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Bright Health

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

Toc - Plan #1 Bright Health
Gold

(EPO) Gold 1000

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
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419,80
$476,47
$536,50
$749,76
$1 139,33
$740,94
$797,61
$857,64
$1 070,90
$1 062,08
$1 118,75
$1 178,78
$1 392,04
$1 383,22
$1 439,89
$1 499,92
$1 713,18
$321,14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839,60
$952,94
$1 073,00
$1 499,52
$2 278,66
$1 160,74
$1 274,08
$1 394,14
$1 820,66
$1 481,88
$1 595,22
$1 715,28
$2 141,80
$1 803,02
$1 916,36
$2 036,42
$2 462,94
$321,14
Toc - Plan #2 Bright Health
Silver

(EPO) Silver 5000

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
$8,550 $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
$355,98
$404,03
$454,94
$635,77
$966,12
$628,30
$676,35
$727,26
$908,09
$900,62
$948,67
$999,58
$1 180,41
$1 172,94
$1 220,99
$1 271,90
$1 452,73
$272,32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711,96
$808,06
$909,88
$1 271,54
$1 932,24
$984,28
$1 080,38
$1 182,20
$1 543,86
$1 256,60
$1 352,70
$1 454,52
$1 816,18
$1 528,92
$1 625,02
$1 726,84
$2 088,50
$272,32
Toc - Plan #3 Bright Health
Silver

(EPO) Silver 3000

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
$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
$369,18
$419,02
$471,81
$659,36
$1 001,95
$651,60
$701,44
$754,23
$941,78
$934,02
$983,86
$1 036,65
$1 224,20
$1 216,44
$1 266,28
$1 319,07
$1 506,62
$282,42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738,36
$838,04
$943,62
$1 318,72
$2 003,90
$1 020,78
$1 120,46
$1 226,04
$1 601,14
$1 303,20
$1 402,88
$1 508,46
$1 883,56
$1 585,62
$1 685,30
$1 790,88
$2 165,98
$282,42
Toc - Plan #4 Bright Health
Silver

(EPO) Silver $0 Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $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
$386,29
$438,44
$493,68
$689,92
$1 048,40
$681,80
$733,95
$789,19
$985,43
$977,31
$1 029,46
$1 084,70
$1 280,94
$1 272,82
$1 324,97
$1 380,21
$1 576,45
$295,51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$772,58
$876,88
$987,36
$1 379,84
$2 096,80
$1 068,09
$1 172,39
$1 282,87
$1 675,35
$1 363,60
$1 467,90
$1 578,38
$1 970,86
$1 659,11
$1 763,41
$1 873,89
$2 266,37
$295,51
Toc - Plan #5 Bright Health
Silver

(EPO) Silver $0 Primary Care

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
$8,550 $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
$369,13
$418,96
$471,75
$659,26
$1 001,82
$651,51
$701,34
$754,13
$941,64
$933,89
$983,72
$1 036,51
$1 224,02
$1 216,27
$1 266,10
$1 318,89
$1 506,40
$282,38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738,26
$837,92
$943,50
$1 318,52
$2 003,64
$1 020,64
$1 120,30
$1 225,88
$1 600,90
$1 303,02
$1 402,68
$1 508,26
$1 883,28
$1 585,40
$1 685,06
$1 790,64
$2 165,66
$282,38
Toc - Plan #6 Bright Health
Expanded Bronze

(EPO) Bronze 8550

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$267,68
$303,81
$342,09
$478,07
$726,48
$472,45
$508,58
$546,86
$682,84
$677,22
$713,35
$751,63
$887,61
$881,99
$918,12
$956,40
$1 092,38
$204,77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$535,36
$607,62
$684,18
$956,14
$1 452,96
$740,13
$812,39
$888,95
$1 160,91
$944,90
$1 017,16
$1 093,72
$1 365,68
$1 149,67
$1 221,93
$1 298,49
$1 570,45
$204,77
Toc - Plan #7 Bright Health
Expanded Bronze

(EPO) Bronze 7000 HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317,54
$360,41
$405,81
$567,12
$861,80
$560,46
$603,33
$648,73
$810,04
$803,38
$846,25
$891,65
$1 052,96
$1 046,30
$1 089,17
$1 134,57
$1 295,88
$242,92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$635,08
$720,82
$811,62
$1 134,24
$1 723,60
$878,00
$963,74
$1 054,54
$1 377,16
$1 120,92
$1 206,66
$1 297,46
$1 620,08
$1 363,84
$1 449,58
$1 540,38
$1 863,00
$242,92
Toc - Plan #8 Bright Health
Expanded Bronze

(EPO) Bronze $0 Primary Care

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
$8,550 $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
$278,55
$316,16
$355,99
$497,49
$755,99
$491,64
$529,25
$569,08
$710,58
$704,73
$742,34
$782,17
$923,67
$917,82
$955,43
$995,26
$1 136,76
$213,09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$557,10
$632,32
$711,98
$994,98
$1 511,98
$770,19
$845,41
$925,07
$1 208,07
$983,28
$1 058,50
$1 138,16
$1 421,16
$1 196,37
$1 271,59
$1 351,25
$1 634,25
$213,09
Toc - Plan #9 Bright Health
Expanded Bronze

(EPO) Bronze $0 Medical Deductible Direct

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $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
$305,35
$346,57
$390,24
$545,35
$828,72
$538,94
$580,16
$623,83
$778,94
$772,53
$813,75
$857,42
$1 012,53
$1 006,12
$1 047,34
$1 091,01
$1 246,12
$233,59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610,70
$693,14
$780,48
$1 090,70
$1 657,44
$844,29
$926,73
$1 014,07
$1 324,29
$1 077,88
$1 160,32
$1 247,66
$1 557,88
$1 311,47
$1 393,91
$1 481,25
$1 791,47
$233,59
Toc - Plan #10 Bright Health
Catastrophic

(EPO) Catastrophic 3 $0 PCP Visits

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$219,30
$248,91
$280,27
$391,68
$595,19
$387,07
$416,68
$448,04
$559,45
$554,84
$584,45
$615,81
$727,22
$722,61
$752,22
$783,58
$894,99
$167,77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$438,60
$497,82
$560,54
$783,36
$1 190,38
$606,37
$665,59
$728,31
$951,13
$774,14
$833,36
$896,08
$1 118,90
$941,91
$1 001,13
$1 063,85
$1 286,67
$167,77
Toc - Plan #11 Bright Health
Gold

(EPO) Super Gold 10 + Dental

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
$8,550 $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
$410,06
$465,42
$524,06
$732,37
$1 112,90
$723,76
$779,12
$837,76
$1 046,07
$1 037,46
$1 092,82
$1 151,46
$1 359,77
$1 351,16
$1 406,52
$1 465,16
$1 673,47
$313,70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$820,12
$930,84
$1 048,12
$1 464,74
$2 225,80
$1 133,82
$1 244,54
$1 361,82
$1 778,44
$1 447,52
$1 558,24
$1 675,52
$2 092,14
$1 761,22
$1 871,94
$1 989,22
$2 405,84
$313,70
Toc - Plan #12 Bright Health
Silver

(EPO) Super Silver 50 + Dental

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
$8,550 $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
$348,07
$395,06
$444,83
$621,65
$944,66
$614,34
$661,33
$711,10
$887,92
$880,61
$927,60
$977,37
$1 154,19
$1 146,88
$1 193,87
$1 243,64
$1 420,46
$266,27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696,14
$790,12
$889,66
$1 243,30
$1 889,32
$962,41
$1 056,39
$1 155,93
$1 509,57
$1 228,68
$1 322,66
$1 422,20
$1 775,84
$1 494,95
$1 588,93
$1 688,47
$2 042,11
$266,27
Toc - Plan #13 Bright Health
Silver

(EPO) Super Silver 30 + Dental

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
$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
$360,87
$409,59
$461,20
$644,52
$979,41
$636,94
$685,66
$737,27
$920,59
$913,01
$961,73
$1 013,34
$1 196,66
$1 189,08
$1 237,80
$1 289,41
$1 472,73
$276,07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721,74
$819,18
$922,40
$1 289,04
$1 958,82
$997,81
$1 095,25
$1 198,47
$1 565,11
$1 273,88
$1 371,32
$1 474,54
$1 841,18
$1 549,95
$1 647,39
$1 750,61
$2 117,25
$276,07
Toc - Plan #14 Bright Health
Silver

(EPO) Super Silver $0 Deductible + Dental

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $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
$377,47
$428,43
$482,41
$674,16
$1 024,46
$666,24
$717,20
$771,18
$962,93
$955,01
$1 005,97
$1 059,95
$1 251,70
$1 243,78
$1 294,74
$1 348,72
$1 540,47
$288,77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$754,94
$856,86
$964,82
$1 348,32
$2 048,92
$1 043,71
$1 145,63
$1 253,59
$1 637,09
$1 332,48
$1 434,40
$1 542,36
$1 925,86
$1 621,25
$1 723,17
$1 831,13
$2 214,63
$288,77
Toc - Plan #15 Bright Health
Silver

(EPO) Super Silver $0 Primary Care + Dental

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
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360,82
$409,54
$461,13
$644,43
$979,28
$636,85
$685,57
$737,16
$920,46
$912,88
$961,60
$1 013,19
$1 196,49
$1 188,91
$1 237,63
$1 289,22
$1 472,52
$276,03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721,64
$819,08
$922,26
$1 288,86
$1 958,56
$997,67
$1 095,11
$1 198,29
$1 564,89
$1 273,70
$1 371,14
$1 474,32
$1 840,92
$1 549,73
$1 647,17
$1 750,35
$2 116,95
$276,03
Toc - Plan #16 Bright Health
Expanded Bronze

(EPO) Super Bronze 85 + Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$262,70
$298,17
$335,73
$469,19
$712,98
$463,67
$499,14
$536,70
$670,16
$664,64
$700,11
$737,67
$871,13
$865,61
$901,08
$938,64
$1 072,10
$200,97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$525,40
$596,34
$671,46
$938,38
$1 425,96
$726,37
$797,31
$872,43
$1 139,35
$927,34
$998,28
$1 073,40
$1 340,32
$1 128,31
$1 199,25
$1 274,37
$1 541,29
$200,97
Toc - Plan #17 Bright Health
Expanded Bronze

(EPO) Super Bronze 70 + Dental HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$311,06
$353,05
$397,53
$555,55
$844,22
$549,02
$591,01
$635,49
$793,51
$786,98
$828,97
$873,45
$1 031,47
$1 024,94
$1 066,93
$1 111,41
$1 269,43
$237,96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$622,12
$706,10
$795,06
$1 111,10
$1 688,44
$860,08
$944,06
$1 033,02
$1 349,06
$1 098,04
$1 182,02
$1 270,98
$1 587,02
$1 336,00
$1 419,98
$1 508,94
$1 824,98
$237,96
Toc - Plan #18 Bright Health
Expanded Bronze

(EPO) Super Bronze $0 Primary Care + Dental

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
$8,550 $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
$273,25
$310,14
$349,21
$488,02
$741,60
$482,29
$519,18
$558,25
$697,06
$691,33
$728,22
$767,29
$906,10
$900,37
$937,26
$976,33
$1 115,14
$209,04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$546,50
$620,28
$698,42
$976,04
$1 483,20
$755,54
$829,32
$907,46
$1 185,08
$964,58
$1 038,36
$1 116,50
$1 394,12
$1 173,62
$1 247,40
$1 325,54
$1 603,16
$209,04
Toc - Plan #19 Bright Health
Expanded Bronze

(EPO) Super Bronze $0 Medical Deductible + Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$299,24
$339,64
$382,43
$534,44
$812,13
$528,16
$568,56
$611,35
$763,36
$757,08
$797,48
$840,27
$992,28
$986,00
$1 026,40
$1 069,19
$1 221,20
$228,92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598,48
$679,28
$764,86
$1 068,88
$1 624,26
$827,40
$908,20
$993,78
$1 297,80
$1 056,32
$1 137,12
$1 222,70
$1 526,72
$1 285,24
$1 366,04
$1 451,62
$1 755,64
$228,92
Toc - Plan #20 Bright Health
Catastrophic

(EPO) Super Catastrophic 3 $0 PCP Visits + Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$215,83
$244,97
$275,83
$385,47
$585,76
$380,94
$410,08
$440,94
$550,58
$546,05
$575,19
$606,05
$715,69
$711,16
$740,30
$771,16
$880,80
$165,11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$431,66
$489,94
$551,66
$770,94
$1 171,52
$596,77
$655,05
$716,77
$936,05
$761,88
$820,16
$881,88
$1 101,16
$926,99
$985,27
$1 046,99
$1 266,27
$165,11

ADVERTISEMENT

Florida Blue (BlueCross BlueShield FL)

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

Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1423 ($0 Virtual Visits / $100+ in 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
$746,67
$847,47
$954,24
$1 333,55
$2 026,46
$1 317,87
$1 418,67
$1 525,44
$1 904,75
$1 889,07
$1 989,87
$2 096,64
$2 475,95
$2 460,27
$2 561,07
$2 667,84
$3 047,15
$571,20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 493,34
$1 694,94
$1 908,48
$2 667,10
$4 052,92
$2 064,54
$2 266,14
$2 479,68
$3 238,30
$2 635,74
$2 837,34
$3 050,88
$3 809,50
$3 206,94
$3 408,54
$3 622,08
$4 380,70
$571,20
Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueOptions Bronze 1419 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$461,64
$523,96
$589,98
$824,49
$1 252,89
$814,79
$877,11
$943,13
$1 177,64
$1 167,94
$1 230,26
$1 296,28
$1 530,79
$1 521,09
$1 583,41
$1 649,43
$1 883,94
$353,15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$923,28
$1 047,92
$1 179,96
$1 648,98
$2 505,78
$1 276,43
$1 401,07
$1 533,11
$2 002,13
$1 629,58
$1 754,22
$1 886,26
$2 355,28
$1 982,73
$2 107,37
$2 239,41
$2 708,43
$353,15
Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1431 ($0 Virtual Visits / $100+ in 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
$768,93
$872,74
$982,69
$1 373,31
$2 086,88
$1 357,16
$1 460,97
$1 570,92
$1 961,54
$1 945,39
$2 049,20
$2 159,15
$2 549,77
$2 533,62
$2 637,43
$2 747,38
$3 138,00
$588,23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 537,86
$1 745,48
$1 965,38
$2 746,62
$4 173,76
$2 126,09
$2 333,71
$2 553,61
$3 334,85
$2 714,32
$2 921,94
$3 141,84
$3 923,08
$3 302,55
$3 510,17
$3 730,07
$4 511,31
$588,23
Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueOptions Platinum 1418 ($0 Virtual Visits / $100+ in 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
$900,03
$1 021,53
$1 150,24
$1 607,45
$2 442,68
$1 588,55
$1 710,05
$1 838,76
$2 295,97
$2 277,07
$2 398,57
$2 527,28
$2 984,49
$2 965,59
$3 087,09
$3 215,80
$3 673,01
$688,52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 800,06
$2 043,06
$2 300,48
$3 214,90
$4 885,36
$2 488,58
$2 731,58
$2 989,00
$3 903,42
$3 177,10
$3 420,10
$3 677,52
$4 591,94
$3 865,62
$4 108,62
$4 366,04
$5 280,46
$688,52
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 1416 ($0 Virtual Visits / 3 PCP Visits for $20)

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
$8,550 $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
$497,54
$564,71
$635,86
$888,61
$1 350,32
$878,16
$945,33
$1 016,48
$1 269,23
$1 258,78
$1 325,95
$1 397,10
$1 649,85
$1 639,40
$1 706,57
$1 777,72
$2 030,47
$380,62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$995,08
$1 129,42
$1 271,72
$1 777,22
$2 700,64
$1 375,70
$1 510,04
$1 652,34
$2 157,84
$1 756,32
$1 890,66
$2 032,96
$2 538,46
$2 136,94
$2 271,28
$2 413,58
$2 919,08
$380,62
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueOptions Platinum 1424 ($0 Virtual Visits / $100+ in 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
$953,71
$1 082,46
$1 218,84
$1 703,33
$2 588,37
$1 683,30
$1 812,05
$1 948,43
$2 432,92
$2 412,89
$2 541,64
$2 678,02
$3 162,51
$3 142,48
$3 271,23
$3 407,61
$3 892,10
$729,59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 907,42
$2 164,92
$2 437,68
$3 406,66
$5 176,74
$2 637,01
$2 894,51
$3 167,27
$4 136,25
$3 366,60
$3 624,10
$3 896,86
$4 865,84
$4 096,19
$4 353,69
$4 626,45
$5 595,43
$729,59
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1410 ($0 Virtual Visits / $100+ in Rewards)

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
$8,550 $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
$680,66
$772,55
$869,88
$1 215,66
$1 847,31
$1 201,36
$1 293,25
$1 390,58
$1 736,36
$1 722,06
$1 813,95
$1 911,28
$2 257,06
$2 242,76
$2 334,65
$2 431,98
$2 777,76
$520,70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 361,32
$1 545,10
$1 739,76
$2 431,32
$3 694,62
$1 882,02
$2 065,80
$2 260,46
$2 952,02
$2 402,72
$2 586,50
$2 781,16
$3 472,72
$2 923,42
$3 107,20
$3 301,86
$3 993,42
$520,70
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1505 ($0 Virtual Visits / $100+ in 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
$757,67
$859,96
$968,30
$1 353,20
$2 056,32
$1 337,29
$1 439,58
$1 547,92
$1 932,82
$1 916,91
$2 019,20
$2 127,54
$2 512,44
$2 496,53
$2 598,82
$2 707,16
$3 092,06
$579,62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 515,34
$1 719,92
$1 936,60
$2 706,40
$4 112,64
$2 094,96
$2 299,54
$2 516,22
$3 286,02
$2 674,58
$2 879,16
$3 095,84
$3 865,64
$3 254,20
$3 458,78
$3 675,46
$4 445,26
$579,62
Toc - Plan #29 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze (HSA) 1705 ($100+ in 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
$482,13
$547,22
$616,16
$861,08
$1 308,50
$850,96
$916,05
$984,99
$1 229,91
$1 219,79
$1 284,88
$1 353,82
$1 598,74
$1 588,62
$1 653,71
$1 722,65
$1 967,57
$368,83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$964,26
$1 094,44
$1 232,32
$1 722,16
$2 617,00
$1 333,09
$1 463,27
$1 601,15
$2 090,99
$1 701,92
$1 832,10
$1 969,98
$2 459,82
$2 070,75
$2 200,93
$2 338,81
$2 828,65
$368,83
Toc - Plan #30 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1706S ($0 Virtual Visits / $100+ in 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
$761,04
$863,78
$972,61
$1 359,22
$2 065,46
$1 343,24
$1 445,98
$1 554,81
$1 941,42
$1 925,44
$2 028,18
$2 137,01
$2 523,62
$2 507,64
$2 610,38
$2 719,21
$3 105,82
$582,20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 522,08
$1 727,56
$1 945,22
$2 718,44
$4 130,92
$2 104,28
$2 309,76
$2 527,42
$3 300,64
$2 686,48
$2 891,96
$3 109,62
$3 882,84
$3 268,68
$3 474,16
$3 691,82
$4 465,04
$582,20
Toc - Plan #31 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 1707S ($0 Virtual Visits / $40 PCP Visits)

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

Annual Out of Pocket Expenses:

Individual Family
$8,150 $16,300 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
$496,22
$563,21
$634,17
$886,25
$1 346,74
$875,83
$942,82
$1 013,78
$1 265,86
$1 255,44
$1 322,43
$1 393,39
$1 645,47
$1 635,05
$1 702,04
$1 773,00
$2 025,08
$379,61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$992,44
$1 126,42
$1 268,34
$1 772,50
$2 693,48
$1 372,05
$1 506,03
$1 647,95
$2 152,11
$1 751,66
$1 885,64
$2 027,56
$2 531,72
$2 131,27
$2 265,25
$2 407,17
$2 911,33
$379,61
Toc - Plan #32 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1805 ($0 Virtual Visits / $100+ in 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
$733,70
$832,75
$937,67
$1 310,39
$1 991,26
$1 294,98
$1 394,03
$1 498,95
$1 871,67
$1 856,26
$1 955,31
$2 060,23
$2 432,95
$2 417,54
$2 516,59
$2 621,51
$2 994,23
$561,28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 467,40
$1 665,50
$1 875,34
$2 620,78
$3 982,52
$2 028,68
$2 226,78
$2 436,62
$3 182,06
$2 589,96
$2 788,06
$2 997,90
$3 743,34
$3 151,24
$3 349,34
$3 559,18
$4 304,62
$561,28
Toc - Plan #33 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 2119 ($0 Deductible / $50 PCP Visits / $100+ in 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
$8,550 $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
$530,87
$602,54
$678,45
$948,13
$1 440,78
$936,99
$1 008,66
$1 084,57
$1 354,25
$1 343,11
$1 414,78
$1 490,69
$1 760,37
$1 749,23
$1 820,90
$1 896,81
$2 166,49
$406,12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 061,74
$1 205,08
$1 356,90
$1 896,26
$2 881,56
$1 467,86
$1 611,20
$1 763,02
$2 302,38
$1 873,98
$2 017,32
$2 169,14
$2 708,50
$2 280,10
$2 423,44
$2 575,26
$3 114,62
$406,12
Toc - Plan #34 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1456 ($0 Virtual Visits / $100+ in 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
$486,04
$551,66
$621,16
$868,07
$1 319,11
$857,86
$923,48
$992,98
$1 239,89
$1 229,68
$1 295,30
$1 364,80
$1 611,71
$1 601,50
$1 667,12
$1 736,62
$1 983,53
$371,82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$972,08
$1 103,32
$1 242,32
$1 736,14
$2 638,22
$1 343,90
$1 475,14
$1 614,14
$2 107,96
$1 715,72
$1 846,96
$1 985,96
$2 479,78
$2 087,54
$2 218,78
$2 357,78
$2 851,60
$371,82
Toc - Plan #35 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueSelect Bronze 1452 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$346,48
$393,25
$442,80
$618,81
$940,35
$611,54
$658,31
$707,86
$883,87
$876,60
$923,37
$972,92
$1 148,93
$1 141,66
$1 188,43
$1 237,98
$1 413,99
$265,06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$692,96
$786,50
$885,60
$1 237,62
$1 880,70
$958,02
$1 051,56
$1 150,66
$1 502,68
$1 223,08
$1 316,62
$1 415,72
$1 767,74
$1 488,14
$1 581,68
$1 680,78
$2 032,80
$265,06
Toc - Plan #36 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1464 ($0 Virtual Visits / $100+ in 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
$503,76
$571,77
$643,81
$899,72
$1 367,20
$889,14
$957,15
$1 029,19
$1 285,10
$1 274,52
$1 342,53
$1 414,57
$1 670,48
$1 659,90
$1 727,91
$1 799,95
$2 055,86
$385,38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 007,52
$1 143,54
$1 287,62
$1 799,44
$2 734,40
$1 392,90
$1 528,92
$1 673,00
$2 184,82
$1 778,28
$1 914,30
$2 058,38
$2 570,20
$2 163,66
$2 299,68
$2 443,76
$2 955,58
$385,38
Toc - Plan #37 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1451 ($0 Virtual Visits / $100+ in 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
$595,23
$675,59
$760,70
$1 063,08
$1 615,45
$1 050,58
$1 130,94
$1 216,05
$1 518,43
$1 505,93
$1 586,29
$1 671,40
$1 973,78
$1 961,28
$2 041,64
$2 126,75
$2 429,13
$455,35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 190,46
$1 351,18
$1 521,40
$2 126,16
$3 230,90
$1 645,81
$1 806,53
$1 976,75
$2 581,51
$2 101,16
$2 261,88
$2 432,10
$3 036,86
$2 556,51
$2 717,23
$2 887,45
$3 492,21
$455,35
Toc - Plan #38 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($0 Virtual Visits / 3 PCP Visits for $20)

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
$8,550 $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
$370,67
$420,71
$473,72
$662,02
$1 006,00
$654,23
$704,27
$757,28
$945,58
$937,79
$987,83
$1 040,84
$1 229,14
$1 221,35
$1 271,39
$1 324,40
$1 512,70
$283,56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$741,34
$841,42
$947,44
$1 324,04
$2 012,00
$1 024,90
$1 124,98
$1 231,00
$1 607,60
$1 308,46
$1 408,54
$1 514,56
$1 891,16
$1 592,02
$1 692,10
$1 798,12
$2 174,72
$283,56
Toc - Plan #39 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1457 ($0 Virtual Visits / $100+ in 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
$638,98
$725,24
$816,62
$1 141,22
$1 734,19
$1 127,80
$1 214,06
$1 305,44
$1 630,04
$1 616,62
$1 702,88
$1 794,26
$2 118,86
$2 105,44
$2 191,70
$2 283,08
$2 607,68
$488,82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 277,96
$1 450,48
$1 633,24
$2 282,44
$3 468,38
$1 766,78
$1 939,30
$2 122,06
$2 771,26
$2 255,60
$2 428,12
$2 610,88
$3 260,08
$2 744,42
$2 916,94
$3 099,70
$3 748,90
$488,82
Toc - Plan #40 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1443 ($0 Labs / $0 Virtual Visits / $100+ in Rewards)

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
$8,550 $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
$441,76
$501,40
$564,57
$788,98
$1 198,94
$779,71
$839,35
$902,52
$1 126,93
$1 117,66
$1 177,30
$1 240,47
$1 464,88
$1 455,61
$1 515,25
$1 578,42
$1 802,83
$337,95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$883,52
$1 002,80
$1 129,14
$1 577,96
$2 397,88
$1 221,47
$1 340,75
$1 467,09
$1 915,91
$1 559,42
$1 678,70
$1 805,04
$2 253,86
$1 897,37
$2 016,65
$2 142,99
$2 591,81
$337,95
Toc - Plan #41 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1535 ($0 Virtual Visits / $100+ in 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
$518,48
$588,47
$662,62
$926,01
$1 407,15
$915,12
$985,11
$1 059,26
$1 322,65
$1 311,76
$1 381,75
$1 455,90
$1 719,29
$1 708,40
$1 778,39
$1 852,54
$2 115,93
$396,64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 036,96
$1 176,94
$1 325,24
$1 852,02
$2 814,30
$1 433,60
$1 573,58
$1 721,88
$2 248,66
$1 830,24
$1 970,22
$2 118,52
$2 645,30
$2 226,88
$2 366,86
$2 515,16
$3 041,94
$396,64
Toc - Plan #42 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze (HSA) 1735 ($100+ in 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
$361,28
$410,05
$461,72
$645,25
$980,51
$637,66
$686,43
$738,10
$921,63
$914,04
$962,81
$1 014,48
$1 198,01
$1 190,42
$1 239,19
$1 290,86
$1 474,39
$276,38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722,56
$820,10
$923,44
$1 290,50
$1 961,02
$998,94
$1 096,48
$1 199,82
$1 566,88
$1 275,32
$1 372,86
$1 476,20
$1 843,26
$1 551,70
$1 649,24
$1 752,58
$2 119,64
$276,38
Toc - Plan #43 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1736S ($0 Virtual Visits / $100+ in 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
$492,55
$559,04
$629,48
$879,69
$1 336,78
$869,35
$935,84
$1 006,28
$1 256,49
$1 246,15
$1 312,64
$1 383,08
$1 633,29
$1 622,95
$1 689,44
$1 759,88
$2 010,09
$376,80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$985,10
$1 118,08
$1 258,96
$1 759,38
$2 673,56
$1 361,90
$1 494,88
$1 635,76
$2 136,18
$1 738,70
$1 871,68
$2 012,56
$2 512,98
$2 115,50
$2 248,48
$2 389,36
$2 889,78
$376,80
Toc - Plan #44 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$8,150 $16,300 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
$370,10
$420,06
$472,99
$661,00
$1 004,45
$653,23
$703,19
$756,12
$944,13
$936,36
$986,32
$1 039,25
$1 227,26
$1 219,49
$1 269,45
$1 322,38
$1 510,39
$283,13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740,20
$840,12
$945,98
$1 322,00
$2 008,90
$1 023,33
$1 123,25
$1 229,11
$1 605,13
$1 306,46
$1 406,38
$1 512,24
$1 888,26
$1 589,59
$1 689,51
$1 795,37
$2 171,39
$283,13
Toc - Plan #45 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1835 ($0 Virtual Visits / $100+ in 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
$495,32
$562,19
$633,02
$884,64
$1 344,30
$874,24
$941,11
$1 011,94
$1 263,56
$1 253,16
$1 320,03
$1 390,86
$1 642,48
$1 632,08
$1 698,95
$1 769,78
$2 021,40
$378,92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$990,64
$1 124,38
$1 266,04
$1 769,28
$2 688,60
$1 369,56
$1 503,30
$1 644,96
$2 148,20
$1 748,48
$1 882,22
$2 023,88
$2 527,12
$2 127,40
$2 261,14
$2 402,80
$2 906,04
$378,92
Toc - Plan #46 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2139 ($0 Deductible / $50 PCP Visits / $100+ in 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
$8,550 $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
$395,52
$448,92
$505,47
$706,40
$1 073,44
$698,09
$751,49
$808,04
$1 008,97
$1 000,66
$1 054,06
$1 110,61
$1 311,54
$1 303,23
$1 356,63
$1 413,18
$1 614,11
$302,57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791,04
$897,84
$1 010,94
$1 412,80
$2 146,88
$1 093,61
$1 200,41
$1 313,51
$1 715,37
$1 396,18
$1 502,98
$1 616,08
$2 017,94
$1 698,75
$1 805,55
$1 918,65
$2 320,51
$302,57

ADVERTISEMENT

AvMed

Local: 1-800-477-8768 | Toll Free: 

Toc - Plan #47 AvMed
Gold

(HMO) AvMed Entrust Gold 125

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
$389,66
$442,26
$497,98
$695,93
$1 057,53
$687,75
$740,35
$796,07
$994,02
$985,84
$1 038,44
$1 094,16
$1 292,11
$1 283,93
$1 336,53
$1 392,25
$1 590,20
$298,09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$779,32
$884,52
$995,96
$1 391,86
$2 115,06
$1 077,41
$1 182,61
$1 294,05
$1 689,95
$1 375,50
$1 480,70
$1 592,14
$1 988,04
$1 673,59
$1 778,79
$1 890,23
$2 286,13
$298,09
Toc - Plan #48 AvMed
Silver

(HMO) AvMed Entrust Silver 300

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
$378,78
$429,92
$484,09
$676,51
$1 028,02
$668,55
$719,69
$773,86
$966,28
$958,32
$1 009,46
$1 063,63
$1 256,05
$1 248,09
$1 299,23
$1 353,40
$1 545,82
$289,77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757,56
$859,84
$968,18
$1 353,02
$2 056,04
$1 047,33
$1 149,61
$1 257,95
$1 642,79
$1 337,10
$1 439,38
$1 547,72
$1 932,56
$1 626,87
$1 729,15
$1 837,49
$2 222,33
$289,77
Toc - Plan #49 AvMed
Silver

(HMO) AvMed Entrust Silver 350

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
$362,52
$411,46
$463,30
$647,46
$983,88
$639,85
$688,79
$740,63
$924,79
$917,18
$966,12
$1 017,96
$1 202,12
$1 194,51
$1 243,45
$1 295,29
$1 479,45
$277,33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$725,04
$822,92
$926,60
$1 294,92
$1 967,76
$1 002,37
$1 100,25
$1 203,93
$1 572,25
$1 279,70
$1 377,58
$1 481,26
$1 849,58
$1 557,03
$1 654,91
$1 758,59
$2 126,91
$277,33
Toc - Plan #50 AvMed
Silver

(HMO) AvMed Entrust Silver 500

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
$361,61
$410,43
$462,14
$645,83
$981,41
$638,24
$687,06
$738,77
$922,46
$914,87
$963,69
$1 015,40
$1 199,09
$1 191,50
$1 240,32
$1 292,03
$1 475,72
$276,63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723,22
$820,86
$924,28
$1 291,66
$1 962,82
$999,85
$1 097,49
$1 200,91
$1 568,29
$1 276,48
$1 374,12
$1 477,54
$1 844,92
$1 553,11
$1 650,75
$1 754,17
$2 121,55
$276,63
Toc - Plan #51 AvMed
Silver

(HMO) AvMed Entrust Silver 550

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
$358,97
$407,43
$458,76
$641,12
$974,24
$633,58
$682,04
$733,37
$915,73
$908,19
$956,65
$1 007,98
$1 190,34
$1 182,80
$1 231,26
$1 282,59
$1 464,95
$274,61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717,94
$814,86
$917,52
$1 282,24
$1 948,48
$992,55
$1 089,47
$1 192,13
$1 556,85
$1 267,16
$1 364,08
$1 466,74
$1 831,46
$1 541,77
$1 638,69
$1 741,35
$2 106,07
$274,61
Toc - Plan #52 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 600

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
$298,61
$338,92
$381,62
$533,31
$810,42
$527,04
$567,35
$610,05
$761,74
$755,47
$795,78
$838,48
$990,17
$983,90
$1 024,21
$1 066,91
$1 218,60
$228,43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$597,22
$677,84
$763,24
$1 066,62
$1 620,84
$825,65
$906,27
$991,67
$1 295,05
$1 054,08
$1 134,70
$1 220,10
$1 523,48
$1 282,51
$1 363,13
$1 448,53
$1 751,91
$228,43
Toc - Plan #53 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 650

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
$274,61
$311,68
$350,95
$490,45
$745,29
$484,69
$521,76
$561,03
$700,53
$694,77
$731,84
$771,11
$910,61
$904,85
$941,92
$981,19
$1 120,69
$210,08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$549,22
$623,36
$701,90
$980,90
$1 490,58
$759,30
$833,44
$911,98
$1 190,98
$969,38
$1 043,52
$1 122,06
$1 401,06
$1 179,46
$1 253,60
$1 332,14
$1 611,14
$210,08
Toc - Plan #54 AvMed
Catastrophic

(HMO) AvMed Catastrophic 100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$241,39
$273,97
$308,49
$431,12
$655,13
$426,05
$458,63
$493,15
$615,78
$610,71
$643,29
$677,81
$800,44
$795,37
$827,95
$862,47
$985,10
$184,66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$482,78
$547,94
$616,98
$862,24
$1 310,26
$667,44
$732,60
$801,64
$1 046,90
$852,10
$917,26
$986,30
$1 231,56
$1 036,76
$1 101,92
$1 170,96
$1 416,22
$184,66
Toc - Plan #55 AvMed
Gold

(HMO) AvMed Entrust Gold 125 Adult Dental + Vision

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
$393,11
$446,18
$502,39
$702,09
$1 066,90
$693,84
$746,91
$803,12
$1 002,82
$994,57
$1 047,64
$1 103,85
$1 303,55
$1 295,30
$1 348,37
$1 404,58
$1 604,28
$300,73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786,22
$892,36
$1 004,78
$1 404,18
$2 133,80
$1 086,95
$1 193,09
$1 305,51
$1 704,91
$1 387,68
$1 493,82
$1 606,24
$2 005,64
$1 688,41
$1 794,55
$1 906,97
$2 306,37
$300,73
Toc - Plan #56 AvMed
Silver

(HMO) AvMed Entrust Silver 300 Adult Dental + Vision

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
$382,14
$433,72
$488,37
$682,50
$1 037,12
$674,47
$726,05
$780,70
$974,83
$966,80
$1 018,38
$1 073,03
$1 267,16
$1 259,13
$1 310,71
$1 365,36
$1 559,49
$292,33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764,28
$867,44
$976,74
$1 365,00
$2 074,24
$1 056,61
$1 159,77
$1 269,07
$1 657,33
$1 348,94
$1 452,10
$1 561,40
$1 949,66
$1 641,27
$1 744,43
$1 853,73
$2 241,99
$292,33
Toc - Plan #57 AvMed
Silver

(HMO) AvMed Entrust Silver 350 Adult Dental + Vision

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
$365,74
$415,11
$467,41
$653,21
$992,61
$645,53
$694,90
$747,20
$933,00
$925,32
$974,69
$1 026,99
$1 212,79
$1 205,11
$1 254,48
$1 306,78
$1 492,58
$279,79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731,48
$830,22
$934,82
$1 306,42
$1 985,22
$1 011,27
$1 110,01
$1 214,61
$1 586,21
$1 291,06
$1 389,80
$1 494,40
$1 866,00
$1 570,85
$1 669,59
$1 774,19
$2 145,79
$279,79
Toc - Plan #58 AvMed
Silver

(HMO) AvMed Entrust Silver 500 Adult Dental + Vision

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
$364,81
$414,06
$466,23
$651,55
$990,09
$643,89
$693,14
$745,31
$930,63
$922,97
$972,22
$1 024,39
$1 209,71
$1 202,05
$1 251,30
$1 303,47
$1 488,79
$279,08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729,62
$828,12
$932,46
$1 303,10
$1 980,18
$1 008,70
$1 107,20
$1 211,54
$1 582,18
$1 287,78
$1 386,28
$1 490,62
$1 861,26
$1 566,86
$1 665,36
$1 769,70
$2 140,34
$279,08

ADVERTISEMENT

Ambetter from Sunshine Health

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

Toc - Plan #59 Ambetter from Sunshine Health
Bronze

(EPO) Ambetter Essential Care 1 (2021)

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
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$267,08
$303,13
$341,32
$476,99
$724,83
$471,39
$507,44
$545,63
$681,30
$675,70
$711,75
$749,94
$885,61
$880,01
$916,06
$954,25
$1 089,92
$204,31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$534,16
$606,26
$682,64
$953,98
$1 449,66
$738,47
$810,57
$886,95
$1 158,29
$942,78
$1 014,88
$1 091,26
$1 362,60
$1 147,09
$1 219,19
$1 295,57
$1 566,91
$204,31
Toc - Plan #60 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 4 (2021)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381,92
$433,47
$488,08
$682,09
$1 036,51
$674,08
$725,63
$780,24
$974,25
$966,24
$1 017,79
$1 072,40
$1 266,41
$1 258,40
$1 309,95
$1 364,56
$1 558,57
$292,16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763,84
$866,94
$976,16
$1 364,18
$2 073,02
$1 056,00
$1 159,10
$1 268,32
$1 656,34
$1 348,16
$1 451,26
$1 560,48
$1 948,50
$1 640,32
$1 743,42
$1 852,64
$2 240,66
$292,16
Toc - Plan #61 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 11 (2021)

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
$372,45
$422,72
$475,98
$665,18
$1 010,80
$657,37
$707,64
$760,90
$950,10
$942,29
$992,56
$1 045,82
$1 235,02
$1 227,21
$1 277,48
$1 330,74
$1 519,94
$284,92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744,90
$845,44
$951,96
$1 330,36
$2 021,60
$1 029,82
$1 130,36
$1 236,88
$1 615,28
$1 314,74
$1 415,28
$1 521,80
$1 900,20
$1 599,66
$1 700,20
$1 806,72
$2 185,12
$284,92
Toc - Plan #62 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 5 (2021)

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
$381,88
$433,43
$488,03
$682,03
$1 036,41
$674,01
$725,56
$780,16
$974,16
$966,14
$1 017,69
$1 072,29
$1 266,29
$1 258,27
$1 309,82
$1 364,42
$1 558,42
$292,13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763,76
$866,86
$976,06
$1 364,06
$2 072,82
$1 055,89
$1 158,99
$1 268,19
$1 656,19
$1 348,02
$1 451,12
$1 560,32
$1 948,32
$1 640,15
$1 743,25
$1 852,45
$2 240,45
$292,13
Toc - Plan #63 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021)

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
$273,19
$310,06
$349,13
$487,90
$741,41
$482,17
$519,04
$558,11
$696,88
$691,15
$728,02
$767,09
$905,86
$900,13
$937,00
$976,07
$1 114,84
$208,98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$546,38
$620,12
$698,26
$975,80
$1 482,82
$755,36
$829,10
$907,24
$1 184,78
$964,34
$1 038,08
$1 116,22
$1 393,76
$1 173,32
$1 247,06
$1 325,20
$1 602,74
$208,98
Toc - Plan #64 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 10 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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
$273,69
$310,62
$349,76
$488,79
$742,76
$483,05
$519,98
$559,12
$698,15
$692,41
$729,34
$768,48
$907,51
$901,77
$938,70
$977,84
$1 116,87
$209,36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$547,38
$621,24
$699,52
$977,58
$1 485,52
$756,74
$830,60
$908,88
$1 186,94
$966,10
$1 039,96
$1 118,24
$1 396,30
$1 175,46
$1 249,32
$1 327,60
$1 605,66
$209,36
Toc - Plan #65 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 12 (2021)

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
$364,28
$413,44
$465,53
$650,58
$988,62
$642,94
$692,10
$744,19
$929,24
$921,60
$970,76
$1 022,85
$1 207,90
$1 200,26
$1 249,42
$1 301,51
$1 486,56
$278,66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728,56
$826,88
$931,06
$1 301,16
$1 977,24
$1 007,22
$1 105,54
$1 209,72
$1 579,82
$1 285,88
$1 384,20
$1 488,38
$1 858,48
$1 564,54
$1 662,86
$1 767,04
$2 137,14
$278,66
Toc - Plan #66 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 24 (2021)

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
$377,64
$428,62
$482,62
$674,46
$1 024,90
$666,53
$717,51
$771,51
$963,35
$955,42
$1 006,40
$1 060,40
$1 252,24
$1 244,31
$1 295,29
$1 349,29
$1 541,13
$288,89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$755,28
$857,24
$965,24
$1 348,92
$2 049,80
$1 044,17
$1 146,13
$1 254,13
$1 637,81
$1 333,06
$1 435,02
$1 543,02
$1 926,70
$1 621,95
$1 723,91
$1 831,91
$2 215,59
$288,89
Toc - Plan #67 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 29 (2021)

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
$8,400 $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
$360,99
$409,72
$461,34
$644,72
$979,71
$637,14
$685,87
$737,49
$920,87
$913,29
$962,02
$1 013,64
$1 197,02
$1 189,44
$1 238,17
$1 289,79
$1 473,17
$276,15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721,98
$819,44
$922,68
$1 289,44
$1 959,42
$998,13
$1 095,59
$1 198,83
$1 565,59
$1 274,28
$1 371,74
$1 474,98
$1 841,74
$1 550,43
$1 647,89
$1 751,13
$2 117,89
$276,15
Toc - Plan #68 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 25 HSA (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376,65
$427,49
$481,35
$672,68
$1 022,21
$664,78
$715,62
$769,48
$960,81
$952,91
$1 003,75
$1 057,61
$1 248,94
$1 241,04
$1 291,88
$1 345,74
$1 537,07
$288,13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753,30
$854,98
$962,70
$1 345,36
$2 044,42
$1 041,43
$1 143,11
$1 250,83
$1 633,49
$1 329,56
$1 431,24
$1 538,96
$1 921,62
$1 617,69
$1 719,37
$1 827,09
$2 209,75
$288,13
Toc - Plan #69 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 26 (2021)

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
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384,02
$435,85
$490,77
$685,85
$1 042,21
$677,79
$729,62
$784,54
$979,62
$971,56
$1 023,39
$1 078,31
$1 273,39
$1 265,33
$1 317,16
$1 372,08
$1 567,16
$293,77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768,04
$871,70
$981,54
$1 371,70
$2 084,42
$1 061,81
$1 165,47
$1 275,31
$1 665,47
$1 355,58
$1 459,24
$1 569,08
$1 959,24
$1 649,35
$1 753,01
$1 862,85
$2 253,01
$293,77
Toc - Plan #70 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 27 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 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
$401,09
$455,23
$512,59
$716,34
$1 088,54
$707,92
$762,06
$819,42
$1 023,17
$1 014,75
$1 068,89
$1 126,25
$1 330,00
$1 321,58
$1 375,72
$1 433,08
$1 636,83
$306,83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802,18
$910,46
$1 025,18
$1 432,68
$2 177,08
$1 109,01
$1 217,29
$1 332,01
$1 739,51
$1 415,84
$1 524,12
$1 638,84
$2 046,34
$1 722,67
$1 830,95
$1 945,67
$2 353,17
$306,83
Toc - Plan #71 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 28 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $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
$408,58
$463,73
$522,15
$729,71
$1 108,86
$721,14
$776,29
$834,71
$1 042,27
$1 033,70
$1 088,85
$1 147,27
$1 354,83
$1 346,26
$1 401,41
$1 459,83
$1 667,39
$312,56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$817,16
$927,46
$1 044,30
$1 459,42
$2 217,72
$1 129,72
$1 240,02
$1 356,86
$1 771,98
$1 442,28
$1 552,58
$1 669,42
$2 084,54
$1 754,84
$1 865,14
$1 981,98
$2 397,10
$312,56
Toc - Plan #72 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 11 (2021) + 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
$387,11
$439,36
$494,71
$691,36
$1 050,59
$683,24
$735,49
$790,84
$987,49
$979,37
$1 031,62
$1 086,97
$1 283,62
$1 275,50
$1 327,75
$1 383,10
$1 579,75
$296,13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774,22
$878,72
$989,42
$1 382,72
$2 101,18
$1 070,35
$1 174,85
$1 285,55
$1 678,85
$1 366,48
$1 470,98
$1 581,68
$1 974,98
$1 662,61
$1 767,11
$1 877,81
$2 271,11
$296,13
Toc - Plan #73 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021) + 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
$283,94
$322,27
$362,87
$507,11
$770,60
$501,15
$539,48
$580,08
$724,32
$718,36
$756,69
$797,29
$941,53
$935,57
$973,90
$1 014,50
$1 158,74
$217,21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$567,88
$644,54
$725,74
$1 014,22
$1 541,20
$785,09
$861,75
$942,95
$1 231,43
$1 002,30
$1 078,96
$1 160,16
$1 448,64
$1 219,51
$1 296,17
$1 377,37
$1 665,85
$217,21
Toc - Plan #74 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 12 (2021) + 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
$378,62
$429,72
$483,86
$676,19
$1 027,54
$668,25
$719,35
$773,49
$965,82
$957,88
$1 008,98
$1 063,12
$1 255,45
$1 247,51
$1 298,61
$1 352,75
$1 545,08
$289,63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757,24
$859,44
$967,72
$1 352,38
$2 055,08
$1 046,87
$1 149,07
$1 257,35
$1 642,01
$1 336,50
$1 438,70
$1 546,98
$1 931,64
$1 626,13
$1 728,33
$1 836,61
$2 221,27
$289,63
Toc - Plan #75 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 5 (2021) + 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
$396,91
$450,49
$507,24
$708,87
$1 077,20
$700,54
$754,12
$810,87
$1 012,50
$1 004,17
$1 057,75
$1 114,50
$1 316,13
$1 307,80
$1 361,38
$1 418,13
$1 619,76
$303,63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793,82
$900,98
$1 014,48
$1 417,74
$2 154,40
$1 097,45
$1 204,61
$1 318,11
$1 721,37
$1 401,08
$1 508,24
$1 621,74
$2 025,00
$1 704,71
$1 811,87
$1 925,37
$2 328,63
$303,63
Toc - Plan #76 Ambetter from Sunshine Health
Bronze

(EPO) Ambetter Essential Care 1 (2021) + 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
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$277,59
$315,06
$354,75
$495,76
$753,36
$489,94
$527,41
$567,10
$708,11
$702,29
$739,76
$779,45
$920,46
$914,64
$952,11
$991,80
$1 132,81
$212,35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$555,18
$630,12
$709,50
$991,52
$1 506,72
$767,53
$842,47
$921,85
$1 203,87
$979,88
$1 054,82
$1 134,20
$1 416,22
$1 192,23
$1 267,17
$1 346,55
$1 628,57
$212,35
Toc - Plan #77 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396,95
$450,53
$507,29
$708,94
$1 077,31
$700,61
$754,19
$810,95
$1 012,60
$1 004,27
$1 057,85
$1 114,61
$1 316,26
$1 307,93
$1 361,51
$1 418,27
$1 619,92
$303,66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793,90
$901,06
$1 014,58
$1 417,88
$2 154,62
$1 097,56
$1 204,72
$1 318,24
$1 721,54
$1 401,22
$1 508,38
$1 621,90
$2 025,20
$1 704,88
$1 812,04
$1 925,56
$2 328,86
$303,66
Toc - Plan #78 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 10 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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
$284,46
$322,85
$363,53
$508,03
$772,00
$502,06
$540,45
$581,13
$725,63
$719,66
$758,05
$798,73
$943,23
$937,26
$975,65
$1 016,33
$1 160,83
$217,60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$568,92
$645,70
$727,06
$1 016,06
$1 544,00
$786,52
$863,30
$944,66
$1 233,66
$1 004,12
$1 080,90
$1 162,26
$1 451,26
$1 221,72
$1 298,50
$1 379,86
$1 668,86
$217,60
Toc - Plan #79 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 24 (2021) + 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
$392,51
$445,49
$501,61
$701,00
$1 065,24
$692,77
$745,75
$801,87
$1 001,26
$993,03
$1 046,01
$1 102,13
$1 301,52
$1 293,29
$1 346,27
$1 402,39
$1 601,78
$300,26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$785,02
$890,98
$1 003,22
$1 402,00
$2 130,48
$1 085,28
$1 191,24
$1 303,48
$1 702,26
$1 385,54
$1 491,50
$1 603,74
$2 002,52
$1 685,80
$1 791,76
$1 904,00
$2 302,78
$300,26
Toc - Plan #80 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391,48
$444,31
$500,29
$699,16
$1 062,44
$690,95
$743,78
$799,76
$998,63
$990,42
$1 043,25
$1 099,23
$1 298,10
$1 289,89
$1 342,72
$1 398,70
$1 597,57
$299,47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782,96
$888,62
$1 000,58
$1 398,32
$2 124,88
$1 082,43
$1 188,09
$1 300,05
$1 697,79
$1 381,90
$1 487,56
$1 599,52
$1 997,26
$1 681,37
$1 787,03
$1 898,99
$2 296,73
$299,47
Toc - Plan #81 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 26 (2021) + 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
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$399,14
$453,01
$510,08
$712,84
$1 083,23
$704,47
$758,34
$815,41
$1 018,17
$1 009,80
$1 063,67
$1 120,74
$1 323,50
$1 315,13
$1 369,00
$1 426,07
$1 628,83
$305,33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798,28
$906,02
$1 020,16
$1 425,68
$2 166,46
$1 103,61
$1 211,35
$1 325,49
$1 731,01
$1 408,94
$1 516,68
$1 630,82
$2 036,34
$1 714,27
$1 822,01
$1 936,15
$2 341,67
$305,33
Toc - Plan #82 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 27 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 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
$416,88
$473,15
$532,76
$744,53
$1 131,39
$735,79
$792,06
$851,67
$1 063,44
$1 054,70
$1 110,97
$1 170,58
$1 382,35
$1 373,61
$1 429,88
$1 489,49
$1 701,26
$318,91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$833,76
$946,30
$1 065,52
$1 489,06
$2 262,78
$1 152,67
$1 265,21
$1 384,43
$1 807,97
$1 471,58
$1 584,12
$1 703,34
$2 126,88
$1 790,49
$1 903,03
$2 022,25
$2 445,79
$318,91
Toc - Plan #83 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 28 (2021) + 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
$8,200 $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
$424,66
$481,98
$542,70
$758,43
$1 152,50
$749,52
$806,84
$867,56
$1 083,29
$1 074,38
$1 131,70
$1 192,42
$1 408,15
$1 399,24
$1 456,56
$1 517,28
$1 733,01
$324,86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849,32
$963,96
$1 085,40
$1 516,86
$2 305,00
$1 174,18
$1 288,82
$1 410,26
$1 841,72
$1 499,04
$1 613,68
$1 735,12
$2 166,58
$1 823,90
$1 938,54
$2 059,98
$2 491,44
$324,86

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 #84 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 2151 ($0 Virtual Visits / $100+ in 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
$764,61
$867,83
$977,17
$1 365,59
$2 075,15
$1 349,54
$1 452,76
$1 562,10
$1 950,52
$1 934,47
$2 037,69
$2 147,03
$2 535,45
$2 519,40
$2 622,62
$2 731,96
$3 120,38
$584,93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 529,22
$1 735,66
$1 954,34
$2 731,18
$4 150,30
$2 114,15
$2 320,59
$2 539,27
$3 316,11
$2 699,08
$2 905,52
$3 124,20
$3 901,04
$3 284,01
$3 490,45
$3 709,13
$4 485,97
$584,93
Toc - Plan #85 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2153 ($0 Virtual Visits / 3 PCP Visits for $20)

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
$8,550 $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
$457,95
$519,77
$585,26
$817,90
$1 242,88
$808,28
$870,10
$935,59
$1 168,23
$1 158,61
$1 220,43
$1 285,92
$1 518,56
$1 508,94
$1 570,76
$1 636,25
$1 868,89
$350,33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$915,90
$1 039,54
$1 170,52
$1 635,80
$2 485,76
$1 266,23
$1 389,87
$1 520,85
$1 986,13
$1 616,56
$1 740,20
$1 871,18
$2 336,46
$1 966,89
$2 090,53
$2 221,51
$2 686,79
$350,33
Toc - Plan #86 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) BlueCare Bronze 2154 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412,40
$468,07
$527,05
$736,55
$1 119,25
$727,89
$783,56
$842,54
$1 052,04
$1 043,38
$1 099,05
$1 158,03
$1 367,53
$1 358,87
$1 414,54
$1 473,52
$1 683,02
$315,49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$824,80
$936,14
$1 054,10
$1 473,10
$2 238,50
$1 140,29
$1 251,63
$1 369,59
$1 788,59
$1 455,78
$1 567,12
$1 685,08
$2 104,08
$1 771,27
$1 882,61
$2 000,57
$2 419,57
$315,49
Toc - Plan #87 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 2156 ($0 Virtual Visits / $100+ in 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
$653,97
$742,26
$835,77
$1 167,99
$1 774,87
$1 154,26
$1 242,55
$1 336,06
$1 668,28
$1 654,55
$1 742,84
$1 836,35
$2 168,57
$2 154,84
$2 243,13
$2 336,64
$2 668,86
$500,29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 307,94
$1 484,52
$1 671,54
$2 335,98
$3 549,74
$1 808,23
$1 984,81
$2 171,83
$2 836,27
$2 308,52
$2 485,10
$2 672,12
$3 336,56
$2 808,81
$2 985,39
$3 172,41
$3 836,85
$500,29
Toc - Plan #88 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 2157 ($0 Virtual Visits / $100+ in Rewards)

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
$8,550 $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
$550,56
$624,89
$703,62
$983,30
$1 494,22
$971,74
$1 046,07
$1 124,80
$1 404,48
$1 392,92
$1 467,25
$1 545,98
$1 825,66
$1 814,10
$1 888,43
$1 967,16
$2 246,84
$421,18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 101,12
$1 249,78
$1 407,24
$1 966,60
$2 988,44
$1 522,30
$1 670,96
$1 828,42
$2 387,78
$1 943,48
$2 092,14
$2 249,60
$2 808,96
$2 364,66
$2 513,32
$2 670,78
$3 230,14
$421,18
Toc - Plan #89 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2159 ($0 Deductible / $50 PCP Visits / $100+ in 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
$8,550 $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
$499,61
$567,06
$638,50
$892,30
$1 355,94
$881,81
$949,26
$1 020,70
$1 274,50
$1 264,01
$1 331,46
$1 402,90
$1 656,70
$1 646,21
$1 713,66
$1 785,10
$2 038,90
$382,20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$999,22
$1 134,12
$1 277,00
$1 784,60
$2 711,88
$1 381,42
$1 516,32
$1 659,20
$2 166,80
$1 763,62
$1 898,52
$2 041,40
$2 549,00
$2 145,82
$2 280,72
$2 423,60
$2 931,20
$382,20
Toc - Plan #90 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 2 PCP Visits for $50)

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
$8,550 $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
$311,59
$353,65
$398,21
$556,50
$845,66
$549,96
$592,02
$636,58
$794,87
$788,33
$830,39
$874,95
$1 033,24
$1 026,70
$1 068,76
$1 113,32
$1 271,61
$238,37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$623,18
$707,30
$796,42
$1 113,00
$1 691,32
$861,55
$945,67
$1 034,79
$1 351,37
$1 099,92
$1 184,04
$1 273,16
$1 589,74
$1 338,29
$1 422,41
$1 511,53
$1 828,11
$238,37
Toc - Plan #91 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1602 ($0 Labs / $0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$278,78
$316,42
$356,28
$497,90
$756,61
$492,05
$529,69
$569,55
$711,17
$705,32
$742,96
$782,82
$924,44
$918,59
$956,23
$996,09
$1 137,71
$213,27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$557,56
$632,84
$712,56
$995,80
$1 513,22
$770,83
$846,11
$925,83
$1 209,07
$984,10
$1 059,38
$1 139,10
$1 422,34
$1 197,37
$1 272,65
$1 352,37
$1 635,61
$213,27
Toc - Plan #92 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1603 ($0 Virtual Visits / $100+ in 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
$404,47
$459,07
$516,91
$722,38
$1 097,73
$713,89
$768,49
$826,33
$1 031,80
$1 023,31
$1 077,91
$1 135,75
$1 341,22
$1 332,73
$1 387,33
$1 445,17
$1 650,64
$309,42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808,94
$918,14
$1 033,82
$1 444,76
$2 195,46
$1 118,36
$1 227,56
$1 343,24
$1 754,18
$1 427,78
$1 536,98
$1 652,66
$2 063,60
$1 737,20
$1 846,40
$1 962,08
$2 373,02
$309,42
Toc - Plan #93 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1604 ($0 Labs / $0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370,35
$420,35
$473,31
$661,45
$1 005,13
$653,67
$703,67
$756,63
$944,77
$936,99
$986,99
$1 039,95
$1 228,09
$1 220,31
$1 270,31
$1 323,27
$1 511,41
$283,32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740,70
$840,70
$946,62
$1 322,90
$2 010,26
$1 024,02
$1 124,02
$1 229,94
$1 606,22
$1 307,34
$1 407,34
$1 513,26
$1 889,54
$1 590,66
$1 690,66
$1 796,58
$2 172,86
$283,32
Toc - Plan #94 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 1605 ($0 Labs / $0 Virtual Visits / $100+ in 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
$419,53
$476,17
$536,16
$749,28
$1 138,60
$740,47
$797,11
$857,10
$1 070,22
$1 061,41
$1 118,05
$1 178,04
$1 391,16
$1 382,35
$1 438,99
$1 498,98
$1 712,10
$320,94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839,06
$952,34
$1 072,32
$1 498,56
$2 277,20
$1 160,00
$1 273,28
$1 393,26
$1 819,50
$1 480,94
$1 594,22
$1 714,20
$2 140,44
$1 801,88
$1 915,16
$2 035,14
$2 461,38
$320,94
Toc - Plan #95 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1710 ($0 Virtual Visits / $100+ in 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
$421,21
$478,07
$538,31
$752,28
$1 143,16
$743,44
$800,30
$860,54
$1 074,51
$1 065,67
$1 122,53
$1 182,77
$1 396,74
$1 387,90
$1 444,76
$1 505,00
$1 718,97
$322,23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$842,42
$956,14
$1 076,62
$1 504,56
$2 286,32
$1 164,65
$1 278,37
$1 398,85
$1 826,79
$1 486,88
$1 600,60
$1 721,08
$2 149,02
$1 809,11
$1 922,83
$2 043,31
$2 471,25
$322,23
Toc - Plan #96 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1711S ($0 Virtual Visits / $55 PCP Visits / $100+ in 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
$8,550 $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
$309,72
$351,53
$395,82
$553,16
$840,58
$546,66
$588,47
$632,76
$790,10
$783,60
$825,41
$869,70
$1 027,04
$1 020,54
$1 062,35
$1 106,64
$1 263,98
$236,94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619,44
$703,06
$791,64
$1 106,32
$1 681,16
$856,38
$940,00
$1 028,58
$1 343,26
$1 093,32
$1 176,94
$1 265,52
$1 580,20
$1 330,26
$1 413,88
$1 502,46
$1 817,14
$236,94
Toc - Plan #97 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1712S ($0 Virtual Visits / $100+ in 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
$413,16
$468,94
$528,02
$737,90
$1 121,32
$729,23
$785,01
$844,09
$1 053,97
$1 045,30
$1 101,08
$1 160,16
$1 370,04
$1 361,37
$1 417,15
$1 476,23
$1 686,11
$316,07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826,32
$937,88
$1 056,04
$1 475,80
$2 242,64
$1 142,39
$1 253,95
$1 372,11
$1 791,87
$1 458,46
$1 570,02
$1 688,18
$2 107,94
$1 774,53
$1 886,09
$2 004,25
$2 424,01
$316,07
Toc - Plan #98 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2017 ($0 Labs / $0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 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
$362,73
$411,70
$463,57
$647,84
$984,45
$640,22
$689,19
$741,06
$925,33
$917,71
$966,68
$1 018,55
$1 202,82
$1 195,20
$1 244,17
$1 296,04
$1 480,31
$277,49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$725,46
$823,40
$927,14
$1 295,68
$1 968,90
$1 002,95
$1 100,89
$1 204,63
$1 573,17
$1 280,44
$1 378,38
$1 482,12
$1 850,66
$1 557,93
$1 655,87
$1 759,61
$2 128,15
$277,49
Toc - Plan #99 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2127 ($0 Labs / $0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$8,450 $16,900 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
$351,25
$398,67
$448,90
$627,33
$953,29
$619,96
$667,38
$717,61
$896,04
$888,67
$936,09
$986,32
$1 164,75
$1 157,38
$1 204,80
$1 255,03
$1 433,46
$268,71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702,50
$797,34
$897,80
$1 254,66
$1 906,58
$971,21
$1 066,05
$1 166,51
$1 523,37
$1 239,92
$1 334,76
$1 435,22
$1 792,08
$1 508,63
$1 603,47
$1 703,93
$2 060,79
$268,71
Toc - Plan #100 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Deductible / $50 PCP Visits / $75 Specialist Visits)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $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
$342,76
$389,03
$438,05
$612,17
$930,25
$604,97
$651,24
$700,26
$874,38
$867,18
$913,45
$962,47
$1 136,59
$1 129,39
$1 175,66
$1 224,68
$1 398,80
$262,21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685,52
$778,06
$876,10
$1 224,34
$1 860,50
$947,73
$1 040,27
$1 138,31
$1 486,55
$1 209,94
$1 302,48
$1 400,52
$1 748,76
$1 472,15
$1 564,69
$1 662,73
$2 010,97
$262,21
Toc - Plan #101 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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
$8,550 $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
$309,52
$351,31
$395,57
$552,80
$840,04
$546,30
$588,09
$632,35
$789,58
$783,08
$824,87
$869,13
$1 026,36
$1 019,86
$1 061,65
$1 105,91
$1 263,14
$236,78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619,04
$702,62
$791,14
$1 105,60
$1 680,08
$855,82
$939,40
$1 027,92
$1 342,38
$1 092,60
$1 176,18
$1 264,70
$1 579,16
$1 329,38
$1 412,96
$1 501,48
$1 815,94
$236,78

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #102 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Simple

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

Annual Out of Pocket Expenses:

Individual Family
$7,300 $14,600 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$280,33
$318,16
$358,25
$500,65
$760,78
$494,77
$532,60
$572,69
$715,09
$709,21
$747,04
$787,13
$929,53
$923,65
$961,48
$1 001,57
$1 143,97
$214,44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$560,66
$636,32
$716,50
$1 001,30
$1 521,56
$775,10
$850,76
$930,94
$1 215,74
$989,54
$1 065,20
$1 145,38
$1 430,18
$1 203,98
$1 279,64
$1 359,82
$1 644,62
$214,44
Toc - Plan #103 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Classic PCP Copay

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$292,72
$332,23
$374,09
$522,78
$794,42
$516,64
$556,15
$598,01
$746,70
$740,56
$780,07
$821,93
$970,62
$964,48
$1 003,99
$1 045,85
$1 194,54
$223,92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$585,44
$664,46
$748,18
$1 045,56
$1 588,84
$809,36
$888,38
$972,10
$1 269,48
$1 033,28
$1 112,30
$1 196,02
$1 493,40
$1 257,20
$1 336,22
$1 419,94
$1 717,32
$223,92
Toc - Plan #104 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$283,15
$321,37
$361,86
$505,70
$768,45
$499,76
$537,98
$578,47
$722,31
$716,37
$754,59
$795,08
$938,92
$932,98
$971,20
$1 011,69
$1 155,53
$216,61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$566,30
$642,74
$723,72
$1 011,40
$1 536,90
$782,91
$859,35
$940,33
$1 228,01
$999,52
$1 075,96
$1 156,94
$1 444,62
$1 216,13
$1 292,57
$1 373,55
$1 661,23
$216,61
Toc - Plan #105 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Classic Next

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333,53
$378,55
$426,24
$595,67
$905,18
$588,68
$633,70
$681,39
$850,82
$843,83
$888,85
$936,54
$1 105,97
$1 098,98
$1 144,00
$1 191,69
$1 361,12
$255,15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$667,06
$757,10
$852,48
$1 191,34
$1 810,36
$922,21
$1 012,25
$1 107,63
$1 446,49
$1 177,36
$1 267,40
$1 362,78
$1 701,64
$1 432,51
$1 522,55
$1 617,93
$1 956,79
$255,15
Toc - Plan #106 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369,98
$419,91
$472,82
$660,76
$1 004,09
$653,00
$702,93
$755,84
$943,78
$936,02
$985,95
$1 038,86
$1 226,80
$1 219,04
$1 268,97
$1 321,88
$1 509,82
$283,02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$739,96
$839,82
$945,64
$1 321,52
$2 008,18
$1 022,98
$1 122,84
$1 228,66
$1 604,54
$1 306,00
$1 405,86
$1 511,68
$1 887,56
$1 589,02
$1 688,88
$1 794,70
$2 170,58
$283,02
Toc - Plan #107 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Saver 2

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366,00
$415,40
$467,73
$653,66
$993,29
$645,98
$695,38
$747,71
$933,64
$925,96
$975,36
$1 027,69
$1 213,62
$1 205,94
$1 255,34
$1 307,67
$1 493,60
$279,98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732,00
$830,80
$935,46
$1 307,32
$1 986,58
$1 011,98
$1 110,78
$1 215,44
$1 587,30
$1 291,96
$1 390,76
$1 495,42
$1 867,28
$1 571,94
$1 670,74
$1 775,40
$2 147,26
$279,98
Toc - Plan #108 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Classic Next

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$368,77
$418,55
$471,28
$658,61
$1 000,82
$650,87
$700,65
$753,38
$940,71
$932,97
$982,75
$1 035,48
$1 222,81
$1 215,07
$1 264,85
$1 317,58
$1 504,91
$282,10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737,54
$837,10
$942,56
$1 317,22
$2 001,64
$1 019,64
$1 119,20
$1 224,66
$1 599,32
$1 301,74
$1 401,30
$1 506,76
$1 881,42
$1 583,84
$1 683,40
$1 788,86
$2 163,52
$282,10
Toc - Plan #109 Oscar Insurance Company of Florida
Catastrophic

(EPO) Oscar Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$230,25
$261,33
$294,25
$411,21
$624,88
$406,39
$437,47
$470,39
$587,35
$582,53
$613,61
$646,53
$763,49
$758,67
$789,75
$822,67
$939,63
$176,14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$460,50
$522,66
$588,50
$822,42
$1 249,76
$636,64
$698,80
$764,64
$998,56
$812,78
$874,94
$940,78
$1 174,70
$988,92
$1 051,08
$1 116,92
$1 350,84
$176,14
Toc - Plan #110 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Classic Next 2

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$334,17
$379,28
$427,06
$596,82
$906,92
$589,81
$634,92
$682,70
$852,46
$845,45
$890,56
$938,34
$1 108,10
$1 101,09
$1 146,20
$1 193,98
$1 363,74
$255,64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$668,34
$758,56
$854,12
$1 193,64
$1 813,84
$923,98
$1 014,20
$1 109,76
$1 449,28
$1 179,62
$1 269,84
$1 365,40
$1 704,92
$1 435,26
$1 525,48
$1 621,04
$1 960,56
$255,64
Toc - Plan #111 Oscar Insurance Company of Florida
Gold

(EPO) Oscar Gold Classic

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389,55
$442,13
$497,84
$695,72
$1 057,22
$687,55
$740,13
$795,84
$993,72
$985,55
$1 038,13
$1 093,84
$1 291,72
$1 283,55
$1 336,13
$1 391,84
$1 589,72
$298,00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$779,10
$884,26
$995,68
$1 391,44
$2 114,44
$1 077,10
$1 182,26
$1 293,68
$1 689,44
$1 375,10
$1 480,26
$1 591,68
$1 987,44
$1 673,10
$1 778,26
$1 889,68
$2 285,44
$298,00
Toc - Plan #112 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze HDHP

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$298,11
$338,34
$380,97
$532,40
$809,03
$526,15
$566,38
$609,01
$760,44
$754,19
$794,42
$837,05
$988,48
$982,23
$1 022,46
$1 065,09
$1 216,52
$228,04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596,22
$676,68
$761,94
$1 064,80
$1 618,06
$824,26
$904,72
$989,98
$1 292,84
$1 052,30
$1 132,76
$1 218,02
$1 520,88
$1 280,34
$1 360,80
$1 446,06
$1 748,92
$228,04
Toc - Plan #113 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Classic Copay

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375,60
$426,29
$480,00
$670,80
$1 019,35
$662,93
$713,62
$767,33
$958,13
$950,26
$1 000,95
$1 054,66
$1 245,46
$1 237,59
$1 288,28
$1 341,99
$1 532,79
$287,33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$751,20
$852,58
$960,00
$1 341,60
$2 038,70
$1 038,53
$1 139,91
$1 247,33
$1 628,93
$1 325,86
$1 427,24
$1 534,66
$1 916,26
$1 613,19
$1 714,57
$1 821,99
$2 203,59
$287,33
Toc - Plan #114 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Classic $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$378,31
$429,37
$483,46
$675,64
$1 026,70
$667,71
$718,77
$772,86
$965,04
$957,11
$1 008,17
$1 062,26
$1 254,44
$1 246,51
$1 297,57
$1 351,66
$1 543,84
$289,40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756,62
$858,74
$966,92
$1 351,28
$2 053,40
$1 046,02
$1 148,14
$1 256,32
$1 640,68
$1 335,42
$1 437,54
$1 545,72
$1 930,08
$1 624,82
$1 726,94
$1 835,12
$2 219,48
$289,40
Toc - Plan #115 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Connect

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

Annual Out of Pocket Expenses:

Individual Family
$6,750 $13,500 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
$358,00
$406,32
$457,52
$639,38
$971,60
$631,87
$680,19
$731,39
$913,25
$905,74
$954,06
$1 005,26
$1 187,12
$1 179,61
$1 227,93
$1 279,13
$1 460,99
$273,87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716,00
$812,64
$915,04
$1 278,76
$1 943,20
$989,87
$1 086,51
$1 188,91
$1 552,63
$1 263,74
$1 360,38
$1 462,78
$1 826,50
$1 537,61
$1 634,25
$1 736,65
$2 100,37
$273,87

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #116 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
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433,98
$492,57
$554,63
$775,10
$1 177,83
$765,98
$824,57
$886,63
$1 107,10
$1 097,98
$1 156,57
$1 218,63
$1 439,10
$1 429,98
$1 488,57
$1 550,63
$1 771,10
$332,00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867,96
$985,14
$1 109,26
$1 550,20
$2 355,66
$1 199,96
$1 317,14
$1 441,26
$1 882,20
$1 531,96
$1 649,14
$1 773,26
$2 214,20
$1 863,96
$1 981,14
$2 105,26
$2 546,20
$332,00
Toc - Plan #117 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
$413,48
$469,30
$528,43
$738,47
$1 122,18
$729,79
$785,61
$844,74
$1 054,78
$1 046,10
$1 101,92
$1 161,05
$1 371,09
$1 362,41
$1 418,23
$1 477,36
$1 687,40
$316,31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826,96
$938,60
$1 056,86
$1 476,94
$2 244,36
$1 143,27
$1 254,91
$1 373,17
$1 793,25
$1 459,58
$1 571,22
$1 689,48
$2 109,56
$1 775,89
$1 887,53
$2 005,79
$2 425,87
$316,31
Toc - Plan #118 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
$288,19
$327,10
$368,31
$514,71
$782,15
$508,66
$547,57
$588,78
$735,18
$729,13
$768,04
$809,25
$955,65
$949,60
$988,51
$1 029,72
$1 176,12
$220,47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576,38
$654,20
$736,62
$1 029,42
$1 564,30
$796,85
$874,67
$957,09
$1 249,89
$1 017,32
$1 095,14
$1 177,56
$1 470,36
$1 237,79
$1 315,61
$1 398,03
$1 690,83
$220,47
Toc - Plan #119 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
$408,93
$464,13
$522,61
$730,34
$1 109,83
$721,76
$776,96
$835,44
$1 043,17
$1 034,59
$1 089,79
$1 148,27
$1 356,00
$1 347,42
$1 402,62
$1 461,10
$1 668,83
$312,83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$817,86
$928,26
$1 045,22
$1 460,68
$2 219,66
$1 130,69
$1 241,09
$1 358,05
$1 773,51
$1 443,52
$1 553,92
$1 670,88
$2 086,34
$1 756,35
$1 866,75
$1 983,71
$2 399,17
$312,83
Toc - Plan #120 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
$301,53
$342,24
$385,36
$538,54
$818,37
$532,20
$572,91
$616,03
$769,21
$762,87
$803,58
$846,70
$999,88
$993,54
$1 034,25
$1 077,37
$1 230,55
$230,67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$603,06
$684,48
$770,72
$1 077,08
$1 636,74
$833,73
$915,15
$1 001,39
$1 307,75
$1 064,40
$1 145,82
$1 232,06
$1 538,42
$1 295,07
$1 376,49
$1 462,73
$1 769,09
$230,67
Toc - Plan #121 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 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
$293,38
$332,98
$374,94
$523,97
$796,23
$517,81
$557,41
$599,37
$748,40
$742,24
$781,84
$823,80
$972,83
$966,67
$1 006,27
$1 048,23
$1 197,26
$224,43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$586,76
$665,96
$749,88
$1 047,94
$1 592,46
$811,19
$890,39
$974,31
$1 272,37
$1 035,62
$1 114,82
$1 198,74
$1 496,80
$1 260,05
$1 339,25
$1 423,17
$1 721,23
$224,43
Toc - Plan #122 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
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$437,48
$496,54
$559,10
$781,34
$1 187,32
$772,15
$831,21
$893,77
$1 116,01
$1 106,82
$1 165,88
$1 228,44
$1 450,68
$1 441,49
$1 500,55
$1 563,11
$1 785,35
$334,67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874,96
$993,08
$1 118,20
$1 562,68
$2 374,64
$1 209,63
$1 327,75
$1 452,87
$1 897,35
$1 544,30
$1 662,42
$1 787,54
$2 232,02
$1 878,97
$1 997,09
$2 122,21
$2 566,69
$334,67
Toc - Plan #123 Molina Healthcare
Silver

(HMO) Confident 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
$416,98
$473,27
$532,89
$744,72
$1 131,67
$735,97
$792,26
$851,88
$1 063,71
$1 054,96
$1 111,25
$1 170,87
$1 382,70
$1 373,95
$1 430,24
$1 489,86
$1 701,69
$318,99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$833,96
$946,54
$1 065,78
$1 489,44
$2 263,34
$1 152,95
$1 265,53
$1 384,77
$1 808,43
$1 471,94
$1 584,52
$1 703,76
$2 127,42
$1 790,93
$1 903,51
$2 022,75
$2 446,41
$318,99
Toc - Plan #124 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1 + Vision

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
$291,69
$331,07
$372,78
$520,95
$791,64
$514,83
$554,21
$595,92
$744,09
$737,97
$777,35
$819,06
$967,23
$961,11
$1 000,49
$1 042,20
$1 190,37
$223,14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$583,38
$662,14
$745,56
$1 041,90
$1 583,28
$806,52
$885,28
$968,70
$1 265,04
$1 029,66
$1 108,42
$1 191,84
$1 488,18
$1 252,80
$1 331,56
$1 414,98
$1 711,32
$223,14
Toc - Plan #125 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
$412,86
$468,60
$527,64
$737,38
$1 120,51
$728,70
$784,44
$843,48
$1 053,22
$1 044,54
$1 100,28
$1 159,32
$1 369,06
$1 360,38
$1 416,12
$1 475,16
$1 684,90
$315,84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$825,72
$937,20
$1 055,28
$1 474,76
$2 241,02
$1 141,56
$1 253,04
$1 371,12
$1 790,60
$1 457,40
$1 568,88
$1 686,96
$2 106,44
$1 773,24
$1 884,72
$2 002,80
$2 422,28
$315,84
Toc - Plan #126 Molina Healthcare
Bronze

(HMO) Core Care Bronze 2

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$285,71
$324,28
$365,14
$510,28
$775,41
$504,28
$542,85
$583,71
$728,85
$722,85
$761,42
$802,28
$947,42
$941,42
$979,99
$1 020,85
$1 165,99
$218,57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$571,42
$648,56
$730,28
$1 020,56
$1 550,82
$789,99
$867,13
$948,85
$1 239,13
$1 008,56
$1 085,70
$1 167,42
$1 457,70
$1 227,13
$1 304,27
$1 385,99
$1 676,27
$218,57

‡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 126 plans offered in Rating Area 43.

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2021 Obamacare Plans for Miami-Dade County, FL

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