Obamacare 2022 Rates for Volusia County

Obamacare > Rates > Florida > Volusia 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 Volusia County, FL.

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, 177 Plans and 2022 Rates for Volusia County, Florida

Below, you’ll find a summary of the 177 plans for Volusia County, Florida 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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Bright HealthCare

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

Toc - Plan #1 Bright HealthCare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$461.88
$524.24
$590.28
$824.92
$1,253.55 		$815.22
$877.58
$943.62
$1,178.26 		$1,168.56
$1,230.92
$1,296.96
$1,531.60 		$1,521.90
$1,584.26
$1,650.30
$1,884.94 		$353.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$923.76
$1,048.48
$1,180.56
$1,649.84
$2,507.10 		$1,277.10
$1,401.82
$1,533.90
$2,003.18 		$1,630.44
$1,755.16
$1,887.24
$2,356.52 		$1,983.78
$2,108.50
$2,240.58
$2,709.86 		$353.34
Toc - Plan #2 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$433.55
$492.08
$554.08
$774.32
$1,176.66 		$765.22
$823.75
$885.75
$1,105.99 		$1,096.89
$1,155.42
$1,217.42
$1,437.66 		$1,428.56
$1,487.09
$1,549.09
$1,769.33 		$331.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.10
$984.16
$1,108.16
$1,548.64
$2,353.32 		$1,198.77
$1,315.83
$1,439.83
$1,880.31 		$1,530.44
$1,647.50
$1,771.50
$2,211.98 		$1,862.11
$1,979.17
$2,103.17
$2,543.65 		$331.67
Toc - Plan #3 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$443.24
$503.08
$566.46
$791.63
$1,202.96 		$782.32
$842.16
$905.54
$1,130.71 		$1,121.40
$1,181.24
$1,244.62
$1,469.79 		$1,460.48
$1,520.32
$1,583.70
$1,808.87 		$339.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.48
$1,006.16
$1,132.92
$1,583.26
$2,405.92 		$1,225.56
$1,345.24
$1,472.00
$1,922.34 		$1,564.64
$1,684.32
$1,811.08
$2,261.42 		$1,903.72
$2,023.40
$2,150.16
$2,600.50 		$339.08
Toc - Plan #4 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$482.84
$548.02
$617.07
$862.35
$1,310.43 		$852.21
$917.39
$986.44
$1,231.72 		$1,221.58
$1,286.76
$1,355.81
$1,601.09 		$1,590.95
$1,656.13
$1,725.18
$1,970.46 		$369.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$965.68
$1,096.04
$1,234.14
$1,724.70
$2,620.86 		$1,335.05
$1,465.41
$1,603.51
$2,094.07 		$1,704.42
$1,834.78
$1,972.88
$2,463.44 		$2,073.79
$2,204.15
$2,342.25
$2,832.81 		$369.37
Toc - Plan #5 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.46
$368.26
$414.66
$579.48
$880.58 		$572.67
$616.47
$662.87
$827.69 		$820.88
$864.68
$911.08
$1,075.90 		$1,069.09
$1,112.89
$1,159.29
$1,324.11 		$248.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.92
$736.52
$829.32
$1,158.96
$1,761.16 		$897.13
$984.73
$1,077.53
$1,407.17 		$1,145.34
$1,232.94
$1,325.74
$1,655.38 		$1,393.55
$1,481.15
$1,573.95
$1,903.59 		$248.21
Toc - Plan #6 Bright HealthCare
Expanded Bronze

(EPO) Bronze 5300 HSA

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

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.16
$406.51
$457.73
$639.67
$972.04 		$632.15
$680.50
$731.72
$913.66 		$906.14
$954.49
$1,005.71
$1,187.65 		$1,180.13
$1,228.48
$1,279.70
$1,461.64 		$273.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.32
$813.02
$915.46
$1,279.34
$1,944.08 		$990.31
$1,087.01
$1,189.45
$1,553.33 		$1,264.30
$1,361.00
$1,463.44
$1,827.32 		$1,538.29
$1,634.99
$1,737.43
$2,101.31 		$273.99
Toc - Plan #7 Bright HealthCare
Catastrophic

(EPO) Catastrophic 8700 ($0 Primary Care)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$238.71
$270.94
$305.08
$426.34
$647.87 		$421.33
$453.56
$487.70
$608.96 		$603.95
$636.18
$670.32
$791.58 		$786.57
$818.80
$852.94
$974.20 		$182.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$477.42
$541.88
$610.16
$852.68
$1,295.74 		$660.04
$724.50
$792.78
$1,035.30 		$842.66
$907.12
$975.40
$1,217.92 		$1,025.28
$1,089.74
$1,158.02
$1,400.54 		$182.62
Toc - Plan #8 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$443.38
$503.24
$566.64
$791.88
$1,203.33 		$782.57
$842.43
$905.83
$1,131.07 		$1,121.76
$1,181.62
$1,245.02
$1,470.26 		$1,460.95
$1,520.81
$1,584.21
$1,809.45 		$339.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.76
$1,006.48
$1,133.28
$1,583.76
$2,406.66 		$1,225.95
$1,345.67
$1,472.47
$1,922.95 		$1,565.14
$1,684.86
$1,811.66
$2,262.14 		$1,904.33
$2,024.05
$2,150.85
$2,601.33 		$339.19
Toc - Plan #9 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$337.92
$383.54
$431.87
$603.53
$917.13 		$596.43
$642.05
$690.38
$862.04 		$854.94
$900.56
$948.89
$1,120.55 		$1,113.45
$1,159.07
$1,207.40
$1,379.06 		$258.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.84
$767.08
$863.74
$1,207.06
$1,834.26 		$934.35
$1,025.59
$1,122.25
$1,465.57 		$1,192.86
$1,284.10
$1,380.76
$1,724.08 		$1,451.37
$1,542.61
$1,639.27
$1,982.59 		$258.51
Toc - Plan #10 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$377.10
$428.00
$481.93
$673.49
$1,023.44 		$665.58
$716.48
$770.41
$961.97 		$954.06
$1,004.96
$1,058.89
$1,250.45 		$1,242.54
$1,293.44
$1,347.37
$1,538.93 		$288.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.20
$856.00
$963.86
$1,346.98
$2,046.88 		$1,042.68
$1,144.48
$1,252.34
$1,635.46 		$1,331.16
$1,432.96
$1,540.82
$1,923.94 		$1,619.64
$1,721.44
$1,829.30
$2,212.42 		$288.48
Toc - Plan #11 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$343.29
$389.63
$438.72
$613.11
$931.68 		$605.91
$652.25
$701.34
$875.73 		$868.53
$914.87
$963.96
$1,138.35 		$1,131.15
$1,177.49
$1,226.58
$1,400.97 		$262.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.58
$779.26
$877.44
$1,226.22
$1,863.36 		$949.20
$1,041.88
$1,140.06
$1,488.84 		$1,211.82
$1,304.50
$1,402.68
$1,751.46 		$1,474.44
$1,567.12
$1,665.30
$2,014.08 		$262.62
Toc - Plan #12 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$448.74
$509.32
$573.49
$801.45
$1,217.89 		$792.03
$852.61
$916.78
$1,144.74 		$1,135.32
$1,195.90
$1,260.07
$1,488.03 		$1,478.61
$1,539.19
$1,603.36
$1,831.32 		$343.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$897.48
$1,018.64
$1,146.98
$1,602.90
$2,435.78 		$1,240.77
$1,361.93
$1,490.27
$1,946.19 		$1,584.06
$1,705.22
$1,833.56
$2,289.48 		$1,927.35
$2,048.51
$2,176.85
$2,632.77 		$343.29
Toc - Plan #13 Bright HealthCare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$500.70
$568.29
$639.89
$894.25
$1,358.89 		$883.73
$951.32
$1,022.92
$1,277.28 		$1,266.76
$1,334.35
$1,405.95
$1,660.31 		$1,649.79
$1,717.38
$1,788.98
$2,043.34 		$383.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,001.40
$1,136.58
$1,279.78
$1,788.50
$2,717.78 		$1,384.43
$1,519.61
$1,662.81
$2,171.53 		$1,767.46
$1,902.64
$2,045.84
$2,554.56 		$2,150.49
$2,285.67
$2,428.87
$2,937.59 		$383.03
Toc - Plan #14 Bright HealthCare
Expanded Bronze

(EPO) Bronze 8700 ($25 Generic)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$318.77
$361.81
$407.39
$569.33
$865.15 		$562.63
$605.67
$651.25
$813.19 		$806.49
$849.53
$895.11
$1,057.05 		$1,050.35
$1,093.39
$1,138.97
$1,300.91 		$243.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637.54
$723.62
$814.78
$1,138.66
$1,730.30 		$881.40
$967.48
$1,058.64
$1,382.52 		$1,125.26
$1,211.34
$1,302.50
$1,626.38 		$1,369.12
$1,455.20
$1,546.36
$1,870.24 		$243.86
Toc - Plan #15 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.27
$467.92
$526.88
$736.31
$1,118.90 		$727.66
$783.31
$842.27
$1,051.70 		$1,043.05
$1,098.70
$1,157.66
$1,367.09 		$1,358.44
$1,414.09
$1,473.05
$1,682.48 		$315.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.54
$935.84
$1,053.76
$1,472.62
$2,237.80 		$1,139.93
$1,251.23
$1,369.15
$1,788.01 		$1,455.32
$1,566.62
$1,684.54
$2,103.40 		$1,770.71
$1,882.01
$1,999.93
$2,418.79 		$315.39

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Florida Blue (BlueCross BlueShield FL)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771
Toc - Plan #16 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$671.28
$761.90
$857.90
$1,198.91
$1,821.85 		$1,184.81
$1,275.43
$1,371.43
$1,712.44 		$1,698.34
$1,788.96
$1,884.96
$2,225.97 		$2,211.87
$2,302.49
$2,398.49
$2,739.50 		$513.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,342.56
$1,523.80
$1,715.80
$2,397.82
$3,643.70 		$1,856.09
$2,037.33
$2,229.33
$2,911.35 		$2,369.62
$2,550.86
$2,742.86
$3,424.88 		$2,883.15
$3,064.39
$3,256.39
$3,938.41 		$513.53
Toc - Plan #17 Florida Blue (BlueCross BlueShield FL)
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.82
$475.36
$535.25
$748.01
$1,136.68 		$739.22
$795.76
$855.65
$1,068.41 		$1,059.62
$1,116.16
$1,176.05
$1,388.81 		$1,380.02
$1,436.56
$1,496.45
$1,709.21 		$320.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.64
$950.72
$1,070.50
$1,496.02
$2,273.36 		$1,158.04
$1,271.12
$1,390.90
$1,816.42 		$1,478.44
$1,591.52
$1,711.30
$2,136.82 		$1,798.84
$1,911.92
$2,031.70
$2,457.22 		$320.40
Toc - Plan #18 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,600 $11,200 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$686.93
$779.67
$877.90
$1,226.86
$1,864.33 		$1,212.43
$1,305.17
$1,403.40
$1,752.36 		$1,737.93
$1,830.67
$1,928.90
$2,277.86 		$2,263.43
$2,356.17
$2,454.40
$2,803.36 		$525.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,373.86
$1,559.34
$1,755.80
$2,453.72
$3,728.66 		$1,899.36
$2,084.84
$2,281.30
$2,979.22 		$2,424.86
$2,610.34
$2,806.80
$3,504.72 		$2,950.36
$3,135.84
$3,332.30
$4,030.22 		$525.50
Toc - Plan #19 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$4,250 $8,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$836.84
$949.81
$1,069.48
$1,494.60
$2,271.18 		$1,477.02
$1,589.99
$1,709.66
$2,134.78 		$2,117.20
$2,230.17
$2,349.84
$2,774.96 		$2,757.38
$2,870.35
$2,990.02
$3,415.14 		$640.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,673.68
$1,899.62
$2,138.96
$2,989.20
$4,542.36 		$2,313.86
$2,539.80
$2,779.14
$3,629.38 		$2,954.04
$3,179.98
$3,419.32
$4,269.56 		$3,594.22
$3,820.16
$4,059.50
$4,909.74 		$640.18
Toc - Plan #20 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$450.00
$510.75
$575.10
$803.70
$1,221.30 		$794.25
$855.00
$919.35
$1,147.95 		$1,138.50
$1,199.25
$1,263.60
$1,492.20 		$1,482.75
$1,543.50
$1,607.85
$1,836.45 		$344.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.00
$1,021.50
$1,150.20
$1,607.40
$2,442.60 		$1,244.25
$1,365.75
$1,494.45
$1,951.65 		$1,588.50
$1,710.00
$1,838.70
$2,295.90 		$1,932.75
$2,054.25
$2,182.95
$2,640.15 		$344.25
Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$882.82
$1,002.00
$1,128.24
$1,576.72
$2,395.97 		$1,558.18
$1,677.36
$1,803.60
$2,252.08 		$2,233.54
$2,352.72
$2,478.96
$2,927.44 		$2,908.90
$3,028.08
$3,154.32
$3,602.80 		$675.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,765.64
$2,004.00
$2,256.48
$3,153.44
$4,791.94 		$2,441.00
$2,679.36
$2,931.84
$3,828.80 		$3,116.36
$3,354.72
$3,607.20
$4,504.16 		$3,791.72
$4,030.08
$4,282.56
$5,179.52 		$675.36
Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$620.37
$704.12
$792.83
$1,107.98
$1,683.68 		$1,094.95
$1,178.70
$1,267.41
$1,582.56 		$1,569.53
$1,653.28
$1,741.99
$2,057.14 		$2,044.11
$2,127.86
$2,216.57
$2,531.72 		$474.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,240.74
$1,408.24
$1,585.66
$2,215.96
$3,367.36 		$1,715.32
$1,882.82
$2,060.24
$2,690.54 		$2,189.90
$2,357.40
$2,534.82
$3,165.12 		$2,664.48
$2,831.98
$3,009.40
$3,639.70 		$474.58
Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$708.19
$803.80
$905.07
$1,264.83
$1,922.03 		$1,249.96
$1,345.57
$1,446.84
$1,806.60 		$1,791.73
$1,887.34
$1,988.61
$2,348.37 		$2,333.50
$2,429.11
$2,530.38
$2,890.14 		$541.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,416.38
$1,607.60
$1,810.14
$2,529.66
$3,844.06 		$1,958.15
$2,149.37
$2,351.91
$3,071.43 		$2,499.92
$2,691.14
$2,893.68
$3,613.20 		$3,041.69
$3,232.91
$3,435.45
$4,154.97 		$541.77
Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$437.53
$496.60
$559.16
$781.43
$1,187.46 		$772.24
$831.31
$893.87
$1,116.14 		$1,106.95
$1,166.02
$1,228.58
$1,450.85 		$1,441.66
$1,500.73
$1,563.29
$1,785.56 		$334.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$875.06
$993.20
$1,118.32
$1,562.86
$2,374.92 		$1,209.77
$1,327.91
$1,453.03
$1,897.57 		$1,544.48
$1,662.62
$1,787.74
$2,232.28 		$1,879.19
$1,997.33
$2,122.45
$2,566.99 		$334.71
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$682.34
$774.46
$872.03
$1,218.66
$1,851.87 		$1,204.33
$1,296.45
$1,394.02
$1,740.65 		$1,726.32
$1,818.44
$1,916.01
$2,262.64 		$2,248.31
$2,340.43
$2,438.00
$2,784.63 		$521.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,364.68
$1,548.92
$1,744.06
$2,437.32
$3,703.74 		$1,886.67
$2,070.91
$2,266.05
$2,959.31 		$2,408.66
$2,592.90
$2,788.04
$3,481.30 		$2,930.65
$3,114.89
$3,310.03
$4,003.29 		$521.99
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$449.43
$510.10
$574.37
$802.68
$1,219.75 		$793.24
$853.91
$918.18
$1,146.49 		$1,137.05
$1,197.72
$1,261.99
$1,490.30 		$1,480.86
$1,541.53
$1,605.80
$1,834.11 		$343.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.86
$1,020.20
$1,148.74
$1,605.36
$2,439.50 		$1,242.67
$1,364.01
$1,492.55
$1,949.17 		$1,586.48
$1,707.82
$1,836.36
$2,292.98 		$1,930.29
$2,051.63
$2,180.17
$2,636.79 		$343.81
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$684.15
$776.51
$874.34
$1,221.89
$1,856.78 		$1,207.52
$1,299.88
$1,397.71
$1,745.26 		$1,730.89
$1,823.25
$1,921.08
$2,268.63 		$2,254.26
$2,346.62
$2,444.45
$2,792.00 		$523.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,368.30
$1,553.02
$1,748.68
$2,443.78
$3,713.56 		$1,891.67
$2,076.39
$2,272.05
$2,967.15 		$2,415.04
$2,599.76
$2,795.42
$3,490.52 		$2,938.41
$3,123.13
$3,318.79
$4,013.89 		$523.37
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$478.92
$543.57
$612.06
$855.35
$1,299.79 		$845.29
$909.94
$978.43
$1,221.72 		$1,211.66
$1,276.31
$1,344.80
$1,588.09 		$1,578.03
$1,642.68
$1,711.17
$1,954.46 		$366.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.84
$1,087.14
$1,224.12
$1,710.70
$2,599.58 		$1,324.21
$1,453.51
$1,590.49
$2,077.07 		$1,690.58
$1,819.88
$1,956.86
$2,443.44 		$2,056.95
$2,186.25
$2,323.23
$2,809.81 		$366.37

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #29 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 5

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.12
$434.82
$489.61
$684.23
$1,039.75 		$676.20
$727.90
$782.69
$977.31 		$969.28
$1,020.98
$1,075.77
$1,270.39 		$1,262.36
$1,314.06
$1,368.85
$1,563.47 		$293.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.24
$869.64
$979.22
$1,368.46
$2,079.50 		$1,059.32
$1,162.72
$1,272.30
$1,661.54 		$1,352.40
$1,455.80
$1,565.38
$1,954.62 		$1,645.48
$1,748.88
$1,858.46
$2,247.70 		$293.08
Toc - Plan #30 Ambetter from Sunshine Health
Bronze

(EPO) Ambetter Essential Care 1

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$269.55
$305.93
$344.47
$481.40
$731.53 		$475.75
$512.13
$550.67
$687.60 		$681.95
$718.33
$756.87
$893.80 		$888.15
$924.53
$963.07
$1,100.00 		$206.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.10
$611.86
$688.94
$962.80
$1,463.06 		$745.30
$818.06
$895.14
$1,169.00 		$951.50
$1,024.26
$1,101.34
$1,375.20 		$1,157.70
$1,230.46
$1,307.54
$1,581.40 		$206.20
Toc - Plan #31 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$296.41
$336.41
$378.80
$529.37
$804.42 		$523.15
$563.15
$605.54
$756.11 		$749.89
$789.89
$832.28
$982.85 		$976.63
$1,016.63
$1,059.02
$1,209.59 		$226.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.82
$672.82
$757.60
$1,058.74
$1,608.84 		$819.56
$899.56
$984.34
$1,285.48 		$1,046.30
$1,126.30
$1,211.08
$1,512.22 		$1,273.04
$1,353.04
$1,437.82
$1,738.96 		$226.74
Toc - Plan #32 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 11

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.67
$427.51
$481.38
$672.72
$1,022.27 		$664.82
$715.66
$769.53
$960.87 		$952.97
$1,003.81
$1,057.68
$1,249.02 		$1,241.12
$1,291.96
$1,345.83
$1,537.17 		$288.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.34
$855.02
$962.76
$1,345.44
$2,044.54 		$1,041.49
$1,143.17
$1,250.91
$1,633.59 		$1,329.64
$1,431.32
$1,539.06
$1,921.74 		$1,617.79
$1,719.47
$1,827.21
$2,209.89 		$288.15
Toc - Plan #33 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 12

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.48
$421.61
$474.73
$663.44
$1,008.16 		$655.65
$705.78
$758.90
$947.61 		$939.82
$989.95
$1,043.07
$1,231.78 		$1,223.99
$1,274.12
$1,327.24
$1,515.95 		$284.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.96
$843.22
$949.46
$1,326.88
$2,016.32 		$1,027.13
$1,127.39
$1,233.63
$1,611.05 		$1,311.30
$1,411.56
$1,517.80
$1,895.22 		$1,595.47
$1,695.73
$1,801.97
$2,179.39 		$284.17
Toc - Plan #34 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 24

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.38
$435.12
$489.95
$684.70
$1,040.46 		$676.66
$728.40
$783.23
$977.98 		$969.94
$1,021.68
$1,076.51
$1,271.26 		$1,263.22
$1,314.96
$1,369.79
$1,564.54 		$293.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.76
$870.24
$979.90
$1,369.40
$2,080.92 		$1,060.04
$1,163.52
$1,273.18
$1,662.68 		$1,353.32
$1,456.80
$1,566.46
$1,955.96 		$1,646.60
$1,750.08
$1,859.74
$2,249.24 		$293.28
Toc - Plan #35 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 29

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.14
$416.70
$469.20
$655.70
$996.40 		$648.00
$697.56
$750.06
$936.56 		$928.86
$978.42
$1,030.92
$1,217.42 		$1,209.72
$1,259.28
$1,311.78
$1,498.28 		$280.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.28
$833.40
$938.40
$1,311.40
$1,992.80 		$1,015.14
$1,114.26
$1,219.26
$1,592.26 		$1,296.00
$1,395.12
$1,500.12
$1,873.12 		$1,576.86
$1,675.98
$1,780.98
$2,153.98 		$280.86
Toc - Plan #36 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 5

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$293.21
$332.78
$374.70
$523.65
$795.73 		$517.50
$557.07
$598.99
$747.94 		$741.79
$781.36
$823.28
$972.23 		$966.08
$1,005.65
$1,047.57
$1,196.52 		$224.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586.42
$665.56
$749.40
$1,047.30
$1,591.46 		$810.71
$889.85
$973.69
$1,271.59 		$1,035.00
$1,114.14
$1,197.98
$1,495.88 		$1,259.29
$1,338.43
$1,422.27
$1,720.17 		$224.29
Toc - Plan #37 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 22

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.55
$355.86
$400.70
$559.97
$850.94 		$553.40
$595.71
$640.55
$799.82 		$793.25
$835.56
$880.40
$1,039.67 		$1,033.10
$1,075.41
$1,120.25
$1,279.52 		$239.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.10
$711.72
$801.40
$1,119.94
$1,701.88 		$866.95
$951.57
$1,041.25
$1,359.79 		$1,106.80
$1,191.42
$1,281.10
$1,599.64 		$1,346.65
$1,431.27
$1,520.95
$1,839.49 		$239.85
Toc - Plan #38 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$322.13
$365.61
$411.67
$575.31
$874.24 		$568.55
$612.03
$658.09
$821.73 		$814.97
$858.45
$904.51
$1,068.15 		$1,061.39
$1,104.87
$1,150.93
$1,314.57 		$246.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.26
$731.22
$823.34
$1,150.62
$1,748.48 		$890.68
$977.64
$1,069.76
$1,397.04 		$1,137.10
$1,224.06
$1,316.18
$1,643.46 		$1,383.52
$1,470.48
$1,562.60
$1,889.88 		$246.42
Toc - Plan #39 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$341.80
$387.93
$436.80
$610.43
$927.61 		$603.27
$649.40
$698.27
$871.90 		$864.74
$910.87
$959.74
$1,133.37 		$1,126.21
$1,172.34
$1,221.21
$1,394.84 		$261.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.60
$775.86
$873.60
$1,220.86
$1,855.22 		$945.07
$1,037.33
$1,135.07
$1,482.33 		$1,206.54
$1,298.80
$1,396.54
$1,743.80 		$1,468.01
$1,560.27
$1,658.01
$2,005.27 		$261.47
Toc - Plan #40 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 30

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.42
$399.98
$450.38
$629.40
$956.43 		$622.01
$669.57
$719.97
$898.99 		$891.60
$939.16
$989.56
$1,168.58 		$1,161.19
$1,208.75
$1,259.15
$1,438.17 		$269.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.84
$799.96
$900.76
$1,258.80
$1,912.86 		$974.43
$1,069.55
$1,170.35
$1,528.39 		$1,244.02
$1,339.14
$1,439.94
$1,797.98 		$1,513.61
$1,608.73
$1,709.53
$2,067.57 		$269.59
Toc - Plan #41 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 31

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$353.17
$400.84
$451.34
$630.74
$958.48 		$623.34
$671.01
$721.51
$900.91 		$893.51
$941.18
$991.68
$1,171.08 		$1,163.68
$1,211.35
$1,261.85
$1,441.25 		$270.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.34
$801.68
$902.68
$1,261.48
$1,916.96 		$976.51
$1,071.85
$1,172.85
$1,531.65 		$1,246.68
$1,342.02
$1,443.02
$1,801.82 		$1,516.85
$1,612.19
$1,713.19
$2,071.99 		$270.17
Toc - Plan #42 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 32

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.05
$407.51
$458.85
$641.24
$974.42 		$633.71
$682.17
$733.51
$915.90 		$908.37
$956.83
$1,008.17
$1,190.56 		$1,183.03
$1,231.49
$1,282.83
$1,465.22 		$274.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.10
$815.02
$917.70
$1,282.48
$1,948.84 		$992.76
$1,089.68
$1,192.36
$1,557.14 		$1,267.42
$1,364.34
$1,467.02
$1,831.80 		$1,542.08
$1,639.00
$1,741.68
$2,106.46 		$274.66
Toc - Plan #43 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 20

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.29
$406.65
$457.89
$639.89
$972.38 		$632.38
$680.74
$731.98
$913.98 		$906.47
$954.83
$1,006.07
$1,188.07 		$1,180.56
$1,228.92
$1,280.16
$1,462.16 		$274.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.58
$813.30
$915.78
$1,279.78
$1,944.76 		$990.67
$1,087.39
$1,189.87
$1,553.87 		$1,264.76
$1,361.48
$1,463.96
$1,827.96 		$1,538.85
$1,635.57
$1,738.05
$2,102.05 		$274.09
Toc - Plan #44 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$384.72
$436.65
$491.67
$687.10
$1,044.12 		$679.03
$730.96
$785.98
$981.41 		$973.34
$1,025.27
$1,080.29
$1,275.72 		$1,267.65
$1,319.58
$1,374.60
$1,570.03 		$294.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.44
$873.30
$983.34
$1,374.20
$2,088.24 		$1,063.75
$1,167.61
$1,277.65
$1,668.51 		$1,358.06
$1,461.92
$1,571.96
$1,962.82 		$1,652.37
$1,756.23
$1,866.27
$2,257.13 		$294.31
Toc - Plan #45 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$306.98
$348.41
$392.31
$548.25
$833.11 		$541.81
$583.24
$627.14
$783.08 		$776.64
$818.07
$861.97
$1,017.91 		$1,011.47
$1,052.90
$1,096.80
$1,252.74 		$234.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.96
$696.82
$784.62
$1,096.50
$1,666.22 		$848.79
$931.65
$1,019.45
$1,331.33 		$1,083.62
$1,166.48
$1,254.28
$1,566.16 		$1,318.45
$1,401.31
$1,489.11
$1,800.99 		$234.83
Toc - Plan #46 Ambetter from Sunshine Health
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$396.78
$450.33
$507.07
$708.63
$1,076.83 		$700.31
$753.86
$810.60
$1,012.16 		$1,003.84
$1,057.39
$1,114.13
$1,315.69 		$1,307.37
$1,360.92
$1,417.66
$1,619.22 		$303.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.56
$900.66
$1,014.14
$1,417.26
$2,153.66 		$1,097.09
$1,204.19
$1,317.67
$1,720.79 		$1,400.62
$1,507.72
$1,621.20
$2,024.32 		$1,704.15
$1,811.25
$1,924.73
$2,327.85 		$303.53
Toc - Plan #47 Ambetter from Sunshine Health
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279.16
$316.84
$356.76
$498.57
$757.62 		$492.71
$530.39
$570.31
$712.12 		$706.26
$743.94
$783.86
$925.67 		$919.81
$957.49
$997.41
$1,139.22 		$213.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558.32
$633.68
$713.52
$997.14
$1,515.24 		$771.87
$847.23
$927.07
$1,210.69 		$985.42
$1,060.78
$1,140.62
$1,424.24 		$1,198.97
$1,274.33
$1,354.17
$1,637.79 		$213.55
Toc - Plan #48 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$390.11
$442.76
$498.55
$696.71
$1,058.73 		$688.53
$741.18
$796.97
$995.13 		$986.95
$1,039.60
$1,095.39
$1,293.55 		$1,285.37
$1,338.02
$1,393.81
$1,591.97 		$298.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.22
$885.52
$997.10
$1,393.42
$2,117.46 		$1,078.64
$1,183.94
$1,295.52
$1,691.84 		$1,377.06
$1,482.36
$1,593.94
$1,990.26 		$1,675.48
$1,780.78
$1,892.36
$2,288.68 		$298.42
Toc - Plan #49 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$397.05
$450.64
$507.42
$709.12
$1,077.57 		$700.79
$754.38
$811.16
$1,012.86 		$1,004.53
$1,058.12
$1,114.90
$1,316.60 		$1,308.27
$1,361.86
$1,418.64
$1,620.34 		$303.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.10
$901.28
$1,014.84
$1,418.24
$2,155.14 		$1,097.84
$1,205.02
$1,318.58
$1,721.98 		$1,401.58
$1,508.76
$1,622.32
$2,025.72 		$1,705.32
$1,812.50
$1,926.06
$2,329.46 		$303.74
Toc - Plan #50 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303.66
$344.65
$388.07
$542.32
$824.11 		$535.95
$576.94
$620.36
$774.61 		$768.24
$809.23
$852.65
$1,006.90 		$1,000.53
$1,041.52
$1,084.94
$1,239.19 		$232.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.32
$689.30
$776.14
$1,084.64
$1,648.22 		$839.61
$921.59
$1,008.43
$1,316.93 		$1,071.90
$1,153.88
$1,240.72
$1,549.22 		$1,304.19
$1,386.17
$1,473.01
$1,781.51 		$232.29
Toc - Plan #51 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.73
$368.55
$414.99
$579.95
$881.28 		$573.14
$616.96
$663.40
$828.36 		$821.55
$865.37
$911.81
$1,076.77 		$1,069.96
$1,113.78
$1,160.22
$1,325.18 		$248.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.46
$737.10
$829.98
$1,159.90
$1,762.56 		$897.87
$985.51
$1,078.39
$1,408.31 		$1,146.28
$1,233.92
$1,326.80
$1,656.72 		$1,394.69
$1,482.33
$1,575.21
$1,905.13 		$248.41
Toc - Plan #52 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$333.62
$378.65
$426.36
$595.83
$905.42 		$588.83
$633.86
$681.57
$851.04 		$844.04
$889.07
$936.78
$1,106.25 		$1,099.25
$1,144.28
$1,191.99
$1,361.46 		$255.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.24
$757.30
$852.72
$1,191.66
$1,810.84 		$922.45
$1,012.51
$1,107.93
$1,446.87 		$1,177.66
$1,267.72
$1,363.14
$1,702.08 		$1,432.87
$1,522.93
$1,618.35
$1,957.29 		$255.21
Toc - Plan #53 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$353.98
$401.76
$452.38
$632.20
$960.69 		$624.77
$672.55
$723.17
$902.99 		$895.56
$943.34
$993.96
$1,173.78 		$1,166.35
$1,214.13
$1,264.75
$1,444.57 		$270.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.96
$803.52
$904.76
$1,264.40
$1,921.38 		$978.75
$1,074.31
$1,175.55
$1,535.19 		$1,249.54
$1,345.10
$1,446.34
$1,805.98 		$1,520.33
$1,615.89
$1,717.13
$2,076.77 		$270.79
Toc - Plan #54 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$365.77
$415.13
$467.44
$653.24
$992.66 		$645.57
$694.93
$747.24
$933.04 		$925.37
$974.73
$1,027.04
$1,212.84 		$1,205.17
$1,254.53
$1,306.84
$1,492.64 		$279.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.54
$830.26
$934.88
$1,306.48
$1,985.32 		$1,011.34
$1,110.06
$1,214.68
$1,586.28 		$1,291.14
$1,389.86
$1,494.48
$1,866.08 		$1,570.94
$1,669.66
$1,774.28
$2,145.88 		$279.80
Toc - Plan #55 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.85
$422.04
$475.21
$664.11
$1,009.18 		$656.31
$706.50
$759.67
$948.57 		$940.77
$990.96
$1,044.13
$1,233.03 		$1,225.23
$1,275.42
$1,328.59
$1,517.49 		$284.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.70
$844.08
$950.42
$1,328.22
$2,018.36 		$1,028.16
$1,128.54
$1,234.88
$1,612.68 		$1,312.62
$1,413.00
$1,519.34
$1,897.14 		$1,597.08
$1,697.46
$1,803.80
$2,181.60 		$284.46
Toc - Plan #56 Ambetter from Sunshine Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.07
$421.15
$474.22
$662.72
$1,007.06 		$654.93
$705.01
$758.08
$946.58 		$938.79
$988.87
$1,041.94
$1,230.44 		$1,222.65
$1,272.73
$1,325.80
$1,514.30 		$283.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.14
$842.30
$948.44
$1,325.44
$2,014.12 		$1,026.00
$1,126.16
$1,232.30
$1,609.30 		$1,309.86
$1,410.02
$1,516.16
$1,893.16 		$1,593.72
$1,693.88
$1,800.02
$2,177.02 		$283.86
Toc - Plan #57 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$380.24
$431.56
$485.93
$679.09
$1,031.94 		$671.11
$722.43
$776.80
$969.96 		$961.98
$1,013.30
$1,067.67
$1,260.83 		$1,252.85
$1,304.17
$1,358.54
$1,551.70 		$290.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.48
$863.12
$971.86
$1,358.18
$2,063.88 		$1,051.35
$1,153.99
$1,262.73
$1,649.05 		$1,342.22
$1,444.86
$1,553.60
$1,939.92 		$1,633.09
$1,735.73
$1,844.47
$2,230.79 		$290.87

ADVERTISEMENT

Florida Blue HMO (a BlueCross BlueShield FL company)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771
Toc - Plan #58 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 1490 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$554.11
$628.91
$708.15
$989.64
$1,503.85 		$978.00
$1,052.80
$1,132.04
$1,413.53 		$1,401.89
$1,476.69
$1,555.93
$1,837.42 		$1,825.78
$1,900.58
$1,979.82
$2,261.31 		$423.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,108.22
$1,257.82
$1,416.30
$1,979.28
$3,007.70 		$1,532.11
$1,681.71
$1,840.19
$2,403.17 		$1,956.00
$2,105.60
$2,264.08
$2,827.06 		$2,379.89
$2,529.49
$2,687.97
$3,250.95 		$423.89
Toc - Plan #59 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) BlueCare Bronze 1486 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.09
$420.05
$472.98
$660.98
$1,004.42 		$653.21
$703.17
$756.10
$944.10 		$936.33
$986.29
$1,039.22
$1,227.22 		$1,219.45
$1,269.41
$1,322.34
$1,510.34 		$283.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.18
$840.10
$945.96
$1,321.96
$2,008.84 		$1,023.30
$1,123.22
$1,229.08
$1,605.08 		$1,306.42
$1,406.34
$1,512.20
$1,888.20 		$1,589.54
$1,689.46
$1,795.32
$2,171.32 		$283.12
Toc - Plan #60 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 1498 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,600 $11,200 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$578.56
$656.67
$739.40
$1,033.31
$1,570.21 		$1,021.16
$1,099.27
$1,182.00
$1,475.91 		$1,463.76
$1,541.87
$1,624.60
$1,918.51 		$1,906.36
$1,984.47
$2,067.20
$2,361.11 		$442.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,157.12
$1,313.34
$1,478.80
$2,066.62
$3,140.42 		$1,599.72
$1,755.94
$1,921.40
$2,509.22 		$2,042.32
$2,198.54
$2,364.00
$2,951.82 		$2,484.92
$2,641.14
$2,806.60
$3,394.42 		$442.60
Toc - Plan #61 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 1485 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$4,250 $8,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$646.04
$733.26
$825.64
$1,153.83
$1,753.35 		$1,140.26
$1,227.48
$1,319.86
$1,648.05 		$1,634.48
$1,721.70
$1,814.08
$2,142.27 		$2,128.70
$2,215.92
$2,308.30
$2,636.49 		$494.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,292.08
$1,466.52
$1,651.28
$2,307.66
$3,506.70 		$1,786.30
$1,960.74
$2,145.50
$2,801.88 		$2,280.52
$2,454.96
$2,639.72
$3,296.10 		$2,774.74
$2,949.18
$3,133.94
$3,790.32 		$494.22
Toc - Plan #62 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 1483 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.68
$464.99
$523.57
$731.69
$1,111.87 		$723.09
$778.40
$836.98
$1,045.10 		$1,036.50
$1,091.81
$1,150.39
$1,358.51 		$1,349.91
$1,405.22
$1,463.80
$1,671.92 		$313.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.36
$929.98
$1,047.14
$1,463.38
$2,223.74 		$1,132.77
$1,243.39
$1,360.55
$1,776.79 		$1,446.18
$1,556.80
$1,673.96
$2,090.20 		$1,759.59
$1,870.21
$1,987.37
$2,403.61 		$313.41
Toc - Plan #63 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 1491 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$693.22
$786.80
$885.94
$1,238.09
$1,881.40 		$1,223.53
$1,317.11
$1,416.25
$1,768.40 		$1,753.84
$1,847.42
$1,946.56
$2,298.71 		$2,284.15
$2,377.73
$2,476.87
$2,829.02 		$530.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,386.44
$1,573.60
$1,771.88
$2,476.18
$3,762.80 		$1,916.75
$2,103.91
$2,302.19
$3,006.49 		$2,447.06
$2,634.22
$2,832.50
$3,536.80 		$2,977.37
$3,164.53
$3,362.81
$4,067.11 		$530.31
Toc - Plan #64 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 1477 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$499.76
$567.23
$638.69
$892.57
$1,356.35 		$882.08
$949.55
$1,021.01
$1,274.89 		$1,264.40
$1,331.87
$1,403.33
$1,657.21 		$1,646.72
$1,714.19
$1,785.65
$2,039.53 		$382.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$999.52
$1,134.46
$1,277.38
$1,785.14
$2,712.70 		$1,381.84
$1,516.78
$1,659.70
$2,167.46 		$1,764.16
$1,899.10
$2,042.02
$2,549.78 		$2,146.48
$2,281.42
$2,424.34
$2,932.10 		$382.32
Toc - Plan #65 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 1565 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$596.32
$676.82
$762.10
$1,065.03
$1,618.41 		$1,052.50
$1,133.00
$1,218.28
$1,521.21 		$1,508.68
$1,589.18
$1,674.46
$1,977.39 		$1,964.86
$2,045.36
$2,130.64
$2,433.57 		$456.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,192.64
$1,353.64
$1,524.20
$2,130.06
$3,236.82 		$1,648.82
$1,809.82
$1,980.38
$2,586.24 		$2,105.00
$2,266.00
$2,436.56
$3,042.42 		$2,561.18
$2,722.18
$2,892.74
$3,498.60 		$456.18
Toc - Plan #66 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$391.28
$444.10
$500.06
$698.83
$1,061.93 		$690.61
$743.43
$799.39
$998.16 		$989.94
$1,042.76
$1,098.72
$1,297.49 		$1,289.27
$1,342.09
$1,398.05
$1,596.82 		$299.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.56
$888.20
$1,000.12
$1,397.66
$2,123.86 		$1,081.89
$1,187.53
$1,299.45
$1,696.99 		$1,381.22
$1,486.86
$1,598.78
$1,996.32 		$1,680.55
$1,786.19
$1,898.11
$2,295.65 		$299.33
Toc - Plan #67 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 1766S ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$568.43
$645.17
$726.45
$1,015.22
$1,542.72 		$1,003.28
$1,080.02
$1,161.30
$1,450.07 		$1,438.13
$1,514.87
$1,596.15
$1,884.92 		$1,872.98
$1,949.72
$2,031.00
$2,319.77 		$434.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,136.86
$1,290.34
$1,452.90
$2,030.44
$3,085.44 		$1,571.71
$1,725.19
$1,887.75
$2,465.29 		$2,006.56
$2,160.04
$2,322.60
$2,900.14 		$2,441.41
$2,594.89
$2,757.45
$3,334.99 		$434.85
Toc - Plan #68 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 1767S ($0 Virtual Visits / $40 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408.18
$463.28
$521.65
$729.01
$1,107.80 		$720.44
$775.54
$833.91
$1,041.27 		$1,032.70
$1,087.80
$1,146.17
$1,353.53 		$1,344.96
$1,400.06
$1,458.43
$1,665.79 		$312.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.36
$926.56
$1,043.30
$1,458.02
$2,215.60 		$1,128.62
$1,238.82
$1,355.56
$1,770.28 		$1,440.88
$1,551.08
$1,667.82
$2,082.54 		$1,753.14
$1,863.34
$1,980.08
$2,394.80 		$312.26
Toc - Plan #69 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 1865 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$569.92
$646.86
$728.36
$1,017.88
$1,546.76 		$1,005.91
$1,082.85
$1,164.35
$1,453.87 		$1,441.90
$1,518.84
$1,600.34
$1,889.86 		$1,877.89
$1,954.83
$2,036.33
$2,325.85 		$435.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,139.84
$1,293.72
$1,456.72
$2,035.76
$3,093.52 		$1,575.83
$1,729.71
$1,892.71
$2,471.75 		$2,011.82
$2,165.70
$2,328.70
$2,907.74 		$2,447.81
$2,601.69
$2,764.69
$3,343.73 		$435.99
Toc - Plan #70 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2179 ($0 Deductible / $35 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$445.30
$505.42
$569.09
$795.31
$1,208.54 		$785.95
$846.07
$909.74
$1,135.96 		$1,126.60
$1,186.72
$1,250.39
$1,476.61 		$1,467.25
$1,527.37
$1,591.04
$1,817.26 		$340.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.60
$1,010.84
$1,138.18
$1,590.62
$2,417.08 		$1,231.25
$1,351.49
$1,478.83
$1,931.27 		$1,571.90
$1,692.14
$1,819.48
$2,271.92 		$1,912.55
$2,032.79
$2,160.13
$2,612.57 		$340.65

ADVERTISEMENT

Health First Commercial Plans, Inc.

Local: 1-855-443-4735 | Toll Free: 1-855-443-4735 | TTY: 1-800-955-8771
Toc - Plan #71 Health First Commercial Plans, Inc.
Gold

(HMO) AdventHealth GYM ACCESS Gold HMO 90 HSA 1745

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$1,700 $3,400 Annual Deductible
$4,000 $8,000 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 		$443.85
$503.77
$567.25
$792.72
$1,204.62 		$783.40
$843.32
$906.80
$1,132.27 		$1,122.95
$1,182.87
$1,246.35
$1,471.82 		$1,462.50
$1,522.42
$1,585.90
$1,811.37 		$339.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.70
$1,007.54
$1,134.50
$1,585.44
$2,409.24 		$1,227.25
$1,347.09
$1,474.05
$1,924.99 		$1,566.80
$1,686.64
$1,813.60
$2,264.54 		$1,906.35
$2,026.19
$2,153.15
$2,604.09 		$339.55
Toc - Plan #72 Health First Commercial Plans, Inc.
Silver

(HMO) AdventHealth GYM ACCESS Silver HMO 80 1696

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$4,950 $9,900 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 		$406.97
$461.91
$520.11
$726.85
$1,104.52 		$718.30
$773.24
$831.44
$1,038.18 		$1,029.63
$1,084.57
$1,142.77
$1,349.51 		$1,340.96
$1,395.90
$1,454.10
$1,660.84 		$311.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.94
$923.82
$1,040.22
$1,453.70
$2,209.04 		$1,125.27
$1,235.15
$1,351.55
$1,765.03 		$1,436.60
$1,546.48
$1,662.88
$2,076.36 		$1,747.93
$1,857.81
$1,974.21
$2,387.69 		$311.33
Toc - Plan #73 Health First Commercial Plans, Inc.
Catastrophic

(HMO) AdventHealth GYM ACCESS Catastrophic HMO 1748

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

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 		$163.69
$185.79
$209.20
$292.35
$444.25 		$288.91
$311.01
$334.42
$417.57 		$414.13
$436.23
$459.64
$542.79 		$539.35
$561.45
$584.86
$668.01 		$125.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$327.38
$371.58
$418.40
$584.70
$888.50 		$452.60
$496.80
$543.62
$709.92 		$577.82
$622.02
$668.84
$835.14 		$703.04
$747.24
$794.06
$960.36 		$125.22
Toc - Plan #74 Health First Commercial Plans, Inc.
Gold

(HMO) AdventHealth GYM ACCESS Gold HMO 70 1743

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,250 $14,500 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 		$447.25
$507.63
$571.59
$798.79
$1,213.84 		$789.40
$849.78
$913.74
$1,140.94 		$1,131.55
$1,191.93
$1,255.89
$1,483.09 		$1,473.70
$1,534.08
$1,598.04
$1,825.24 		$342.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.50
$1,015.26
$1,143.18
$1,597.58
$2,427.68 		$1,236.65
$1,357.41
$1,485.33
$1,939.73 		$1,578.80
$1,699.56
$1,827.48
$2,281.88 		$1,920.95
$2,041.71
$2,169.63
$2,624.03 		$342.15
Toc - Plan #75 Health First Commercial Plans, Inc.
Gold

(HMO) AdventHealth GYM ACCESS Gold HMO 100 1738

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$2,650 $5,300 Annual Deductible
$6,800 $13,600 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 		$443.63
$503.52
$566.96
$792.33
$1,204.02 		$783.01
$842.90
$906.34
$1,131.71 		$1,122.39
$1,182.28
$1,245.72
$1,471.09 		$1,461.77
$1,521.66
$1,585.10
$1,810.47 		$339.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.26
$1,007.04
$1,133.92
$1,584.66
$2,408.04 		$1,226.64
$1,346.42
$1,473.30
$1,924.04 		$1,566.02
$1,685.80
$1,812.68
$2,263.42 		$1,905.40
$2,025.18
$2,152.06
$2,602.80 		$339.38
Toc - Plan #76 Health First Commercial Plans, Inc.
Gold

(HMO) AdventHealth GYM ACCESS Gold HMO 80 1741

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$428.38
$486.21
$547.47
$765.09
$1,162.63 		$756.09
$813.92
$875.18
$1,092.80 		$1,083.80
$1,141.63
$1,202.89
$1,420.51 		$1,411.51
$1,469.34
$1,530.60
$1,748.22 		$327.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.76
$972.42
$1,094.94
$1,530.18
$2,325.26 		$1,184.47
$1,300.13
$1,422.65
$1,857.89 		$1,512.18
$1,627.84
$1,750.36
$2,185.60 		$1,839.89
$1,955.55
$2,078.07
$2,513.31 		$327.71
Toc - Plan #77 Health First Commercial Plans, Inc.
Silver

(HMO) AdventHealth GYM ACCESS Silver HMO 100 1668

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

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 		$419.82
$476.50
$536.53
$749.80
$1,139.40 		$740.98
$797.66
$857.69
$1,070.96 		$1,062.14
$1,118.82
$1,178.85
$1,392.12 		$1,383.30
$1,439.98
$1,500.01
$1,713.28 		$321.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.64
$953.00
$1,073.06
$1,499.60
$2,278.80 		$1,160.80
$1,274.16
$1,394.22
$1,820.76 		$1,481.96
$1,595.32
$1,715.38
$2,141.92 		$1,803.12
$1,916.48
$2,036.54
$2,463.08 		$321.16
Toc - Plan #78 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) AdventHealth GYM ACCESS Bronze HMO 100 HSA 1660

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

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 		$295.60
$335.50
$377.77
$527.93
$802.25 		$521.73
$561.63
$603.90
$754.06 		$747.86
$787.76
$830.03
$980.19 		$973.99
$1,013.89
$1,056.16
$1,206.32 		$226.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591.20
$671.00
$755.54
$1,055.86
$1,604.50 		$817.33
$897.13
$981.67
$1,281.99 		$1,043.46
$1,123.26
$1,207.80
$1,508.12 		$1,269.59
$1,349.39
$1,433.93
$1,734.25 		$226.13
Toc - Plan #79 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) AdventHealthGYM ACCESS Bronze HMO 50 1797

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 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 		$285.25
$323.76
$364.55
$509.46
$774.17 		$503.47
$541.98
$582.77
$727.68 		$721.69
$760.20
$800.99
$945.90 		$939.91
$978.42
$1,019.21
$1,164.12 		$218.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.50
$647.52
$729.10
$1,018.92
$1,548.34 		$788.72
$865.74
$947.32
$1,237.14 		$1,006.94
$1,083.96
$1,165.54
$1,455.36 		$1,225.16
$1,302.18
$1,383.76
$1,673.58 		$218.22
Toc - Plan #80 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) AdventHealth GYM ACCESS Bronze HMO 60 1657

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 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 		$292.65
$332.15
$374.00
$522.67
$794.24 		$516.52
$556.02
$597.87
$746.54 		$740.39
$779.89
$821.74
$970.41 		$964.26
$1,003.76
$1,045.61
$1,194.28 		$223.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.30
$664.30
$748.00
$1,045.34
$1,588.48 		$809.17
$888.17
$971.87
$1,269.21 		$1,033.04
$1,112.04
$1,195.74
$1,493.08 		$1,256.91
$1,335.91
$1,419.61
$1,716.95 		$223.87
Toc - Plan #81 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) AdventHealth Bronze HMO 60 1752

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.05
$326.93
$368.12
$514.45
$781.75 		$508.40
$547.28
$588.47
$734.80 		$728.75
$767.63
$808.82
$955.15 		$949.10
$987.98
$1,029.17
$1,175.50 		$220.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.10
$653.86
$736.24
$1,028.90
$1,563.50 		$796.45
$874.21
$956.59
$1,249.25 		$1,016.80
$1,094.56
$1,176.94
$1,469.60 		$1,237.15
$1,314.91
$1,397.29
$1,689.95 		$220.35
Toc - Plan #82 Health First Commercial Plans, Inc.
Gold

(HMO) AdventHealth Gold HMO 80 1772

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 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 		$428.76
$486.64
$547.95
$765.76
$1,163.64 		$756.76
$814.64
$875.95
$1,093.76 		$1,084.76
$1,142.64
$1,203.95
$1,421.76 		$1,412.76
$1,470.64
$1,531.95
$1,749.76 		$328.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.52
$973.28
$1,095.90
$1,531.52
$2,327.28 		$1,185.52
$1,301.28
$1,423.90
$1,859.52 		$1,513.52
$1,629.28
$1,751.90
$2,187.52 		$1,841.52
$1,957.28
$2,079.90
$2,515.52 		$328.00
Toc - Plan #83 Health First Commercial Plans, Inc.
Bronze

(HMO) AdventHealth Bronze HMO 100 1776

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279.01
$316.67
$356.57
$498.31
$757.23 		$492.45
$530.11
$570.01
$711.75 		$705.89
$743.55
$783.45
$925.19 		$919.33
$956.99
$996.89
$1,138.63 		$213.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558.02
$633.34
$713.14
$996.62
$1,514.46 		$771.46
$846.78
$926.58
$1,210.06 		$984.90
$1,060.22
$1,140.02
$1,423.50 		$1,198.34
$1,273.66
$1,353.46
$1,636.94 		$213.44
Toc - Plan #84 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) AdventHealth Bronze HMO 100 HSA 1795

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

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 		$292.38
$331.85
$373.66
$522.19
$793.52 		$516.05
$555.52
$597.33
$745.86 		$739.72
$779.19
$821.00
$969.53 		$963.39
$1,002.86
$1,044.67
$1,193.20 		$223.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.76
$663.70
$747.32
$1,044.38
$1,587.04 		$808.43
$887.37
$970.99
$1,268.05 		$1,032.10
$1,111.04
$1,194.66
$1,491.72 		$1,255.77
$1,334.71
$1,418.33
$1,715.39 		$223.67
Toc - Plan #85 Health First Commercial Plans, Inc.
Silver

(HMO) AdventHealth Silver HMO 65 1810

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375.71
$426.43
$480.15
$671.01
$1,019.67 		$663.13
$713.85
$767.57
$958.43 		$950.55
$1,001.27
$1,054.99
$1,245.85 		$1,237.97
$1,288.69
$1,342.41
$1,533.27 		$287.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.42
$852.86
$960.30
$1,342.02
$2,039.34 		$1,038.84
$1,140.28
$1,247.72
$1,629.44 		$1,326.26
$1,427.70
$1,535.14
$1,916.86 		$1,613.68
$1,715.12
$1,822.56
$2,204.28 		$287.42
Toc - Plan #86 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) AdventHealth Bronze VALUE RX 50 1820

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$271.07
$307.66
$346.42
$484.12
$735.67 		$478.44
$515.03
$553.79
$691.49 		$685.81
$722.40
$761.16
$898.86 		$893.18
$929.77
$968.53
$1,106.23 		$207.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$542.14
$615.32
$692.84
$968.24
$1,471.34 		$749.51
$822.69
$900.21
$1,175.61 		$956.88
$1,030.06
$1,107.58
$1,382.98 		$1,164.25
$1,237.43
$1,314.95
$1,590.35 		$207.37
Toc - Plan #87 Health First Commercial Plans, Inc.
Silver

(HMO) AdventHealth Silver VALUE RX 80 1821

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$7,100 $14,200 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 		$361.73
$410.56
$462.29
$646.05
$981.73 		$638.45
$687.28
$739.01
$922.77 		$915.17
$964.00
$1,015.73
$1,199.49 		$1,191.89
$1,240.72
$1,292.45
$1,476.21 		$276.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.46
$821.12
$924.58
$1,292.10
$1,963.46 		$1,000.18
$1,097.84
$1,201.30
$1,568.82 		$1,276.90
$1,374.56
$1,478.02
$1,845.54 		$1,553.62
$1,651.28
$1,754.74
$2,122.26 		$276.72
Toc - Plan #88 Health First Commercial Plans, Inc.
Gold

(HMO) AdventHealth Gold VALUE RX 75 1825

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$387.44
$439.75
$495.15
$691.97
$1,051.52 		$683.83
$736.14
$791.54
$988.36 		$980.22
$1,032.53
$1,087.93
$1,284.75 		$1,276.61
$1,328.92
$1,384.32
$1,581.14 		$296.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.88
$879.50
$990.30
$1,383.94
$2,103.04 		$1,071.27
$1,175.89
$1,286.69
$1,680.33 		$1,367.66
$1,472.28
$1,583.08
$1,976.72 		$1,664.05
$1,768.67
$1,879.47
$2,273.11 		$296.39

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #89 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.41
$319.39
$359.63
$502.58
$763.72 		$496.68
$534.66
$574.90
$717.85 		$711.95
$749.93
$790.17
$933.12 		$927.22
$965.20
$1,005.44
$1,148.39 		$215.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.82
$638.78
$719.26
$1,005.16
$1,527.44 		$778.09
$854.05
$934.53
$1,220.43 		$993.36
$1,069.32
$1,149.80
$1,435.70 		$1,208.63
$1,284.59
$1,365.07
$1,650.97 		$215.27
Toc - Plan #90 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$289.17
$328.20
$369.55
$516.44
$784.78 		$510.38
$549.41
$590.76
$737.65 		$731.59
$770.62
$811.97
$958.86 		$952.80
$991.83
$1,033.18
$1,180.07 		$221.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.34
$656.40
$739.10
$1,032.88
$1,569.56 		$799.55
$877.61
$960.31
$1,254.09 		$1,020.76
$1,098.82
$1,181.52
$1,475.30 		$1,241.97
$1,320.03
$1,402.73
$1,696.51 		$221.21
Toc - Plan #91 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282.18
$320.26
$360.61
$503.95
$765.80 		$498.04
$536.12
$576.47
$719.81 		$713.90
$751.98
$792.33
$935.67 		$929.76
$967.84
$1,008.19
$1,151.53 		$215.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.36
$640.52
$721.22
$1,007.90
$1,531.60 		$780.22
$856.38
$937.08
$1,223.76 		$996.08
$1,072.24
$1,152.94
$1,439.62 		$1,211.94
$1,288.10
$1,368.80
$1,655.48 		$215.86
Toc - Plan #92 Oscar Insurance Company of Florida
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$329.39
$373.85
$420.95
$588.28
$893.95 		$581.37
$625.83
$672.93
$840.26 		$833.35
$877.81
$924.91
$1,092.24 		$1,085.33
$1,129.79
$1,176.89
$1,344.22 		$251.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658.78
$747.70
$841.90
$1,176.56
$1,787.90 		$910.76
$999.68
$1,093.88
$1,428.54 		$1,162.74
$1,251.66
$1,345.86
$1,680.52 		$1,414.72
$1,503.64
$1,597.84
$1,932.50 		$251.98
Toc - Plan #93 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.17
$415.59
$467.95
$653.96
$993.76 		$646.28
$695.70
$748.06
$934.07 		$926.39
$975.81
$1,028.17
$1,214.18 		$1,206.50
$1,255.92
$1,308.28
$1,494.29 		$280.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.34
$831.18
$935.90
$1,307.92
$1,987.52 		$1,012.45
$1,111.29
$1,216.01
$1,588.03 		$1,292.56
$1,391.40
$1,496.12
$1,868.14 		$1,572.67
$1,671.51
$1,776.23
$2,148.25 		$280.11
Toc - Plan #94 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.22
$413.38
$465.46
$650.48
$988.47 		$642.84
$692.00
$744.08
$929.10 		$921.46
$970.62
$1,022.70
$1,207.72 		$1,200.08
$1,249.24
$1,301.32
$1,486.34 		$278.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.44
$826.76
$930.92
$1,300.96
$1,976.94 		$1,007.06
$1,105.38
$1,209.54
$1,579.58 		$1,285.68
$1,384.00
$1,488.16
$1,858.20 		$1,564.30
$1,662.62
$1,766.78
$2,136.82 		$278.62
Toc - Plan #95 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.49
$415.95
$468.36
$654.53
$994.62 		$646.85
$696.31
$748.72
$934.89 		$927.21
$976.67
$1,029.08
$1,215.25 		$1,207.57
$1,257.03
$1,309.44
$1,495.61 		$280.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.98
$831.90
$936.72
$1,309.06
$1,989.24 		$1,013.34
$1,112.26
$1,217.08
$1,589.42 		$1,293.70
$1,392.62
$1,497.44
$1,869.78 		$1,574.06
$1,672.98
$1,777.80
$2,150.14 		$280.36
Toc - Plan #96 Oscar Insurance Company of Florida
Catastrophic

(EPO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$218.40
$247.87
$279.10
$390.04
$592.70 		$385.47
$414.94
$446.17
$557.11 		$552.54
$582.01
$613.24
$724.18 		$719.61
$749.08
$780.31
$891.25 		$167.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$436.80
$495.74
$558.20
$780.08
$1,185.40 		$603.87
$662.81
$725.27
$947.15 		$770.94
$829.88
$892.34
$1,114.22 		$938.01
$996.95
$1,059.41
$1,281.29 		$167.07
Toc - Plan #97 Oscar Insurance Company of Florida
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$329.56
$374.04
$421.17
$588.58
$894.40 		$581.67
$626.15
$673.28
$840.69 		$833.78
$878.26
$925.39
$1,092.80 		$1,085.89
$1,130.37
$1,177.50
$1,344.91 		$252.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.12
$748.08
$842.34
$1,177.16
$1,788.80 		$911.23
$1,000.19
$1,094.45
$1,429.27 		$1,163.34
$1,252.30
$1,346.56
$1,681.38 		$1,415.45
$1,504.41
$1,598.67
$1,933.49 		$252.11
Toc - Plan #98 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$392.78
$445.80
$501.97
$701.50
$1,065.99 		$693.25
$746.27
$802.44
$1,001.97 		$993.72
$1,046.74
$1,102.91
$1,302.44 		$1,294.19
$1,347.21
$1,403.38
$1,602.91 		$300.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.56
$891.60
$1,003.94
$1,403.00
$2,131.98 		$1,086.03
$1,192.07
$1,304.41
$1,703.47 		$1,386.50
$1,492.54
$1,604.88
$2,003.94 		$1,686.97
$1,793.01
$1,905.35
$2,304.41 		$300.47
Toc - Plan #99 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$304.20
$345.26
$388.76
$543.28
$825.57 		$536.91
$577.97
$621.47
$775.99 		$769.62
$810.68
$854.18
$1,008.70 		$1,002.33
$1,043.39
$1,086.89
$1,241.41 		$232.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.40
$690.52
$777.52
$1,086.56
$1,651.14 		$841.11
$923.23
$1,010.23
$1,319.27 		$1,073.82
$1,155.94
$1,242.94
$1,551.98 		$1,306.53
$1,388.65
$1,475.65
$1,784.69 		$232.71
Toc - Plan #100 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.19
$412.21
$464.14
$648.64
$985.67 		$641.02
$690.04
$741.97
$926.47 		$918.85
$967.87
$1,019.80
$1,204.30 		$1,196.68
$1,245.70
$1,297.63
$1,482.13 		$277.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.38
$824.42
$928.28
$1,297.28
$1,971.34 		$1,004.21
$1,102.25
$1,206.11
$1,575.11 		$1,282.04
$1,380.08
$1,483.94
$1,852.94 		$1,559.87
$1,657.91
$1,761.77
$2,130.77 		$277.83
Toc - Plan #101 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.81
$420.86
$473.89
$662.26
$1,006.36 		$654.47
$704.52
$757.55
$945.92 		$938.13
$988.18
$1,041.21
$1,229.58 		$1,221.79
$1,271.84
$1,324.87
$1,513.24 		$283.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.62
$841.72
$947.78
$1,324.52
$2,012.72 		$1,025.28
$1,125.38
$1,231.44
$1,608.18 		$1,308.94
$1,409.04
$1,515.10
$1,891.84 		$1,592.60
$1,692.70
$1,798.76
$2,175.50 		$283.66
Toc - Plan #102 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$373.07
$423.42
$476.77
$666.28
$1,012.47 		$658.46
$708.81
$762.16
$951.67 		$943.85
$994.20
$1,047.55
$1,237.06 		$1,229.24
$1,279.59
$1,332.94
$1,522.45 		$285.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.14
$846.84
$953.54
$1,332.56
$2,024.94 		$1,031.53
$1,132.23
$1,238.93
$1,617.95 		$1,316.92
$1,417.62
$1,524.32
$1,903.34 		$1,602.31
$1,703.01
$1,809.71
$2,188.73 		$285.39
Toc - Plan #103 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- Low Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.75
$446.90
$503.20
$703.22
$1,068.61 		$694.96
$748.11
$804.41
$1,004.43 		$996.17
$1,049.32
$1,105.62
$1,305.64 		$1,297.38
$1,350.53
$1,406.83
$1,606.85 		$301.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.50
$893.80
$1,006.40
$1,406.44
$2,137.22 		$1,088.71
$1,195.01
$1,307.61
$1,707.65 		$1,389.92
$1,496.22
$1,608.82
$2,008.86 		$1,691.13
$1,797.43
$1,910.03
$2,310.07 		$301.21
Toc - Plan #104 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$296.94
$337.02
$379.48
$530.32
$805.88 		$524.09
$564.17
$606.63
$757.47 		$751.24
$791.32
$833.78
$984.62 		$978.39
$1,018.47
$1,060.93
$1,211.77 		$227.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$593.88
$674.04
$758.96
$1,060.64
$1,611.76 		$821.03
$901.19
$986.11
$1,287.79 		$1,048.18
$1,128.34
$1,213.26
$1,514.94 		$1,275.33
$1,355.49
$1,440.41
$1,742.09 		$227.15
Toc - Plan #105 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.42
$359.12
$404.37
$565.10
$858.73 		$558.47
$601.17
$646.42
$807.15 		$800.52
$843.22
$888.47
$1,049.20 		$1,042.57
$1,085.27
$1,130.52
$1,291.25 		$242.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.84
$718.24
$808.74
$1,130.20
$1,717.46 		$874.89
$960.29
$1,050.79
$1,372.25 		$1,116.94
$1,202.34
$1,292.84
$1,614.30 		$1,358.99
$1,444.39
$1,534.89
$1,856.35 		$242.05
Toc - Plan #106 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.22
$343.01
$386.23
$539.75
$820.20 		$533.41
$574.20
$617.42
$770.94 		$764.60
$805.39
$848.61
$1,002.13 		$995.79
$1,036.58
$1,079.80
$1,233.32 		$231.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.44
$686.02
$772.46
$1,079.50
$1,640.40 		$835.63
$917.21
$1,003.65
$1,310.69 		$1,066.82
$1,148.40
$1,234.84
$1,541.88 		$1,298.01
$1,379.59
$1,466.03
$1,773.07 		$231.19
Toc - Plan #107 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.26
$408.88
$460.39
$643.40
$977.71 		$635.85
$684.47
$735.98
$918.99 		$911.44
$960.06
$1,011.57
$1,194.58 		$1,187.03
$1,235.65
$1,287.16
$1,470.17 		$275.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.52
$817.76
$920.78
$1,286.80
$1,955.42 		$996.11
$1,093.35
$1,196.37
$1,562.39 		$1,271.70
$1,368.94
$1,471.96
$1,837.98 		$1,547.29
$1,644.53
$1,747.55
$2,113.57 		$275.59
Toc - Plan #108 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- Low Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$365.30
$414.60
$466.84
$652.40
$991.39 		$644.75
$694.05
$746.29
$931.85 		$924.20
$973.50
$1,025.74
$1,211.30 		$1,203.65
$1,252.95
$1,305.19
$1,490.75 		$279.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.60
$829.20
$933.68
$1,304.80
$1,982.78 		$1,010.05
$1,108.65
$1,213.13
$1,584.25 		$1,289.50
$1,388.10
$1,492.58
$1,863.70 		$1,568.95
$1,667.55
$1,772.03
$2,143.15 		$279.45
Toc - Plan #109 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- $0 PCP

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$374.64
$425.21
$478.78
$669.09
$1,016.75 		$661.23
$711.80
$765.37
$955.68 		$947.82
$998.39
$1,051.96
$1,242.27 		$1,234.41
$1,284.98
$1,338.55
$1,528.86 		$286.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.28
$850.42
$957.56
$1,338.18
$2,033.50 		$1,035.87
$1,137.01
$1,244.15
$1,624.77 		$1,322.46
$1,423.60
$1,530.74
$1,911.36 		$1,609.05
$1,710.19
$1,817.33
$2,197.95 		$286.59
Toc - Plan #110 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$369.43
$419.29
$472.11
$659.78
$1,002.59 		$652.03
$701.89
$754.71
$942.38 		$934.63
$984.49
$1,037.31
$1,224.98 		$1,217.23
$1,267.09
$1,319.91
$1,507.58 		$282.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.86
$838.58
$944.22
$1,319.56
$2,005.18 		$1,021.46
$1,121.18
$1,226.82
$1,602.16 		$1,304.06
$1,403.78
$1,509.42
$1,884.76 		$1,586.66
$1,686.38
$1,792.02
$2,167.36 		$282.60
Toc - Plan #111 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.58
$416.06
$468.48
$654.70
$994.88 		$647.01
$696.49
$748.91
$935.13 		$927.44
$976.92
$1,029.34
$1,215.56 		$1,207.87
$1,257.35
$1,309.77
$1,495.99 		$280.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.16
$832.12
$936.96
$1,309.40
$1,989.76 		$1,013.59
$1,112.55
$1,217.39
$1,589.83 		$1,294.02
$1,392.98
$1,497.82
$1,870.26 		$1,574.45
$1,673.41
$1,778.25
$2,150.69 		$280.43
Toc - Plan #112 Oscar Insurance Company of Florida
Gold

(EPO) Gold Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$378.61
$429.72
$483.86
$676.19
$1,027.53 		$668.24
$719.35
$773.49
$965.82 		$957.87
$1,008.98
$1,063.12
$1,255.45 		$1,247.50
$1,298.61
$1,352.75
$1,545.08 		$289.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.22
$859.44
$967.72
$1,352.38
$2,055.06 		$1,046.85
$1,149.07
$1,257.35
$1,642.01 		$1,336.48
$1,438.70
$1,546.98
$1,931.64 		$1,626.11
$1,728.33
$1,836.61
$2,221.27 		$289.63
Toc - Plan #113 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- $0 PCP

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$385.04
$437.01
$492.07
$687.67
$1,044.98 		$679.59
$731.56
$786.62
$982.22 		$974.14
$1,026.11
$1,081.17
$1,276.77 		$1,268.69
$1,320.66
$1,375.72
$1,571.32 		$294.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.08
$874.02
$984.14
$1,375.34
$2,089.96 		$1,064.63
$1,168.57
$1,278.69
$1,669.89 		$1,359.18
$1,463.12
$1,573.24
$1,964.44 		$1,653.73
$1,757.67
$1,867.79
$2,258.99 		$294.55
Toc - Plan #114 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$422.89
$479.97
$540.45
$755.27
$1,147.71 		$746.40
$803.48
$863.96
$1,078.78 		$1,069.91
$1,126.99
$1,187.47
$1,402.29 		$1,393.42
$1,450.50
$1,510.98
$1,725.80 		$323.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.78
$959.94
$1,080.90
$1,510.54
$2,295.42 		$1,169.29
$1,283.45
$1,404.41
$1,834.05 		$1,492.80
$1,606.96
$1,727.92
$2,157.56 		$1,816.31
$1,930.47
$2,051.43
$2,481.07 		$323.51
Toc - Plan #115 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.66
$455.87
$513.30
$717.34
$1,090.07 		$708.92
$763.13
$820.56
$1,024.60 		$1,016.18
$1,070.39
$1,127.82
$1,331.86 		$1,323.44
$1,377.65
$1,435.08
$1,639.12 		$307.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.32
$911.74
$1,026.60
$1,434.68
$2,180.14 		$1,110.58
$1,219.00
$1,333.86
$1,741.94 		$1,417.84
$1,526.26
$1,641.12
$2,049.20 		$1,725.10
$1,833.52
$1,948.38
$2,356.46 		$307.26
Toc - Plan #116 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$377.61
$428.58
$482.57
$674.40
$1,024.81 		$666.47
$717.44
$771.43
$963.26 		$955.33
$1,006.30
$1,060.29
$1,252.12 		$1,244.19
$1,295.16
$1,349.15
$1,540.98 		$288.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.22
$857.16
$965.14
$1,348.80
$2,049.62 		$1,044.08
$1,146.02
$1,254.00
$1,637.66 		$1,332.94
$1,434.88
$1,542.86
$1,926.52 		$1,621.80
$1,723.74
$1,831.72
$2,215.38 		$288.86
Toc - Plan #117 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- $4000 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317.93
$360.84
$406.31
$567.81
$862.84 		$561.14
$604.05
$649.52
$811.02 		$804.35
$847.26
$892.73
$1,054.23 		$1,047.56
$1,090.47
$1,135.94
$1,297.44 		$243.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.86
$721.68
$812.62
$1,135.62
$1,725.68 		$879.07
$964.89
$1,055.83
$1,378.83 		$1,122.28
$1,208.10
$1,299.04
$1,622.04 		$1,365.49
$1,451.31
$1,542.25
$1,865.25 		$243.21
Toc - Plan #118 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- $1000 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.16
$369.05
$415.55
$580.73
$882.47 		$573.90
$617.79
$664.29
$829.47 		$822.64
$866.53
$913.03
$1,078.21 		$1,071.38
$1,115.27
$1,161.77
$1,326.95 		$248.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.32
$738.10
$831.10
$1,161.46
$1,764.94 		$899.06
$986.84
$1,079.84
$1,410.20 		$1,147.80
$1,235.58
$1,328.58
$1,658.94 		$1,396.54
$1,484.32
$1,577.32
$1,907.68 		$248.74
Toc - Plan #119 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$326.22
$370.25
$416.90
$582.61
$885.34 		$575.77
$619.80
$666.45
$832.16 		$825.32
$869.35
$916.00
$1,081.71 		$1,074.87
$1,118.90
$1,165.55
$1,331.26 		$249.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.44
$740.50
$833.80
$1,165.22
$1,770.68 		$901.99
$990.05
$1,083.35
$1,414.77 		$1,151.54
$1,239.60
$1,332.90
$1,664.32 		$1,401.09
$1,489.15
$1,582.45
$1,913.87 		$249.55
Toc - Plan #120 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$365.27
$414.58
$466.81
$652.36
$991.33 		$644.70
$694.01
$746.24
$931.79 		$924.13
$973.44
$1,025.67
$1,211.22 		$1,203.56
$1,252.87
$1,305.10
$1,490.65 		$279.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.54
$829.16
$933.62
$1,304.72
$1,982.66 		$1,009.97
$1,108.59
$1,213.05
$1,584.15 		$1,289.40
$1,388.02
$1,492.48
$1,863.58 		$1,568.83
$1,667.45
$1,771.91
$2,143.01 		$279.43

ADVERTISEMENT

Florida Health Care Plans

Local: 1-386-676-7110 | Toll Free: 1-800-232-0578 | TTY: 1-800-955-8771
Toc - Plan #121 Florida Health Care Plans
Catastrophic

(HMO) Gym Access IND Essential Plus Catastrophic HMO 36

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$220.79
$250.60
$282.17
$394.33
$599.22 		$389.69
$419.50
$451.07
$563.23 		$558.59
$588.40
$619.97
$732.13 		$727.49
$757.30
$788.87
$901.03 		$168.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$441.58
$501.20
$564.34
$788.66
$1,198.44 		$610.48
$670.10
$733.24
$957.56 		$779.38
$839.00
$902.14
$1,126.46 		$948.28
$1,007.90
$1,071.04
$1,295.36 		$168.90
Toc - Plan #122 Florida Health Care Plans
Catastrophic

(POS) Gym Access IND Essential Plus Catastrophic POS 37

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

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 		$238.45
$270.64
$304.74
$425.88
$647.16 		$420.87
$453.06
$487.16
$608.30 		$603.29
$635.48
$669.58
$790.72 		$785.71
$817.90
$852.00
$973.14 		$182.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$476.90
$541.28
$609.48
$851.76
$1,294.32 		$659.32
$723.70
$791.90
$1,034.18 		$841.74
$906.12
$974.32
$1,216.60 		$1,024.16
$1,088.54
$1,156.74
$1,399.02 		$182.42
Toc - Plan #123 Florida Health Care Plans
Silver

(HMO) Gym Access IND Essential Plus Silver HMO 53

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,900 $5,800 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 		$397.35
$450.99
$507.81
$709.66
$1,078.40 		$701.32
$754.96
$811.78
$1,013.63 		$1,005.29
$1,058.93
$1,115.75
$1,317.60 		$1,309.26
$1,362.90
$1,419.72
$1,621.57 		$303.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.70
$901.98
$1,015.62
$1,419.32
$2,156.80 		$1,098.67
$1,205.95
$1,319.59
$1,723.29 		$1,402.64
$1,509.92
$1,623.56
$2,027.26 		$1,706.61
$1,813.89
$1,927.53
$2,331.23 		$303.97
Toc - Plan #124 Florida Health Care Plans
Gold

(HMO) Gym Access IND Essential Plus Gold HMO 63

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$5,100 $10,200 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 		$402.42
$456.75
$514.30
$718.73
$1,092.18 		$710.27
$764.60
$822.15
$1,026.58 		$1,018.12
$1,072.45
$1,130.00
$1,334.43 		$1,325.97
$1,380.30
$1,437.85
$1,642.28 		$307.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.84
$913.50
$1,028.60
$1,437.46
$2,184.36 		$1,112.69
$1,221.35
$1,336.45
$1,745.31 		$1,420.54
$1,529.20
$1,644.30
$2,053.16 		$1,728.39
$1,837.05
$1,952.15
$2,361.01 		$307.85
Toc - Plan #125 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Essential Plus Platinum HMO 65

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$561.67
$637.50
$717.82
$1,003.15
$1,524.38 		$991.35
$1,067.18
$1,147.50
$1,432.83 		$1,421.03
$1,496.86
$1,577.18
$1,862.51 		$1,850.71
$1,926.54
$2,006.86
$2,292.19 		$429.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,123.34
$1,275.00
$1,435.64
$2,006.30
$3,048.76 		$1,553.02
$1,704.68
$1,865.32
$2,435.98 		$1,982.70
$2,134.36
$2,295.00
$2,865.66 		$2,412.38
$2,564.04
$2,724.68
$3,295.34 		$429.68
Toc - Plan #126 Florida Health Care Plans
Silver

(POS) Gym Access IND Essential Plus Silver POS 54

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,900 $5,800 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 		$409.98
$465.33
$523.96
$732.23
$1,112.69 		$723.62
$778.97
$837.60
$1,045.87 		$1,037.26
$1,092.61
$1,151.24
$1,359.51 		$1,350.90
$1,406.25
$1,464.88
$1,673.15 		$313.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.96
$930.66
$1,047.92
$1,464.46
$2,225.38 		$1,133.60
$1,244.30
$1,361.56
$1,778.10 		$1,447.24
$1,557.94
$1,675.20
$2,091.74 		$1,760.88
$1,871.58
$1,988.84
$2,405.38 		$313.64
Toc - Plan #127 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$4,000 $8,000 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 		$554.34
$629.18
$708.45
$990.06
$1,504.49 		$978.41
$1,053.25
$1,132.52
$1,414.13 		$1,402.48
$1,477.32
$1,556.59
$1,838.20 		$1,826.55
$1,901.39
$1,980.66
$2,262.27 		$424.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,108.68
$1,258.36
$1,416.90
$1,980.12
$3,008.98 		$1,532.75
$1,682.43
$1,840.97
$2,404.19 		$1,956.82
$2,106.50
$2,265.04
$2,828.26 		$2,380.89
$2,530.57
$2,689.11
$3,252.33 		$424.07
Toc - Plan #128 Florida Health Care Plans
Platinum

(POS) Gym Access IND Platinum POS 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$4,000 $8,000 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 		$598.69
$679.51
$765.13
$1,069.26
$1,624.85 		$1,056.69
$1,137.51
$1,223.13
$1,527.26 		$1,514.69
$1,595.51
$1,681.13
$1,985.26 		$1,972.69
$2,053.51
$2,139.13
$2,443.26 		$458.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,197.38
$1,359.02
$1,530.26
$2,138.52
$3,249.70 		$1,655.38
$1,817.02
$1,988.26
$2,596.52 		$2,113.38
$2,275.02
$2,446.26
$3,054.52 		$2,571.38
$2,733.02
$2,904.26
$3,512.52 		$458.00
Toc - Plan #129 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO 55001

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$6,400 $12,800 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 		$414.64
$470.62
$529.91
$740.55
$1,125.34 		$731.84
$787.82
$847.11
$1,057.75 		$1,049.04
$1,105.02
$1,164.31
$1,374.95 		$1,366.24
$1,422.22
$1,481.51
$1,692.15 		$317.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.28
$941.24
$1,059.82
$1,481.10
$2,250.68 		$1,146.48
$1,258.44
$1,377.02
$1,798.30 		$1,463.68
$1,575.64
$1,694.22
$2,115.50 		$1,780.88
$1,892.84
$2,011.42
$2,432.70 		$317.20
Toc - Plan #130 Florida Health Care Plans
Gold

(POS) Gym Access IND Gold POS 55001

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$6,400 $12,800 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 		$447.81
$508.27
$572.30
$799.79
$1,215.36 		$790.39
$850.85
$914.88
$1,142.37 		$1,132.97
$1,193.43
$1,257.46
$1,484.95 		$1,475.55
$1,536.01
$1,600.04
$1,827.53 		$342.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.62
$1,016.54
$1,144.60
$1,599.58
$2,430.72 		$1,238.20
$1,359.12
$1,487.18
$1,942.16 		$1,580.78
$1,701.70
$1,829.76
$2,284.74 		$1,923.36
$2,044.28
$2,172.34
$2,627.32 		$342.58
Toc - Plan #131 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,550 $5,100 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.92
$462.99
$521.32
$728.55
$1,107.10 		$719.98
$775.05
$833.38
$1,040.61 		$1,032.04
$1,087.11
$1,145.44
$1,352.67 		$1,344.10
$1,399.17
$1,457.50
$1,664.73 		$312.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.84
$925.98
$1,042.64
$1,457.10
$2,214.20 		$1,127.90
$1,238.04
$1,354.70
$1,769.16 		$1,439.96
$1,550.10
$1,666.76
$2,081.22 		$1,752.02
$1,862.16
$1,978.82
$2,393.28 		$312.06
Toc - Plan #132 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO HSA 5065

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282.09
$320.17
$360.51
$503.81
$765.59 		$497.89
$535.97
$576.31
$719.61 		$713.69
$751.77
$792.11
$935.41 		$929.49
$967.57
$1,007.91
$1,151.21 		$215.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.18
$640.34
$721.02
$1,007.62
$1,531.18 		$779.98
$856.14
$936.82
$1,223.42 		$995.78
$1,071.94
$1,152.62
$1,439.22 		$1,211.58
$1,287.74
$1,368.42
$1,655.02 		$215.80
Toc - Plan #133 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO HSA 6060

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282.53
$320.67
$361.07
$504.60
$766.78 		$498.66
$536.80
$577.20
$720.73 		$714.79
$752.93
$793.33
$936.86 		$930.92
$969.06
$1,009.46
$1,152.99 		$216.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.06
$641.34
$722.14
$1,009.20
$1,533.56 		$781.19
$857.47
$938.27
$1,225.33 		$997.32
$1,073.60
$1,154.40
$1,441.46 		$1,213.45
$1,289.73
$1,370.53
$1,657.59 		$216.13
Toc - Plan #134 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO BC 3841

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$297.41
$337.56
$380.09
$531.18
$807.18 		$524.93
$565.08
$607.61
$758.70 		$752.45
$792.60
$835.13
$986.22 		$979.97
$1,020.12
$1,062.65
$1,213.74 		$227.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$594.82
$675.12
$760.18
$1,062.36
$1,614.36 		$822.34
$902.64
$987.70
$1,289.88 		$1,049.86
$1,130.16
$1,215.22
$1,517.40 		$1,277.38
$1,357.68
$1,442.74
$1,744.92 		$227.52
Toc - Plan #135 Florida Health Care Plans
Expanded Bronze

(POS) Gym Access IND Bronze POS BC 3841

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

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 		$321.21
$364.57
$410.50
$573.67
$871.75 		$566.93
$610.29
$656.22
$819.39 		$812.65
$856.01
$901.94
$1,065.11 		$1,058.37
$1,101.73
$1,147.66
$1,310.83 		$245.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.42
$729.14
$821.00
$1,147.34
$1,743.50 		$888.14
$974.86
$1,066.72
$1,393.06 		$1,133.86
$1,220.58
$1,312.44
$1,638.78 		$1,379.58
$1,466.30
$1,558.16
$1,884.50 		$245.72
Toc - Plan #136 Florida Health Care Plans
Silver

(HMO) Gym Access IND Silver HMO BC 0941

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$383.21
$434.94
$489.74
$684.41
$1,040.03 		$676.37
$728.10
$782.90
$977.57 		$969.53
$1,021.26
$1,076.06
$1,270.73 		$1,262.69
$1,314.42
$1,369.22
$1,563.89 		$293.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.42
$869.88
$979.48
$1,368.82
$2,080.06 		$1,059.58
$1,163.04
$1,272.64
$1,661.98 		$1,352.74
$1,456.20
$1,565.80
$1,955.14 		$1,645.90
$1,749.36
$1,858.96
$2,248.30 		$293.16
Toc - Plan #137 Florida Health Care Plans
Silver

(POS) Gym Access IND Silver POS BC 0941

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$413.87
$469.74
$528.92
$739.17
$1,123.23 		$730.48
$786.35
$845.53
$1,055.78 		$1,047.09
$1,102.96
$1,162.14
$1,372.39 		$1,363.70
$1,419.57
$1,478.75
$1,689.00 		$316.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.74
$939.48
$1,057.84
$1,478.34
$2,246.46 		$1,144.35
$1,256.09
$1,374.45
$1,794.95 		$1,460.96
$1,572.70
$1,691.06
$2,111.56 		$1,777.57
$1,889.31
$2,007.67
$2,428.17 		$316.61
Toc - Plan #138 Florida Health Care Plans
Silver

(HMO) Gym Access IND Silver HMO BC 7741

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.62
$417.25
$469.82
$656.58
$997.73 		$648.85
$698.48
$751.05
$937.81 		$930.08
$979.71
$1,032.28
$1,219.04 		$1,211.31
$1,260.94
$1,313.51
$1,500.27 		$281.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.24
$834.50
$939.64
$1,313.16
$1,995.46 		$1,016.47
$1,115.73
$1,220.87
$1,594.39 		$1,297.70
$1,396.96
$1,502.10
$1,875.62 		$1,578.93
$1,678.19
$1,783.33
$2,156.85 		$281.23
Toc - Plan #139 Florida Health Care Plans
Silver

(POS) Gym Access IND Silver POS BC 7741

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$397.03
$450.63
$507.41
$709.10
$1,077.55 		$700.76
$754.36
$811.14
$1,012.83 		$1,004.49
$1,058.09
$1,114.87
$1,316.56 		$1,308.22
$1,361.82
$1,418.60
$1,620.29 		$303.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.06
$901.26
$1,014.82
$1,418.20
$2,155.10 		$1,097.79
$1,204.99
$1,318.55
$1,721.93 		$1,401.52
$1,508.72
$1,622.28
$2,025.66 		$1,705.25
$1,812.45
$1,926.01
$2,329.39 		$303.73
Toc - Plan #140 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO BC 5651

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,900 $11,800 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 		$424.70
$482.04
$542.77
$758.52
$1,152.65 		$749.60
$806.94
$867.67
$1,083.42 		$1,074.50
$1,131.84
$1,192.57
$1,408.32 		$1,399.40
$1,456.74
$1,517.47
$1,733.22 		$324.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.40
$964.08
$1,085.54
$1,517.04
$2,305.30 		$1,174.30
$1,288.98
$1,410.44
$1,841.94 		$1,499.20
$1,613.88
$1,735.34
$2,166.84 		$1,824.10
$1,938.78
$2,060.24
$2,491.74 		$324.90
Toc - Plan #141 Florida Health Care Plans
Gold

(POS) Gym Access IND Gold POS BC 5651

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,900 $11,800 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 		$458.68
$520.60
$586.19
$819.20
$1,244.86 		$809.57
$871.49
$937.08
$1,170.09 		$1,160.46
$1,222.38
$1,287.97
$1,520.98 		$1,511.35
$1,573.27
$1,638.86
$1,871.87 		$350.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.36
$1,041.20
$1,172.38
$1,638.40
$2,489.72 		$1,268.25
$1,392.09
$1,523.27
$1,989.29 		$1,619.14
$1,742.98
$1,874.16
$2,340.18 		$1,970.03
$2,093.87
$2,225.05
$2,691.07 		$350.89
Toc - Plan #142 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO BC 5841

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$800 $1,600 Annual Deductible
$2,500 $5,000 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 		$546.06
$619.78
$697.87
$975.27
$1,482.01 		$963.80
$1,037.52
$1,115.61
$1,393.01 		$1,381.54
$1,455.26
$1,533.35
$1,810.75 		$1,799.28
$1,873.00
$1,951.09
$2,228.49 		$417.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,092.12
$1,239.56
$1,395.74
$1,950.54
$2,964.02 		$1,509.86
$1,657.30
$1,813.48
$2,368.28 		$1,927.60
$2,075.04
$2,231.22
$2,786.02 		$2,345.34
$2,492.78
$2,648.96
$3,203.76 		$417.74
Toc - Plan #143 Florida Health Care Plans
Platinum

(POS) Gym Access IND Platinum POS BC 5841

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$800 $1,600 Annual Deductible
$2,500 $5,000 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 		$589.75
$669.36
$753.70
$1,053.29
$1,600.57 		$1,040.91
$1,120.52
$1,204.86
$1,504.45 		$1,492.07
$1,571.68
$1,656.02
$1,955.61 		$1,943.23
$2,022.84
$2,107.18
$2,406.77 		$451.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,179.50
$1,338.72
$1,507.40
$2,106.58
$3,201.14 		$1,630.66
$1,789.88
$1,958.56
$2,557.74 		$2,081.82
$2,241.04
$2,409.72
$3,008.90 		$2,532.98
$2,692.20
$2,860.88
$3,460.06 		$451.16
Toc - Plan #144 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO BC 1941

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$564.34
$640.52
$721.22
$1,007.91
$1,531.61 		$996.06
$1,072.24
$1,152.94
$1,439.63 		$1,427.78
$1,503.96
$1,584.66
$1,871.35 		$1,859.50
$1,935.68
$2,016.38
$2,303.07 		$431.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,128.68
$1,281.04
$1,442.44
$2,015.82
$3,063.22 		$1,560.40
$1,712.76
$1,874.16
$2,447.54 		$1,992.12
$2,144.48
$2,305.88
$2,879.26 		$2,423.84
$2,576.20
$2,737.60
$3,310.98 		$431.72
Toc - Plan #145 Florida Health Care Plans
Platinum

(POS) Gym Access IND Platinum POS BC 1941

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$609.48
$691.76
$778.92
$1,088.54
$1,654.14 		$1,075.73
$1,158.01
$1,245.17
$1,554.79 		$1,541.98
$1,624.26
$1,711.42
$2,021.04 		$2,008.23
$2,090.51
$2,177.67
$2,487.29 		$466.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,218.96
$1,383.52
$1,557.84
$2,177.08
$3,308.28 		$1,685.21
$1,849.77
$2,024.09
$2,643.33 		$2,151.46
$2,316.02
$2,490.34
$3,109.58 		$2,617.71
$2,782.27
$2,956.59
$3,575.83 		$466.25
Toc - Plan #146 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO 91

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$250 $500 Annual Deductible
$2,500 $5,000 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 		$560.06
$635.67
$715.76
$1,000.27
$1,520.01 		$988.51
$1,064.12
$1,144.21
$1,428.72 		$1,416.96
$1,492.57
$1,572.66
$1,857.17 		$1,845.41
$1,921.02
$2,001.11
$2,285.62 		$428.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,120.12
$1,271.34
$1,431.52
$2,000.54
$3,040.02 		$1,548.57
$1,699.79
$1,859.97
$2,428.99 		$1,977.02
$2,128.24
$2,288.42
$2,857.44 		$2,405.47
$2,556.69
$2,716.87
$3,285.89 		$428.45
Toc - Plan #147 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO 92

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$3,000 $6,000 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 		$559.47
$635.00
$715.00
$999.21
$1,518.40 		$987.46
$1,062.99
$1,142.99
$1,427.20 		$1,415.45
$1,490.98
$1,570.98
$1,855.19 		$1,843.44
$1,918.97
$1,998.97
$2,283.18 		$427.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,118.94
$1,270.00
$1,430.00
$1,998.42
$3,036.80 		$1,546.93
$1,697.99
$1,857.99
$2,426.41 		$1,974.92
$2,125.98
$2,285.98
$2,854.40 		$2,402.91
$2,553.97
$2,713.97
$3,282.39 		$427.99
Toc - Plan #148 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze Standardized HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$7,150 $14,300 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$290.01
$329.16
$370.64
$517.96
$787.09 		$511.87
$551.02
$592.50
$739.82 		$733.73
$772.88
$814.36
$961.68 		$955.59
$994.74
$1,036.22
$1,183.54 		$221.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.02
$658.32
$741.28
$1,035.92
$1,574.18 		$801.88
$880.18
$963.14
$1,257.78 		$1,023.74
$1,102.04
$1,185.00
$1,479.64 		$1,245.60
$1,323.90
$1,406.86
$1,701.50 		$221.86
Toc - Plan #149 Florida Health Care Plans
Silver

(HMO) Gym Access IND Silver Standardized HMO 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$400.86
$454.98
$512.30
$715.94
$1,087.94 		$707.52
$761.64
$818.96
$1,022.60 		$1,014.18
$1,068.30
$1,125.62
$1,329.26 		$1,320.84
$1,374.96
$1,432.28
$1,635.92 		$306.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.72
$909.96
$1,024.60
$1,431.88
$2,175.88 		$1,108.38
$1,216.62
$1,331.26
$1,738.54 		$1,415.04
$1,523.28
$1,637.92
$2,045.20 		$1,721.70
$1,829.94
$1,944.58
$2,351.86 		$306.66
Toc - Plan #150 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO 1340

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

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 		$275.01
$312.14
$351.47
$491.18
$746.39 		$485.40
$522.53
$561.86
$701.57 		$695.79
$732.92
$772.25
$911.96 		$906.18
$943.31
$982.64
$1,122.35 		$210.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.02
$624.28
$702.94
$982.36
$1,492.78 		$760.41
$834.67
$913.33
$1,192.75 		$970.80
$1,045.06
$1,123.72
$1,403.14 		$1,181.19
$1,255.45
$1,334.11
$1,613.53 		$210.39
Toc - Plan #151 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO 1041

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

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 		$289.98
$329.12
$370.59
$517.90
$786.99 		$511.81
$550.95
$592.42
$739.73 		$733.64
$772.78
$814.25
$961.56 		$955.47
$994.61
$1,036.08
$1,183.39 		$221.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.96
$658.24
$741.18
$1,035.80
$1,573.98 		$801.79
$880.07
$963.01
$1,257.63 		$1,023.62
$1,101.90
$1,184.84
$1,479.46 		$1,245.45
$1,323.73
$1,406.67
$1,701.29 		$221.83
Toc - Plan #152 Florida Health Care Plans
Expanded Bronze

(POS) Gym Access IND Bronze POS 1042

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 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 		$313.17
$355.45
$400.24
$559.33
$849.95 		$552.75
$595.03
$639.82
$798.91 		$792.33
$834.61
$879.40
$1,038.49 		$1,031.91
$1,074.19
$1,118.98
$1,278.07 		$239.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.34
$710.90
$800.48
$1,118.66
$1,699.90 		$865.92
$950.48
$1,040.06
$1,358.24 		$1,105.50
$1,190.06
$1,279.64
$1,597.82 		$1,345.08
$1,429.64
$1,519.22
$1,837.40 		$239.58
Toc - Plan #153 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO H.S.A 9010

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$1,700 $3,400 Annual Deductible
$4,000 $8,000 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 		$389.50
$442.08
$497.78
$695.64
$1,057.09 		$687.46
$740.04
$795.74
$993.60 		$985.42
$1,038.00
$1,093.70
$1,291.56 		$1,283.38
$1,335.96
$1,391.66
$1,589.52 		$297.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.00
$884.16
$995.56
$1,391.28
$2,114.18 		$1,076.96
$1,182.12
$1,293.52
$1,689.24 		$1,374.92
$1,480.08
$1,591.48
$1,987.20 		$1,672.88
$1,778.04
$1,889.44
$2,285.16 		$297.96
Toc - Plan #154 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO OA 1211

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

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 		$318.89
$361.95
$407.55
$569.55
$865.48 		$562.84
$605.90
$651.50
$813.50 		$806.79
$849.85
$895.45
$1,057.45 		$1,050.74
$1,093.80
$1,139.40
$1,301.40 		$243.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637.78
$723.90
$815.10
$1,139.10
$1,730.96 		$881.73
$967.85
$1,059.05
$1,383.05 		$1,125.68
$1,211.80
$1,303.00
$1,627.00 		$1,369.63
$1,455.75
$1,546.95
$1,870.95 		$243.95
Toc - Plan #155 Florida Health Care Plans
Silver

(HMO) Gym Access IND Silver HMO OA 1009

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.19
$465.57
$524.22
$732.60
$1,113.26 		$723.99
$779.37
$838.02
$1,046.40 		$1,037.79
$1,093.17
$1,151.82
$1,360.20 		$1,351.59
$1,406.97
$1,465.62
$1,674.00 		$313.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.38
$931.14
$1,048.44
$1,465.20
$2,226.52 		$1,134.18
$1,244.94
$1,362.24
$1,779.00 		$1,447.98
$1,558.74
$1,676.04
$2,092.80 		$1,761.78
$1,872.54
$1,989.84
$2,406.60 		$313.80
Toc - Plan #156 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO OA 0928

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.42
$343.24
$386.49
$540.12
$820.76 		$533.77
$574.59
$617.84
$771.47 		$765.12
$805.94
$849.19
$1,002.82 		$996.47
$1,037.29
$1,080.54
$1,234.17 		$231.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.84
$686.48
$772.98
$1,080.24
$1,641.52 		$836.19
$917.83
$1,004.33
$1,311.59 		$1,067.54
$1,149.18
$1,235.68
$1,542.94 		$1,298.89
$1,380.53
$1,467.03
$1,774.29 		$231.35
Toc - Plan #157 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO OA 28

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$428.71
$486.58
$547.89
$765.67
$1,163.51 		$756.67
$814.54
$875.85
$1,093.63 		$1,084.63
$1,142.50
$1,203.81
$1,421.59 		$1,412.59
$1,470.46
$1,531.77
$1,749.55 		$327.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.42
$973.16
$1,095.78
$1,531.34
$2,327.02 		$1,185.38
$1,301.12
$1,423.74
$1,859.30 		$1,513.34
$1,629.08
$1,751.70
$2,187.26 		$1,841.30
$1,957.04
$2,079.66
$2,515.22 		$327.96

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0405 | Toll Free: 1-888-200-0405 | TTY: 1-888-200-0405
Toc - Plan #158 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$416.35
$472.56
$532.10
$743.60
$1,129.98 		$734.86
$791.07
$850.61
$1,062.11 		$1,053.37
$1,109.58
$1,169.12
$1,380.62 		$1,371.88
$1,428.09
$1,487.63
$1,699.13 		$318.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.70
$945.12
$1,064.20
$1,487.20
$2,259.96 		$1,151.21
$1,263.63
$1,382.71
$1,805.71 		$1,469.72
$1,582.14
$1,701.22
$2,124.22 		$1,788.23
$1,900.65
$2,019.73
$2,442.73 		$318.51
Toc - Plan #159 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$426.86
$484.49
$545.53
$762.38
$1,158.50 		$753.41
$811.04
$872.08
$1,088.93 		$1,079.96
$1,137.59
$1,198.63
$1,415.48 		$1,406.51
$1,464.14
$1,525.18
$1,742.03 		$326.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.72
$968.98
$1,091.06
$1,524.76
$2,317.00 		$1,180.27
$1,295.53
$1,417.61
$1,851.31 		$1,506.82
$1,622.08
$1,744.16
$2,177.86 		$1,833.37
$1,948.63
$2,070.71
$2,504.41 		$326.55
Toc - Plan #160 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$397.66
$451.35
$508.22
$710.23
$1,079.26 		$701.87
$755.56
$812.43
$1,014.44 		$1,006.08
$1,059.77
$1,116.64
$1,318.65 		$1,310.29
$1,363.98
$1,420.85
$1,622.86 		$304.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.32
$902.70
$1,016.44
$1,420.46
$2,158.52 		$1,099.53
$1,206.91
$1,320.65
$1,724.67 		$1,403.74
$1,511.12
$1,624.86
$2,028.88 		$1,707.95
$1,815.33
$1,929.07
$2,333.09 		$304.21
Toc - Plan #161 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.91
$449.36
$505.98
$707.10
$1,074.51 		$698.78
$752.23
$808.85
$1,009.97 		$1,001.65
$1,055.10
$1,111.72
$1,312.84 		$1,304.52
$1,357.97
$1,414.59
$1,615.71 		$302.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.82
$898.72
$1,011.96
$1,414.20
$2,149.02 		$1,094.69
$1,201.59
$1,314.83
$1,717.07 		$1,397.56
$1,504.46
$1,617.70
$2,019.94 		$1,700.43
$1,807.33
$1,920.57
$2,322.81 		$302.87
Toc - Plan #162 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.68
$421.86
$475.01
$663.82
$1,008.74 		$656.01
$706.19
$759.34
$948.15 		$940.34
$990.52
$1,043.67
$1,232.48 		$1,224.67
$1,274.85
$1,328.00
$1,516.81 		$284.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.36
$843.72
$950.02
$1,327.64
$2,017.48 		$1,027.69
$1,128.05
$1,234.35
$1,611.97 		$1,312.02
$1,412.38
$1,518.68
$1,896.30 		$1,596.35
$1,696.71
$1,803.01
$2,180.63 		$284.33
Toc - Plan #163 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.67
$413.90
$466.05
$651.30
$989.72 		$643.64
$692.87
$745.02
$930.27 		$922.61
$971.84
$1,023.99
$1,209.24 		$1,201.58
$1,250.81
$1,302.96
$1,488.21 		$278.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.34
$827.80
$932.10
$1,302.60
$1,979.44 		$1,008.31
$1,106.77
$1,211.07
$1,581.57 		$1,287.28
$1,385.74
$1,490.04
$1,860.54 		$1,566.25
$1,664.71
$1,769.01
$2,139.51 		$278.97
Toc - Plan #164 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.80
$420.86
$473.89
$662.25
$1,006.36 		$654.46
$704.52
$757.55
$945.91 		$938.12
$988.18
$1,041.21
$1,229.57 		$1,221.78
$1,271.84
$1,324.87
$1,513.23 		$283.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.60
$841.72
$947.78
$1,324.50
$2,012.72 		$1,025.26
$1,125.38
$1,231.44
$1,608.16 		$1,308.92
$1,409.04
$1,515.10
$1,891.82 		$1,592.58
$1,692.70
$1,798.76
$2,175.48 		$283.66
Toc - Plan #165 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.10
$421.19
$474.26
$662.78
$1,007.15 		$654.99
$705.08
$758.15
$946.67 		$938.88
$988.97
$1,042.04
$1,230.56 		$1,222.77
$1,272.86
$1,325.93
$1,514.45 		$283.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.20
$842.38
$948.52
$1,325.56
$2,014.30 		$1,026.09
$1,126.27
$1,232.41
$1,609.45 		$1,309.98
$1,410.16
$1,516.30
$1,893.34 		$1,593.87
$1,694.05
$1,800.19
$2,177.23 		$283.89
Toc - Plan #166 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$385.69
$437.76
$492.92
$688.85
$1,046.77 		$680.75
$732.82
$787.98
$983.91 		$975.81
$1,027.88
$1,083.04
$1,278.97 		$1,270.87
$1,322.94
$1,378.10
$1,574.03 		$295.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.38
$875.52
$985.84
$1,377.70
$2,093.54 		$1,066.44
$1,170.58
$1,280.90
$1,672.76 		$1,361.50
$1,465.64
$1,575.96
$1,967.82 		$1,656.56
$1,760.70
$1,871.02
$2,262.88 		$295.06
Toc - Plan #167 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.20
$441.74
$497.39
$695.11
$1,056.28 		$686.94
$739.48
$795.13
$992.85 		$984.68
$1,037.22
$1,092.87
$1,290.59 		$1,282.42
$1,334.96
$1,390.61
$1,588.33 		$297.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.40
$883.48
$994.78
$1,390.22
$2,112.56 		$1,076.14
$1,181.22
$1,292.52
$1,687.96 		$1,373.88
$1,478.96
$1,590.26
$1,985.70 		$1,671.62
$1,776.70
$1,888.00
$2,283.44 		$297.74
Toc - Plan #168 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.21
$412.25
$464.19
$648.70
$985.76 		$641.07
$690.11
$742.05
$926.56 		$918.93
$967.97
$1,019.91
$1,204.42 		$1,196.79
$1,245.83
$1,297.77
$1,482.28 		$277.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.42
$824.50
$928.38
$1,297.40
$1,971.52 		$1,004.28
$1,102.36
$1,206.24
$1,575.26 		$1,282.14
$1,380.22
$1,484.10
$1,853.12 		$1,560.00
$1,658.08
$1,761.96
$2,130.98 		$277.86
Toc - Plan #169 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$369.34
$419.20
$472.02
$659.65
$1,002.40 		$651.89
$701.75
$754.57
$942.20 		$934.44
$984.30
$1,037.12
$1,224.75 		$1,216.99
$1,266.85
$1,319.67
$1,507.30 		$282.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.68
$838.40
$944.04
$1,319.30
$2,004.80 		$1,021.23
$1,120.95
$1,226.59
$1,601.85 		$1,303.78
$1,403.50
$1,509.14
$1,884.40 		$1,586.33
$1,686.05
$1,791.69
$2,166.95 		$282.55
Toc - Plan #170 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.39
$421.52
$474.63
$663.30
$1,007.95 		$655.50
$705.63
$758.74
$947.41 		$939.61
$989.74
$1,042.85
$1,231.52 		$1,223.72
$1,273.85
$1,326.96
$1,515.63 		$284.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.78
$843.04
$949.26
$1,326.60
$2,015.90 		$1,026.89
$1,127.15
$1,233.37
$1,610.71 		$1,311.00
$1,411.26
$1,517.48
$1,894.82 		$1,595.11
$1,695.37
$1,801.59
$2,178.93 		$284.11
Toc - Plan #171 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382.77
$434.45
$489.19
$683.63
$1,038.85 		$675.59
$727.27
$782.01
$976.45 		$968.41
$1,020.09
$1,074.83
$1,269.27 		$1,261.23
$1,312.91
$1,367.65
$1,562.09 		$292.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.54
$868.90
$978.38
$1,367.26
$2,077.70 		$1,058.36
$1,161.72
$1,271.20
$1,660.08 		$1,351.18
$1,454.54
$1,564.02
$1,952.90 		$1,644.00
$1,747.36
$1,856.84
$2,245.72 		$292.82
Toc - Plan #172 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.07
$434.78
$489.56
$684.16
$1,039.64 		$676.12
$727.83
$782.61
$977.21 		$969.17
$1,020.88
$1,075.66
$1,270.26 		$1,262.22
$1,313.93
$1,368.71
$1,563.31 		$293.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.14
$869.56
$979.12
$1,368.32
$2,079.28 		$1,059.19
$1,162.61
$1,272.17
$1,661.37 		$1,352.24
$1,455.66
$1,565.22
$1,954.42 		$1,645.29
$1,748.71
$1,858.27
$2,247.47 		$293.05
Toc - Plan #173 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential+ (Low Premium)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$291.97
$331.39
$373.14
$521.46
$792.41 		$515.33
$554.75
$596.50
$744.82 		$738.69
$778.11
$819.86
$968.18 		$962.05
$1,001.47
$1,043.22
$1,191.54 		$223.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.94
$662.78
$746.28
$1,042.92
$1,584.82 		$807.30
$886.14
$969.64
$1,266.28 		$1,030.66
$1,109.50
$1,193.00
$1,489.64 		$1,254.02
$1,332.86
$1,416.36
$1,713.00 		$223.36
Toc - Plan #174 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$308.32
$349.94
$394.03
$550.66
$836.78 		$544.19
$585.81
$629.90
$786.53 		$780.06
$821.68
$865.77
$1,022.40 		$1,015.93
$1,057.55
$1,101.64
$1,258.27 		$235.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.64
$699.88
$788.06
$1,101.32
$1,673.56 		$852.51
$935.75
$1,023.93
$1,337.19 		$1,088.38
$1,171.62
$1,259.80
$1,573.06 		$1,324.25
$1,407.49
$1,495.67
$1,808.93 		$235.87
Toc - Plan #175 UnitedHealthcare
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.15
$340.67
$383.59
$536.06
$814.60 		$529.76
$570.28
$613.20
$765.67 		$759.37
$799.89
$842.81
$995.28 		$988.98
$1,029.50
$1,072.42
$1,224.89 		$229.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.30
$681.34
$767.18
$1,072.12
$1,629.20 		$829.91
$910.95
$996.79
$1,301.73 		$1,059.52
$1,140.56
$1,226.40
$1,531.34 		$1,289.13
$1,370.17
$1,456.01
$1,760.95 		$229.61
Toc - Plan #176 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$310.37
$352.26
$396.65
$554.31
$842.33 		$547.80
$589.69
$634.08
$791.74 		$785.23
$827.12
$871.51
$1,029.17 		$1,022.66
$1,064.55
$1,108.94
$1,266.60 		$237.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$620.74
$704.52
$793.30
$1,108.62
$1,684.66 		$858.17
$941.95
$1,030.73
$1,346.05 		$1,095.60
$1,179.38
$1,268.16
$1,583.48 		$1,333.03
$1,416.81
$1,505.59
$1,820.91 		$237.43
Toc - Plan #177 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.48
$343.32
$386.57
$540.23
$820.94 		$533.88
$574.72
$617.97
$771.63 		$765.28
$806.12
$849.37
$1,003.03 		$996.68
$1,037.52
$1,080.77
$1,234.43 		$231.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.96
$686.64
$773.14
$1,080.46
$1,641.88 		$836.36
$918.04
$1,004.54
$1,311.86 		$1,067.76
$1,149.44
$1,235.94
$1,543.26 		$1,299.16
$1,380.84
$1,467.34
$1,774.66 		$231.40

‡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 Volusia County here.

Volusia County is in “Rating Area 64” of Florida.

Currently, there are 177 plans offered in Rating Area 64.

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2022 Obamacare Plans for Volusia County, FL

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