Obamacare 2022 Rates for Hays County

Obamacare > Rates > Texas > Hays County

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

The health insurance rates listed below are for calendar year 2022.

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

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

Obamacare Providers, 119 Plans and 2022 Rates for Hays County, Texas

Below, you’ll find a summary of the 119 plans for Hays County, Texas and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Moda Health, Inc.

Local: 1-855-718-1767 | Toll Free: 1-855-718-1767 | TTY: 1-800-735-2989
Toc - Plan #1 Moda Health, Inc.
Gold

(EPO) Moda Select Gold 1000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-718-1767

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$454.00
$515.00
$580.00
$811.00
$1,232.00 		$801.00
$862.00
$927.00
$1,158.00 		$1,148.00
$1,209.00
$1,274.00
$1,505.00 		$1,495.00
$1,556.00
$1,621.00
$1,852.00 		$347.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.00
$1,030.00
$1,160.00
$1,622.00
$2,464.00 		$1,255.00
$1,377.00
$1,507.00
$1,969.00 		$1,602.00
$1,724.00
$1,854.00
$2,316.00 		$1,949.00
$2,071.00
$2,201.00
$2,663.00 		$347.00
Toc - Plan #2 Moda Health, Inc.
Gold

(EPO) Moda Select Gold 1800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-718-1767

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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 		$433.00
$492.00
$553.00
$773.00
$1,175.00 		$764.00
$823.00
$884.00
$1,104.00 		$1,095.00
$1,154.00
$1,215.00
$1,435.00 		$1,426.00
$1,485.00
$1,546.00
$1,766.00 		$331.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.00
$984.00
$1,106.00
$1,546.00
$2,350.00 		$1,197.00
$1,315.00
$1,437.00
$1,877.00 		$1,528.00
$1,646.00
$1,768.00
$2,208.00 		$1,859.00
$1,977.00
$2,099.00
$2,539.00 		$331.00
Toc - Plan #3 Moda Health, Inc.
Silver

(EPO) Moda Select Silver 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-718-1767

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.00
$441.00
$497.00
$694.00
$1,055.00 		$686.00
$738.00
$794.00
$991.00 		$983.00
$1,035.00
$1,091.00
$1,288.00 		$1,280.00
$1,332.00
$1,388.00
$1,585.00 		$297.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.00
$882.00
$994.00
$1,388.00
$2,110.00 		$1,075.00
$1,179.00
$1,291.00
$1,685.00 		$1,372.00
$1,476.00
$1,588.00
$1,982.00 		$1,669.00
$1,773.00
$1,885.00
$2,279.00 		$297.00
Toc - Plan #4 Moda Health, Inc.
Silver

(EPO) Moda Select Silver 4800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-718-1767

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$381.00
$432.00
$487.00
$680.00
$1,033.00 		$672.00
$723.00
$778.00
$971.00 		$963.00
$1,014.00
$1,069.00
$1,262.00 		$1,254.00
$1,305.00
$1,360.00
$1,553.00 		$291.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.00
$864.00
$974.00
$1,360.00
$2,066.00 		$1,053.00
$1,155.00
$1,265.00
$1,651.00 		$1,344.00
$1,446.00
$1,556.00
$1,942.00 		$1,635.00
$1,737.00
$1,847.00
$2,233.00 		$291.00
Toc - Plan #5 Moda Health, Inc.
Silver

(EPO) Moda Select Silver 6400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-718-1767

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.00
$427.00
$481.00
$672.00
$1,021.00 		$664.00
$715.00
$769.00
$960.00 		$952.00
$1,003.00
$1,057.00
$1,248.00 		$1,240.00
$1,291.00
$1,345.00
$1,536.00 		$288.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.00
$854.00
$962.00
$1,344.00
$2,042.00 		$1,040.00
$1,142.00
$1,250.00
$1,632.00 		$1,328.00
$1,430.00
$1,538.00
$1,920.00 		$1,616.00
$1,718.00
$1,826.00
$2,208.00 		$288.00
Toc - Plan #6 Moda Health, Inc.
Expanded Bronze

(EPO) Moda Select Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-718-1767

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.00
$355.00
$399.00
$558.00
$848.00 		$552.00
$594.00
$638.00
$797.00 		$791.00
$833.00
$877.00
$1,036.00 		$1,030.00
$1,072.00
$1,116.00
$1,275.00 		$239.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.00
$710.00
$798.00
$1,116.00
$1,696.00 		$865.00
$949.00
$1,037.00
$1,355.00 		$1,104.00
$1,188.00
$1,276.00
$1,594.00 		$1,343.00
$1,427.00
$1,515.00
$1,833.00 		$239.00
Toc - Plan #7 Moda Health, Inc.
Expanded Bronze

(EPO) Moda Select Bronze HSA 6900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-718-1767

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 		$323.00
$366.00
$413.00
$577.00
$876.00 		$570.00
$613.00
$660.00
$824.00 		$817.00
$860.00
$907.00
$1,071.00 		$1,064.00
$1,107.00
$1,154.00
$1,318.00 		$247.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.00
$732.00
$826.00
$1,154.00
$1,752.00 		$893.00
$979.00
$1,073.00
$1,401.00 		$1,140.00
$1,226.00
$1,320.00
$1,648.00 		$1,387.00
$1,473.00
$1,567.00
$1,895.00 		$247.00

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Oscar Insurance Company

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

Toc - Plan #8 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$287.24
$326.01
$367.08
$513.00
$779.55 		$506.97
$545.74
$586.81
$732.73 		$726.70
$765.47
$806.54
$952.46 		$946.43
$985.20
$1,026.27
$1,172.19 		$219.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.48
$652.02
$734.16
$1,026.00
$1,559.10 		$794.21
$871.75
$953.89
$1,245.73 		$1,013.94
$1,091.48
$1,173.62
$1,465.46 		$1,233.67
$1,311.21
$1,393.35
$1,685.19 		$219.73
Toc - Plan #9 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$291.95
$331.35
$373.10
$521.40
$792.32 		$515.28
$554.68
$596.43
$744.73 		$738.61
$778.01
$819.76
$968.06 		$961.94
$1,001.34
$1,043.09
$1,191.39 		$223.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.90
$662.70
$746.20
$1,042.80
$1,584.64 		$807.23
$886.03
$969.53
$1,266.13 		$1,030.56
$1,109.36
$1,192.86
$1,489.46 		$1,253.89
$1,332.69
$1,416.19
$1,712.79 		$223.33
Toc - Plan #10 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$287.59
$326.40
$367.52
$513.61
$780.48 		$507.59
$546.40
$587.52
$733.61 		$727.59
$766.40
$807.52
$953.61 		$947.59
$986.40
$1,027.52
$1,173.61 		$220.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.18
$652.80
$735.04
$1,027.22
$1,560.96 		$795.18
$872.80
$955.04
$1,247.22 		$1,015.18
$1,092.80
$1,175.04
$1,467.22 		$1,235.18
$1,312.80
$1,395.04
$1,687.22 		$220.00
Toc - Plan #11 Oscar Insurance Company
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$344.00
$390.42
$439.61
$614.36
$933.58 		$607.15
$653.57
$702.76
$877.51 		$870.30
$916.72
$965.91
$1,140.66 		$1,133.45
$1,179.87
$1,229.06
$1,403.81 		$263.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.00
$780.84
$879.22
$1,228.72
$1,867.16 		$951.15
$1,043.99
$1,142.37
$1,491.87 		$1,214.30
$1,307.14
$1,405.52
$1,755.02 		$1,477.45
$1,570.29
$1,668.67
$2,018.17 		$263.15
Toc - Plan #12 Oscar Insurance Company
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$402.06
$456.33
$513.83
$718.07
$1,091.18 		$709.63
$763.90
$821.40
$1,025.64 		$1,017.20
$1,071.47
$1,128.97
$1,333.21 		$1,324.77
$1,379.04
$1,436.54
$1,640.78 		$307.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.12
$912.66
$1,027.66
$1,436.14
$2,182.36 		$1,111.69
$1,220.23
$1,335.23
$1,743.71 		$1,419.26
$1,527.80
$1,642.80
$2,051.28 		$1,726.83
$1,835.37
$1,950.37
$2,358.85 		$307.57
Toc - Plan #13 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.94
$447.11
$503.44
$703.55
$1,069.12 		$695.29
$748.46
$804.79
$1,004.90 		$996.64
$1,049.81
$1,106.14
$1,306.25 		$1,297.99
$1,351.16
$1,407.49
$1,607.60 		$301.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.88
$894.22
$1,006.88
$1,407.10
$2,138.24 		$1,089.23
$1,195.57
$1,308.23
$1,708.45 		$1,390.58
$1,496.92
$1,609.58
$2,009.80 		$1,691.93
$1,798.27
$1,910.93
$2,311.15 		$301.35
Toc - Plan #14 Oscar Insurance Company
Silver

(EPO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,450 $16,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$402.44
$456.75
$514.30
$718.73
$1,092.19 		$710.30
$764.61
$822.16
$1,026.59 		$1,018.16
$1,072.47
$1,130.02
$1,334.45 		$1,326.02
$1,380.33
$1,437.88
$1,642.31 		$307.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.88
$913.50
$1,028.60
$1,437.46
$2,184.38 		$1,112.74
$1,221.36
$1,336.46
$1,745.32 		$1,420.60
$1,529.22
$1,644.32
$2,053.18 		$1,728.46
$1,837.08
$1,952.18
$2,361.04 		$307.86
Toc - Plan #15 Oscar Insurance Company
Catastrophic

(EPO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$237.69
$269.76
$303.75
$424.49
$645.06 		$419.51
$451.58
$485.57
$606.31 		$601.33
$633.40
$667.39
$788.13 		$783.15
$815.22
$849.21
$969.95 		$181.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$475.38
$539.52
$607.50
$848.98
$1,290.12 		$657.20
$721.34
$789.32
$1,030.80 		$839.02
$903.16
$971.14
$1,212.62 		$1,020.84
$1,084.98
$1,152.96
$1,394.44 		$181.82
Toc - Plan #16 Oscar Insurance Company
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$344.08
$390.52
$439.72
$614.50
$933.80 		$607.29
$653.73
$702.93
$877.71 		$870.50
$916.94
$966.14
$1,140.92 		$1,133.71
$1,180.15
$1,229.35
$1,404.13 		$263.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.16
$781.04
$879.44
$1,229.00
$1,867.60 		$951.37
$1,044.25
$1,142.65
$1,492.21 		$1,214.58
$1,307.46
$1,405.86
$1,755.42 		$1,477.79
$1,570.67
$1,669.07
$2,018.63 		$263.21
Toc - Plan #17 Oscar Insurance Company
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$396.52
$450.04
$506.74
$708.17
$1,076.13 		$699.85
$753.37
$810.07
$1,011.50 		$1,003.18
$1,056.70
$1,113.40
$1,314.83 		$1,306.51
$1,360.03
$1,416.73
$1,618.16 		$303.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.04
$900.08
$1,013.48
$1,416.34
$2,152.26 		$1,096.37
$1,203.41
$1,316.81
$1,719.67 		$1,399.70
$1,506.74
$1,620.14
$2,023.00 		$1,703.03
$1,810.07
$1,923.47
$2,326.33 		$303.33
Toc - Plan #18 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$315.53
$358.11
$403.23
$563.51
$856.32 		$556.90
$599.48
$644.60
$804.88 		$798.27
$840.85
$885.97
$1,046.25 		$1,039.64
$1,082.22
$1,127.34
$1,287.62 		$241.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.06
$716.22
$806.46
$1,127.02
$1,712.64 		$872.43
$957.59
$1,047.83
$1,368.39 		$1,113.80
$1,198.96
$1,289.20
$1,609.76 		$1,355.17
$1,440.33
$1,530.57
$1,851.13 		$241.37
Toc - Plan #19 Oscar Insurance Company
Silver

(EPO) Silver Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.39
$447.62
$504.01
$704.35
$1,070.33 		$696.09
$749.32
$805.71
$1,006.05 		$997.79
$1,051.02
$1,107.41
$1,307.75 		$1,299.49
$1,352.72
$1,409.11
$1,609.45 		$301.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.78
$895.24
$1,008.02
$1,408.70
$2,140.66 		$1,090.48
$1,196.94
$1,309.72
$1,710.40 		$1,392.18
$1,498.64
$1,611.42
$2,012.10 		$1,693.88
$1,800.34
$1,913.12
$2,313.80 		$301.70
Toc - Plan #20 Oscar Insurance Company
Silver

(EPO) Silver Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408.91
$464.10
$522.57
$730.29
$1,109.74 		$721.71
$776.90
$835.37
$1,043.09 		$1,034.51
$1,089.70
$1,148.17
$1,355.89 		$1,347.31
$1,402.50
$1,460.97
$1,668.69 		$312.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817.82
$928.20
$1,045.14
$1,460.58
$2,219.48 		$1,130.62
$1,241.00
$1,357.94
$1,773.38 		$1,443.42
$1,553.80
$1,670.74
$2,086.18 		$1,756.22
$1,866.60
$1,983.54
$2,398.98 		$312.80
Toc - Plan #21 Oscar Insurance Company
Silver

(EPO) Silver Classic- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.55
$482.99
$543.84
$760.02
$1,154.92 		$751.09
$808.53
$869.38
$1,085.56 		$1,076.63
$1,134.07
$1,194.92
$1,411.10 		$1,402.17
$1,459.61
$1,520.46
$1,736.64 		$325.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.10
$965.98
$1,087.68
$1,520.04
$2,309.84 		$1,176.64
$1,291.52
$1,413.22
$1,845.58 		$1,502.18
$1,617.06
$1,738.76
$2,171.12 		$1,827.72
$1,942.60
$2,064.30
$2,496.66 		$325.54
Toc - Plan #22 Oscar Insurance Company
Gold

(EPO) Gold Classic- Low Ded

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$404.84
$459.48
$517.37
$723.03
$1,098.71 		$714.54
$769.18
$827.07
$1,032.73 		$1,024.24
$1,078.88
$1,136.77
$1,342.43 		$1,333.94
$1,388.58
$1,446.47
$1,652.13 		$309.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.68
$918.96
$1,034.74
$1,446.06
$2,197.42 		$1,119.38
$1,228.66
$1,344.44
$1,755.76 		$1,429.08
$1,538.36
$1,654.14
$2,065.46 		$1,738.78
$1,848.06
$1,963.84
$2,375.16 		$309.70
Toc - Plan #23 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$304.17
$345.23
$388.72
$543.24
$825.50 		$536.86
$577.92
$621.41
$775.93 		$769.55
$810.61
$854.10
$1,008.62 		$1,002.24
$1,043.30
$1,086.79
$1,241.31 		$232.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.34
$690.46
$777.44
$1,086.48
$1,651.00 		$841.03
$923.15
$1,010.13
$1,319.17 		$1,073.72
$1,155.84
$1,242.82
$1,551.86 		$1,306.41
$1,388.53
$1,475.51
$1,784.55 		$232.69
Toc - Plan #24 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$330.33
$374.92
$422.15
$589.96
$896.50 		$583.03
$627.62
$674.85
$842.66 		$835.73
$880.32
$927.55
$1,095.36 		$1,088.43
$1,133.02
$1,180.25
$1,348.06 		$252.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$660.66
$749.84
$844.30
$1,179.92
$1,793.00 		$913.36
$1,002.54
$1,097.00
$1,432.62 		$1,166.06
$1,255.24
$1,349.70
$1,685.32 		$1,418.76
$1,507.94
$1,602.40
$1,938.02 		$252.70
Toc - Plan #25 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $3250 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.61
$372.96
$419.95
$586.87
$891.81 		$579.99
$624.34
$671.33
$838.25 		$831.37
$875.72
$922.71
$1,089.63 		$1,082.75
$1,127.10
$1,174.09
$1,341.01 		$251.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.22
$745.92
$839.90
$1,173.74
$1,783.62 		$908.60
$997.30
$1,091.28
$1,425.12 		$1,159.98
$1,248.68
$1,342.66
$1,676.50 		$1,411.36
$1,500.06
$1,594.04
$1,927.88 		$251.38
Toc - Plan #26 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303.12
$344.03
$387.37
$541.35
$822.63 		$535.00
$575.91
$619.25
$773.23 		$766.88
$807.79
$851.13
$1,005.11 		$998.76
$1,039.67
$1,083.01
$1,236.99 		$231.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.24
$688.06
$774.74
$1,082.70
$1,645.26 		$838.12
$919.94
$1,006.62
$1,314.58 		$1,070.00
$1,151.82
$1,238.50
$1,546.46 		$1,301.88
$1,383.70
$1,470.38
$1,778.34 		$231.88
Toc - Plan #27 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,375 $16,750 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.76
$442.37
$498.10
$696.09
$1,057.78 		$687.92
$740.53
$796.26
$994.25 		$986.08
$1,038.69
$1,094.42
$1,292.41 		$1,284.24
$1,336.85
$1,392.58
$1,590.57 		$298.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.52
$884.74
$996.20
$1,392.18
$2,115.56 		$1,077.68
$1,182.90
$1,294.36
$1,690.34 		$1,375.84
$1,481.06
$1,592.52
$1,988.50 		$1,674.00
$1,779.22
$1,890.68
$2,286.66 		$298.16
Toc - Plan #28 Oscar Insurance Company
Silver

(EPO) Silver Elite- Specialist Saver

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
$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 		$421.38
$478.25
$538.51
$752.56
$1,143.59 		$743.73
$800.60
$860.86
$1,074.91 		$1,066.08
$1,122.95
$1,183.21
$1,397.26 		$1,388.43
$1,445.30
$1,505.56
$1,719.61 		$322.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.76
$956.50
$1,077.02
$1,505.12
$2,287.18 		$1,165.11
$1,278.85
$1,399.37
$1,827.47 		$1,487.46
$1,601.20
$1,721.72
$2,149.82 		$1,809.81
$1,923.55
$2,044.07
$2,472.17 		$322.35
Toc - Plan #29 Oscar Insurance Company
Silver

(EPO) Silver Classic- Low Ded

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.44
$460.16
$518.13
$724.09
$1,100.33 		$715.59
$770.31
$828.28
$1,034.24 		$1,025.74
$1,080.46
$1,138.43
$1,344.39 		$1,335.89
$1,390.61
$1,448.58
$1,654.54 		$310.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.88
$920.32
$1,036.26
$1,448.18
$2,200.66 		$1,121.03
$1,230.47
$1,346.41
$1,758.33 		$1,431.18
$1,540.62
$1,656.56
$2,068.48 		$1,741.33
$1,850.77
$1,966.71
$2,378.63 		$310.15
Toc - Plan #30 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.60
$475.09
$534.95
$747.59
$1,136.04 		$738.82
$795.31
$855.17
$1,067.81 		$1,059.04
$1,115.53
$1,175.39
$1,388.03 		$1,379.26
$1,435.75
$1,495.61
$1,708.25 		$320.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.20
$950.18
$1,069.90
$1,495.18
$2,272.08 		$1,157.42
$1,270.40
$1,390.12
$1,815.40 		$1,477.64
$1,590.62
$1,710.34
$2,135.62 		$1,797.86
$1,910.84
$2,030.56
$2,455.84 		$320.22
Toc - Plan #31 Oscar Insurance Company
Silver

(EPO) Silver Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.70
$474.08
$533.81
$746.00
$1,133.62 		$737.23
$793.61
$853.34
$1,065.53 		$1,056.76
$1,113.14
$1,172.87
$1,385.06 		$1,376.29
$1,432.67
$1,492.40
$1,704.59 		$319.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.40
$948.16
$1,067.62
$1,492.00
$2,267.24 		$1,154.93
$1,267.69
$1,387.15
$1,811.53 		$1,474.46
$1,587.22
$1,706.68
$2,131.06 		$1,793.99
$1,906.75
$2,026.21
$2,450.59 		$319.53
Toc - Plan #32 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$413.66
$469.50
$528.65
$738.79
$1,122.66 		$730.11
$785.95
$845.10
$1,055.24 		$1,046.56
$1,102.40
$1,161.55
$1,371.69 		$1,363.01
$1,418.85
$1,478.00
$1,688.14 		$316.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.32
$939.00
$1,057.30
$1,477.58
$2,245.32 		$1,143.77
$1,255.45
$1,373.75
$1,794.03 		$1,460.22
$1,571.90
$1,690.20
$2,110.48 		$1,776.67
$1,888.35
$2,006.65
$2,426.93 		$316.45
Toc - Plan #33 Oscar Insurance Company
Gold

(EPO) Gold Simple

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$6,550 $13,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$380.16
$431.46
$485.83
$678.94
$1,031.71 		$670.97
$722.27
$776.64
$969.75 		$961.78
$1,013.08
$1,067.45
$1,260.56 		$1,252.59
$1,303.89
$1,358.26
$1,551.37 		$290.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.32
$862.92
$971.66
$1,357.88
$2,063.42 		$1,051.13
$1,153.73
$1,262.47
$1,648.69 		$1,341.94
$1,444.54
$1,553.28
$1,939.50 		$1,632.75
$1,735.35
$1,844.09
$2,230.31 		$290.81
Toc - Plan #34 Oscar Insurance Company
Gold

(EPO) Gold Classic- $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,750 $13,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$387.59
$439.90
$495.32
$692.21
$1,051.88 		$684.09
$736.40
$791.82
$988.71 		$980.59
$1,032.90
$1,088.32
$1,285.21 		$1,277.09
$1,329.40
$1,384.82
$1,581.71 		$296.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.18
$879.80
$990.64
$1,384.42
$2,103.76 		$1,071.68
$1,176.30
$1,287.14
$1,680.92 		$1,368.18
$1,472.80
$1,583.64
$1,977.42 		$1,664.68
$1,769.30
$1,880.14
$2,273.92 		$296.50
Toc - Plan #35 Oscar Insurance Company
Gold

(EPO) Gold Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$443.58
$503.45
$566.88
$792.22
$1,203.85 		$782.91
$842.78
$906.21
$1,131.55 		$1,122.24
$1,182.11
$1,245.54
$1,470.88 		$1,461.57
$1,521.44
$1,584.87
$1,810.21 		$339.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.16
$1,006.90
$1,133.76
$1,584.44
$2,407.70 		$1,226.49
$1,346.23
$1,473.09
$1,923.77 		$1,565.82
$1,685.56
$1,812.42
$2,263.10 		$1,905.15
$2,024.89
$2,151.75
$2,602.43 		$339.33
Toc - Plan #36 Oscar Insurance Company
Gold

(EPO) Gold Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$419.24
$475.83
$535.78
$748.75
$1,137.79 		$739.95
$796.54
$856.49
$1,069.46 		$1,060.66
$1,117.25
$1,177.20
$1,390.17 		$1,381.37
$1,437.96
$1,497.91
$1,710.88 		$320.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.48
$951.66
$1,071.56
$1,497.50
$2,275.58 		$1,159.19
$1,272.37
$1,392.27
$1,818.21 		$1,479.90
$1,593.08
$1,712.98
$2,138.92 		$1,800.61
$1,913.79
$2,033.69
$2,459.63 		$320.71
Toc - Plan #37 Oscar Insurance Company
Gold

(EPO) Gold Classic- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$390.32
$443.00
$498.82
$697.09
$1,059.30 		$688.91
$741.59
$797.41
$995.68 		$987.50
$1,040.18
$1,096.00
$1,294.27 		$1,286.09
$1,338.77
$1,394.59
$1,592.86 		$298.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.64
$886.00
$997.64
$1,394.18
$2,118.60 		$1,079.23
$1,184.59
$1,296.23
$1,692.77 		$1,377.82
$1,483.18
$1,594.82
$1,991.36 		$1,676.41
$1,781.77
$1,893.41
$2,289.95 		$298.59
Toc - Plan #38 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4000 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$327.52
$371.72
$418.56
$584.93
$888.86 		$578.07
$622.27
$669.11
$835.48 		$828.62
$872.82
$919.66
$1,086.03 		$1,079.17
$1,123.37
$1,170.21
$1,336.58 		$250.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.04
$743.44
$837.12
$1,169.86
$1,777.72 		$905.59
$993.99
$1,087.67
$1,420.41 		$1,156.14
$1,244.54
$1,338.22
$1,670.96 		$1,406.69
$1,495.09
$1,588.77
$1,921.51 		$250.55
Toc - Plan #39 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336.56
$381.98
$430.11
$601.07
$913.39 		$594.02
$639.44
$687.57
$858.53 		$851.48
$896.90
$945.03
$1,115.99 		$1,108.94
$1,154.36
$1,202.49
$1,373.45 		$257.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$673.12
$763.96
$860.22
$1,202.14
$1,826.78 		$930.58
$1,021.42
$1,117.68
$1,459.60 		$1,188.04
$1,278.88
$1,375.14
$1,717.06 		$1,445.50
$1,536.34
$1,632.60
$1,974.52 		$257.46
Toc - Plan #40 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $1000 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$337.56
$383.11
$431.38
$602.86
$916.10 		$595.78
$641.33
$689.60
$861.08 		$854.00
$899.55
$947.82
$1,119.30 		$1,112.22
$1,157.77
$1,206.04
$1,377.52 		$258.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.12
$766.22
$862.76
$1,205.72
$1,832.20 		$933.34
$1,024.44
$1,120.98
$1,463.94 		$1,191.56
$1,282.66
$1,379.20
$1,722.16 		$1,449.78
$1,540.88
$1,637.42
$1,980.38 		$258.22
Toc - Plan #41 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$398.32
$452.08
$509.03
$711.37
$1,081.00 		$703.02
$756.78
$813.73
$1,016.07 		$1,007.72
$1,061.48
$1,118.43
$1,320.77 		$1,312.42
$1,366.18
$1,423.13
$1,625.47 		$304.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.64
$904.16
$1,018.06
$1,422.74
$2,162.00 		$1,101.34
$1,208.86
$1,322.76
$1,727.44 		$1,406.04
$1,513.56
$1,627.46
$2,032.14 		$1,710.74
$1,818.26
$1,932.16
$2,336.84 		$304.70

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #42 Ambetter from Superior HealthPlan
Bronze

(EPO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.88
$448.18
$504.64
$705.23
$1,071.67 		$696.95
$750.25
$806.71
$1,007.30 		$999.02
$1,052.32
$1,108.78
$1,309.37 		$1,301.09
$1,354.39
$1,410.85
$1,611.44 		$302.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.76
$896.36
$1,009.28
$1,410.46
$2,143.34 		$1,091.83
$1,198.43
$1,311.35
$1,712.53 		$1,393.90
$1,500.50
$1,613.42
$2,014.60 		$1,695.97
$1,802.57
$1,915.49
$2,316.67 		$302.07
Toc - Plan #43 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$471.33
$534.94
$602.34
$841.77
$1,279.15 		$831.89
$895.50
$962.90
$1,202.33 		$1,192.45
$1,256.06
$1,323.46
$1,562.89 		$1,553.01
$1,616.62
$1,684.02
$1,923.45 		$360.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942.66
$1,069.88
$1,204.68
$1,683.54
$2,558.30 		$1,303.22
$1,430.44
$1,565.24
$2,044.10 		$1,663.78
$1,791.00
$1,925.80
$2,404.66 		$2,024.34
$2,151.56
$2,286.36
$2,765.22 		$360.56
Toc - Plan #44 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 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 		$473.96
$537.94
$605.71
$846.48
$1,286.31 		$836.54
$900.52
$968.29
$1,209.06 		$1,199.12
$1,263.10
$1,330.87
$1,571.64 		$1,561.70
$1,625.68
$1,693.45
$1,934.22 		$362.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$947.92
$1,075.88
$1,211.42
$1,692.96
$2,572.62 		$1,310.50
$1,438.46
$1,574.00
$2,055.54 		$1,673.08
$1,801.04
$1,936.58
$2,418.12 		$2,035.66
$2,163.62
$2,299.16
$2,780.70 		$362.58
Toc - Plan #45 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 10

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$417.03
$473.32
$532.95
$744.80
$1,131.79 		$736.05
$792.34
$851.97
$1,063.82 		$1,055.07
$1,111.36
$1,170.99
$1,382.84 		$1,374.09
$1,430.38
$1,490.01
$1,701.86 		$319.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.06
$946.64
$1,065.90
$1,489.60
$2,263.58 		$1,153.08
$1,265.66
$1,384.92
$1,808.62 		$1,472.10
$1,584.68
$1,703.94
$2,127.64 		$1,791.12
$1,903.70
$2,022.96
$2,446.66 		$319.02
Toc - Plan #46 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$618.80
$702.33
$790.81
$1,105.16
$1,679.40 		$1,092.17
$1,175.70
$1,264.18
$1,578.53 		$1,565.54
$1,649.07
$1,737.55
$2,051.90 		$2,038.91
$2,122.44
$2,210.92
$2,525.27 		$473.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,237.60
$1,404.66
$1,581.62
$2,210.32
$3,358.80 		$1,710.97
$1,878.03
$2,054.99
$2,683.69 		$2,184.34
$2,351.40
$2,528.36
$3,157.06 		$2,657.71
$2,824.77
$3,001.73
$3,630.43 		$473.37
Toc - Plan #47 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$431.59
$489.85
$551.56
$770.81
$1,171.32 		$761.75
$820.01
$881.72
$1,100.97 		$1,091.91
$1,150.17
$1,211.88
$1,431.13 		$1,422.07
$1,480.33
$1,542.04
$1,761.29 		$330.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.18
$979.70
$1,103.12
$1,541.62
$2,342.64 		$1,193.34
$1,309.86
$1,433.28
$1,871.78 		$1,523.50
$1,640.02
$1,763.44
$2,201.94 		$1,853.66
$1,970.18
$2,093.60
$2,532.10 		$330.16
Toc - Plan #48 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$464.96
$527.72
$594.21
$830.41
$1,261.88 		$820.65
$883.41
$949.90
$1,186.10 		$1,176.34
$1,239.10
$1,305.59
$1,541.79 		$1,532.03
$1,594.79
$1,661.28
$1,897.48 		$355.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.92
$1,055.44
$1,188.42
$1,660.82
$2,523.76 		$1,285.61
$1,411.13
$1,544.11
$2,016.51 		$1,641.30
$1,766.82
$1,899.80
$2,372.20 		$1,996.99
$2,122.51
$2,255.49
$2,727.89 		$355.69
Toc - Plan #49 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 29

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$458.93
$520.87
$586.50
$819.63
$1,245.51 		$810.00
$871.94
$937.57
$1,170.70 		$1,161.07
$1,223.01
$1,288.64
$1,521.77 		$1,512.14
$1,574.08
$1,639.71
$1,872.84 		$351.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.86
$1,041.74
$1,173.00
$1,639.26
$2,491.02 		$1,268.93
$1,392.81
$1,524.07
$1,990.33 		$1,620.00
$1,743.88
$1,875.14
$2,341.40 		$1,971.07
$2,094.95
$2,226.21
$2,692.47 		$351.07
Toc - Plan #50 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 22

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$458.46
$520.34
$585.90
$818.79
$1,244.23 		$809.17
$871.05
$936.61
$1,169.50 		$1,159.88
$1,221.76
$1,287.32
$1,520.21 		$1,510.59
$1,572.47
$1,638.03
$1,870.92 		$350.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$916.92
$1,040.68
$1,171.80
$1,637.58
$2,488.46 		$1,267.63
$1,391.39
$1,522.51
$1,988.29 		$1,618.34
$1,742.10
$1,873.22
$2,339.00 		$1,969.05
$2,092.81
$2,223.93
$2,689.71 		$350.71
Toc - Plan #51 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$469.82
$533.23
$600.41
$839.08
$1,275.06 		$829.22
$892.63
$959.81
$1,198.48 		$1,188.62
$1,252.03
$1,319.21
$1,557.88 		$1,548.02
$1,611.43
$1,678.61
$1,917.28 		$359.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.64
$1,066.46
$1,200.82
$1,678.16
$2,550.12 		$1,299.04
$1,425.86
$1,560.22
$2,037.56 		$1,658.44
$1,785.26
$1,919.62
$2,396.96 		$2,017.84
$2,144.66
$2,279.02
$2,756.36 		$359.40
Toc - Plan #52 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$495.65
$562.55
$633.42
$885.20
$1,345.15 		$874.81
$941.71
$1,012.58
$1,264.36 		$1,253.97
$1,320.87
$1,391.74
$1,643.52 		$1,633.13
$1,700.03
$1,770.90
$2,022.68 		$379.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.30
$1,125.10
$1,266.84
$1,770.40
$2,690.30 		$1,370.46
$1,504.26
$1,646.00
$2,149.56 		$1,749.62
$1,883.42
$2,025.16
$2,528.72 		$2,128.78
$2,262.58
$2,404.32
$2,907.88 		$379.16
Toc - Plan #53 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$435.32
$494.07
$556.32
$777.46
$1,181.42 		$768.33
$827.08
$889.33
$1,110.47 		$1,101.34
$1,160.09
$1,222.34
$1,443.48 		$1,434.35
$1,493.10
$1,555.35
$1,776.49 		$333.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.64
$988.14
$1,112.64
$1,554.92
$2,362.84 		$1,203.65
$1,321.15
$1,445.65
$1,887.93 		$1,536.66
$1,654.16
$1,778.66
$2,220.94 		$1,869.67
$1,987.17
$2,111.67
$2,553.95 		$333.01
Toc - Plan #54 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$435.93
$494.77
$557.11
$778.55
$1,183.09 		$769.41
$828.25
$890.59
$1,112.03 		$1,102.89
$1,161.73
$1,224.07
$1,445.51 		$1,436.37
$1,495.21
$1,557.55
$1,778.99 		$333.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.86
$989.54
$1,114.22
$1,557.10
$2,366.18 		$1,205.34
$1,323.02
$1,447.70
$1,890.58 		$1,538.82
$1,656.50
$1,781.18
$2,224.06 		$1,872.30
$1,989.98
$2,114.66
$2,557.54 		$333.48
Toc - Plan #55 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$450.02
$510.76
$575.12
$803.72
$1,221.33 		$794.28
$855.02
$919.38
$1,147.98 		$1,138.54
$1,199.28
$1,263.64
$1,492.24 		$1,482.80
$1,543.54
$1,607.90
$1,836.50 		$344.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.04
$1,021.52
$1,150.24
$1,607.44
$2,442.66 		$1,244.30
$1,365.78
$1,494.50
$1,951.70 		$1,588.56
$1,710.04
$1,838.76
$2,295.96 		$1,932.82
$2,054.30
$2,183.02
$2,640.22 		$344.26
Toc - Plan #56 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$578.83
$656.96
$739.74
$1,033.78
$1,570.92 		$1,021.63
$1,099.76
$1,182.54
$1,476.58 		$1,464.43
$1,542.56
$1,625.34
$1,919.38 		$1,907.23
$1,985.36
$2,068.14
$2,362.18 		$442.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,157.66
$1,313.92
$1,479.48
$2,067.56
$3,141.84 		$1,600.46
$1,756.72
$1,922.28
$2,510.36 		$2,043.26
$2,199.52
$2,365.08
$2,953.16 		$2,486.06
$2,642.32
$2,807.88
$3,395.96 		$442.80
Toc - Plan #57 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 5 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$624.97
$709.33
$798.70
$1,116.18
$1,696.15 		$1,103.07
$1,187.43
$1,276.80
$1,594.28 		$1,581.17
$1,665.53
$1,754.90
$2,072.38 		$2,059.27
$2,143.63
$2,233.00
$2,550.48 		$478.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,249.94
$1,418.66
$1,597.40
$2,232.36
$3,392.30 		$1,728.04
$1,896.76
$2,075.50
$2,710.46 		$2,206.14
$2,374.86
$2,553.60
$3,188.56 		$2,684.24
$2,852.96
$3,031.70
$3,666.66 		$478.10
Toc - Plan #58 Ambetter from Superior HealthPlan
Bronze

(EPO) Ambetter Essential Care 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$398.82
$452.65
$509.68
$712.27
$1,082.36 		$703.91
$757.74
$814.77
$1,017.36 		$1,009.00
$1,062.83
$1,119.86
$1,322.45 		$1,314.09
$1,367.92
$1,424.95
$1,627.54 		$305.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.64
$905.30
$1,019.36
$1,424.54
$2,164.72 		$1,102.73
$1,210.39
$1,324.45
$1,729.63 		$1,407.82
$1,515.48
$1,629.54
$2,034.72 		$1,712.91
$1,820.57
$1,934.63
$2,339.81 		$305.09
Toc - Plan #59 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 10 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$421.19
$478.04
$538.27
$752.23
$1,143.08 		$743.39
$800.24
$860.47
$1,074.43 		$1,065.59
$1,122.44
$1,182.67
$1,396.63 		$1,387.79
$1,444.64
$1,504.87
$1,718.83 		$322.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.38
$956.08
$1,076.54
$1,504.46
$2,286.16 		$1,164.58
$1,278.28
$1,398.74
$1,826.66 		$1,486.78
$1,600.48
$1,720.94
$2,148.86 		$1,808.98
$1,922.68
$2,043.14
$2,471.06 		$322.20
Toc - Plan #60 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 11 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$476.03
$540.28
$608.35
$850.17
$1,291.91 		$840.18
$904.43
$972.50
$1,214.32 		$1,204.33
$1,268.58
$1,336.65
$1,578.47 		$1,568.48
$1,632.73
$1,700.80
$1,942.62 		$364.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952.06
$1,080.56
$1,216.70
$1,700.34
$2,583.82 		$1,316.21
$1,444.71
$1,580.85
$2,064.49 		$1,680.36
$1,808.86
$1,945.00
$2,428.64 		$2,044.51
$2,173.01
$2,309.15
$2,792.79 		$364.15
Toc - Plan #61 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 5 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 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 		$478.69
$543.30
$611.76
$854.93
$1,299.14 		$844.88
$909.49
$977.95
$1,221.12 		$1,211.07
$1,275.68
$1,344.14
$1,587.31 		$1,577.26
$1,641.87
$1,710.33
$1,953.50 		$366.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.38
$1,086.60
$1,223.52
$1,709.86
$2,598.28 		$1,323.57
$1,452.79
$1,589.71
$2,076.05 		$1,689.76
$1,818.98
$1,955.90
$2,442.24 		$2,055.95
$2,185.17
$2,322.09
$2,808.43 		$366.19
Toc - Plan #62 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$435.90
$494.73
$557.07
$778.50
$1,183.00 		$769.35
$828.18
$890.52
$1,111.95 		$1,102.80
$1,161.63
$1,223.97
$1,445.40 		$1,436.25
$1,495.08
$1,557.42
$1,778.85 		$333.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.80
$989.46
$1,114.14
$1,557.00
$2,366.00 		$1,205.25
$1,322.91
$1,447.59
$1,890.45 		$1,538.70
$1,656.36
$1,781.04
$2,223.90 		$1,872.15
$1,989.81
$2,114.49
$2,557.35 		$333.45
Toc - Plan #63 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 12 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$469.60
$532.99
$600.14
$838.69
$1,274.47 		$828.84
$892.23
$959.38
$1,197.93 		$1,188.08
$1,251.47
$1,318.62
$1,557.17 		$1,547.32
$1,610.71
$1,677.86
$1,916.41 		$359.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.20
$1,065.98
$1,200.28
$1,677.38
$2,548.94 		$1,298.44
$1,425.22
$1,559.52
$2,036.62 		$1,657.68
$1,784.46
$1,918.76
$2,395.86 		$2,016.92
$2,143.70
$2,278.00
$2,755.10 		$359.24
Toc - Plan #64 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 22 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$463.03
$525.53
$591.74
$826.96
$1,256.64 		$817.24
$879.74
$945.95
$1,181.17 		$1,171.45
$1,233.95
$1,300.16
$1,535.38 		$1,525.66
$1,588.16
$1,654.37
$1,889.59 		$354.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$926.06
$1,051.06
$1,183.48
$1,653.92
$2,513.28 		$1,280.27
$1,405.27
$1,537.69
$2,008.13 		$1,634.48
$1,759.48
$1,891.90
$2,362.34 		$1,988.69
$2,113.69
$2,246.11
$2,716.55 		$354.21
Toc - Plan #65 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$474.50
$538.55
$606.40
$847.45
$1,287.78 		$837.49
$901.54
$969.39
$1,210.44 		$1,200.48
$1,264.53
$1,332.38
$1,573.43 		$1,563.47
$1,627.52
$1,695.37
$1,936.42 		$362.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$949.00
$1,077.10
$1,212.80
$1,694.90
$2,575.56 		$1,311.99
$1,440.09
$1,575.79
$2,057.89 		$1,674.98
$1,803.08
$1,938.78
$2,420.88 		$2,037.97
$2,166.07
$2,301.77
$2,783.87 		$362.99
Toc - Plan #66 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$500.59
$568.16
$639.74
$894.03
$1,358.57 		$883.53
$951.10
$1,022.68
$1,276.97 		$1,266.47
$1,334.04
$1,405.62
$1,659.91 		$1,649.41
$1,716.98
$1,788.56
$2,042.85 		$382.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,001.18
$1,136.32
$1,279.48
$1,788.06
$2,717.14 		$1,384.12
$1,519.26
$1,662.42
$2,171.00 		$1,767.06
$1,902.20
$2,045.36
$2,553.94 		$2,150.00
$2,285.14
$2,428.30
$2,936.88 		$382.94
Toc - Plan #67 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 31 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$440.28
$499.70
$562.66
$786.32
$1,194.89 		$777.08
$836.50
$899.46
$1,123.12 		$1,113.88
$1,173.30
$1,236.26
$1,459.92 		$1,450.68
$1,510.10
$1,573.06
$1,796.72 		$336.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.56
$999.40
$1,125.32
$1,572.64
$2,389.78 		$1,217.36
$1,336.20
$1,462.12
$1,909.44 		$1,554.16
$1,673.00
$1,798.92
$2,246.24 		$1,890.96
$2,009.80
$2,135.72
$2,583.04 		$336.80
Toc - Plan #68 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 32 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$454.51
$515.86
$580.85
$811.74
$1,233.52 		$802.20
$863.55
$928.54
$1,159.43 		$1,149.89
$1,211.24
$1,276.23
$1,507.12 		$1,497.58
$1,558.93
$1,623.92
$1,854.81 		$347.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.02
$1,031.72
$1,161.70
$1,623.48
$2,467.04 		$1,256.71
$1,379.41
$1,509.39
$1,971.17 		$1,604.40
$1,727.10
$1,857.08
$2,318.86 		$1,952.09
$2,074.79
$2,204.77
$2,666.55 		$347.69
Toc - Plan #69 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 20 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$584.61
$663.52
$747.11
$1,044.09
$1,586.59 		$1,031.83
$1,110.74
$1,194.33
$1,491.31 		$1,479.05
$1,557.96
$1,641.55
$1,938.53 		$1,926.27
$2,005.18
$2,088.77
$2,385.75 		$447.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,169.22
$1,327.04
$1,494.22
$2,088.18
$3,173.18 		$1,616.44
$1,774.26
$1,941.44
$2,535.40 		$2,063.66
$2,221.48
$2,388.66
$2,982.62 		$2,510.88
$2,668.70
$2,835.88
$3,429.84 		$447.22
Toc - Plan #70 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 29 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$463.51
$526.07
$592.35
$827.81
$1,257.93 		$818.09
$880.65
$946.93
$1,182.39 		$1,172.67
$1,235.23
$1,301.51
$1,536.97 		$1,527.25
$1,589.81
$1,656.09
$1,891.55 		$354.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.02
$1,052.14
$1,184.70
$1,655.62
$2,515.86 		$1,281.60
$1,406.72
$1,539.28
$2,010.20 		$1,636.18
$1,761.30
$1,893.86
$2,364.78 		$1,990.76
$2,115.88
$2,248.44
$2,719.36 		$354.58
Toc - Plan #71 Ambetter from Superior HealthPlan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$644.44
$731.43
$823.59
$1,150.96
$1,749.00 		$1,137.43
$1,224.42
$1,316.58
$1,643.95 		$1,630.42
$1,717.41
$1,809.57
$2,136.94 		$2,123.41
$2,210.40
$2,302.56
$2,629.93 		$492.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,288.88
$1,462.86
$1,647.18
$2,301.92
$3,498.00 		$1,781.87
$1,955.85
$2,140.17
$2,794.91 		$2,274.86
$2,448.84
$2,633.16
$3,287.90 		$2,767.85
$2,941.83
$3,126.15
$3,780.89 		$492.99
Toc - Plan #72 Ambetter from Superior HealthPlan
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.24
$466.75
$525.56
$734.46
$1,116.09 		$725.83
$781.34
$840.15
$1,049.05 		$1,040.42
$1,095.93
$1,154.74
$1,363.64 		$1,355.01
$1,410.52
$1,469.33
$1,678.23 		$314.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.48
$933.50
$1,051.12
$1,468.92
$2,232.18 		$1,137.07
$1,248.09
$1,365.71
$1,783.51 		$1,451.66
$1,562.68
$1,680.30
$2,098.10 		$1,766.25
$1,877.27
$1,994.89
$2,412.69 		$314.59
Toc - Plan #73 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$434.31
$492.93
$555.04
$775.66
$1,178.70 		$766.55
$825.17
$887.28
$1,107.90 		$1,098.79
$1,157.41
$1,219.52
$1,440.14 		$1,431.03
$1,489.65
$1,551.76
$1,772.38 		$332.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.62
$985.86
$1,110.08
$1,551.32
$2,357.40 		$1,200.86
$1,318.10
$1,442.32
$1,883.56 		$1,533.10
$1,650.34
$1,774.56
$2,215.80 		$1,865.34
$1,982.58
$2,106.80
$2,548.04 		$332.24
Toc - Plan #74 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$490.86
$557.11
$627.30
$876.65
$1,332.16 		$866.36
$932.61
$1,002.80
$1,252.15 		$1,241.86
$1,308.11
$1,378.30
$1,627.65 		$1,617.36
$1,683.61
$1,753.80
$2,003.15 		$375.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$981.72
$1,114.22
$1,254.60
$1,753.30
$2,664.32 		$1,357.22
$1,489.72
$1,630.10
$2,128.80 		$1,732.72
$1,865.22
$2,005.60
$2,504.30 		$2,108.22
$2,240.72
$2,381.10
$2,879.80 		$375.50
Toc - Plan #75 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 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 		$493.61
$560.23
$630.82
$881.56
$1,339.62 		$871.21
$937.83
$1,008.42
$1,259.16 		$1,248.81
$1,315.43
$1,386.02
$1,636.76 		$1,626.41
$1,693.03
$1,763.62
$2,014.36 		$377.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$987.22
$1,120.46
$1,261.64
$1,763.12
$2,679.24 		$1,364.82
$1,498.06
$1,639.24
$2,140.72 		$1,742.42
$1,875.66
$2,016.84
$2,518.32 		$2,120.02
$2,253.26
$2,394.44
$2,895.92 		$377.60
Toc - Plan #76 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$449.48
$510.15
$574.42
$802.75
$1,219.86 		$793.32
$853.99
$918.26
$1,146.59 		$1,137.16
$1,197.83
$1,262.10
$1,490.43 		$1,481.00
$1,541.67
$1,605.94
$1,834.27 		$343.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.96
$1,020.30
$1,148.84
$1,605.50
$2,439.72 		$1,242.80
$1,364.14
$1,492.68
$1,949.34 		$1,586.64
$1,707.98
$1,836.52
$2,293.18 		$1,930.48
$2,051.82
$2,180.36
$2,637.02 		$343.84
Toc - Plan #77 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$484.23
$549.59
$618.84
$864.82
$1,314.18 		$854.66
$920.02
$989.27
$1,235.25 		$1,225.09
$1,290.45
$1,359.70
$1,605.68 		$1,595.52
$1,660.88
$1,730.13
$1,976.11 		$370.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$968.46
$1,099.18
$1,237.68
$1,729.64
$2,628.36 		$1,338.89
$1,469.61
$1,608.11
$2,100.07 		$1,709.32
$1,840.04
$1,978.54
$2,470.50 		$2,079.75
$2,210.47
$2,348.97
$2,840.93 		$370.43
Toc - Plan #78 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$477.46
$541.90
$610.18
$852.72
$1,295.79 		$842.71
$907.15
$975.43
$1,217.97 		$1,207.96
$1,272.40
$1,340.68
$1,583.22 		$1,573.21
$1,637.65
$1,705.93
$1,948.47 		$365.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954.92
$1,083.80
$1,220.36
$1,705.44
$2,591.58 		$1,320.17
$1,449.05
$1,585.61
$2,070.69 		$1,685.42
$1,814.30
$1,950.86
$2,435.94 		$2,050.67
$2,179.55
$2,316.11
$2,801.19 		$365.25
Toc - Plan #79 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$489.29
$555.33
$625.30
$873.85
$1,327.90 		$863.59
$929.63
$999.60
$1,248.15 		$1,237.89
$1,303.93
$1,373.90
$1,622.45 		$1,612.19
$1,678.23
$1,748.20
$1,996.75 		$374.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$978.58
$1,110.66
$1,250.60
$1,747.70
$2,655.80 		$1,352.88
$1,484.96
$1,624.90
$2,122.00 		$1,727.18
$1,859.26
$1,999.20
$2,496.30 		$2,101.48
$2,233.56
$2,373.50
$2,870.60 		$374.30
Toc - Plan #80 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$516.19
$585.86
$659.67
$921.89
$1,400.90 		$911.06
$980.73
$1,054.54
$1,316.76 		$1,305.93
$1,375.60
$1,449.41
$1,711.63 		$1,700.80
$1,770.47
$1,844.28
$2,106.50 		$394.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,032.38
$1,171.72
$1,319.34
$1,843.78
$2,801.80 		$1,427.25
$1,566.59
$1,714.21
$2,238.65 		$1,822.12
$1,961.46
$2,109.08
$2,633.52 		$2,216.99
$2,356.33
$2,503.95
$3,028.39 		$394.87
Toc - Plan #81 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$454.00
$515.27
$580.19
$810.82
$1,232.12 		$801.30
$862.57
$927.49
$1,158.12 		$1,148.60
$1,209.87
$1,274.79
$1,505.42 		$1,495.90
$1,557.17
$1,622.09
$1,852.72 		$347.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.00
$1,030.54
$1,160.38
$1,621.64
$2,464.24 		$1,255.30
$1,377.84
$1,507.68
$1,968.94 		$1,602.60
$1,725.14
$1,854.98
$2,316.24 		$1,949.90
$2,072.44
$2,202.28
$2,663.54 		$347.30
Toc - Plan #82 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$468.67
$531.93
$598.95
$837.03
$1,271.95 		$827.20
$890.46
$957.48
$1,195.56 		$1,185.73
$1,248.99
$1,316.01
$1,554.09 		$1,544.26
$1,607.52
$1,674.54
$1,912.62 		$358.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$937.34
$1,063.86
$1,197.90
$1,674.06
$2,543.90 		$1,295.87
$1,422.39
$1,556.43
$2,032.59 		$1,654.40
$1,780.92
$1,914.96
$2,391.12 		$2,012.93
$2,139.45
$2,273.49
$2,749.65 		$358.53
Toc - Plan #83 Ambetter from Superior HealthPlan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$602.82
$684.19
$770.39
$1,076.62
$1,636.03 		$1,063.97
$1,145.34
$1,231.54
$1,537.77 		$1,525.12
$1,606.49
$1,692.69
$1,998.92 		$1,986.27
$2,067.64
$2,153.84
$2,460.07 		$461.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,205.64
$1,368.38
$1,540.78
$2,153.24
$3,272.06 		$1,666.79
$1,829.53
$2,001.93
$2,614.39 		$2,127.94
$2,290.68
$2,463.08
$3,075.54 		$2,589.09
$2,751.83
$2,924.23
$3,536.69 		$461.15
Toc - Plan #84 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$477.95
$542.46
$610.81
$853.60
$1,297.13 		$843.57
$908.08
$976.43
$1,219.22 		$1,209.19
$1,273.70
$1,342.05
$1,584.84 		$1,574.81
$1,639.32
$1,707.67
$1,950.46 		$365.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$955.90
$1,084.92
$1,221.62
$1,707.20
$2,594.26 		$1,321.52
$1,450.54
$1,587.24
$2,072.82 		$1,687.14
$1,816.16
$1,952.86
$2,438.44 		$2,052.76
$2,181.78
$2,318.48
$2,804.06 		$365.62

ADVERTISEMENT

Blue Cross and Blue Shield of Texas

Local: 1-888-697-0683 | Toll Free: 1-888-697-0683 | TTY: 1-800-735-2989
Toc - Plan #85 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$427.25
$484.93
$546.03
$763.07
$1,159.56 		$754.10
$811.78
$872.88
$1,089.92 		$1,080.95
$1,138.63
$1,199.73
$1,416.77 		$1,407.80
$1,465.48
$1,526.58
$1,743.62 		$326.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.50
$969.86
$1,092.06
$1,526.14
$2,319.12 		$1,181.35
$1,296.71
$1,418.91
$1,852.99 		$1,508.20
$1,623.56
$1,745.76
$2,179.84 		$1,835.05
$1,950.41
$2,072.61
$2,506.69 		$326.85
Toc - Plan #86 Blue Cross and Blue Shield of Texas
Catastrophic

(HMO) Blue Advantage Security HMO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.34
$359.05
$404.28
$564.98
$858.55 		$558.34
$601.05
$646.28
$806.98 		$800.34
$843.05
$888.28
$1,048.98 		$1,042.34
$1,085.05
$1,130.28
$1,290.98 		$242.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.68
$718.10
$808.56
$1,129.96
$1,717.10 		$874.68
$960.10
$1,050.56
$1,371.96 		$1,116.68
$1,202.10
$1,292.56
$1,613.96 		$1,358.68
$1,444.10
$1,534.56
$1,855.96 		$242.00
Toc - Plan #87 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$2,050 $6,150 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$454.05
$515.34
$580.27
$810.93
$1,232.29 		$801.40
$862.69
$927.62
$1,158.28 		$1,148.75
$1,210.04
$1,274.97
$1,505.63 		$1,496.10
$1,557.39
$1,622.32
$1,852.98 		$347.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.10
$1,030.68
$1,160.54
$1,621.86
$2,464.58 		$1,255.45
$1,378.03
$1,507.89
$1,969.21 		$1,602.80
$1,725.38
$1,855.24
$2,316.56 		$1,950.15
$2,072.73
$2,202.59
$2,663.91 		$347.35
Toc - Plan #88 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.30
$399.86
$450.24
$629.21
$956.15 		$621.81
$669.37
$719.75
$898.72 		$891.32
$938.88
$989.26
$1,168.23 		$1,160.83
$1,208.39
$1,258.77
$1,437.74 		$269.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.60
$799.72
$900.48
$1,258.42
$1,912.30 		$974.11
$1,069.23
$1,169.99
$1,527.93 		$1,243.62
$1,338.74
$1,439.50
$1,797.44 		$1,513.13
$1,608.25
$1,709.01
$2,066.95 		$269.51
Toc - Plan #89 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO? 301

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$342.58
$388.83
$437.82
$611.85
$929.77 		$604.66
$650.91
$699.90
$873.93 		$866.74
$912.99
$961.98
$1,136.01 		$1,128.82
$1,175.07
$1,224.06
$1,398.09 		$262.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.16
$777.66
$875.64
$1,223.70
$1,859.54 		$947.24
$1,039.74
$1,137.72
$1,485.78 		$1,209.32
$1,301.82
$1,399.80
$1,747.86 		$1,471.40
$1,563.90
$1,661.88
$2,009.94 		$262.08
Toc - Plan #90 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 603

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,500 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 		$450.65
$511.49
$575.94
$804.87
$1,223.07 		$795.40
$856.24
$920.69
$1,149.62 		$1,140.15
$1,200.99
$1,265.44
$1,494.37 		$1,484.90
$1,545.74
$1,610.19
$1,839.12 		$344.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901.30
$1,022.98
$1,151.88
$1,609.74
$2,446.14 		$1,246.05
$1,367.73
$1,496.63
$1,954.49 		$1,590.80
$1,712.48
$1,841.38
$2,299.24 		$1,935.55
$2,057.23
$2,186.13
$2,643.99 		$344.75
Toc - Plan #91 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Plus Gold? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$850 $2,550 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$497.70
$564.89
$636.06
$888.89
$1,350.75 		$878.44
$945.63
$1,016.80
$1,269.63 		$1,259.18
$1,326.37
$1,397.54
$1,650.37 		$1,639.92
$1,707.11
$1,778.28
$2,031.11 		$380.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$995.40
$1,129.78
$1,272.12
$1,777.78
$2,701.50 		$1,376.14
$1,510.52
$1,652.86
$2,158.52 		$1,756.88
$1,891.26
$2,033.60
$2,539.26 		$2,137.62
$2,272.00
$2,414.34
$2,920.00 		$380.74
Toc - Plan #92 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$1,250 $3,750 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$530.30
$601.89
$677.72
$947.12
$1,439.23 		$935.98
$1,007.57
$1,083.40
$1,352.80 		$1,341.66
$1,413.25
$1,489.08
$1,758.48 		$1,747.34
$1,818.93
$1,894.76
$2,164.16 		$405.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,060.60
$1,203.78
$1,355.44
$1,894.24
$2,878.46 		$1,466.28
$1,609.46
$1,761.12
$2,299.92 		$1,871.96
$2,015.14
$2,166.80
$2,705.60 		$2,277.64
$2,420.82
$2,572.48
$3,111.28 		$405.68
Toc - Plan #93 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Plus Bronze? 303

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$5,500 $16,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.42
$465.83
$524.52
$733.02
$1,113.89 		$724.39
$779.80
$838.49
$1,046.99 		$1,038.36
$1,093.77
$1,152.46
$1,360.96 		$1,352.33
$1,407.74
$1,466.43
$1,674.93 		$313.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.84
$931.66
$1,049.04
$1,466.04
$2,227.78 		$1,134.81
$1,245.63
$1,363.01
$1,780.01 		$1,448.78
$1,559.60
$1,676.98
$2,093.98 		$1,762.75
$1,873.57
$1,990.95
$2,407.95 		$313.97
Toc - Plan #94 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Plus Bronze? 305

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.89
$422.09
$475.27
$664.19
$1,009.30 		$656.38
$706.58
$759.76
$948.68 		$940.87
$991.07
$1,044.25
$1,233.17 		$1,225.36
$1,275.56
$1,328.74
$1,517.66 		$284.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.78
$844.18
$950.54
$1,328.38
$2,018.60 		$1,028.27
$1,128.67
$1,235.03
$1,612.87 		$1,312.76
$1,413.16
$1,519.52
$1,897.36 		$1,597.25
$1,697.65
$1,804.01
$2,181.85 		$284.49
Toc - Plan #95 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 605

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$539.36
$612.17
$689.30
$963.29
$1,463.82 		$951.97
$1,024.78
$1,101.91
$1,375.90 		$1,364.58
$1,437.39
$1,514.52
$1,788.51 		$1,777.19
$1,850.00
$1,927.13
$2,201.12 		$412.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,078.72
$1,224.34
$1,378.60
$1,926.58
$2,927.64 		$1,491.33
$1,636.95
$1,791.21
$2,339.19 		$1,903.94
$2,049.56
$2,203.82
$2,751.80 		$2,316.55
$2,462.17
$2,616.43
$3,164.41 		$412.61

ADVERTISEMENT

Aetna Life Insurance Company

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #96 Aetna Life Insurance Company
Expanded Bronze

(HMO) Aetna CVS Bronze: Low-Cost Walk-In Clinic Visits, Telehealth, Store Discounts, Austin

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

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 		$330.83
$375.49
$422.80
$590.87
$897.88 		$583.92
$628.58
$675.89
$843.96 		$837.01
$881.67
$928.98
$1,097.05 		$1,090.10
$1,134.76
$1,182.07
$1,350.14 		$253.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$661.66
$750.98
$845.60
$1,181.74
$1,795.76 		$914.75
$1,004.07
$1,098.69
$1,434.83 		$1,167.84
$1,257.16
$1,351.78
$1,687.92 		$1,420.93
$1,510.25
$1,604.87
$1,941.01 		$253.09
Toc - Plan #97 Aetna Life Insurance Company
Bronze

(HMO) Aetna CVS Bronze: $0 Walk-In Clinic Visits, Telehealth, Store Discounts, Austin

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$297.29
$337.43
$379.94
$530.96
$806.85 		$524.72
$564.86
$607.37
$758.39 		$752.15
$792.29
$834.80
$985.82 		$979.58
$1,019.72
$1,062.23
$1,213.25 		$227.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$594.58
$674.86
$759.88
$1,061.92
$1,613.70 		$822.01
$902.29
$987.31
$1,289.35 		$1,049.44
$1,129.72
$1,214.74
$1,516.78 		$1,276.87
$1,357.15
$1,442.17
$1,744.21 		$227.43
Toc - Plan #98 Aetna Life Insurance Company
Gold

(HMO) Aetna CVS Gold: $0 Walk-In Clinic Visits, Telehealth, Store Discounts, Austin

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$458.34
$520.22
$585.76
$818.60
$1,243.94 		$808.97
$870.85
$936.39
$1,169.23 		$1,159.60
$1,221.48
$1,287.02
$1,519.86 		$1,510.23
$1,572.11
$1,637.65
$1,870.49 		$350.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$916.68
$1,040.44
$1,171.52
$1,637.20
$2,487.88 		$1,267.31
$1,391.07
$1,522.15
$1,987.83 		$1,617.94
$1,741.70
$1,872.78
$2,338.46 		$1,968.57
$2,092.33
$2,223.41
$2,689.09 		$350.63
Toc - Plan #99 Aetna Life Insurance Company
Silver

(HMO) Aetna CVS Silver 2: $0 Walk-In Clinic Visits, Telehealth, Store Discounts, Austin

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$397.81
$451.52
$508.41
$710.50
$1,079.67 		$702.14
$755.85
$812.74
$1,014.83 		$1,006.47
$1,060.18
$1,117.07
$1,319.16 		$1,310.80
$1,364.51
$1,421.40
$1,623.49 		$304.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.62
$903.04
$1,016.82
$1,421.00
$2,159.34 		$1,099.95
$1,207.37
$1,321.15
$1,725.33 		$1,404.28
$1,511.70
$1,625.48
$2,029.66 		$1,708.61
$1,816.03
$1,929.81
$2,333.99 		$304.33
Toc - Plan #100 Aetna Life Insurance Company
Silver

(HMO) Aetna CVS Silver 1: $0 Walk-In Clinic Visits, Telehealth, Store Discounts, Austin

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$459.39
$521.41
$587.11
$820.48
$1,246.79 		$810.83
$872.85
$938.55
$1,171.92 		$1,162.27
$1,224.29
$1,289.99
$1,523.36 		$1,513.71
$1,575.73
$1,641.43
$1,874.80 		$351.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.78
$1,042.82
$1,174.22
$1,640.96
$2,493.58 		$1,270.22
$1,394.26
$1,525.66
$1,992.40 		$1,621.66
$1,745.70
$1,877.10
$2,343.84 		$1,973.10
$2,097.14
$2,228.54
$2,695.28 		$351.44

ADVERTISEMENT

CHRISTUS Health Plan

Local: 1-844-282-3025 | Toll Free: 1-844-282-3025 | TTY: 1-800-659-8331
Toc - Plan #101 CHRISTUS Health Plan
Catastrophic

(HMO) CHP TX Catastrophic - Three Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$229.33
$260.28
$293.08
$409.58
$622.39 		$404.76
$435.71
$468.51
$585.01 		$580.19
$611.14
$643.94
$760.44 		$755.62
$786.57
$819.37
$935.87 		$175.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$458.66
$520.56
$586.16
$819.16
$1,244.78 		$634.09
$695.99
$761.59
$994.59 		$809.52
$871.42
$937.02
$1,170.02 		$984.95
$1,046.85
$1,112.45
$1,345.45 		$175.43
Toc - Plan #102 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHP TX Bronze - Two Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$284.69
$323.12
$363.83
$508.45
$772.64 		$502.48
$540.91
$581.62
$726.24 		$720.27
$758.70
$799.41
$944.03 		$938.06
$976.49
$1,017.20
$1,161.82 		$217.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569.38
$646.24
$727.66
$1,016.90
$1,545.28 		$787.17
$864.03
$945.45
$1,234.69 		$1,004.96
$1,081.82
$1,163.24
$1,452.48 		$1,222.75
$1,299.61
$1,381.03
$1,670.27 		$217.79
Toc - Plan #103 CHRISTUS Health Plan
Silver

(HMO) CHP TX Silver HD - Two Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.01
$452.88
$509.94
$712.64
$1,082.92 		$704.25
$758.12
$815.18
$1,017.88 		$1,009.49
$1,063.36
$1,120.42
$1,323.12 		$1,314.73
$1,368.60
$1,425.66
$1,628.36 		$305.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.02
$905.76
$1,019.88
$1,425.28
$2,165.84 		$1,103.26
$1,211.00
$1,325.12
$1,730.52 		$1,408.50
$1,516.24
$1,630.36
$2,035.76 		$1,713.74
$1,821.48
$1,935.60
$2,341.00 		$305.24
Toc - Plan #104 CHRISTUS Health Plan
Silver

(HMO) CHP TX Silver LD - Two Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.00
$473.30
$532.93
$744.77
$1,131.75 		$736.01
$792.31
$851.94
$1,063.78 		$1,055.02
$1,111.32
$1,170.95
$1,382.79 		$1,374.03
$1,430.33
$1,489.96
$1,701.80 		$319.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.00
$946.60
$1,065.86
$1,489.54
$2,263.50 		$1,153.01
$1,265.61
$1,384.87
$1,808.55 		$1,472.02
$1,584.62
$1,703.88
$2,127.56 		$1,791.03
$1,903.63
$2,022.89
$2,446.57 		$319.01
Toc - Plan #105 CHRISTUS Health Plan
Gold

(HMO) CHP TX Gold - Two Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.71
$447.99
$504.43
$704.94
$1,071.23 		$696.66
$749.94
$806.38
$1,006.89 		$998.61
$1,051.89
$1,108.33
$1,308.84 		$1,300.56
$1,353.84
$1,410.28
$1,610.79 		$301.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.42
$895.98
$1,008.86
$1,409.88
$2,142.46 		$1,091.37
$1,197.93
$1,310.81
$1,711.83 		$1,393.32
$1,499.88
$1,612.76
$2,013.78 		$1,695.27
$1,801.83
$1,914.71
$2,315.73 		$301.95
Toc - Plan #106 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHP TX Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$309.13
$350.87
$395.07
$552.11
$838.99 		$545.62
$587.36
$631.56
$788.60 		$782.11
$823.85
$868.05
$1,025.09 		$1,018.60
$1,060.34
$1,104.54
$1,261.58 		$236.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.26
$701.74
$790.14
$1,104.22
$1,677.98 		$854.75
$938.23
$1,026.63
$1,340.71 		$1,091.24
$1,174.72
$1,263.12
$1,577.20 		$1,327.73
$1,411.21
$1,499.61
$1,813.69 		$236.49
Toc - Plan #107 CHRISTUS Health Plan
Gold

(HMO) CHP TX Gold Plus - Two Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.33
$468.00
$526.96
$736.42
$1,119.07 		$727.76
$783.43
$842.39
$1,051.85 		$1,043.19
$1,098.86
$1,157.82
$1,367.28 		$1,358.62
$1,414.29
$1,473.25
$1,682.71 		$315.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.66
$936.00
$1,053.92
$1,472.84
$2,238.14 		$1,140.09
$1,251.43
$1,369.35
$1,788.27 		$1,455.52
$1,566.86
$1,684.78
$2,103.70 		$1,770.95
$1,882.29
$2,000.21
$2,419.13 		$315.43
Toc - Plan #108 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHP TX Bronze Plus - Two Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.31
$343.12
$386.35
$539.93
$820.47 		$533.58
$574.39
$617.62
$771.20 		$764.85
$805.66
$848.89
$1,002.47 		$996.12
$1,036.93
$1,080.16
$1,233.74 		$231.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.62
$686.24
$772.70
$1,079.86
$1,640.94 		$835.89
$917.51
$1,003.97
$1,311.13 		$1,067.16
$1,148.78
$1,235.24
$1,542.40 		$1,298.43
$1,380.05
$1,466.51
$1,773.67 		$231.27
Toc - Plan #109 CHRISTUS Health Plan
Silver

(HMO) CHP TX Silver Plus HD - Two Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$416.64
$472.88
$532.46
$744.12
$1,130.76 		$735.37
$791.61
$851.19
$1,062.85 		$1,054.10
$1,110.34
$1,169.92
$1,381.58 		$1,372.83
$1,429.07
$1,488.65
$1,700.31 		$318.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$833.28
$945.76
$1,064.92
$1,488.24
$2,261.52 		$1,152.01
$1,264.49
$1,383.65
$1,806.97 		$1,470.74
$1,583.22
$1,702.38
$2,125.70 		$1,789.47
$1,901.95
$2,021.11
$2,444.43 		$318.73
Toc - Plan #110 CHRISTUS Health Plan
Silver

(HMO) CHP TX Basic Silver - Two Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$355.50
$403.50
$454.33
$634.93
$964.84 		$627.46
$675.46
$726.29
$906.89 		$899.42
$947.42
$998.25
$1,178.85 		$1,171.38
$1,219.38
$1,270.21
$1,450.81 		$271.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.00
$807.00
$908.66
$1,269.86
$1,929.68 		$982.96
$1,078.96
$1,180.62
$1,541.82 		$1,254.92
$1,350.92
$1,452.58
$1,813.78 		$1,526.88
$1,622.88
$1,724.54
$2,085.74 		$271.96
Toc - Plan #111 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHP TX Basic Bronze - Two Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$275.20
$312.35
$351.71
$491.51
$746.89 		$485.73
$522.88
$562.24
$702.04 		$696.26
$733.41
$772.77
$912.57 		$906.79
$943.94
$983.30
$1,123.10 		$210.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.40
$624.70
$703.42
$983.02
$1,493.78 		$760.93
$835.23
$913.95
$1,193.55 		$971.46
$1,045.76
$1,124.48
$1,404.08 		$1,181.99
$1,256.29
$1,335.01
$1,614.61 		$210.53

ADVERTISEMENT

Sendero Health Plans, Local Nonprofit

Local: 1-844-800-4693 | Toll Free: 1-844-800-4693 | TTY: 1-800-855-2880
Toc - Plan #112 Sendero Health Plans, Local Nonprofit
Silver

(HMO) Sendero IdealCare Silver / $20 PCP / $10 Gen Rx + Free Wellness & Preventive Screening + Free Dedicated Healthcare

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$4,250 $8,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$466.53
$529.51
$596.23
$833.22
$1,266.16 		$823.43
$886.41
$953.13
$1,190.12 		$1,180.33
$1,243.31
$1,310.03
$1,547.02 		$1,537.23
$1,600.21
$1,666.93
$1,903.92 		$356.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$933.06
$1,059.02
$1,192.46
$1,666.44
$2,532.32 		$1,289.96
$1,415.92
$1,549.36
$2,023.34 		$1,646.86
$1,772.82
$1,906.26
$2,380.24 		$2,003.76
$2,129.72
$2,263.16
$2,737.14 		$356.90
Toc - Plan #113 Sendero Health Plans, Local Nonprofit
Gold

(HMO) Sendero IdealCare Gold / Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + Free 24/7 Virtual

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$350 $700 Annual Deductible
$6,750 $13,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$467.25
$530.33
$597.15
$834.51
$1,268.12 		$824.70
$887.78
$954.60
$1,191.96 		$1,182.15
$1,245.23
$1,312.05
$1,549.41 		$1,539.60
$1,602.68
$1,669.50
$1,906.86 		$357.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.50
$1,060.66
$1,194.30
$1,669.02
$2,536.24 		$1,291.95
$1,418.11
$1,551.75
$2,026.47 		$1,649.40
$1,775.56
$1,909.20
$2,383.92 		$2,006.85
$2,133.01
$2,266.65
$2,741.37 		$357.45
Toc - Plan #114 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero IdealCare Bronze / $25 PCP / $11 Gen Rx + Free Wellness & Preventive Screening + Free Dedicated Healthcare

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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 		$324.71
$368.55
$414.98
$579.93
$881.26 		$573.11
$616.95
$663.38
$828.33 		$821.51
$865.35
$911.78
$1,076.73 		$1,069.91
$1,113.75
$1,160.18
$1,325.13 		$248.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.42
$737.10
$829.96
$1,159.86
$1,762.52 		$897.82
$985.50
$1,078.36
$1,408.26 		$1,146.22
$1,233.90
$1,326.76
$1,656.66 		$1,394.62
$1,482.30
$1,575.16
$1,905.06 		$248.40
Toc - Plan #115 Sendero Health Plans, Local Nonprofit
Bronze

(HMO) Sendero IdealCare Bronze High Deductible / Free Wellness & Preventive Screening + Free Dedicated Healthcare Team +

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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 		$309.22
$350.96
$395.18
$552.27
$839.22 		$545.77
$587.51
$631.73
$788.82 		$782.32
$824.06
$868.28
$1,025.37 		$1,018.87
$1,060.61
$1,104.83
$1,261.92 		$236.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.44
$701.92
$790.36
$1,104.54
$1,678.44 		$854.99
$938.47
$1,026.91
$1,341.09 		$1,091.54
$1,175.02
$1,263.46
$1,577.64 		$1,328.09
$1,411.57
$1,500.01
$1,814.19 		$236.55
Toc - Plan #116 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero IdealCare Bronze / $25 PCP / $75 Specialist + Free Wellness & Preventive Screening + Free Dedicated Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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 		$334.27
$379.40
$427.20
$597.01
$907.21 		$589.99
$635.12
$682.92
$852.73 		$845.71
$890.84
$938.64
$1,108.45 		$1,101.43
$1,146.56
$1,194.36
$1,364.17 		$255.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.54
$758.80
$854.40
$1,194.02
$1,814.42 		$924.26
$1,014.52
$1,110.12
$1,449.74 		$1,179.98
$1,270.24
$1,365.84
$1,705.46 		$1,435.70
$1,525.96
$1,621.56
$1,961.18 		$255.72

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Ambetter from Superior Healthplan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-877-941-9237
Toc - Plan #117 Ambetter from Superior Healthplan
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$422.69
$479.74
$540.18
$754.90
$1,147.15 		$746.04
$803.09
$863.53
$1,078.25 		$1,069.39
$1,126.44
$1,186.88
$1,401.60 		$1,392.74
$1,449.79
$1,510.23
$1,724.95 		$323.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.38
$959.48
$1,080.36
$1,509.80
$2,294.30 		$1,168.73
$1,282.83
$1,403.71
$1,833.15 		$1,492.08
$1,606.18
$1,727.06
$2,156.50 		$1,815.43
$1,929.53
$2,050.41
$2,479.85 		$323.35
Toc - Plan #118 Ambetter from Superior Healthplan
Silver

(HMO) Ambetter Virtual Access Silver ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$454.72
$516.09
$581.12
$812.11
$1,234.08 		$802.57
$863.94
$928.97
$1,159.96 		$1,150.42
$1,211.79
$1,276.82
$1,507.81 		$1,498.27
$1,559.64
$1,624.67
$1,855.66 		$347.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.44
$1,032.18
$1,162.24
$1,624.22
$2,468.16 		$1,257.29
$1,380.03
$1,510.09
$1,972.07 		$1,605.14
$1,727.88
$1,857.94
$2,319.92 		$1,952.99
$2,075.73
$2,205.79
$2,667.77 		$347.85
Toc - Plan #119 Ambetter from Superior Healthplan
Gold

(HMO) Ambetter Virtual Access Gold ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$604.55
$686.16
$772.61
$1,079.72
$1,640.73 		$1,067.03
$1,148.64
$1,235.09
$1,542.20 		$1,529.51
$1,611.12
$1,697.57
$2,004.68 		$1,991.99
$2,073.60
$2,160.05
$2,467.16 		$462.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,209.10
$1,372.32
$1,545.22
$2,159.44
$3,281.46 		$1,671.58
$1,834.80
$2,007.70
$2,621.92 		$2,134.06
$2,297.28
$2,470.18
$3,084.40 		$2,596.54
$2,759.76
$2,932.66
$3,546.88 		$462.48

‡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 Hays County here.

Hays County is in “Rating Area 3” of Texas.

Currently, there are 119 plans offered in Rating Area 3.

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2022 Obamacare Plans for Hays County, TX

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