Obamacare 2022 Rates for Tulsa County

Obamacare > Rates > Oklahoma > Tulsa 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 Tulsa County, OK.

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, 68 Plans and 2022 Rates for Tulsa County, Oklahoma

Below, you’ll find a summary of the 68 plans for Tulsa County, Oklahoma 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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Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-676-3777
Toc - Plan #1 Medica
Gold

(PPO) Harmony by Medica Gold Copay ($0 Virtual Care + $5 Generic Drugs + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,200 $3,600 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.19
$459.88
$517.82
$723.65
$1,099.66 		$715.15
$769.84
$827.78
$1,033.61 		$1,025.11
$1,079.80
$1,137.74
$1,343.57 		$1,335.07
$1,389.76
$1,447.70
$1,653.53 		$309.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.38
$919.76
$1,035.64
$1,447.30
$2,199.32 		$1,120.34
$1,229.72
$1,345.60
$1,757.26 		$1,430.30
$1,539.68
$1,655.56
$2,067.22 		$1,740.26
$1,849.64
$1,965.52
$2,377.18 		$309.96
Toc - Plan #2 Medica
Silver

(PPO) Harmony by Medica Silver Copay ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$381.71
$433.23
$487.81
$681.72
$1,035.94 		$673.71
$725.23
$779.81
$973.72 		$965.71
$1,017.23
$1,071.81
$1,265.72 		$1,257.71
$1,309.23
$1,363.81
$1,557.72 		$292.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.42
$866.46
$975.62
$1,363.44
$2,071.88 		$1,055.42
$1,158.46
$1,267.62
$1,655.44 		$1,347.42
$1,450.46
$1,559.62
$1,947.44 		$1,639.42
$1,742.46
$1,851.62
$2,239.44 		$292.00
Toc - Plan #3 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze HSA ($0 Virtual Care after deductible + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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 		$348.36
$395.37
$445.19
$622.14
$945.41 		$614.84
$661.85
$711.67
$888.62 		$881.32
$928.33
$978.15
$1,155.10 		$1,147.80
$1,194.81
$1,244.63
$1,421.58 		$266.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.72
$790.74
$890.38
$1,244.28
$1,890.82 		$963.20
$1,057.22
$1,156.86
$1,510.76 		$1,229.68
$1,323.70
$1,423.34
$1,777.24 		$1,496.16
$1,590.18
$1,689.82
$2,043.72 		$266.48
Toc - Plan #4 Medica
Catastrophic

(PPO) Harmony by Medica Catastrophic ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$219.69
$249.34
$280.75
$392.35
$596.22 		$387.75
$417.40
$448.81
$560.41 		$555.81
$585.46
$616.87
$728.47 		$723.87
$753.52
$784.93
$896.53 		$168.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$439.38
$498.68
$561.50
$784.70
$1,192.44 		$607.44
$666.74
$729.56
$952.76 		$775.50
$834.80
$897.62
$1,120.82 		$943.56
$1,002.86
$1,065.68
$1,288.88 		$168.06
Toc - Plan #5 Medica
Gold

(PPO) Harmony by Medica Gold Share ($0 Virtual Care + $5 Generic Drugs + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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 		$390.62
$443.34
$499.20
$697.63
$1,060.12 		$689.44
$742.16
$798.02
$996.45 		$988.26
$1,040.98
$1,096.84
$1,295.27 		$1,287.08
$1,339.80
$1,395.66
$1,594.09 		$298.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.24
$886.68
$998.40
$1,395.26
$2,120.24 		$1,080.06
$1,185.50
$1,297.22
$1,694.08 		$1,378.88
$1,484.32
$1,596.04
$1,992.90 		$1,677.70
$1,783.14
$1,894.86
$2,291.72 		$298.82
Toc - Plan #6 Medica
Silver

(PPO) Harmony by Medica Silver Share ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,800 $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 		$389.30
$441.85
$497.52
$695.28
$1,056.54 		$687.11
$739.66
$795.33
$993.09 		$984.92
$1,037.47
$1,093.14
$1,290.90 		$1,282.73
$1,335.28
$1,390.95
$1,588.71 		$297.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.60
$883.70
$995.04
$1,390.56
$2,113.08 		$1,076.41
$1,181.51
$1,292.85
$1,688.37 		$1,374.22
$1,479.32
$1,590.66
$1,986.18 		$1,672.03
$1,777.13
$1,888.47
$2,283.99 		$297.81
Toc - Plan #7 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze Share Plus ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,300 $6,900 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 		$318.12
$361.05
$406.54
$568.14
$863.34 		$561.47
$604.40
$649.89
$811.49 		$804.82
$847.75
$893.24
$1,054.84 		$1,048.17
$1,091.10
$1,136.59
$1,298.19 		$243.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.24
$722.10
$813.08
$1,136.28
$1,726.68 		$879.59
$965.45
$1,056.43
$1,379.63 		$1,122.94
$1,208.80
$1,299.78
$1,622.98 		$1,366.29
$1,452.15
$1,543.13
$1,866.33 		$243.35
Toc - Plan #8 Medica
Bronze

(PPO) Harmony by Medica Bronze Value ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$299.86
$340.33
$383.21
$535.53
$813.79 		$529.24
$569.71
$612.59
$764.91 		$758.62
$799.09
$841.97
$994.29 		$988.00
$1,028.47
$1,071.35
$1,223.67 		$229.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.72
$680.66
$766.42
$1,071.06
$1,627.58 		$829.10
$910.04
$995.80
$1,300.44 		$1,058.48
$1,139.42
$1,225.18
$1,529.82 		$1,287.86
$1,368.80
$1,454.56
$1,759.20 		$229.38
Toc - Plan #9 Medica
Bronze

(PPO) Harmony by Medica Bronze Value + Dental Reimbursement ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$328.94
$373.34
$420.38
$587.48
$892.73 		$580.57
$624.97
$672.01
$839.11 		$832.20
$876.60
$923.64
$1,090.74 		$1,083.83
$1,128.23
$1,175.27
$1,342.37 		$251.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.88
$746.68
$840.76
$1,174.96
$1,785.46 		$909.51
$998.31
$1,092.39
$1,426.59 		$1,161.14
$1,249.94
$1,344.02
$1,678.22 		$1,412.77
$1,501.57
$1,595.65
$1,929.85 		$251.63
Toc - Plan #10 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze Copay $0 Primary Care ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$313.90
$356.27
$401.15
$560.61
$851.90 		$554.03
$596.40
$641.28
$800.74 		$794.16
$836.53
$881.41
$1,040.87 		$1,034.29
$1,076.66
$1,121.54
$1,281.00 		$240.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.80
$712.54
$802.30
$1,121.22
$1,703.80 		$867.93
$952.67
$1,042.43
$1,361.35 		$1,108.06
$1,192.80
$1,282.56
$1,601.48 		$1,348.19
$1,432.93
$1,522.69
$1,841.61 		$240.13

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-980-5319 | Toll Free: 1-800-980-5319

Toc - Plan #11 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

Annual Out of Pocket Expenses:

Individual Family
$1,700 $3,400 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 		$421.65
$478.58
$538.87
$753.07
$1,144.36 		$744.21
$801.14
$861.43
$1,075.63 		$1,066.77
$1,123.70
$1,183.99
$1,398.19 		$1,389.33
$1,446.26
$1,506.55
$1,720.75 		$322.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.30
$957.16
$1,077.74
$1,506.14
$2,288.72 		$1,165.86
$1,279.72
$1,400.30
$1,828.70 		$1,488.42
$1,602.28
$1,722.86
$2,151.26 		$1,810.98
$1,924.84
$2,045.42
$2,473.82 		$322.56
Toc - Plan #12 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$439.51
$498.85
$561.70
$784.97
$1,192.84 		$775.74
$835.08
$897.93
$1,121.20 		$1,111.97
$1,171.31
$1,234.16
$1,457.43 		$1,448.20
$1,507.54
$1,570.39
$1,793.66 		$336.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.02
$997.70
$1,123.40
$1,569.94
$2,385.68 		$1,215.25
$1,333.93
$1,459.63
$1,906.17 		$1,551.48
$1,670.16
$1,795.86
$2,242.40 		$1,887.71
$2,006.39
$2,132.09
$2,578.63 		$336.23
Toc - Plan #13 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$399.15
$453.03
$510.11
$712.88
$1,083.29 		$704.50
$758.38
$815.46
$1,018.23 		$1,009.85
$1,063.73
$1,120.81
$1,323.58 		$1,315.20
$1,369.08
$1,426.16
$1,628.93 		$305.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.30
$906.06
$1,020.22
$1,425.76
$2,166.58 		$1,103.65
$1,211.41
$1,325.57
$1,731.11 		$1,409.00
$1,516.76
$1,630.92
$2,036.46 		$1,714.35
$1,822.11
$1,936.27
$2,341.81 		$305.35
Toc - Plan #14 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$7,950 $15,900 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 		$400.07
$454.08
$511.29
$714.52
$1,085.78 		$706.12
$760.13
$817.34
$1,020.57 		$1,012.17
$1,066.18
$1,123.39
$1,326.62 		$1,318.22
$1,372.23
$1,429.44
$1,632.67 		$306.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800.14
$908.16
$1,022.58
$1,429.04
$2,171.56 		$1,106.19
$1,214.21
$1,328.63
$1,735.09 		$1,412.24
$1,520.26
$1,634.68
$2,041.14 		$1,718.29
$1,826.31
$1,940.73
$2,347.19 		$306.05
Toc - Plan #15 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$395.29
$448.65
$505.18
$705.98
$1,072.81 		$697.68
$751.04
$807.57
$1,008.37 		$1,000.07
$1,053.43
$1,109.96
$1,310.76 		$1,302.46
$1,355.82
$1,412.35
$1,613.15 		$302.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.58
$897.30
$1,010.36
$1,411.96
$2,145.62 		$1,092.97
$1,199.69
$1,312.75
$1,714.35 		$1,395.36
$1,502.08
$1,615.14
$2,016.74 		$1,697.75
$1,804.47
$1,917.53
$2,319.13 		$302.39
Toc - Plan #16 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$315.26
$357.82
$402.91
$563.06
$855.62 		$556.44
$599.00
$644.09
$804.24 		$797.62
$840.18
$885.27
$1,045.42 		$1,038.80
$1,081.36
$1,126.45
$1,286.60 		$241.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.52
$715.64
$805.82
$1,126.12
$1,711.24 		$871.70
$956.82
$1,047.00
$1,367.30 		$1,112.88
$1,198.00
$1,288.18
$1,608.48 		$1,354.06
$1,439.18
$1,529.36
$1,849.66 		$241.18
Toc - Plan #17 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$313.35
$355.65
$400.46
$559.64
$850.42 		$553.06
$595.36
$640.17
$799.35 		$792.77
$835.07
$879.88
$1,039.06 		$1,032.48
$1,074.78
$1,119.59
$1,278.77 		$239.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.70
$711.30
$800.92
$1,119.28
$1,700.84 		$866.41
$951.01
$1,040.63
$1,358.99 		$1,106.12
$1,190.72
$1,280.34
$1,598.70 		$1,345.83
$1,430.43
$1,520.05
$1,838.41 		$239.71
Toc - Plan #18 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$313.59
$355.93
$400.77
$560.08
$851.09 		$553.49
$595.83
$640.67
$799.98 		$793.39
$835.73
$880.57
$1,039.88 		$1,033.29
$1,075.63
$1,120.47
$1,279.78 		$239.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.18
$711.86
$801.54
$1,120.16
$1,702.18 		$867.08
$951.76
$1,041.44
$1,360.06 		$1,106.98
$1,191.66
$1,281.34
$1,599.96 		$1,346.88
$1,431.56
$1,521.24
$1,839.86 		$239.90
Toc - Plan #19 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential+ (Low Premium)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$301.94
$342.70
$385.88
$539.27
$819.47 		$532.93
$573.69
$616.87
$770.26 		$763.92
$804.68
$847.86
$1,001.25 		$994.91
$1,035.67
$1,078.85
$1,232.24 		$230.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.88
$685.40
$771.76
$1,078.54
$1,638.94 		$834.87
$916.39
$1,002.75
$1,309.53 		$1,065.86
$1,147.38
$1,233.74
$1,540.52 		$1,296.85
$1,378.37
$1,464.73
$1,771.51 		$230.99
Toc - Plan #20 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ (HSA)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

Annual Out of Pocket Expenses:

Individual Family
$5,850 $11,700 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 		$315.02
$357.54
$402.59
$562.62
$854.95 		$556.01
$598.53
$643.58
$803.61 		$797.00
$839.52
$884.57
$1,044.60 		$1,037.99
$1,080.51
$1,125.56
$1,285.59 		$240.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.04
$715.08
$805.18
$1,125.24
$1,709.90 		$871.03
$956.07
$1,046.17
$1,366.23 		$1,112.02
$1,197.06
$1,287.16
$1,607.22 		$1,353.01
$1,438.05
$1,528.15
$1,848.21 		$240.99

ADVERTISEMENT

Ambetter of Oklahoma

Local: 1-312-332-5401 | Toll Free: 1-800-779-7989

Toc - Plan #21 Ambetter of Oklahoma
Bronze

(PPO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$288.61
$327.56
$368.83
$515.45
$783.27 		$509.39
$548.34
$589.61
$736.23 		$730.17
$769.12
$810.39
$957.01 		$950.95
$989.90
$1,031.17
$1,177.79 		$220.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.22
$655.12
$737.66
$1,030.90
$1,566.54 		$798.00
$875.90
$958.44
$1,251.68 		$1,018.78
$1,096.68
$1,179.22
$1,472.46 		$1,239.56
$1,317.46
$1,400.00
$1,693.24 		$220.78
Toc - Plan #22 Ambetter of Oklahoma
Expanded Bronze

(PPO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$312.96
$355.20
$399.95
$558.93
$849.35 		$552.37
$594.61
$639.36
$798.34 		$791.78
$834.02
$878.77
$1,037.75 		$1,031.19
$1,073.43
$1,118.18
$1,277.16 		$239.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.92
$710.40
$799.90
$1,117.86
$1,698.70 		$865.33
$949.81
$1,039.31
$1,357.27 		$1,104.74
$1,189.22
$1,278.72
$1,596.68 		$1,344.15
$1,428.63
$1,518.13
$1,836.09 		$239.41
Toc - Plan #23 Ambetter of Oklahoma
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$338.25
$383.90
$432.27
$604.10
$917.99 		$597.00
$642.65
$691.02
$862.85 		$855.75
$901.40
$949.77
$1,121.60 		$1,114.50
$1,160.15
$1,208.52
$1,380.35 		$258.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$676.50
$767.80
$864.54
$1,208.20
$1,835.98 		$935.25
$1,026.55
$1,123.29
$1,466.95 		$1,194.00
$1,285.30
$1,382.04
$1,725.70 		$1,452.75
$1,544.05
$1,640.79
$1,984.45 		$258.75
Toc - Plan #24 Ambetter of Oklahoma
Expanded Bronze

(PPO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$355.75
$403.77
$454.64
$635.36
$965.49 		$627.89
$675.91
$726.78
$907.50 		$900.03
$948.05
$998.92
$1,179.64 		$1,172.17
$1,220.19
$1,271.06
$1,451.78 		$272.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.50
$807.54
$909.28
$1,270.72
$1,930.98 		$983.64
$1,079.68
$1,181.42
$1,542.86 		$1,255.78
$1,351.82
$1,453.56
$1,815.00 		$1,527.92
$1,623.96
$1,725.70
$2,087.14 		$272.14
Toc - Plan #25 Ambetter of Oklahoma
Silver

(PPO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$378.06
$429.09
$483.15
$675.20
$1,026.03 		$667.27
$718.30
$772.36
$964.41 		$956.48
$1,007.51
$1,061.57
$1,253.62 		$1,245.69
$1,296.72
$1,350.78
$1,542.83 		$289.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.12
$858.18
$966.30
$1,350.40
$2,052.06 		$1,045.33
$1,147.39
$1,255.51
$1,639.61 		$1,334.54
$1,436.60
$1,544.72
$1,928.82 		$1,623.75
$1,725.81
$1,833.93
$2,218.03 		$289.21
Toc - Plan #26 Ambetter of Oklahoma
Silver

(PPO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$373.30
$423.68
$477.06
$666.69
$1,013.10 		$658.86
$709.24
$762.62
$952.25 		$944.42
$994.80
$1,048.18
$1,237.81 		$1,229.98
$1,280.36
$1,333.74
$1,523.37 		$285.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.60
$847.36
$954.12
$1,333.38
$2,026.20 		$1,032.16
$1,132.92
$1,239.68
$1,618.94 		$1,317.72
$1,418.48
$1,525.24
$1,904.50 		$1,603.28
$1,704.04
$1,810.80
$2,190.06 		$285.56
Toc - Plan #27 Ambetter of Oklahoma
Silver

(PPO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$352.43
$399.99
$450.39
$629.42
$956.46 		$622.03
$669.59
$719.99
$899.02 		$891.63
$939.19
$989.59
$1,168.62 		$1,161.23
$1,208.79
$1,259.19
$1,438.22 		$269.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.86
$799.98
$900.78
$1,258.84
$1,912.92 		$974.46
$1,069.58
$1,170.38
$1,528.44 		$1,244.06
$1,339.18
$1,439.98
$1,798.04 		$1,513.66
$1,608.78
$1,709.58
$2,067.64 		$269.60
Toc - Plan #28 Ambetter of Oklahoma
Silver

(PPO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$352.50
$400.08
$450.49
$629.55
$956.67 		$622.16
$669.74
$720.15
$899.21 		$891.82
$939.40
$989.81
$1,168.87 		$1,161.48
$1,209.06
$1,259.47
$1,438.53 		$269.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.00
$800.16
$900.98
$1,259.10
$1,913.34 		$974.66
$1,069.82
$1,170.64
$1,528.76 		$1,244.32
$1,339.48
$1,440.30
$1,798.42 		$1,513.98
$1,609.14
$1,709.96
$2,068.08 		$269.66
Toc - Plan #29 Ambetter of Oklahoma
Silver

(PPO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$362.14
$411.02
$462.81
$646.77
$982.83 		$639.17
$688.05
$739.84
$923.80 		$916.20
$965.08
$1,016.87
$1,200.83 		$1,193.23
$1,242.11
$1,293.90
$1,477.86 		$277.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.28
$822.04
$925.62
$1,293.54
$1,965.66 		$1,001.31
$1,099.07
$1,202.65
$1,570.57 		$1,278.34
$1,376.10
$1,479.68
$1,847.60 		$1,555.37
$1,653.13
$1,756.71
$2,124.63 		$277.03
Toc - Plan #30 Ambetter of Oklahoma
Gold

(PPO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$438.59
$497.78
$560.50
$783.30
$1,190.29 		$774.10
$833.29
$896.01
$1,118.81 		$1,109.61
$1,168.80
$1,231.52
$1,454.32 		$1,445.12
$1,504.31
$1,567.03
$1,789.83 		$335.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$877.18
$995.56
$1,121.00
$1,566.60
$2,380.58 		$1,212.69
$1,331.07
$1,456.51
$1,902.11 		$1,548.20
$1,666.58
$1,792.02
$2,237.62 		$1,883.71
$2,002.09
$2,127.53
$2,573.13 		$335.51
Toc - Plan #31 Ambetter of Oklahoma
Gold

(PPO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$411.52
$467.06
$525.91
$734.95
$1,116.83 		$726.32
$781.86
$840.71
$1,049.75 		$1,041.12
$1,096.66
$1,155.51
$1,364.55 		$1,355.92
$1,411.46
$1,470.31
$1,679.35 		$314.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.04
$934.12
$1,051.82
$1,469.90
$2,233.66 		$1,137.84
$1,248.92
$1,366.62
$1,784.70 		$1,452.64
$1,563.72
$1,681.42
$2,099.50 		$1,767.44
$1,878.52
$1,996.22
$2,414.30 		$314.80
Toc - Plan #32 Ambetter of Oklahoma
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301.73
$342.45
$385.60
$538.88
$818.87 		$532.55
$573.27
$616.42
$769.70 		$763.37
$804.09
$847.24
$1,000.52 		$994.19
$1,034.91
$1,078.06
$1,231.34 		$230.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.46
$684.90
$771.20
$1,077.76
$1,637.74 		$834.28
$915.72
$1,002.02
$1,308.58 		$1,065.10
$1,146.54
$1,232.84
$1,539.40 		$1,295.92
$1,377.36
$1,463.66
$1,770.22 		$230.82
Toc - Plan #33 Ambetter of Oklahoma
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$327.18
$371.34
$418.13
$584.33
$887.95 		$577.47
$621.63
$668.42
$834.62 		$827.76
$871.92
$918.71
$1,084.91 		$1,078.05
$1,122.21
$1,169.00
$1,335.20 		$250.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.36
$742.68
$836.26
$1,168.66
$1,775.90 		$904.65
$992.97
$1,086.55
$1,418.95 		$1,154.94
$1,243.26
$1,336.84
$1,669.24 		$1,405.23
$1,493.55
$1,587.13
$1,919.53 		$250.29
Toc - Plan #34 Ambetter of Oklahoma
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$353.63
$401.35
$451.92
$631.56
$959.71 		$624.15
$671.87
$722.44
$902.08 		$894.67
$942.39
$992.96
$1,172.60 		$1,165.19
$1,212.91
$1,263.48
$1,443.12 		$270.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.26
$802.70
$903.84
$1,263.12
$1,919.42 		$977.78
$1,073.22
$1,174.36
$1,533.64 		$1,248.30
$1,343.74
$1,444.88
$1,804.16 		$1,518.82
$1,614.26
$1,715.40
$2,074.68 		$270.52
Toc - Plan #35 Ambetter of Oklahoma
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$371.93
$422.12
$475.31
$664.24
$1,009.38 		$656.45
$706.64
$759.83
$948.76 		$940.97
$991.16
$1,044.35
$1,233.28 		$1,225.49
$1,275.68
$1,328.87
$1,517.80 		$284.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.86
$844.24
$950.62
$1,328.48
$2,018.76 		$1,028.38
$1,128.76
$1,235.14
$1,613.00 		$1,312.90
$1,413.28
$1,519.66
$1,897.52 		$1,597.42
$1,697.80
$1,804.18
$2,182.04 		$284.52
Toc - Plan #36 Ambetter of Oklahoma
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$395.24
$448.59
$505.11
$705.89
$1,072.67 		$697.59
$750.94
$807.46
$1,008.24 		$999.94
$1,053.29
$1,109.81
$1,310.59 		$1,302.29
$1,355.64
$1,412.16
$1,612.94 		$302.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.48
$897.18
$1,010.22
$1,411.78
$2,145.34 		$1,092.83
$1,199.53
$1,312.57
$1,714.13 		$1,395.18
$1,501.88
$1,614.92
$2,016.48 		$1,697.53
$1,804.23
$1,917.27
$2,318.83 		$302.35
Toc - Plan #37 Ambetter of Oklahoma
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$390.26
$442.94
$498.75
$696.99
$1,059.15 		$688.80
$741.48
$797.29
$995.53 		$987.34
$1,040.02
$1,095.83
$1,294.07 		$1,285.88
$1,338.56
$1,394.37
$1,592.61 		$298.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.52
$885.88
$997.50
$1,393.98
$2,118.30 		$1,079.06
$1,184.42
$1,296.04
$1,692.52 		$1,377.60
$1,482.96
$1,594.58
$1,991.06 		$1,676.14
$1,781.50
$1,893.12
$2,289.60 		$298.54
Toc - Plan #38 Ambetter of Oklahoma
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$368.53
$418.27
$470.96
$658.17
$1,000.15 		$650.45
$700.19
$752.88
$940.09 		$932.37
$982.11
$1,034.80
$1,222.01 		$1,214.29
$1,264.03
$1,316.72
$1,503.93 		$281.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.06
$836.54
$941.92
$1,316.34
$2,000.30 		$1,018.98
$1,118.46
$1,223.84
$1,598.26 		$1,300.90
$1,400.38
$1,505.76
$1,880.18 		$1,582.82
$1,682.30
$1,787.68
$2,162.10 		$281.92
Toc - Plan #39 Ambetter of Oklahoma
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$378.60
$429.71
$483.84
$676.17
$1,027.51 		$668.23
$719.34
$773.47
$965.80 		$957.86
$1,008.97
$1,063.10
$1,255.43 		$1,247.49
$1,298.60
$1,352.73
$1,545.06 		$289.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.20
$859.42
$967.68
$1,352.34
$2,055.02 		$1,046.83
$1,149.05
$1,257.31
$1,641.97 		$1,336.46
$1,438.68
$1,546.94
$1,931.60 		$1,626.09
$1,728.31
$1,836.57
$2,221.23 		$289.63
Toc - Plan #40 Ambetter of Oklahoma
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$458.52
$520.41
$585.98
$818.90
$1,244.40 		$809.28
$871.17
$936.74
$1,169.66 		$1,160.04
$1,221.93
$1,287.50
$1,520.42 		$1,510.80
$1,572.69
$1,638.26
$1,871.18 		$350.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.04
$1,040.82
$1,171.96
$1,637.80
$2,488.80 		$1,267.80
$1,391.58
$1,522.72
$1,988.56 		$1,618.56
$1,742.34
$1,873.48
$2,339.32 		$1,969.32
$2,093.10
$2,224.24
$2,690.08 		$350.76
Toc - Plan #41 Ambetter of Oklahoma
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$430.22
$488.29
$549.81
$768.36
$1,167.60 		$759.33
$817.40
$878.92
$1,097.47 		$1,088.44
$1,146.51
$1,208.03
$1,426.58 		$1,417.55
$1,475.62
$1,537.14
$1,755.69 		$329.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.44
$976.58
$1,099.62
$1,536.72
$2,335.20 		$1,189.55
$1,305.69
$1,428.73
$1,865.83 		$1,518.66
$1,634.80
$1,757.84
$2,194.94 		$1,847.77
$1,963.91
$2,086.95
$2,524.05 		$329.11

ADVERTISEMENT

Blue Cross and Blue Shield of Oklahoma

Local: 1-866-520-2507 | Toll Free: 1-866-520-2507 | TTY: 1-800-722-0353
Toc - Plan #42 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Preferred Silver PPO? 201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$553.65
$628.40
$707.57
$988.82
$1,502.61 		$977.19
$1,051.94
$1,131.11
$1,412.36 		$1,400.73
$1,475.48
$1,554.65
$1,835.90 		$1,824.27
$1,899.02
$1,978.19
$2,259.44 		$423.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,107.30
$1,256.80
$1,415.14
$1,977.64
$3,005.22 		$1,530.84
$1,680.34
$1,838.68
$2,401.18 		$1,954.38
$2,103.88
$2,262.22
$2,824.72 		$2,377.92
$2,527.42
$2,685.76
$3,248.26 		$423.54
Toc - Plan #43 Blue Cross and Blue Shield of Oklahoma
Catastrophic

(PPO) Blue Preferred Security PPO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$334.18
$379.29
$427.08
$596.84
$906.96 		$589.83
$634.94
$682.73
$852.49 		$845.48
$890.59
$938.38
$1,108.14 		$1,101.13
$1,146.24
$1,194.03
$1,363.79 		$255.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.36
$758.58
$854.16
$1,193.68
$1,813.92 		$924.01
$1,014.23
$1,109.81
$1,449.33 		$1,179.66
$1,269.88
$1,365.46
$1,704.98 		$1,435.31
$1,525.53
$1,621.11
$1,960.63 		$255.65
Toc - Plan #44 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Preferred Gold PPO? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$550 $1,650 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$503.33
$571.28
$643.26
$898.96
$1,366.05 		$888.38
$956.33
$1,028.31
$1,284.01 		$1,273.43
$1,341.38
$1,413.36
$1,669.06 		$1,658.48
$1,726.43
$1,798.41
$2,054.11 		$385.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,006.66
$1,142.56
$1,286.52
$1,797.92
$2,732.10 		$1,391.71
$1,527.61
$1,671.57
$2,182.97 		$1,776.76
$1,912.66
$2,056.62
$2,568.02 		$2,161.81
$2,297.71
$2,441.67
$2,953.07 		$385.05
Toc - Plan #45 Blue Cross and Blue Shield of Oklahoma
Bronze

(PPO) Blue Preferred Bronze PPO? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.28
$399.83
$450.21
$629.16
$956.08 		$621.77
$669.32
$719.70
$898.65 		$891.26
$938.81
$989.19
$1,168.14 		$1,160.75
$1,208.30
$1,258.68
$1,437.63 		$269.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.56
$799.66
$900.42
$1,258.32
$1,912.16 		$974.05
$1,069.15
$1,169.91
$1,527.81 		$1,243.54
$1,338.64
$1,439.40
$1,797.30 		$1,513.03
$1,608.13
$1,708.89
$2,066.79 		$269.49
Toc - Plan #46 Blue Cross and Blue Shield of Oklahoma
Bronze

(PPO) Blue Preferred Bronze PPO? 603

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$7,500 $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 		$340.01
$385.92
$434.54
$607.26
$922.80 		$600.12
$646.03
$694.65
$867.37 		$860.23
$906.14
$954.76
$1,127.48 		$1,120.34
$1,166.25
$1,214.87
$1,387.59 		$260.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.02
$771.84
$869.08
$1,214.52
$1,845.60 		$940.13
$1,031.95
$1,129.19
$1,474.63 		$1,200.24
$1,292.06
$1,389.30
$1,734.74 		$1,460.35
$1,552.17
$1,649.41
$1,994.85 		$260.11
Toc - Plan #47 Blue Cross and Blue Shield of Oklahoma
Expanded Bronze

(PPO) Blue Advantage Bronze PPO? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$4,500 $13,500 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 		$333.36
$378.37
$426.04
$595.39
$904.75 		$588.38
$633.39
$681.06
$850.41 		$843.40
$888.41
$936.08
$1,105.43 		$1,098.42
$1,143.43
$1,191.10
$1,360.45 		$255.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.72
$756.74
$852.08
$1,190.78
$1,809.50 		$921.74
$1,011.76
$1,107.10
$1,445.80 		$1,176.76
$1,266.78
$1,362.12
$1,700.82 		$1,431.78
$1,521.80
$1,617.14
$1,955.84 		$255.02
Toc - Plan #48 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Advantage Silver PPO? 204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,600 $4,800 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 		$433.79
$492.35
$554.38
$774.74
$1,177.30 		$765.64
$824.20
$886.23
$1,106.59 		$1,097.49
$1,156.05
$1,218.08
$1,438.44 		$1,429.34
$1,487.90
$1,549.93
$1,770.29 		$331.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.58
$984.70
$1,108.76
$1,549.48
$2,354.60 		$1,199.43
$1,316.55
$1,440.61
$1,881.33 		$1,531.28
$1,648.40
$1,772.46
$2,213.18 		$1,863.13
$1,980.25
$2,104.31
$2,545.03 		$331.85
Toc - Plan #49 Blue Cross and Blue Shield of Oklahoma
Bronze

(PPO) Blue Advantage Bronze PPO? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$292.95
$332.50
$374.39
$523.21
$795.06 		$517.06
$556.61
$598.50
$747.32 		$741.17
$780.72
$822.61
$971.43 		$965.28
$1,004.83
$1,046.72
$1,195.54 		$224.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.90
$665.00
$748.78
$1,046.42
$1,590.12 		$810.01
$889.11
$972.89
$1,270.53 		$1,034.12
$1,113.22
$1,197.00
$1,494.64 		$1,258.23
$1,337.33
$1,421.11
$1,718.75 		$224.11
Toc - Plan #50 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Advantage Gold PPO? 309

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,200 $3,600 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 		$428.06
$485.85
$547.06
$764.51
$1,161.75 		$755.52
$813.31
$874.52
$1,091.97 		$1,082.98
$1,140.77
$1,201.98
$1,419.43 		$1,410.44
$1,468.23
$1,529.44
$1,746.89 		$327.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.12
$971.70
$1,094.12
$1,529.02
$2,323.50 		$1,183.58
$1,299.16
$1,421.58
$1,856.48 		$1,511.04
$1,626.62
$1,749.04
$2,183.94 		$1,838.50
$1,954.08
$2,076.50
$2,511.40 		$327.46
Toc - Plan #51 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Advantage Silver PPO? 605

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$466.66
$529.66
$596.39
$833.45
$1,266.51 		$823.65
$886.65
$953.38
$1,190.44 		$1,180.64
$1,243.64
$1,310.37
$1,547.43 		$1,537.63
$1,600.63
$1,667.36
$1,904.42 		$356.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$933.32
$1,059.32
$1,192.78
$1,666.90
$2,533.02 		$1,290.31
$1,416.31
$1,549.77
$2,023.89 		$1,647.30
$1,773.30
$1,906.76
$2,380.88 		$2,004.29
$2,130.29
$2,263.75
$2,737.87 		$356.99
Toc - Plan #52 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Advantage Gold PPO? 604

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,500 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 		$408.59
$463.75
$522.18
$729.74
$1,108.92 		$721.16
$776.32
$834.75
$1,042.31 		$1,033.73
$1,088.89
$1,147.32
$1,354.88 		$1,346.30
$1,401.46
$1,459.89
$1,667.45 		$312.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817.18
$927.50
$1,044.36
$1,459.48
$2,217.84 		$1,129.75
$1,240.07
$1,356.93
$1,772.05 		$1,442.32
$1,552.64
$1,669.50
$2,084.62 		$1,754.89
$1,865.21
$1,982.07
$2,397.19 		$312.57

ADVERTISEMENT

Friday Health Plans

Local: 1-844-817-1600 | Toll Free: 1-844-817-1600 | TTY: 1-800-659-2656
Toc - Plan #53 Friday Health Plans
Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$229.32
$260.28
$293.08
$409.57
$622.39 		$404.75
$435.71
$468.51
$585.00 		$580.18
$611.14
$643.94
$760.43 		$755.61
$786.57
$819.37
$935.86 		$175.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$458.64
$520.56
$586.16
$819.14
$1,244.78 		$634.07
$695.99
$761.59
$994.57 		$809.50
$871.42
$937.02
$1,170.00 		$984.93
$1,046.85
$1,112.45
$1,345.43 		$175.43
Toc - Plan #54 Friday Health Plans
Bronze

(HMO) Friday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$274.12
$311.13
$350.33
$489.59
$743.97 		$483.83
$520.84
$560.04
$699.30 		$693.54
$730.55
$769.75
$909.01 		$903.25
$940.26
$979.46
$1,118.72 		$209.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.24
$622.26
$700.66
$979.18
$1,487.94 		$757.95
$831.97
$910.37
$1,188.89 		$967.66
$1,041.68
$1,120.08
$1,398.60 		$1,177.37
$1,251.39
$1,329.79
$1,608.31 		$209.71
Toc - Plan #55 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$280.04
$317.84
$357.89
$500.15
$760.03 		$494.27
$532.07
$572.12
$714.38 		$708.50
$746.30
$786.35
$928.61 		$922.73
$960.53
$1,000.58
$1,142.84 		$214.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560.08
$635.68
$715.78
$1,000.30
$1,520.06 		$774.31
$849.91
$930.01
$1,214.53 		$988.54
$1,064.14
$1,144.24
$1,428.76 		$1,202.77
$1,278.37
$1,358.47
$1,642.99 		$214.23
Toc - Plan #56 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.99
$328.01
$369.33
$516.14
$784.32 		$510.07
$549.09
$590.41
$737.22 		$731.15
$770.17
$811.49
$958.30 		$952.23
$991.25
$1,032.57
$1,179.38 		$221.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.98
$656.02
$738.66
$1,032.28
$1,568.64 		$799.06
$877.10
$959.74
$1,253.36 		$1,020.14
$1,098.18
$1,180.82
$1,474.44 		$1,241.22
$1,319.26
$1,401.90
$1,695.52 		$221.08
Toc - Plan #57 Friday Health Plans
Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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 		$359.88
$408.46
$459.92
$642.74
$976.71 		$635.19
$683.77
$735.23
$918.05 		$910.50
$959.08
$1,010.54
$1,193.36 		$1,185.81
$1,234.39
$1,285.85
$1,468.67 		$275.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.76
$816.92
$919.84
$1,285.48
$1,953.42 		$995.07
$1,092.23
$1,195.15
$1,560.79 		$1,270.38
$1,367.54
$1,470.46
$1,836.10 		$1,545.69
$1,642.85
$1,745.77
$2,111.41 		$275.31
Toc - Plan #58 Friday Health Plans
Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 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 		$347.43
$394.33
$444.01
$620.51
$942.92 		$613.21
$660.11
$709.79
$886.29 		$878.99
$925.89
$975.57
$1,152.07 		$1,144.77
$1,191.67
$1,241.35
$1,417.85 		$265.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.86
$788.66
$888.02
$1,241.02
$1,885.84 		$960.64
$1,054.44
$1,153.80
$1,506.80 		$1,226.42
$1,320.22
$1,419.58
$1,772.58 		$1,492.20
$1,586.00
$1,685.36
$2,038.36 		$265.78
Toc - Plan #59 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

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 		$282.37
$320.49
$360.87
$504.31
$766.35 		$498.38
$536.50
$576.88
$720.32 		$714.39
$752.51
$792.89
$936.33 		$930.40
$968.52
$1,008.90
$1,152.34 		$216.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.74
$640.98
$721.74
$1,008.62
$1,532.70 		$780.75
$856.99
$937.75
$1,224.63 		$996.76
$1,073.00
$1,153.76
$1,440.64 		$1,212.77
$1,289.01
$1,369.77
$1,656.65 		$216.01
Toc - Plan #60 Friday Health Plans
Silver

(HMO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.26
$416.84
$469.36
$655.93
$996.75 		$648.22
$697.80
$750.32
$936.89 		$929.18
$978.76
$1,031.28
$1,217.85 		$1,210.14
$1,259.72
$1,312.24
$1,498.81 		$280.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.52
$833.68
$938.72
$1,311.86
$1,993.50 		$1,015.48
$1,114.64
$1,219.68
$1,592.82 		$1,296.44
$1,395.60
$1,500.64
$1,873.78 		$1,577.40
$1,676.56
$1,781.60
$2,154.74 		$280.96
Toc - Plan #61 Friday Health Plans
Gold

(HMO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 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 		$362.72
$411.69
$463.56
$647.82
$984.43 		$640.20
$689.17
$741.04
$925.30 		$917.68
$966.65
$1,018.52
$1,202.78 		$1,195.16
$1,244.13
$1,296.00
$1,480.26 		$277.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.44
$823.38
$927.12
$1,295.64
$1,968.86 		$1,002.92
$1,100.86
$1,204.60
$1,573.12 		$1,280.40
$1,378.34
$1,482.08
$1,850.60 		$1,557.88
$1,655.82
$1,759.56
$2,128.08 		$277.48

ADVERTISEMENT

CommunityCare

Local: 1-918-594-5242 | Toll Free: 1-800-777-4890 | TTY: 1-800-722-0353
Toc - Plan #62 CommunityCare
Catastrophic

(HMO) CommunityCare Catastrophic Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

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 		$196.01
$222.47
$250.50
$350.08
$531.97 		$345.96
$372.42
$400.45
$500.03 		$495.91
$522.37
$550.40
$649.98 		$645.86
$672.32
$700.35
$799.93 		$149.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$392.02
$444.94
$501.00
$700.16
$1,063.94 		$541.97
$594.89
$650.95
$850.11 		$691.92
$744.84
$800.90
$1,000.06 		$841.87
$894.79
$950.85
$1,150.01 		$149.95
Toc - Plan #63 CommunityCare
Gold

(HMO) CommunityCare Gold L21 Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$4,000 $12,000 Annual Deductible
$8,300 $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 		$373.49
$423.91
$477.32
$667.05
$1,013.65 		$659.21
$709.63
$763.04
$952.77 		$944.93
$995.35
$1,048.76
$1,238.49 		$1,230.65
$1,281.07
$1,334.48
$1,524.21 		$285.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.98
$847.82
$954.64
$1,334.10
$2,027.30 		$1,032.70
$1,133.54
$1,240.36
$1,619.82 		$1,318.42
$1,419.26
$1,526.08
$1,905.54 		$1,604.14
$1,704.98
$1,811.80
$2,191.26 		$285.72
Toc - Plan #64 CommunityCare
Silver

(HMO) CommunityCare Silver L21 Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$7,700 $17,100 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 		$390.48
$443.20
$499.04
$697.40
$1,059.76 		$689.20
$741.92
$797.76
$996.12 		$987.92
$1,040.64
$1,096.48
$1,294.84 		$1,286.64
$1,339.36
$1,395.20
$1,593.56 		$298.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.96
$886.40
$998.08
$1,394.80
$2,119.52 		$1,079.68
$1,185.12
$1,296.80
$1,693.52 		$1,378.40
$1,483.84
$1,595.52
$1,992.24 		$1,677.12
$1,782.56
$1,894.24
$2,290.96 		$298.72
Toc - Plan #65 CommunityCare
Gold

(HMO) CommunityCare Gold IH221

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$1,100 $3,300 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 		$385.33
$437.34
$492.45
$688.19
$1,045.77 		$680.11
$732.12
$787.23
$982.97 		$974.89
$1,026.90
$1,082.01
$1,277.75 		$1,269.67
$1,321.68
$1,376.79
$1,572.53 		$294.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.66
$874.68
$984.90
$1,376.38
$2,091.54 		$1,065.44
$1,169.46
$1,279.68
$1,671.16 		$1,360.22
$1,464.24
$1,574.46
$1,965.94 		$1,655.00
$1,759.02
$1,869.24
$2,260.72 		$294.78
Toc - Plan #66 CommunityCare
Gold

(HMO) CommunityCare Gold IH222

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$2,200 $6,600 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 		$379.66
$430.92
$485.21
$678.07
$1,030.40 		$670.10
$721.36
$775.65
$968.51 		$960.54
$1,011.80
$1,066.09
$1,258.95 		$1,250.98
$1,302.24
$1,356.53
$1,549.39 		$290.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$759.32
$861.84
$970.42
$1,356.14
$2,060.80 		$1,049.76
$1,152.28
$1,260.86
$1,646.58 		$1,340.20
$1,442.72
$1,551.30
$1,937.02 		$1,630.64
$1,733.16
$1,841.74
$2,227.46 		$290.44
Toc - Plan #67 CommunityCare
Expanded Bronze

(HMO) CommunityCare Bronze IH223

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$5,000 $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 		$280.20
$318.03
$358.09
$500.43
$760.45 		$494.55
$532.38
$572.44
$714.78 		$708.90
$746.73
$786.79
$929.13 		$923.25
$961.08
$1,001.14
$1,143.48 		$214.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560.40
$636.06
$716.18
$1,000.86
$1,520.90 		$774.75
$850.41
$930.53
$1,215.21 		$989.10
$1,064.76
$1,144.88
$1,429.56 		$1,203.45
$1,279.11
$1,359.23
$1,643.91 		$214.35
Toc - Plan #68 CommunityCare
Expanded Bronze

(HMO) CommunityCare Bronze IH224

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

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 		$285.76
$324.34
$365.20
$510.37
$775.55 		$504.37
$542.95
$583.81
$728.98 		$722.98
$761.56
$802.42
$947.59 		$941.59
$980.17
$1,021.03
$1,166.20 		$218.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.52
$648.68
$730.40
$1,020.74
$1,551.10 		$790.13
$867.29
$949.01
$1,239.35 		$1,008.74
$1,085.90
$1,167.62
$1,457.96 		$1,227.35
$1,304.51
$1,386.23
$1,676.57 		$218.61

‡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 Tulsa County here.

Tulsa County is in “Rating Area 4” of Oklahoma.

Currently, there are 68 plans offered in Rating Area 4.

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2022 Obamacare Plans for Tulsa County, OK

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