$1,203.25
$1,252.55
$1,304.77
$1,490.27
$279.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.34
$828.94
$933.38
$1,304.38
$1,982.14
$1,009.70
$1,108.30
$1,212.74
$1,583.74
$1,289.06
$1,387.66
$1,492.10
$1,863.10
$1,568.42
$1,667.02
$1,771.46
$2,142.46
$279.36
Toc - Plan #121 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Deductible / $0 Virtual Visits / $35 PCP Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$342.61
$388.86
$437.86
$611.90
$929.84
$604.71
$650.96
$699.96
$874.00
$866.81
$913.06
$962.06
$1,136.10
$1,128.91
$1,175.16
$1,224.16
$1,398.20
$262.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.22
$777.72
$875.72
$1,223.80
$1,859.68
$947.32
$1,039.82
$1,137.82
$1,485.90
$1,209.42
$1,301.92
$1,399.92
$1,748.00
$1,471.52
$1,564.02
$1,662.02
$2,010.10
$262.10
Toc - Plan #122 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2126 (3 PCP Visits for $0 / $0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.04
$358.71
$403.90
$564.45
$857.73
$557.81
$600.48
$645.67
$806.22
$799.58
$842.25
$887.44
$1,047.99
$1,041.35
$1,084.02
$1,129.21
$1,289.76
$241.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.08
$717.42
$807.80
$1,128.90
$1,715.46
$873.85
$959.19
$1,049.57
$1,370.67
$1,115.62
$1,200.96
$1,291.34
$1,612.44
$1,357.39
$1,442.73
$1,533.11
$1,854.21
$241.77
Toc - Plan #123 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237 ($0 Labs / $0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$8,650 $17,300 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.28
$400.97
$451.49
$630.96
$958.80
$623.54
$671.23
$721.75
$901.22
$893.80
$941.49
$992.01
$1,171.48
$1,164.06
$1,211.75
$1,262.27
$1,441.74
$270.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.56
$801.94
$902.98
$1,261.92
$1,917.60
$976.82
$1,072.20
$1,173.24
$1,532.18
$1,247.08
$1,342.46
$1,443.50
$1,802.44
$1,517.34
$1,612.72
$1,713.76
$2,072.70
$270.26
Toc - Plan #124 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2219 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$307.87
$349.43
$393.46
$549.86
$835.56
$543.39
$584.95
$628.98
$785.38
$778.91
$820.47
$864.50
$1,020.90
$1,014.43
$1,055.99
$1,100.02
$1,256.42
$235.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$615.74
$698.86
$786.92
$1,099.72
$1,671.12
$851.26
$934.38
$1,022.44
$1,335.24
$1,086.78
$1,169.90
$1,257.96
$1,570.76
$1,322.30
$1,405.42
$1,493.48
$1,806.28
$235.52
Toc - Plan #125 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2266 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$2,900 $5,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$308.75
$350.43
$394.58
$551.43
$837.95
$544.94
$586.62
$630.77
$787.62
$781.13
$822.81
$866.96
$1,023.81
$1,017.32
$1,059.00
$1,103.15
$1,260.00
$236.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$617.50
$700.86
$789.16
$1,102.86
$1,675.90
$853.69
$937.05
$1,025.35
$1,339.05
$1,089.88
$1,173.24
$1,261.54
$1,575.24
$1,326.07
$1,409.43
$1,497.73
$1,811.43
$236.19
Toc - Plan #126 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Connected Care Silver 2230 ($0 Primary Care Virtual Visits / $0 Primary Care Visits with Select Providers /

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$8,650 $17,300 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$349.66
$396.86
$446.87
$624.49
$948.98
$617.15
$664.35
$714.36
$891.98
$884.64
$931.84
$981.85
$1,159.47
$1,152.13
$1,199.33
$1,249.34
$1,426.96
$267.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$699.32
$793.72
$893.74
$1,248.98
$1,897.96
$966.81
$1,061.21
$1,161.23
$1,516.47
$1,234.30
$1,328.70
$1,428.72
$1,783.96
$1,501.79
$1,596.19
$1,696.21
$2,051.45
$267.49
Toc - Plan #127 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Connected Care Bronze 2231 ($0 Virtual Visits / $0 Primary Care and Specialist Visits with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$280.96
$318.89
$359.07
$501.79
$762.53
$495.89
$533.82
$574.00
$716.72
$710.82
$748.75
$788.93
$931.65
$925.75
$963.68
$1,003.86
$1,146.58
$214.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$561.92
$637.78
$718.14
$1,003.58
$1,525.06
$776.85
$852.71
$933.07
$1,218.51
$991.78
$1,067.64
$1,148.00
$1,433.44
$1,206.71
$1,282.57
$1,362.93
$1,648.37
$214.93
Toc - Plan #128 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237D ($0 Labs / $0 Virtual Visits / Adult Dental / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$8,650 $17,300 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.31
$410.09
$461.75
$645.30
$980.60
$637.71
$686.49
$738.15
$921.70
$914.11
$962.89
$1,014.55
$1,198.10
$1,190.51
$1,239.29
$1,290.95
$1,474.50
$276.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.62
$820.18
$923.50
$1,290.60
$1,961.20
$999.02
$1,096.58
$1,199.90
$1,567.00
$1,275.42
$1,372.98
$1,476.30
$1,843.40
$1,551.82
$1,649.38
$1,752.70
$2,119.80
$276.40

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #129 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple

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

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.21
$408.82
$460.33
$643.31
$977.58
$635.76
$684.37
$735.88
$918.86
$911.31
$959.92
$1,011.43
$1,194.41
$1,186.86
$1,235.47
$1,286.98
$1,469.96
$275.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.42
$817.64
$920.66
$1,286.62
$1,955.16
$995.97
$1,093.19
$1,196.21
$1,562.17
$1,271.52
$1,368.74
$1,471.76
$1,837.72
$1,547.07
$1,644.29
$1,747.31
$2,113.27
$275.55
Toc - Plan #130 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.93
$331.33
$373.08
$521.37
$792.27
$515.25
$554.65
$596.40
$744.69
$738.57
$777.97
$819.72
$968.01
$961.89
$1,001.29
$1,043.04
$1,191.33
$223.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$583.86
$662.66
$746.16
$1,042.74
$1,584.54
$807.18
$885.98
$969.48
$1,266.06
$1,030.50
$1,109.30
$1,192.80
$1,489.38
$1,253.82
$1,332.62
$1,416.12
$1,712.70
$223.32
Toc - Plan #131 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.25
$327.15
$368.37
$514.79
$782.28
$508.75
$547.65
$588.87
$735.29
$729.25
$768.15
$809.37
$955.79
$949.75
$988.65
$1,029.87
$1,176.29
$220.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.50
$654.30
$736.74
$1,029.58
$1,564.56
$797.00
$874.80
$957.24
$1,250.08
$1,017.50
$1,095.30
$1,177.74
$1,470.58
$1,238.00
$1,315.80
$1,398.24
$1,691.08
$220.50
Toc - Plan #132 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Simple

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.13
$327.01
$368.21
$514.57
$781.95
$508.54
$547.42
$588.62
$734.98
$728.95
$767.83
$809.03
$955.39
$949.36
$988.24
$1,029.44
$1,175.80
$220.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.26
$654.02
$736.42
$1,029.14
$1,563.90
$796.67
$874.43
$956.83
$1,249.55
$1,017.08
$1,094.84
$1,177.24
$1,469.96
$1,237.49
$1,315.25
$1,397.65
$1,690.37
$220.41
Toc - Plan #133 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.18
$377.02
$424.52
$593.26
$901.52
$586.29
$631.13
$678.63
$847.37
$840.40
$885.24
$932.74
$1,101.48
$1,094.51
$1,139.35
$1,186.85
$1,355.59
$254.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.36
$754.04
$849.04
$1,186.52
$1,803.04
$918.47
$1,008.15
$1,103.15
$1,440.63
$1,172.58
$1,262.26
$1,357.26
$1,694.74
$1,426.69
$1,516.37
$1,611.37
$1,948.85
$254.11
Toc - Plan #134 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.09
$418.90
$471.68
$659.17
$1,001.68
$651.43
$701.24
$754.02
$941.51
$933.77
$983.58
$1,036.36
$1,223.85
$1,216.11
$1,265.92
$1,318.70
$1,506.19
$282.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.18
$837.80
$943.36
$1,318.34
$2,003.36
$1,020.52
$1,120.14
$1,225.70
$1,600.68
$1,302.86
$1,402.48
$1,508.04
$1,883.02
$1,585.20
$1,684.82
$1,790.38
$2,165.36
$282.34
Toc - Plan #135 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.06
$416.60
$469.09
$655.55
$996.18
$647.85
$697.39
$749.88
$936.34
$928.64
$978.18
$1,030.67
$1,217.13
$1,209.43
$1,258.97
$1,311.46
$1,497.92
$280.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.12
$833.20
$938.18
$1,311.10
$1,992.36
$1,014.91
$1,113.99
$1,218.97
$1,591.89
$1,295.70
$1,394.78
$1,499.76
$1,872.68
$1,576.49
$1,675.57
$1,780.55
$2,153.47
$280.79
Toc - Plan #136 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- PCP Saver

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
$8,450 $16,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.34
$419.19
$472.01
$659.63
$1,002.36
$651.88
$701.73
$754.55
$942.17
$934.42
$984.27
$1,037.09
$1,224.71
$1,216.96
$1,266.81
$1,319.63
$1,507.25
$282.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.68
$838.38
$944.02
$1,319.26
$2,004.72
$1,021.22
$1,120.92
$1,226.56
$1,601.80
$1,303.76
$1,403.46
$1,509.10
$1,884.34
$1,586.30
$1,686.00
$1,791.64
$2,166.88
$282.54
Toc - Plan #137 Oscar Insurance Company of Florida
Catastrophic

(EPO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$220.46
$250.21
$281.73
$393.72
$598.30
$389.10
$418.85
$450.37
$562.36
$557.74
$587.49
$619.01
$731.00
$726.38
$756.13
$787.65
$899.64
$168.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$440.92
$500.42
$563.46
$787.44
$1,196.60
$609.56
$669.06
$732.10
$956.08
$778.20
$837.70
$900.74
$1,124.72
$946.84
$1,006.34
$1,069.38
$1,293.36
$168.64
Toc - Plan #138 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.37
$378.36
$426.03
$595.38
$904.73
$588.39
$633.38
$681.05
$850.40
$843.41
$888.40
$936.07
$1,105.42
$1,098.43
$1,143.42
$1,191.09
$1,360.44
$255.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.74
$756.72
$852.06
$1,190.76
$1,809.46
$921.76
$1,011.74
$1,107.08
$1,445.78
$1,176.78
$1,266.76
$1,362.10
$1,700.80
$1,431.80
$1,521.78
$1,617.12
$1,955.82
$255.02
Toc - Plan #139 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$399.40
$453.31
$510.42
$713.31
$1,083.95
$704.93
$758.84
$815.95
$1,018.84
$1,010.46
$1,064.37
$1,121.48
$1,324.37
$1,315.99
$1,369.90
$1,427.01
$1,629.90
$305.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798.80
$906.62
$1,020.84
$1,426.62
$2,167.90
$1,104.33
$1,212.15
$1,326.37
$1,732.15
$1,409.86
$1,517.68
$1,631.90
$2,037.68
$1,715.39
$1,823.21
$1,937.43
$2,343.21
$305.53
Toc - Plan #140 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Simple- HSA

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
$305.50
$346.74
$390.42
$545.61
$829.11
$539.20
$580.44
$624.12
$779.31
$772.90
$814.14
$857.82
$1,013.01
$1,006.60
$1,047.84
$1,091.52
$1,246.71
$233.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$611.00
$693.48
$780.84
$1,091.22
$1,658.22
$844.70
$927.18
$1,014.54
$1,324.92
$1,078.40
$1,160.88
$1,248.24
$1,558.62
$1,312.10
$1,394.58
$1,481.94
$1,792.32
$233.70
Toc - Plan #141 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite

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
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$374.12
$424.62
$478.12
$668.17
$1,015.35
$660.32
$710.82
$764.32
$954.37
$946.52
$997.02
$1,050.52
$1,240.57
$1,232.72
$1,283.22
$1,336.72
$1,526.77
$286.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$748.24
$849.24
$956.24
$1,336.34
$2,030.70
$1,034.44
$1,135.44
$1,242.44
$1,622.54
$1,320.64
$1,421.64
$1,528.64
$1,908.74
$1,606.84
$1,707.84
$1,814.84
$2,194.94
$286.20
Toc - Plan #142 Oscar Insurance Company of Florida
Silver

(EPO) 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
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.09
$426.85
$480.63
$671.68
$1,020.68
$663.79
$714.55
$768.33
$959.38
$951.49
$1,002.25
$1,056.03
$1,247.08
$1,239.19
$1,289.95
$1,343.73
$1,534.78
$287.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.18
$853.70
$961.26
$1,343.36
$2,041.36
$1,039.88
$1,141.40
$1,248.96
$1,631.06
$1,327.58
$1,429.10
$1,536.66
$1,918.76
$1,615.28
$1,716.80
$1,824.36
$2,206.46
$287.70
Toc - Plan #143 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- Low Ded

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 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
$399.75
$453.70
$510.87
$713.93
$1,084.89
$705.55
$759.50
$816.67
$1,019.73
$1,011.35
$1,065.30
$1,122.47
$1,325.53
$1,317.15
$1,371.10
$1,428.27
$1,631.33
$305.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$799.50
$907.40
$1,021.74
$1,427.86
$2,169.78
$1,105.30
$1,213.20
$1,327.54
$1,733.66
$1,411.10
$1,519.00
$1,633.34
$2,039.46
$1,716.90
$1,824.80
$1,939.14
$2,345.26
$305.80
Toc - Plan #144 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$297.52
$337.67
$380.22
$531.35
$807.44
$525.12
$565.27
$607.82
$758.95
$752.72
$792.87
$835.42
$986.55
$980.32
$1,020.47
$1,063.02
$1,214.15
$227.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.04
$675.34
$760.44
$1,062.70
$1,614.88
$822.64
$902.94
$988.04
$1,290.30
$1,050.24
$1,130.54
$1,215.64
$1,517.90
$1,277.84
$1,358.14
$1,443.24
$1,745.50
$227.60
Toc - Plan #145 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.38
$368.16
$414.55
$579.33
$880.35
$572.53
$616.31
$662.70
$827.48
$820.68
$864.46
$910.85
$1,075.63
$1,068.83
$1,112.61
$1,159.00
$1,323.78
$248.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.76
$736.32
$829.10
$1,158.66
$1,760.70
$896.91
$984.47
$1,077.25
$1,406.81
$1,145.06
$1,232.62
$1,325.40
$1,654.96
$1,393.21
$1,480.77
$1,573.55
$1,903.11
$248.15
Toc - Plan #146 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$306.07
$347.38
$391.14
$546.62
$830.64
$540.20
$581.51
$625.27
$780.75
$774.33
$815.64
$859.40
$1,014.88
$1,008.46
$1,049.77
$1,093.53
$1,249.01
$234.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.14
$694.76
$782.28
$1,093.24
$1,661.28
$846.27
$928.89
$1,016.41
$1,327.37
$1,080.40
$1,163.02
$1,250.54
$1,561.50
$1,314.53
$1,397.15
$1,484.67
$1,795.63
$234.13
Toc - Plan #147 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- PCP Saver

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
$8,600 $17,200 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
$352.91
$400.54
$451.01
$630.28
$957.77
$622.88
$670.51
$720.98
$900.25
$892.85
$940.48
$990.95
$1,170.22
$1,162.82
$1,210.45
$1,260.92
$1,440.19
$269.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$705.82
$801.08
$902.02
$1,260.56
$1,915.54
$975.79
$1,071.05
$1,171.99
$1,530.53
$1,245.76
$1,341.02
$1,441.96
$1,800.50
$1,515.73
$1,610.99
$1,711.93
$2,070.47
$269.97
Toc - Plan #148 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- Low Ded

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$368.68
$418.44
$471.16
$658.45
$1,000.58
$650.71
$700.47
$753.19
$940.48
$932.74
$982.50
$1,035.22
$1,222.51
$1,214.77
$1,264.53
$1,317.25
$1,504.54
$282.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737.36
$836.88
$942.32
$1,316.90
$2,001.16
$1,019.39
$1,118.91
$1,224.35
$1,598.93
$1,301.42
$1,400.94
$1,506.38
$1,880.96
$1,583.45
$1,682.97
$1,788.41
$2,162.99
$282.03
Toc - Plan #149 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$376.88
$427.75
$481.64
$673.09
$1,022.83
$665.19
$716.06
$769.95
$961.40
$953.50
$1,004.37
$1,058.26
$1,249.71
$1,241.81
$1,292.68
$1,346.57
$1,538.02
$288.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.76
$855.50
$963.28
$1,346.18
$2,045.66
$1,042.07
$1,143.81
$1,251.59
$1,634.49
$1,330.38
$1,432.12
$1,539.90
$1,922.80
$1,618.69
$1,720.43
$1,828.21
$2,211.11
$288.31
Toc - Plan #150 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370.95
$421.02
$474.06
$662.50
$1,006.73
$654.72
$704.79
$757.83
$946.27
$938.49
$988.56
$1,041.60
$1,230.04
$1,222.26
$1,272.33
$1,325.37
$1,513.81
$283.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$741.90
$842.04
$948.12
$1,325.00
$2,013.46
$1,025.67
$1,125.81
$1,231.89
$1,608.77
$1,309.44
$1,409.58
$1,515.66
$1,892.54
$1,593.21
$1,693.35
$1,799.43
$2,176.31
$283.77
Toc - Plan #151 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- $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
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.27
$419.10
$471.91
$659.49
$1,002.16
$651.75
$701.58
$754.39
$941.97
$934.23
$984.06
$1,036.87
$1,224.45
$1,216.71
$1,266.54
$1,319.35
$1,506.93
$282.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.54
$838.20
$943.82
$1,318.98
$2,004.32
$1,021.02
$1,120.68
$1,226.30
$1,601.46
$1,303.50
$1,403.16
$1,508.78
$1,883.94
$1,585.98
$1,685.64
$1,791.26
$2,166.42
$282.48
Toc - Plan #152 Oscar Insurance Company of Florida
Gold

(EPO) Gold Simple

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$6,550 $13,100 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
$384.41
$436.29
$491.26
$686.53
$1,043.25
$678.47
$730.35
$785.32
$980.59
$972.53
$1,024.41
$1,079.38
$1,274.65
$1,266.59
$1,318.47
$1,373.44
$1,568.71
$294.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.82
$872.58
$982.52
$1,373.06
$2,086.50
$1,062.88
$1,166.64
$1,276.58
$1,667.12
$1,356.94
$1,460.70
$1,570.64
$1,961.18
$1,651.00
$1,754.76
$1,864.70
$2,255.24
$294.06
Toc - Plan #153 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- $0 PCP

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
$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
$388.50
$440.94
$496.49
$693.85
$1,054.37
$685.70
$738.14
$793.69
$991.05
$982.90
$1,035.34
$1,090.89
$1,288.25
$1,280.10
$1,332.54
$1,388.09
$1,585.45
$297.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.00
$881.88
$992.98
$1,387.70
$2,108.74
$1,074.20
$1,179.08
$1,290.18
$1,684.90
$1,371.40
$1,476.28
$1,587.38
$1,982.10
$1,668.60
$1,773.48
$1,884.58
$2,279.30
$297.20
Toc - Plan #154 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite- $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
$8,000 $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
$426.91
$484.53
$545.58
$762.45
$1,158.61
$753.49
$811.11
$872.16
$1,089.03
$1,080.07
$1,137.69
$1,198.74
$1,415.61
$1,406.65
$1,464.27
$1,525.32
$1,742.19
$326.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.82
$969.06
$1,091.16
$1,524.90
$2,317.22
$1,180.40
$1,295.64
$1,417.74
$1,851.48
$1,506.98
$1,622.22
$1,744.32
$2,178.06
$1,833.56
$1,948.80
$2,070.90
$2,504.64
$326.58
Toc - Plan #155 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite

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

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.00
$463.07
$521.42
$728.68
$1,107.29
$720.12
$775.19
$833.54
$1,040.80
$1,032.24
$1,087.31
$1,145.66
$1,352.92
$1,344.36
$1,399.43
$1,457.78
$1,665.04
$312.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$816.00
$926.14
$1,042.84
$1,457.36
$2,214.58
$1,128.12
$1,238.26
$1,354.96
$1,769.48
$1,440.24
$1,550.38
$1,667.08
$2,081.60
$1,752.36
$1,862.50
$1,979.20
$2,393.72
$312.12
Toc - Plan #156 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$2,850 $5,700 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$379.31
$430.51
$484.75
$677.44
$1,029.43
$669.48
$720.68
$774.92
$967.61
$959.65
$1,010.85
$1,065.09
$1,257.78
$1,249.82
$1,301.02
$1,355.26
$1,547.95
$290.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.62
$861.02
$969.50
$1,354.88
$2,058.86
$1,048.79
$1,151.19
$1,259.67
$1,645.05
$1,338.96
$1,441.36
$1,549.84
$1,935.22
$1,629.13
$1,731.53
$1,840.01
$2,225.39
$290.17
Toc - Plan #157 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- $4000 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322.00
$365.46
$411.50
$575.08
$873.88
$568.32
$611.78
$657.82
$821.40
$814.64
$858.10
$904.14
$1,067.72
$1,060.96
$1,104.42
$1,150.46
$1,314.04
$246.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$644.00
$730.92
$823.00
$1,150.16
$1,747.76
$890.32
$977.24
$1,069.32
$1,396.48
$1,136.64
$1,223.56
$1,315.64
$1,642.80
$1,382.96
$1,469.88
$1,561.96
$1,889.12
$246.32
Toc - Plan #158 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- $1000 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328.64
$373.00
$419.99
$586.93
$891.90
$580.04
$624.40
$671.39
$838.33
$831.44
$875.80
$922.79
$1,089.73
$1,082.84
$1,127.20
$1,174.19
$1,341.13
$251.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$657.28
$746.00
$839.98
$1,173.86
$1,783.80
$908.68
$997.40
$1,091.38
$1,425.26
$1,160.08
$1,248.80
$1,342.78
$1,676.66
$1,411.48
$1,500.20
$1,594.18
$1,928.06
$251.40
Toc - Plan #159 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- $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
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$329.71
$374.21
$421.36
$588.84
$894.81
$581.93
$626.43
$673.58
$841.06
$834.15
$878.65
$925.80
$1,093.28
$1,086.37
$1,130.87
$1,178.02
$1,345.50
$252.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$659.42
$748.42
$842.72
$1,177.68
$1,789.62
$911.64
$1,000.64
$1,094.94
$1,429.90
$1,163.86
$1,252.86
$1,347.16
$1,682.12
$1,416.08
$1,505.08
$1,599.38
$1,934.34
$252.22
Toc - Plan #160 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.62
$417.23
$469.80
$656.54
$997.68
$648.84
$698.45
$751.02
$937.76
$930.06
$979.67
$1,032.24
$1,218.98
$1,211.28
$1,260.89
$1,313.46
$1,500.20
$281.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.24
$834.46
$939.60
$1,313.08
$1,995.36
$1,016.46
$1,115.68
$1,220.82
$1,594.30
$1,297.68
$1,396.90
$1,502.04
$1,875.52
$1,578.90
$1,678.12
$1,783.26
$2,156.74
$281.22

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

Toc - Plan #161 Cigna Healthcare
Bronze

(EPO) Cigna Connect 8700A ($0 Telehealth)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.35
$359.05
$404.29
$564.99
$858.56
$558.36
$601.06
$646.30
$807.00
$800.37
$843.07
$888.31
$1,049.01
$1,042.38
$1,085.08
$1,130.32
$1,291.02
$242.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.70
$718.10
$808.58
$1,129.98
$1,717.12
$874.71
$960.11
$1,050.59
$1,371.99
$1,116.72
$1,202.12
$1,292.60
$1,614.00
$1,358.73
$1,444.13
$1,534.61
$1,856.01
$242.01
Toc - Plan #162 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7300 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$7,300 $14,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.53
$378.56
$426.25
$595.68
$905.20
$588.68
$633.71
$681.40
$850.83
$843.83
$888.86
$936.55
$1,105.98
$1,098.98
$1,144.01
$1,191.70
$1,361.13
$255.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$667.06
$757.12
$852.50
$1,191.36
$1,810.40
$922.21
$1,012.27
$1,107.65
$1,446.51
$1,177.36
$1,267.42
$1,362.80
$1,701.66
$1,432.51
$1,522.57
$1,617.95
$1,956.81
$255.15
Toc - Plan #163 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 8200 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$330.67
$375.31
$422.60
$590.58
$897.45
$583.63
$628.27
$675.56
$843.54
$836.59
$881.23
$928.52
$1,096.50
$1,089.55
$1,134.19
$1,181.48
$1,349.46
$252.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$661.34
$750.62
$845.20
$1,181.16
$1,794.90
$914.30
$1,003.58
$1,098.16
$1,434.12
$1,167.26
$1,256.54
$1,351.12
$1,687.08
$1,420.22
$1,509.50
$1,604.08
$1,940.04
$252.96
Toc - Plan #164 Cigna Healthcare
Silver

(EPO) Cigna Connect 6000 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$401.57
$455.78
$513.20
$717.20
$1,089.86
$708.77
$762.98
$820.40
$1,024.40
$1,015.97
$1,070.18
$1,127.60
$1,331.60
$1,323.17
$1,377.38
$1,434.80
$1,638.80
$307.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.14
$911.56
$1,026.40
$1,434.40
$2,179.72
$1,110.34
$1,218.76
$1,333.60
$1,741.60
$1,417.54
$1,525.96
$1,640.80
$2,048.80
$1,724.74
$1,833.16
$1,948.00
$2,356.00
$307.20
Toc - Plan #165 Cigna Healthcare
Silver

(EPO) Cigna Connect 4500 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.54
$462.56
$520.84
$727.87
$1,106.07
$719.31
$774.33
$832.61
$1,039.64
$1,031.08
$1,086.10
$1,144.38
$1,351.41
$1,342.85
$1,397.87
$1,456.15
$1,663.18
$311.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$815.08
$925.12
$1,041.68
$1,455.74
$2,212.14
$1,126.85
$1,236.89
$1,353.45
$1,767.51
$1,438.62
$1,548.66
$1,665.22
$2,079.28
$1,750.39
$1,860.43
$1,976.99
$2,391.05
$311.77
Toc - Plan #166 Cigna Healthcare
Silver

(EPO) Cigna Connect 8700B ($0 Telehealth)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.48
$467.03
$525.87
$734.90
$1,116.76
$726.26
$781.81
$840.65
$1,049.68
$1,041.04
$1,096.59
$1,155.43
$1,364.46
$1,355.82
$1,411.37
$1,470.21
$1,679.24
$314.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.96
$934.06
$1,051.74
$1,469.80
$2,233.52
$1,137.74
$1,248.84
$1,366.52
$1,784.58
$1,452.52
$1,563.62
$1,681.30
$2,099.36
$1,767.30
$1,878.40
$1,996.08
$2,414.14
$314.78
Toc - Plan #167 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500 ($0 Tier 1 RX, $0 Telehealth)

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
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$420.74
$477.54
$537.71
$751.45
$1,141.89
$742.61
$799.41
$859.58
$1,073.32
$1,064.48
$1,121.28
$1,181.45
$1,395.19
$1,386.35
$1,443.15
$1,503.32
$1,717.06
$321.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$841.48
$955.08
$1,075.42
$1,502.90
$2,283.78
$1,163.35
$1,276.95
$1,397.29
$1,824.77
$1,485.22
$1,598.82
$1,719.16
$2,146.64
$1,807.09
$1,920.69
$2,041.03
$2,468.51
$321.87
Toc - Plan #168 Cigna Healthcare
Gold

(EPO) Cigna Connect 2000 ($0 Tier 1 RX, $0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$456.19
$517.78
$583.01
$814.76
$1,238.10
$805.18
$866.77
$932.00
$1,163.75
$1,154.17
$1,215.76
$1,280.99
$1,512.74
$1,503.16
$1,564.75
$1,629.98
$1,861.73
$348.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$912.38
$1,035.56
$1,166.02
$1,629.52
$2,476.20
$1,261.37
$1,384.55
$1,515.01
$1,978.51
$1,610.36
$1,733.54
$1,864.00
$2,327.50
$1,959.35
$2,082.53
$2,212.99
$2,676.49
$348.99
Toc - Plan #169 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 8000 ($0 Telehealth)

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
$8,700 $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
$329.50
$373.99
$421.11
$588.49
$894.27
$581.57
$626.06
$673.18
$840.56
$833.64
$878.13
$925.25
$1,092.63
$1,085.71
$1,130.20
$1,177.32
$1,344.70
$252.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$659.00
$747.98
$842.22
$1,176.98
$1,788.54
$911.07
$1,000.05
$1,094.29
$1,429.05
$1,163.14
$1,252.12
$1,346.36
$1,681.12
$1,415.21
$1,504.19
$1,598.43
$1,933.19
$252.07
Toc - Plan #170 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6800 Enhanced Diabetes Care ($0 Preferred Insulin)

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

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$330.54
$375.17
$422.43
$590.35
$897.09
$583.41
$628.04
$675.30
$843.22
$836.28
$880.91
$928.17
$1,096.09
$1,089.15
$1,133.78
$1,181.04
$1,348.96
$252.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$661.08
$750.34
$844.86
$1,180.70
$1,794.18
$913.95
$1,003.21
$1,097.73
$1,433.57
$1,166.82
$1,256.08
$1,350.60
$1,686.44
$1,419.69
$1,508.95
$1,603.47
$1,939.31
$252.87
Toc - Plan #171 Cigna Healthcare
Silver

(EPO) Cigna Connect 8400 ($0 Tier 1 RX, $0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$8,400 $16,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419.83
$476.51
$536.55
$749.82
$1,139.43
$741.00
$797.68
$857.72
$1,070.99
$1,062.17
$1,118.85
$1,178.89
$1,392.16
$1,383.34
$1,440.02
$1,500.06
$1,713.33
$321.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839.66
$953.02
$1,073.10
$1,499.64
$2,278.86
$1,160.83
$1,274.19
$1,394.27
$1,820.81
$1,482.00
$1,595.36
$1,715.44
$2,141.98
$1,803.17
$1,916.53
$2,036.61
$2,463.15
$321.17
Toc - Plan #172 Cigna Healthcare
Silver

(EPO) Cigna Connect 3000 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$397.20
$450.82
$507.62
$709.39
$1,077.99
$701.06
$754.68
$811.48
$1,013.25
$1,004.92
$1,058.54
$1,115.34
$1,317.11
$1,308.78
$1,362.40
$1,419.20
$1,620.97
$303.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$794.40
$901.64
$1,015.24
$1,418.78
$2,155.98
$1,098.26
$1,205.50
$1,319.10
$1,722.64
$1,402.12
$1,509.36
$1,622.96
$2,026.50
$1,705.98
$1,813.22
$1,926.82
$2,330.36
$303.86
Toc - Plan #173 Cigna Healthcare
Silver

(EPO) Cigna Connect 0 ($0 Deductible, $0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.92
$487.96
$549.44
$767.83
$1,166.80
$758.81
$816.85
$878.33
$1,096.72
$1,087.70
$1,145.74
$1,207.22
$1,425.61
$1,416.59
$1,474.63
$1,536.11
$1,754.50
$328.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.84
$975.92
$1,098.88
$1,535.66
$2,333.60
$1,188.73
$1,304.81
$1,427.77
$1,864.55
$1,517.62
$1,633.70
$1,756.66
$2,193.44
$1,846.51
$1,962.59
$2,085.55
$2,522.33
$328.89
Toc - Plan #174 Cigna Healthcare
Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412.56
$468.26
$527.25
$736.84
$1,119.69
$728.17
$783.87
$842.86
$1,052.45
$1,043.78
$1,099.48
$1,158.47
$1,368.06
$1,359.39
$1,415.09
$1,474.08
$1,683.67
$315.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$825.12
$936.52
$1,054.50
$1,473.68
$2,239.38
$1,140.73
$1,252.13
$1,370.11
$1,789.29
$1,456.34
$1,567.74
$1,685.72
$2,104.90
$1,771.95
$1,883.35
$2,001.33
$2,420.51
$315.61
Toc - Plan #175 Cigna Healthcare
Gold

(EPO) Cigna Connect 1250 Enhanced Diabetes Care ($0 Preferred Insulin)

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 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
$474.63
$538.70
$606.57
$847.69
$1,288.14
$837.72
$901.79
$969.66
$1,210.78
$1,200.81
$1,264.88
$1,332.75
$1,573.87
$1,563.90
$1,627.97
$1,695.84
$1,936.96
$363.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$949.26
$1,077.40
$1,213.14
$1,695.38
$2,576.28
$1,312.35
$1,440.49
$1,576.23
$2,058.47
$1,675.44
$1,803.58
$1,939.32
$2,421.56
$2,038.53
$2,166.67
$2,302.41
$2,784.65
$363.09
Toc - Plan #176 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 5400 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.40
$377.28
$424.81
$593.67
$902.14
$586.69
$631.57
$679.10
$847.96
$840.98
$885.86
$933.39
$1,102.25
$1,095.27
$1,140.15
$1,187.68
$1,356.54
$254.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.80
$754.56
$849.62
$1,187.34
$1,804.28
$919.09
$1,008.85
$1,103.91
$1,441.63
$1,173.38
$1,263.14
$1,358.20
$1,695.92
$1,427.67
$1,517.43
$1,612.49
$1,950.21
$254.29
Toc - Plan #177 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500 Enhanced Diabetes Care ($0 Preferred Insulin)

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
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$422.60
$479.65
$540.09
$754.77
$1,146.95
$745.89
$802.94
$863.38
$1,078.06
$1,069.18
$1,126.23
$1,186.67
$1,401.35
$1,392.47
$1,449.52
$1,509.96
$1,724.64
$323.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.20
$959.30
$1,080.18
$1,509.54
$2,293.90
$1,168.49
$1,282.59
$1,403.47
$1,832.83
$1,491.78
$1,605.88
$1,726.76
$2,156.12
$1,815.07
$1,929.17
$2,050.05
$2,479.41
$323.29

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-5716 | Toll Free: 1-888-560-5716 | TTY: 1-800-955-8771

Toc - Plan #178 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.88
$487.91
$549.39
$767.77
$1,166.69
$758.74
$816.77
$878.25
$1,096.63
$1,087.60
$1,145.63
$1,207.11
$1,425.49
$1,416.46
$1,474.49
$1,535.97
$1,754.35
$328.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.76
$975.82
$1,098.78
$1,535.54
$2,333.38
$1,188.62
$1,304.68
$1,427.64
$1,864.40
$1,517.48
$1,633.54
$1,756.50
$2,193.26
$1,846.34
$1,962.40
$2,085.36
$2,522.12
$328.86
Toc - Plan #179 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.51
$434.15
$488.85
$683.17
$1,038.14
$675.13
$726.77
$781.47
$975.79
$967.75
$1,019.39
$1,074.09
$1,268.41
$1,260.37
$1,312.01
$1,366.71
$1,561.03
$292.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.02
$868.30
$977.70
$1,366.34
$2,076.28
$1,057.64
$1,160.92
$1,270.32
$1,658.96
$1,350.26
$1,453.54
$1,562.94
$1,951.58
$1,642.88
$1,746.16
$1,855.56
$2,244.20
$292.62
Toc - Plan #180 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$289.81
$328.94
$370.38
$517.61
$786.55
$511.52
$550.65
$592.09
$739.32
$733.23
$772.36
$813.80
$961.03
$954.94
$994.07
$1,035.51
$1,182.74
$221.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$579.62
$657.88
$740.76
$1,035.22
$1,573.10
$801.33
$879.59
$962.47
$1,256.93
$1,023.04
$1,101.30
$1,184.18
$1,478.64
$1,244.75
$1,323.01
$1,405.89
$1,700.35
$221.71
Toc - Plan #181 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$378.69
$429.81
$483.96
$676.34
$1,027.76
$668.39
$719.51
$773.66
$966.04
$958.09
$1,009.21
$1,063.36
$1,255.74
$1,247.79
$1,298.91
$1,353.06
$1,545.44
$289.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.38
$859.62
$967.92
$1,352.68
$2,055.52
$1,047.08
$1,149.32
$1,257.62
$1,642.38
$1,336.78
$1,439.02
$1,547.32
$1,932.08
$1,626.48
$1,728.72
$1,837.02
$2,221.78
$289.70
Toc - Plan #182 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

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
$323.30
$366.95
$413.18
$577.42
$877.44
$570.63
$614.28
$660.51
$824.75
$817.96
$861.61
$907.84
$1,072.08
$1,065.29
$1,108.94
$1,155.17
$1,319.41
$247.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.60
$733.90
$826.36
$1,154.84
$1,754.88
$893.93
$981.23
$1,073.69
$1,402.17
$1,141.26
$1,228.56
$1,321.02
$1,649.50
$1,388.59
$1,475.89
$1,568.35
$1,896.83
$247.33
Toc - Plan #183 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.85
$493.55
$555.74
$776.64
$1,180.18
$767.51
$826.21
$888.40
$1,109.30
$1,100.17
$1,158.87
$1,221.06
$1,441.96
$1,432.83
$1,491.53
$1,553.72
$1,774.62
$332.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869.70
$987.10
$1,111.48
$1,553.28
$2,360.36
$1,202.36
$1,319.76
$1,444.14
$1,885.94
$1,535.02
$1,652.42
$1,776.80
$2,218.60
$1,867.68
$1,985.08
$2,109.46
$2,551.26
$332.66
Toc - Plan #184 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.74
$437.82
$492.98
$688.93
$1,046.90
$680.83
$732.91
$788.07
$984.02
$975.92
$1,028.00
$1,083.16
$1,279.11
$1,271.01
$1,323.09
$1,378.25
$1,574.20
$295.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.48
$875.64
$985.96
$1,377.86
$2,093.80
$1,066.57
$1,170.73
$1,281.05
$1,672.95
$1,361.66
$1,465.82
$1,576.14
$1,968.04
$1,656.75
$1,760.91
$1,871.23
$2,263.13
$295.09
Toc - Plan #185 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.41
$431.77
$486.16
$679.41
$1,032.43
$671.42
$722.78
$777.17
$970.42
$962.43
$1,013.79
$1,068.18
$1,261.43
$1,253.44
$1,304.80
$1,359.19
$1,552.44
$291.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.82
$863.54
$972.32
$1,358.82
$2,064.86
$1,051.83
$1,154.55
$1,263.33
$1,649.83
$1,342.84
$1,445.56
$1,554.34
$1,940.84
$1,633.85
$1,736.57
$1,845.35
$2,231.85
$291.01
Toc - Plan #186 Molina Healthcare
Silver

(HMO) Constant Care Silver 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

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
$366.08
$415.50
$467.85
$653.82
$993.54
$646.13
$695.55
$747.90
$933.87
$926.18
$975.60
$1,027.95
$1,213.92
$1,206.23
$1,255.65
$1,308.00
$1,493.97
$280.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732.16
$831.00
$935.70
$1,307.64
$1,987.08
$1,012.21
$1,111.05
$1,215.75
$1,587.69
$1,292.26
$1,391.10
$1,495.80
$1,867.74
$1,572.31
$1,671.15
$1,775.85
$2,147.79
$280.05

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0405 | Toll Free: 1-888-200-0405 | TTY: 1-888-200-0405

Toc - Plan #187 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($1 Rx + Unlimited Free Primary Care & Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.60
$466.03
$524.75
$733.34
$1,114.38
$724.71
$780.14
$838.86
$1,047.45
$1,038.82
$1,094.25
$1,152.97
$1,361.56
$1,352.93
$1,408.36
$1,467.08
$1,675.67
$314.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.20
$932.06
$1,049.50
$1,466.68
$2,228.76
$1,135.31
$1,246.17
$1,363.61
$1,780.79
$1,449.42
$1,560.28
$1,677.72
$2,094.90
$1,763.53
$1,874.39
$1,991.83
$2,409.01
$314.11
Toc - Plan #188 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ Extra ($1 Rx + Dental + Vision + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$420.97
$477.80
$538.00
$751.85
$1,142.51
$743.01
$799.84
$860.04
$1,073.89
$1,065.05
$1,121.88
$1,182.08
$1,395.93
$1,387.09
$1,443.92
$1,504.12
$1,717.97
$322.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$841.94
$955.60
$1,076.00
$1,503.70
$2,285.02
$1,163.98
$1,277.64
$1,398.04
$1,825.74
$1,486.02
$1,599.68
$1,720.08
$2,147.78
$1,808.06
$1,921.72
$2,042.12
$2,469.82
$322.04
Toc - Plan #189 UnitedHealthcare
Gold

(HMO) UHC Gold Value+ ($2 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$392.17
$445.12
$501.20
$700.42
$1,064.36
$692.18
$745.13
$801.21
$1,000.43
$992.19
$1,045.14
$1,101.22
$1,300.44
$1,292.20
$1,345.15
$1,401.23
$1,600.45
$300.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.34
$890.24
$1,002.40
$1,400.84
$2,128.72
$1,084.35
$1,190.25
$1,302.41
$1,700.85
$1,384.36
$1,490.26
$1,602.42
$2,000.86
$1,684.37
$1,790.27
$1,902.43
$2,300.87
$300.01
Toc - Plan #190 UnitedHealthcare
Gold

(HMO) UHC Gold Value+ ($2 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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
$390.45
$443.16
$498.99
$697.34
$1,059.67
$689.14
$741.85
$797.68
$996.03
$987.83
$1,040.54
$1,096.37
$1,294.72
$1,286.52
$1,339.23
$1,395.06
$1,593.41
$298.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.90
$886.32
$997.98
$1,394.68
$2,119.34
$1,079.59
$1,185.01
$1,296.67
$1,693.37
$1,378.28
$1,483.70
$1,595.36
$1,992.06
$1,676.97
$1,782.39
$1,894.05
$2,290.75
$298.69
Toc - Plan #191 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.55
$416.03
$468.45
$654.65
$994.81
$646.96
$696.44
$748.86
$935.06
$927.37
$976.85
$1,029.27
$1,215.47
$1,207.78
$1,257.26
$1,309.68
$1,495.88
$280.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.10
$832.06
$936.90
$1,309.30
$1,989.62
$1,013.51
$1,112.47
$1,217.31
$1,589.71
$1,293.92
$1,392.88
$1,497.72
$1,870.12
$1,574.33
$1,673.29
$1,778.13
$2,150.53
$280.41
Toc - Plan #192 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First ($3 Rx + Unlimited Free App-based Care) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$359.64
$408.19
$459.62
$642.31
$976.05
$634.76
$683.31
$734.74
$917.43
$909.88
$958.43
$1,009.86
$1,192.55
$1,185.00
$1,233.55
$1,284.98
$1,467.67
$275.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$719.28
$816.38
$919.24
$1,284.62
$1,952.10
$994.40
$1,091.50
$1,194.36
$1,559.74
$1,269.52
$1,366.62
$1,469.48
$1,834.86
$1,544.64
$1,641.74
$1,744.60
$2,109.98
$275.12
Toc - Plan #193 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ Saver ($3 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$365.68
$415.05
$467.34
$653.11
$992.47
$645.43
$694.80
$747.09
$932.86
$925.18
$974.55
$1,026.84
$1,212.61
$1,204.93
$1,254.30
$1,306.59
$1,492.36
$279.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.36
$830.10
$934.68
$1,306.22
$1,984.94
$1,011.11
$1,109.85
$1,214.43
$1,585.97
$1,290.86
$1,389.60
$1,494.18
$1,865.72
$1,570.61
$1,669.35
$1,773.93
$2,145.47
$279.75
Toc - Plan #194 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ Saver ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 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
$365.97
$415.38
$467.71
$653.63
$993.25
$645.94
$695.35
$747.68
$933.60
$925.91
$975.32
$1,027.65
$1,213.57
$1,205.88
$1,255.29
$1,307.62
$1,493.54
$279.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.94
$830.76
$935.42
$1,307.26
$1,986.50
$1,011.91
$1,110.73
$1,215.39
$1,587.23
$1,291.88
$1,390.70
$1,495.36
$1,867.20
$1,571.85
$1,670.67
$1,775.33
$2,147.17
$279.97
Toc - Plan #195 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ Base ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$380.37
$431.72
$486.11
$679.34
$1,032.32
$671.35
$722.70
$777.09
$970.32
$962.33
$1,013.68
$1,068.07
$1,261.30
$1,253.31
$1,304.66
$1,359.05
$1,552.28
$290.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.74
$863.44
$972.22
$1,358.68
$2,064.64
$1,051.72
$1,154.42
$1,263.20
$1,649.66
$1,342.70
$1,445.40
$1,554.18
$1,940.64
$1,633.68
$1,736.38
$1,845.16
$2,231.62
$290.98
Toc - Plan #196 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.82
$435.64
$490.53
$685.51
$1,041.70
$677.45
$729.27
$784.16
$979.14
$971.08
$1,022.90
$1,077.79
$1,272.77
$1,264.71
$1,316.53
$1,371.42
$1,566.40
$293.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.64
$871.28
$981.06
$1,371.02
$2,083.40
$1,061.27
$1,164.91
$1,274.69
$1,664.65
$1,354.90
$1,458.54
$1,568.32
$1,958.28
$1,648.53
$1,752.17
$1,861.95
$2,251.91
$293.63
Toc - Plan #197 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First Saver ($3 Rx + Unlimited Free App-based Care) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.20
$406.55
$457.78
$639.74
$972.15
$632.22
$680.57
$731.80
$913.76
$906.24
$954.59
$1,005.82
$1,187.78
$1,180.26
$1,228.61
$1,279.84
$1,461.80
$274.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716.40
$813.10
$915.56
$1,279.48
$1,944.30
$990.42
$1,087.12
$1,189.58
$1,553.50
$1,264.44
$1,361.14
$1,463.60
$1,827.52
$1,538.46
$1,635.16
$1,737.62
$2,101.54
$274.02
Toc - Plan #198 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ Saver ($5 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$364.24
$413.42
$465.50
$650.54
$988.56
$642.89
$692.07
$744.15
$929.19
$921.54
$970.72
$1,022.80
$1,207.84
$1,200.19
$1,249.37
$1,301.45
$1,486.49
$278.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728.48
$826.84
$931.00
$1,301.08
$1,977.12
$1,007.13
$1,105.49
$1,209.65
$1,579.73
$1,285.78
$1,384.14
$1,488.30
$1,858.38
$1,564.43
$1,662.79
$1,766.95
$2,137.03
$278.65
Toc - Plan #199 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ Base ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$366.26
$415.70
$468.08
$654.14
$994.03
$646.45
$695.89
$748.27
$934.33
$926.64
$976.08
$1,028.46
$1,214.52
$1,206.83
$1,256.27
$1,308.65
$1,494.71
$280.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732.52
$831.40
$936.16
$1,308.28
$1,988.06
$1,012.71
$1,111.59
$1,216.35
$1,588.47
$1,292.90
$1,391.78
$1,496.54
$1,868.66
$1,573.09
$1,671.97
$1,776.73
$2,148.85
$280.19
Toc - Plan #200 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ Extra ($3 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$377.49
$428.45
$482.43
$674.20
$1,024.51
$666.27
$717.23
$771.21
$962.98
$955.05
$1,006.01
$1,059.99
$1,251.76
$1,243.83
$1,294.79
$1,348.77
$1,540.54
$288.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$754.98
$856.90
$964.86
$1,348.40
$2,049.02
$1,043.76
$1,145.68
$1,253.64
$1,637.18
$1,332.54
$1,434.46
$1,542.42
$1,925.96
$1,621.32
$1,723.24
$1,831.20
$2,214.74
$288.78
Toc - Plan #201 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ Extra Saver ($3 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$377.78
$428.78
$482.80
$674.71
$1,025.29
$666.78
$717.78
$771.80
$963.71
$955.78
$1,006.78
$1,060.80
$1,252.71
$1,244.78
$1,295.78
$1,349.80
$1,541.71
$289.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$755.56
$857.56
$965.60
$1,349.42
$2,050.58
$1,044.56
$1,146.56
$1,254.60
$1,638.42
$1,333.56
$1,435.56
$1,543.60
$1,927.42
$1,622.56
$1,724.56
$1,832.60
$2,216.42
$289.00
Toc - Plan #202 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential+ (Low Premium)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$287.94
$326.81
$367.99
$514.26
$781.47
$508.21
$547.08
$588.26
$734.53
$728.48
$767.35
$808.53
$954.80
$948.75
$987.62
$1,028.80
$1,175.07
$220.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$575.88
$653.62
$735.98
$1,028.52
$1,562.94
$796.15
$873.89
$956.25
$1,248.79
$1,016.42
$1,094.16
$1,176.52
$1,469.06
$1,236.69
$1,314.43
$1,396.79
$1,689.33
$220.27
Toc - Plan #203 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ ($3 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304.06
$345.11
$388.59
$543.06
$825.23
$536.67
$577.72
$621.20
$775.67
$769.28
$810.33
$853.81
$1,008.28
$1,001.89
$1,042.94
$1,086.42
$1,240.89
$232.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$608.12
$690.22
$777.18
$1,086.12
$1,650.46
$840.73
$922.83
$1,009.79
$1,318.73
$1,073.34
$1,155.44
$1,242.40
$1,551.34
$1,305.95
$1,388.05
$1,475.01
$1,783.95
$232.61
Toc - Plan #204 UnitedHealthcare
Bronze

(HMO) UHC Bronze Value+ Saver ($5 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$296.00
$335.96
$378.29
$528.66
$803.35
$522.44
$562.40
$604.73
$755.10
$748.88
$788.84
$831.17
$981.54
$975.32
$1,015.28
$1,057.61
$1,207.98
$226.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$592.00
$671.92
$756.58
$1,057.32
$1,606.70
$818.44
$898.36
$983.02
$1,283.76
$1,044.88
$1,124.80
$1,209.46
$1,510.20
$1,271.32
$1,351.24
$1,435.90
$1,736.64
$226.44
Toc - Plan #205 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$306.08
$347.40
$391.17
$546.66
$830.70
$540.23
$581.55
$625.32
$780.81
$774.38
$815.70
$859.47
$1,014.96
$1,008.53
$1,049.85
$1,093.62
$1,249.11
$234.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.16
$694.80
$782.34
$1,093.32
$1,661.40
$846.31
$928.95
$1,016.49
$1,327.47
$1,080.46
$1,163.10
$1,250.64
$1,561.62
$1,314.61
$1,397.25
$1,484.79
$1,795.77
$234.15
Toc - Plan #206 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First ($3 Rx + Unlimited Free App-based Care) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$298.31
$338.58
$381.23
$532.77
$809.60
$526.51
$566.78
$609.43
$760.97
$754.71
$794.98
$837.63
$989.17
$982.91
$1,023.18
$1,065.83
$1,217.37
$228.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.62
$677.16
$762.46
$1,065.54
$1,619.20
$824.82
$905.36
$990.66
$1,293.74
$1,053.02
$1,133.56
$1,218.86
$1,521.94
$1,281.22
$1,361.76
$1,447.06
$1,750.14
$228.20

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-877-941-9230

Toc - Plan #207 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Ambetter Select Bronze: $1,500 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.89
$386.90
$435.65
$608.82
$925.16
$601.67
$647.68
$696.43
$869.60
$862.45
$908.46
$957.21
$1,130.38
$1,123.23
$1,169.24
$1,217.99
$1,391.16
$260.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$681.78
$773.80
$871.30
$1,217.64
$1,850.32
$942.56
$1,034.58
$1,132.08
$1,478.42
$1,203.34
$1,295.36
$1,392.86
$1,739.20
$1,464.12
$1,556.14
$1,653.64
$1,999.98
$260.78
Toc - Plan #208 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Ambetter Select Bronze: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.70
$410.52
$462.25
$645.99
$981.64
$638.40
$687.22
$738.95
$922.69
$915.10
$963.92
$1,015.65
$1,199.39
$1,191.80
$1,240.62
$1,292.35
$1,476.09
$276.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.40
$821.04
$924.50
$1,291.98
$1,963.28
$1,000.10
$1,097.74
$1,201.20
$1,568.68
$1,276.80
$1,374.44
$1,477.90
$1,845.38
$1,553.50
$1,651.14
$1,754.60
$2,122.08
$276.70
Toc - Plan #209 Ambetter from Sunshine Health
Silver

(HMO) Ambetter Select Silver 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$398.66
$452.47
$509.47
$711.99
$1,081.93
$703.63
$757.44
$814.44
$1,016.96
$1,008.60
$1,062.41
$1,119.41
$1,321.93
$1,313.57
$1,367.38
$1,424.38
$1,626.90
$304.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$797.32
$904.94
$1,018.94
$1,423.98
$2,163.86
$1,102.29
$1,209.91
$1,323.91
$1,728.95
$1,407.26
$1,514.88
$1,628.88
$2,033.92
$1,712.23
$1,819.85
$1,933.85
$2,338.89
$304.97
Toc - Plan #210 Ambetter from Sunshine Health
Silver

(HMO) Ambetter Select Silver 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.99
$423.33
$476.66
$666.14
$1,012.26
$658.32
$708.66
$761.99
$951.47
$943.65
$993.99
$1,047.32
$1,236.80
$1,228.98
$1,279.32
$1,332.65
$1,522.13
$285.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$745.98
$846.66
$953.32
$1,332.28
$2,024.52
$1,031.31
$1,131.99
$1,238.65
$1,617.61
$1,316.64
$1,417.32
$1,523.98
$1,902.94
$1,601.97
$1,702.65
$1,809.31
$2,188.27
$285.33
Toc - Plan #211 Ambetter from Sunshine Health
Silver

(HMO) Ambetter Select Silver 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.78
$424.23
$477.68
$667.56
$1,014.42
$659.72
$710.17
$763.62
$953.50
$945.66
$996.11
$1,049.56
$1,239.44
$1,231.60
$1,282.05
$1,335.50
$1,525.38
$285.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.56
$848.46
$955.36
$1,335.12
$2,028.84
$1,033.50
$1,134.40
$1,241.30
$1,621.06
$1,319.44
$1,420.34
$1,527.24
$1,907.00
$1,605.38
$1,706.28
$1,813.18
$2,192.94
$285.94
Toc - Plan #212 Ambetter from Sunshine Health
Silver

(HMO) Ambetter Select Silver 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.00
$431.29
$485.63
$678.67
$1,031.30
$670.69
$721.98
$776.32
$969.36
$961.38
$1,012.67
$1,067.01
$1,260.05
$1,252.07
$1,303.36
$1,357.70
$1,550.74
$290.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.00
$862.58
$971.26
$1,357.34
$2,062.60
$1,050.69
$1,153.27
$1,261.95
$1,648.03
$1,341.38
$1,443.96
$1,552.64
$1,938.72
$1,632.07
$1,734.65
$1,843.33
$2,229.41
$290.69
Toc - Plan #213 Ambetter from Sunshine Health
Gold

(HMO) Ambetter Select Gold 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$405.44
$460.16
$518.13
$724.09
$1,100.33
$715.59
$770.31
$828.28
$1,034.24
$1,025.74
$1,080.46
$1,138.43
$1,344.39
$1,335.89
$1,390.61
$1,448.58
$1,654.54
$310.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.88
$920.32
$1,036.26
$1,448.18
$2,200.66
$1,121.03
$1,230.47
$1,346.41
$1,758.33
$1,431.18
$1,540.62
$1,656.56
$2,068.48
$1,741.33
$1,850.77
$1,966.71
$2,378.63
$310.15
Toc - Plan #214 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Ambetter Value Bronze: $1,500 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.23
$366.86
$413.08
$577.28
$877.23
$570.50
$614.13
$660.35
$824.55
$817.77
$861.40
$907.62
$1,071.82
$1,065.04
$1,108.67
$1,154.89
$1,319.09
$247.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.46
$733.72
$826.16
$1,154.56
$1,754.46
$893.73
$980.99
$1,073.43
$1,401.83
$1,141.00
$1,228.26
$1,320.70
$1,649.10
$1,388.27
$1,475.53
$1,567.97
$1,896.37
$247.27
Toc - Plan #215 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Ambetter Value Bronze: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.01
$389.30
$438.35
$612.59
$930.90
$605.40
$651.69
$700.74
$874.98
$867.79
$914.08
$963.13
$1,137.37
$1,130.18
$1,176.47
$1,225.52
$1,399.76
$262.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.02
$778.60
$876.70
$1,225.18
$1,861.80
$948.41
$1,040.99
$1,139.09
$1,487.57
$1,210.80
$1,303.38
$1,401.48
$1,749.96
$1,473.19
$1,565.77
$1,663.87
$2,012.35
$262.39
Toc - Plan #216 Ambetter from Sunshine Health
Silver

(HMO) Ambetter Value Silver 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$378.05
$429.07
$483.13
$675.18
$1,026.00
$667.25
$718.27
$772.33
$964.38
$956.45
$1,007.47
$1,061.53
$1,253.58
$1,245.65
$1,296.67
$1,350.73
$1,542.78
$289.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.10
$858.14
$966.26
$1,350.36
$2,052.00
$1,045.30
$1,147.34
$1,255.46
$1,639.56
$1,334.50
$1,436.54
$1,544.66
$1,928.76
$1,623.70
$1,725.74
$1,833.86
$2,217.96
$289.20
Toc - Plan #217 Ambetter from Sunshine Health
Silver

(HMO) Ambetter Value Silver 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$6,100 $12,200 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
$353.69
$401.43
$452.01
$631.68
$959.89
$624.26
$672.00
$722.58
$902.25
$894.83
$942.57
$993.15
$1,172.82
$1,165.40
$1,213.14
$1,263.72
$1,443.39
$270.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.38
$802.86
$904.02
$1,263.36
$1,919.78
$977.95
$1,073.43
$1,174.59
$1,533.93
$1,248.52
$1,344.00
$1,445.16
$1,804.50
$1,519.09
$1,614.57
$1,715.73
$2,075.07
$270.57
Toc - Plan #218 Ambetter from Sunshine Health
Silver

(HMO) Ambetter Value Silver 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354.45
$402.29
$452.97
$633.03
$961.95
$625.60
$673.44
$724.12
$904.18
$896.75
$944.59
$995.27
$1,175.33
$1,167.90
$1,215.74
$1,266.42
$1,446.48
$271.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.90
$804.58
$905.94
$1,266.06
$1,923.90
$980.05
$1,075.73
$1,177.09
$1,537.21
$1,251.20
$1,346.88
$1,448.24
$1,808.36
$1,522.35
$1,618.03
$1,719.39
$2,079.51
$271.15
Toc - Plan #219 Ambetter from Sunshine Health
Silver

(HMO) Ambetter Value Silver 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.35
$408.98
$460.51
$643.57
$977.96
$636.01
$684.64
$736.17
$919.23
$911.67
$960.30
$1,011.83
$1,194.89
$1,187.33
$1,235.96
$1,287.49
$1,470.55
$275.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.70
$817.96
$921.02
$1,287.14
$1,955.92
$996.36
$1,093.62
$1,196.68
$1,562.80
$1,272.02
$1,369.28
$1,472.34
$1,838.46
$1,547.68
$1,644.94
$1,748.00
$2,114.12
$275.66
Toc - Plan #220 Ambetter from Sunshine Health
Gold

(HMO) Ambetter Value Gold 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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
$384.47
$436.36
$491.34
$686.64
$1,043.42
$678.58
$730.47
$785.45
$980.75
$972.69
$1,024.58
$1,079.56
$1,274.86
$1,266.80
$1,318.69
$1,373.67
$1,568.97
$294.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.94
$872.72
$982.68
$1,373.28
$2,086.84
$1,063.05
$1,166.83
$1,276.79
$1,667.39
$1,357.16
$1,460.94
$1,570.90
$1,961.50
$1,651.27
$1,755.05
$1,865.01
$2,255.61
$294.11

ADVERTISEMENT

Aetna CVS Health

Local: 1-195-485-8300 | Toll Free: 1-888-275-2700

Toc - Plan #221 Aetna CVS Health
Expanded Bronze

(HMO) Aetna CVS Bronze: Low-Cost MinuteClinic Visits, Telehealth, South FL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-275-2700

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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
$331.64
$376.41
$423.83
$592.31
$900.07
$585.34
$630.11
$677.53
$846.01
$839.04
$883.81
$931.23
$1,099.71
$1,092.74
$1,137.51
$1,184.93
$1,353.41
$253.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$663.28
$752.82
$847.66
$1,184.62
$1,800.14
$916.98
$1,006.52
$1,101.36
$1,438.32
$1,170.68
$1,260.22
$1,355.06
$1,692.02
$1,424.38
$1,513.92
$1,608.76
$1,945.72
$253.70
Toc - Plan #222 Aetna CVS Health
Bronze

(HMO) Aetna CVS Bronze: $0 MinuteClinic Visits, Telehealth, South FL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-275-2700

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$283.01
$321.21
$361.68
$505.45
$768.08
$499.51
$537.71
$578.18
$721.95
$716.01
$754.21
$794.68
$938.45
$932.51
$970.71
$1,011.18
$1,154.95
$216.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$566.02
$642.42
$723.36
$1,010.90
$1,536.16
$782.52
$858.92
$939.86
$1,227.40
$999.02
$1,075.42
$1,156.36
$1,443.90
$1,215.52
$1,291.92
$1,372.86
$1,660.40
$216.50
Toc - Plan #223 Aetna CVS Health
Gold

(HMO) Aetna CVS Gold: $0 MinuteClinic Visits, Telehealth, South FL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-275-2700

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$430.38
$488.48
$550.03
$768.66
$1,168.06
$759.62
$817.72
$879.27
$1,097.90
$1,088.86
$1,146.96
$1,208.51
$1,427.14
$1,418.10
$1,476.20
$1,537.75
$1,756.38
$329.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$860.76
$976.96
$1,100.06
$1,537.32
$2,336.12
$1,190.00
$1,306.20
$1,429.30
$1,866.56
$1,519.24
$1,635.44
$1,758.54
$2,195.80
$1,848.48
$1,964.68
$2,087.78
$2,525.04
$329.24
Toc - Plan #224 Aetna CVS Health
Silver

(HMO) Aetna CVS Silver 2: $0 MinuteClinic Visits, Telehealth, South FL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-275-2700

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$362.55
$411.49
$463.34
$647.51
$983.96
$639.90
$688.84
$740.69
$924.86
$917.25
$966.19
$1,018.04
$1,202.21
$1,194.60
$1,243.54
$1,295.39
$1,479.56
$277.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$725.10
$822.98
$926.68
$1,295.02
$1,967.92
$1,002.45
$1,100.33
$1,204.03
$1,572.37
$1,279.80
$1,377.68
$1,481.38
$1,849.72
$1,557.15
$1,655.03
$1,758.73
$2,127.07
$277.35
Toc - Plan #225 Aetna CVS Health
Silver

(HMO) Aetna CVS Silver 1: $0 MinuteClinic Visits, Telehealth, South FL

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-275-2700

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$447.76
$508.20
$572.23
$799.69
$1,215.21
$790.29
$850.73
$914.76
$1,142.22
$1,132.82
$1,193.26
$1,257.29
$1,484.75
$1,475.35
$1,535.79
$1,599.82
$1,827.28
$342.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$895.52
$1,016.40
$1,144.46
$1,599.38
$2,430.42
$1,238.05
$1,358.93
$1,486.99
$1,941.91
$1,580.58
$1,701.46
$1,829.52
$2,284.44
$1,923.11
$2,043.99
$2,172.05
$2,626.97
$342.53

‡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 Miami-Dade County here.

Miami-Dade County is in “Rating Area 43” of Florida.

Currently, there are 225 plans offered in Rating Area 43.

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2022 Obamacare Plans for Miami-Dade County, FL

Plan Browser: 225 Plans
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