Obamacare 2024 Rates for Levy County, Florida

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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 Williston, FL.

The health insurance rates listed below are for calendar year 2024.

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, 69 Plans and 2024 Rates for Levy County, Florida

Below, you’ll find a summary of the 69 plans for Levy County, Florida and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |

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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 #1 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-03 ($0 Virtual Visits / $0 Labs / 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
$8,000 $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 		$792.53
$899.52
$1,012.85
$1,415.46
$2,150.93 		$1,398.82
$1,505.81
$1,619.14
$2,021.75 		$2,005.11
$2,112.10
$2,225.43
$2,628.04 		$2,611.40
$2,718.39
$2,831.72
$3,234.33 		$606.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,585.06
$1,799.04
$2,025.70
$2,830.92
$4,301.86 		$2,191.35
$2,405.33
$2,631.99
$3,437.21 		$2,797.64
$3,011.62
$3,238.28
$4,043.50 		$3,403.93
$3,617.91
$3,844.57
$4,649.79 		$606.29
Toc - Plan #2 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-04 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,450 $18,900 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 		$566.46
$642.93
$723.94
$1,011.70
$1,537.37 		$999.80
$1,076.27
$1,157.28
$1,445.04 		$1,433.14
$1,509.61
$1,590.62
$1,878.38 		$1,866.48
$1,942.95
$2,023.96
$2,311.72 		$433.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,132.92
$1,285.86
$1,447.88
$2,023.40
$3,074.74 		$1,566.26
$1,719.20
$1,881.22
$2,456.74 		$1,999.60
$2,152.54
$2,314.56
$2,890.08 		$2,432.94
$2,585.88
$2,747.90
$3,323.42 		$433.34
Toc - Plan #3 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-05 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$1,069.38
$1,213.75
$1,366.67
$1,909.91
$2,902.30 		$1,887.46
$2,031.83
$2,184.75
$2,727.99 		$2,705.54
$2,849.91
$3,002.83
$3,546.07 		$3,523.62
$3,667.99
$3,820.91
$4,364.15 		$818.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,138.76
$2,427.50
$2,733.34
$3,819.82
$5,804.60 		$2,956.84
$3,245.58
$3,551.42
$4,637.90 		$3,774.92
$4,063.66
$4,369.50
$5,455.98 		$4,593.00
$4,881.74
$5,187.58
$6,274.06 		$818.08
Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)
Bronze

(PPO) BlueOptions Bronze 24J01-06 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$9,450 $18,900 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 		$529.97
$601.52
$677.30
$946.53
$1,438.34 		$935.40
$1,006.95
$1,082.73
$1,351.96 		$1,340.83
$1,412.38
$1,488.16
$1,757.39 		$1,746.26
$1,817.81
$1,893.59
$2,162.82 		$405.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,059.94
$1,203.04
$1,354.60
$1,893.06
$2,876.68 		$1,465.37
$1,608.47
$1,760.03
$2,298.49 		$1,870.80
$2,013.90
$2,165.46
$2,703.92 		$2,276.23
$2,419.33
$2,570.89
$3,109.35 		$405.43
Toc - Plan #5 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-07 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$847.79
$962.24
$1,083.48
$1,514.15
$2,300.90 		$1,496.35
$1,610.80
$1,732.04
$2,162.71 		$2,144.91
$2,259.36
$2,380.60
$2,811.27 		$2,793.47
$2,907.92
$3,029.16
$3,459.83 		$648.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,695.58
$1,924.48
$2,166.96
$3,028.30
$4,601.80 		$2,344.14
$2,573.04
$2,815.52
$3,676.86 		$2,992.70
$3,221.60
$3,464.08
$4,325.42 		$3,641.26
$3,870.16
$4,112.64
$4,973.98 		$648.56
Toc - Plan #6 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-08 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$1,112.27
$1,262.43
$1,421.48
$1,986.51
$3,018.70 		$1,963.16
$2,113.32
$2,272.37
$2,837.40 		$2,814.05
$2,964.21
$3,123.26
$3,688.29 		$3,664.94
$3,815.10
$3,974.15
$4,539.18 		$850.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,224.54
$2,524.86
$2,842.96
$3,973.02
$6,037.40 		$3,075.43
$3,375.75
$3,693.85
$4,823.91 		$3,926.32
$4,226.64
$4,544.74
$5,674.80 		$4,777.21
$5,077.53
$5,395.63
$6,525.69 		$850.89
Toc - Plan #7 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-09 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / 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
$6,250 $12,500 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 		$912.63
$1,035.84
$1,166.34
$1,629.96
$2,476.88 		$1,610.79
$1,734.00
$1,864.50
$2,328.12 		$2,308.95
$2,432.16
$2,562.66
$3,026.28 		$3,007.11
$3,130.32
$3,260.82
$3,724.44 		$698.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,825.26
$2,071.68
$2,332.68
$3,259.92
$4,953.76 		$2,523.42
$2,769.84
$3,030.84
$3,958.08 		$3,221.58
$3,468.00
$3,729.00
$4,656.24 		$3,919.74
$4,166.16
$4,427.16
$5,354.40 		$698.16
Toc - Plan #8 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze (HSA) 24J01-10 (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
$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 		$551.00
$625.39
$704.18
$984.09
$1,495.41 		$972.52
$1,046.91
$1,125.70
$1,405.61 		$1,394.04
$1,468.43
$1,547.22
$1,827.13 		$1,815.56
$1,889.95
$1,968.74
$2,248.65 		$421.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,102.00
$1,250.78
$1,408.36
$1,968.18
$2,990.82 		$1,523.52
$1,672.30
$1,829.88
$2,389.70 		$1,945.04
$2,093.82
$2,251.40
$2,811.22 		$2,366.56
$2,515.34
$2,672.92
$3,232.74 		$421.52
Toc - Plan #9 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-12 ($0 Virtual Visits / $20 Labs / 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
$5,900 $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 		$885.66
$1,005.22
$1,131.87
$1,581.79
$2,403.68 		$1,563.19
$1,682.75
$1,809.40
$2,259.32 		$2,240.72
$2,360.28
$2,486.93
$2,936.85 		$2,918.25
$3,037.81
$3,164.46
$3,614.38 		$677.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,771.32
$2,010.44
$2,263.74
$3,163.58
$4,807.36 		$2,448.85
$2,687.97
$2,941.27
$3,841.11 		$3,126.38
$3,365.50
$3,618.80
$4,518.64 		$3,803.91
$4,043.03
$4,296.33
$5,196.17 		$677.53
Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-17 ($0 Virtual Visits / $50 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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 		$593.12
$673.19
$758.01
$1,059.31
$1,609.73 		$1,046.86
$1,126.93
$1,211.75
$1,513.05 		$1,500.60
$1,580.67
$1,665.49
$1,966.79 		$1,954.34
$2,034.41
$2,119.23
$2,420.53 		$453.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,186.24
$1,346.38
$1,516.02
$2,118.62
$3,219.46 		$1,639.98
$1,800.12
$1,969.76
$2,572.36 		$2,093.72
$2,253.86
$2,423.50
$3,026.10 		$2,547.46
$2,707.60
$2,877.24
$3,479.84 		$453.74
Toc - Plan #11 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-18S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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 		$555.25
$630.21
$709.61
$991.68
$1,506.95 		$980.02
$1,054.98
$1,134.38
$1,416.45 		$1,404.79
$1,479.75
$1,559.15
$1,841.22 		$1,829.56
$1,904.52
$1,983.92
$2,265.99 		$424.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,110.50
$1,260.42
$1,419.22
$1,983.36
$3,013.90 		$1,535.27
$1,685.19
$1,843.99
$2,408.13 		$1,960.04
$2,109.96
$2,268.76
$2,832.90 		$2,384.81
$2,534.73
$2,693.53
$3,257.67 		$424.77
Toc - Plan #12 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-19S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 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 		$823.67
$934.87
$1,052.65
$1,471.07
$2,235.44 		$1,453.78
$1,564.98
$1,682.76
$2,101.18 		$2,083.89
$2,195.09
$2,312.87
$2,731.29 		$2,714.00
$2,825.20
$2,942.98
$3,361.40 		$630.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,647.34
$1,869.74
$2,105.30
$2,942.14
$4,470.88 		$2,277.45
$2,499.85
$2,735.41
$3,572.25 		$2,907.56
$3,129.96
$3,365.52
$4,202.36 		$3,537.67
$3,760.07
$3,995.63
$4,832.47 		$630.11
Toc - Plan #13 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-20S ($30 PCP Visits / Multilingual Available / 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
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$863.79
$980.40
$1,103.92
$1,542.73
$2,344.33 		$1,524.59
$1,641.20
$1,764.72
$2,203.53 		$2,185.39
$2,302.00
$2,425.52
$2,864.33 		$2,846.19
$2,962.80
$3,086.32
$3,525.13 		$660.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,727.58
$1,960.80
$2,207.84
$3,085.46
$4,688.66 		$2,388.38
$2,621.60
$2,868.64
$3,746.26 		$3,049.18
$3,282.40
$3,529.44
$4,407.06 		$3,709.98
$3,943.20
$4,190.24
$5,067.86 		$660.80
Toc - Plan #14 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-21S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / 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
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$1,105.32
$1,254.54
$1,412.60
$1,974.10
$2,999.84 		$1,950.89
$2,100.11
$2,258.17
$2,819.67 		$2,796.46
$2,945.68
$3,103.74
$3,665.24 		$3,642.03
$3,791.25
$3,949.31
$4,510.81 		$845.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,210.64
$2,509.08
$2,825.20
$3,948.20
$5,999.68 		$3,056.21
$3,354.65
$3,670.77
$4,793.77 		$3,901.78
$4,200.22
$4,516.34
$5,639.34 		$4,747.35
$5,045.79
$5,361.91
$6,484.91 		$845.57

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Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #15 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold

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
$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 		$424.86
$482.20
$542.95
$758.78
$1,153.03 		$749.87
$807.21
$867.96
$1,083.79 		$1,074.88
$1,132.22
$1,192.97
$1,408.80 		$1,399.89
$1,457.23
$1,517.98
$1,733.81 		$325.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.72
$964.40
$1,085.90
$1,517.56
$2,306.06 		$1,174.73
$1,289.41
$1,410.91
$1,842.57 		$1,499.74
$1,614.42
$1,735.92
$2,167.58 		$1,824.75
$1,939.43
$2,060.93
$2,492.59 		$325.01
Toc - Plan #16 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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 		$350.95
$398.32
$448.51
$626.78
$952.46 		$619.42
$666.79
$716.98
$895.25 		$887.89
$935.26
$985.45
$1,163.72 		$1,156.36
$1,203.73
$1,253.92
$1,432.19 		$268.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$701.90
$796.64
$897.02
$1,253.56
$1,904.92 		$970.37
$1,065.11
$1,165.49
$1,522.03 		$1,238.84
$1,333.58
$1,433.96
$1,790.50 		$1,507.31
$1,602.05
$1,702.43
$2,058.97 		$268.47
Toc - Plan #17 Ambetter from Sunshine Health
Silver

(EPO) Everyday Silver

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 		$442.96
$502.74
$566.08
$791.10
$1,202.15 		$781.81
$841.59
$904.93
$1,129.95 		$1,120.66
$1,180.44
$1,243.78
$1,468.80 		$1,459.51
$1,519.29
$1,582.63
$1,807.65 		$338.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$885.92
$1,005.48
$1,132.16
$1,582.20
$2,404.30 		$1,224.77
$1,344.33
$1,471.01
$1,921.05 		$1,563.62
$1,683.18
$1,809.86
$2,259.90 		$1,902.47
$2,022.03
$2,148.71
$2,598.75 		$338.85
Toc - Plan #18 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$8,450 $16,900 Annual Deductible
$9,250 $18,500 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 		$346.18
$392.90
$442.41
$618.26
$939.51 		$611.00
$657.72
$707.23
$883.08 		$875.82
$922.54
$972.05
$1,147.90 		$1,140.64
$1,187.36
$1,236.87
$1,412.72 		$264.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.36
$785.80
$884.82
$1,236.52
$1,879.02 		$957.18
$1,050.62
$1,149.64
$1,501.34 		$1,222.00
$1,315.44
$1,414.46
$1,766.16 		$1,486.82
$1,580.26
$1,679.28
$2,030.98 		$264.82
Toc - Plan #19 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,250 $18,500 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 		$397.47
$451.12
$507.95
$709.86
$1,078.71 		$701.53
$755.18
$812.01
$1,013.92 		$1,005.59
$1,059.24
$1,116.07
$1,317.98 		$1,309.65
$1,363.30
$1,420.13
$1,622.04 		$304.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.94
$902.24
$1,015.90
$1,419.72
$2,157.42 		$1,099.00
$1,206.30
$1,319.96
$1,723.78 		$1,403.06
$1,510.36
$1,624.02
$2,027.84 		$1,707.12
$1,814.42
$1,928.08
$2,331.90 		$304.06
Toc - Plan #20 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$431.39
$489.62
$551.30
$770.45
$1,170.77 		$761.40
$819.63
$881.31
$1,100.46 		$1,091.41
$1,149.64
$1,211.32
$1,430.47 		$1,421.42
$1,479.65
$1,541.33
$1,760.48 		$330.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.78
$979.24
$1,102.60
$1,540.90
$2,341.54 		$1,192.79
$1,309.25
$1,432.61
$1,870.91 		$1,522.80
$1,639.26
$1,762.62
$2,200.92 		$1,852.81
$1,969.27
$2,092.63
$2,530.93 		$330.01
Toc - Plan #21 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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 		$439.09
$498.35
$561.14
$784.19
$1,191.65 		$774.98
$834.24
$897.03
$1,120.08 		$1,110.87
$1,170.13
$1,232.92
$1,455.97 		$1,446.76
$1,506.02
$1,568.81
$1,791.86 		$335.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.18
$996.70
$1,122.28
$1,568.38
$2,383.30 		$1,214.07
$1,332.59
$1,458.17
$1,904.27 		$1,549.96
$1,668.48
$1,794.06
$2,240.16 		$1,885.85
$2,004.37
$2,129.95
$2,576.05 		$335.89
Toc - Plan #22 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold

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 		$406.11
$460.93
$519.00
$725.30
$1,102.16 		$716.78
$771.60
$829.67
$1,035.97 		$1,027.45
$1,082.27
$1,140.34
$1,346.64 		$1,338.12
$1,392.94
$1,451.01
$1,657.31 		$310.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.22
$921.86
$1,038.00
$1,450.60
$2,204.32 		$1,122.89
$1,232.53
$1,348.67
$1,761.27 		$1,433.56
$1,543.20
$1,659.34
$2,071.94 		$1,744.23
$1,853.87
$1,970.01
$2,382.61 		$310.67
Toc - Plan #23 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$467.16
$530.22
$597.02
$834.33
$1,267.85 		$824.53
$887.59
$954.39
$1,191.70 		$1,181.90
$1,244.96
$1,311.76
$1,549.07 		$1,539.27
$1,602.33
$1,669.13
$1,906.44 		$357.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.32
$1,060.44
$1,194.04
$1,668.66
$2,535.70 		$1,291.69
$1,417.81
$1,551.41
$2,026.03 		$1,649.06
$1,775.18
$1,908.78
$2,383.40 		$2,006.43
$2,132.55
$2,266.15
$2,740.77 		$357.37
Toc - Plan #24 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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 		$339.47
$385.29
$433.84
$606.28
$921.31 		$599.16
$644.98
$693.53
$865.97 		$858.85
$904.67
$953.22
$1,125.66 		$1,118.54
$1,164.36
$1,212.91
$1,385.35 		$259.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.94
$770.58
$867.68
$1,212.56
$1,842.62 		$938.63
$1,030.27
$1,127.37
$1,472.25 		$1,198.32
$1,289.96
$1,387.06
$1,731.94 		$1,458.01
$1,549.65
$1,646.75
$1,991.63 		$259.69
Toc - Plan #25 Ambetter from Sunshine Health
Silver

(EPO) Standard Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 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 		$429.93
$487.96
$549.44
$767.84
$1,166.80 		$758.82
$816.85
$878.33
$1,096.73 		$1,087.71
$1,145.74
$1,207.22
$1,425.62 		$1,416.60
$1,474.63
$1,536.11
$1,754.51 		$328.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.86
$975.92
$1,098.88
$1,535.68
$2,333.60 		$1,188.75
$1,304.81
$1,427.77
$1,864.57 		$1,517.64
$1,633.70
$1,756.66
$2,193.46 		$1,846.53
$1,962.59
$2,085.55
$2,522.35 		$328.89
Toc - Plan #26 Ambetter from Sunshine Health
Gold

(EPO) Standard Gold

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 		$403.66
$458.14
$515.87
$720.92
$1,095.51 		$712.45
$766.93
$824.66
$1,029.71 		$1,021.24
$1,075.72
$1,133.45
$1,338.50 		$1,330.03
$1,384.51
$1,442.24
$1,647.29 		$308.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.32
$916.28
$1,031.74
$1,441.84
$2,191.02 		$1,116.11
$1,225.07
$1,340.53
$1,750.63 		$1,424.90
$1,533.86
$1,649.32
$2,059.42 		$1,733.69
$1,842.65
$1,958.11
$2,368.21 		$308.79
Toc - Plan #27 Ambetter from Sunshine Health
Silver

(EPO) Everyday Silver + 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 		$458.20
$520.05
$585.57
$818.33
$1,243.53 		$808.72
$870.57
$936.09
$1,168.85 		$1,159.24
$1,221.09
$1,286.61
$1,519.37 		$1,509.76
$1,571.61
$1,637.13
$1,869.89 		$350.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$916.40
$1,040.10
$1,171.14
$1,636.66
$2,487.06 		$1,266.92
$1,390.62
$1,521.66
$1,987.18 		$1,617.44
$1,741.14
$1,872.18
$2,337.70 		$1,967.96
$2,091.66
$2,222.70
$2,688.22 		$350.52
Toc - Plan #28 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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 		$363.03
$412.03
$463.94
$648.36
$985.24 		$640.74
$689.74
$741.65
$926.07 		$918.45
$967.45
$1,019.36
$1,203.78 		$1,196.16
$1,245.16
$1,297.07
$1,481.49 		$277.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.06
$824.06
$927.88
$1,296.72
$1,970.48 		$1,003.77
$1,101.77
$1,205.59
$1,574.43 		$1,281.48
$1,379.48
$1,483.30
$1,852.14 		$1,559.19
$1,657.19
$1,761.01
$2,129.85 		$277.71
Toc - Plan #29 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold + 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
$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 		$439.48
$498.80
$561.64
$784.89
$1,192.72 		$775.67
$834.99
$897.83
$1,121.08 		$1,111.86
$1,171.18
$1,234.02
$1,457.27 		$1,448.05
$1,507.37
$1,570.21
$1,793.46 		$336.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.96
$997.60
$1,123.28
$1,569.78
$2,385.44 		$1,215.15
$1,333.79
$1,459.47
$1,905.97 		$1,551.34
$1,669.98
$1,795.66
$2,242.16 		$1,887.53
$2,006.17
$2,131.85
$2,578.35 		$336.19
Toc - Plan #30 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 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 		$446.24
$506.47
$570.28
$796.96
$1,211.06 		$787.60
$847.83
$911.64
$1,138.32 		$1,128.96
$1,189.19
$1,253.00
$1,479.68 		$1,470.32
$1,530.55
$1,594.36
$1,821.04 		$341.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.48
$1,012.94
$1,140.56
$1,593.92
$2,422.12 		$1,233.84
$1,354.30
$1,481.92
$1,935.28 		$1,575.20
$1,695.66
$1,823.28
$2,276.64 		$1,916.56
$2,037.02
$2,164.64
$2,618.00 		$341.36
Toc - Plan #31 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold + 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
$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 		$483.24
$548.46
$617.57
$863.04
$1,311.48 		$852.91
$918.13
$987.24
$1,232.71 		$1,222.58
$1,287.80
$1,356.91
$1,602.38 		$1,592.25
$1,657.47
$1,726.58
$1,972.05 		$369.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$966.48
$1,096.92
$1,235.14
$1,726.08
$2,622.96 		$1,336.15
$1,466.59
$1,604.81
$2,095.75 		$1,705.82
$1,836.26
$1,974.48
$2,465.42 		$2,075.49
$2,205.93
$2,344.15
$2,835.09 		$369.67
Toc - Plan #32 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Standard Expanded Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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 		$351.16
$398.55
$448.77
$627.15
$953.01 		$619.79
$667.18
$717.40
$895.78 		$888.42
$935.81
$986.03
$1,164.41 		$1,157.05
$1,204.44
$1,254.66
$1,433.04 		$268.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.32
$797.10
$897.54
$1,254.30
$1,906.02 		$970.95
$1,065.73
$1,166.17
$1,522.93 		$1,239.58
$1,334.36
$1,434.80
$1,791.56 		$1,508.21
$1,602.99
$1,703.43
$2,060.19 		$268.63
Toc - Plan #33 Ambetter from Sunshine Health
Silver

(EPO) Standard Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 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 		$444.73
$504.75
$568.35
$794.26
$1,206.96 		$784.94
$844.96
$908.56
$1,134.47 		$1,125.15
$1,185.17
$1,248.77
$1,474.68 		$1,465.36
$1,525.38
$1,588.98
$1,814.89 		$340.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.46
$1,009.50
$1,136.70
$1,588.52
$2,413.92 		$1,229.67
$1,349.71
$1,476.91
$1,928.73 		$1,569.88
$1,689.92
$1,817.12
$2,268.94 		$1,910.09
$2,030.13
$2,157.33
$2,609.15 		$340.21
Toc - Plan #34 Ambetter from Sunshine Health
Gold

(EPO) Standard Gold + 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 		$417.55
$473.91
$533.62
$745.73
$1,133.21 		$736.97
$793.33
$853.04
$1,065.15 		$1,056.39
$1,112.75
$1,172.46
$1,384.57 		$1,375.81
$1,432.17
$1,491.88
$1,703.99 		$319.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.10
$947.82
$1,067.24
$1,491.46
$2,266.42 		$1,154.52
$1,267.24
$1,386.66
$1,810.88 		$1,473.94
$1,586.66
$1,706.08
$2,130.30 		$1,793.36
$1,906.08
$2,025.50
$2,449.72 		$319.42
Toc - Plan #35 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$8,450 $16,900 Annual Deductible
$9,250 $18,500 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 		$358.09
$406.43
$457.63
$639.54
$971.84 		$632.02
$680.36
$731.56
$913.47 		$905.95
$954.29
$1,005.49
$1,187.40 		$1,179.88
$1,228.22
$1,279.42
$1,461.33 		$273.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.18
$812.86
$915.26
$1,279.08
$1,943.68 		$990.11
$1,086.79
$1,189.19
$1,553.01 		$1,264.04
$1,360.72
$1,463.12
$1,826.94 		$1,537.97
$1,634.65
$1,737.05
$2,100.87 		$273.93
Toc - Plan #36 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze + 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
$9,250 $18,500 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 		$411.15
$466.64
$525.44
$734.29
$1,115.83 		$725.67
$781.16
$839.96
$1,048.81 		$1,040.19
$1,095.68
$1,154.48
$1,363.33 		$1,354.71
$1,410.20
$1,469.00
$1,677.85 		$314.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.30
$933.28
$1,050.88
$1,468.58
$2,231.66 		$1,136.82
$1,247.80
$1,365.40
$1,783.10 		$1,451.34
$1,562.32
$1,679.92
$2,097.62 		$1,765.86
$1,876.84
$1,994.44
$2,412.14 		$314.52
Toc - Plan #37 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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 		$454.20
$515.50
$580.45
$811.18
$1,232.67 		$801.65
$862.95
$927.90
$1,158.63 		$1,149.10
$1,210.40
$1,275.35
$1,506.08 		$1,496.55
$1,557.85
$1,622.80
$1,853.53 		$347.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.40
$1,031.00
$1,160.90
$1,622.36
$2,465.34 		$1,255.85
$1,378.45
$1,508.35
$1,969.81 		$1,603.30
$1,725.90
$1,855.80
$2,317.26 		$1,950.75
$2,073.35
$2,203.25
$2,664.71 		$347.45
Toc - Plan #38 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold + 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 		$420.09
$476.79
$536.86
$750.26
$1,140.09 		$741.45
$798.15
$858.22
$1,071.62 		$1,062.81
$1,119.51
$1,179.58
$1,392.98 		$1,384.17
$1,440.87
$1,500.94
$1,714.34 		$321.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.18
$953.58
$1,073.72
$1,500.52
$2,280.18 		$1,161.54
$1,274.94
$1,395.08
$1,821.88 		$1,482.90
$1,596.30
$1,716.44
$2,143.24 		$1,804.26
$1,917.66
$2,037.80
$2,464.60 		$321.36

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 #39 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 then $45 / 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
$9,450 $18,900 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 		$406.12
$460.95
$519.02
$725.33
$1,102.21 		$716.80
$771.63
$829.70
$1,036.01 		$1,027.48
$1,082.31
$1,140.38
$1,346.69 		$1,338.16
$1,392.99
$1,451.06
$1,657.37 		$310.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.24
$921.90
$1,038.04
$1,450.66
$2,204.42 		$1,122.92
$1,232.58
$1,348.72
$1,761.34 		$1,433.60
$1,543.26
$1,659.40
$2,072.02 		$1,744.28
$1,853.94
$1,970.08
$2,382.70 		$310.68
Toc - Plan #40 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$940 $1,880 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$550.39
$624.69
$703.40
$983.00
$1,493.76 		$971.44
$1,045.74
$1,124.45
$1,404.05 		$1,392.49
$1,466.79
$1,545.50
$1,825.10 		$1,813.54
$1,887.84
$1,966.55
$2,246.15 		$421.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,100.78
$1,249.38
$1,406.80
$1,966.00
$2,987.52 		$1,521.83
$1,670.43
$1,827.85
$2,387.05 		$1,942.88
$2,091.48
$2,248.90
$2,808.10 		$2,363.93
$2,512.53
$2,669.95
$3,229.15 		$421.05
Toc - Plan #41 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2017 ($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
$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 		$470.75
$534.30
$601.62
$840.76
$1,277.62 		$830.87
$894.42
$961.74
$1,200.88 		$1,190.99
$1,254.54
$1,321.86
$1,561.00 		$1,551.11
$1,614.66
$1,681.98
$1,921.12 		$360.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$941.50
$1,068.60
$1,203.24
$1,681.52
$2,555.24 		$1,301.62
$1,428.72
$1,563.36
$2,041.64 		$1,661.74
$1,788.84
$1,923.48
$2,401.76 		$2,021.86
$2,148.96
$2,283.60
$2,761.88 		$360.12
Toc - Plan #42 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Virtual Visits / $35 PCP Visit / $75 Specialist Visits / $30 Generic Meds / 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
$9,450 $18,900 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 		$427.44
$485.14
$546.27
$763.41
$1,160.07 		$754.43
$812.13
$873.26
$1,090.40 		$1,081.42
$1,139.12
$1,200.25
$1,417.39 		$1,408.41
$1,466.11
$1,527.24
$1,744.38 		$326.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.88
$970.28
$1,092.54
$1,526.82
$2,320.14 		$1,181.87
$1,297.27
$1,419.53
$1,853.81 		$1,508.86
$1,624.26
$1,746.52
$2,180.80 		$1,835.85
$1,951.25
$2,073.51
$2,507.79 		$326.99
Toc - Plan #43 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237 ($0 Virtual Visits / $60 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$9,450 $18,900 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 		$446.52
$506.80
$570.65
$797.48
$1,211.86 		$788.11
$848.39
$912.24
$1,139.07 		$1,129.70
$1,189.98
$1,253.83
$1,480.66 		$1,471.29
$1,531.57
$1,595.42
$1,822.25 		$341.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$893.04
$1,013.60
$1,141.30
$1,594.96
$2,423.72 		$1,234.63
$1,355.19
$1,482.89
$1,936.55 		$1,576.22
$1,696.78
$1,824.48
$2,278.14 		$1,917.81
$2,038.37
$2,166.07
$2,619.73 		$341.59
Toc - Plan #44 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,650 $3,300 Annual Deductible
$9,450 $18,900 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 		$397.60
$451.28
$508.13
$710.11
$1,079.09 		$701.76
$755.44
$812.29
$1,014.27 		$1,005.92
$1,059.60
$1,116.45
$1,318.43 		$1,310.08
$1,363.76
$1,420.61
$1,622.59 		$304.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.20
$902.56
$1,016.26
$1,420.22
$2,158.18 		$1,099.36
$1,206.72
$1,320.42
$1,724.38 		$1,403.52
$1,510.88
$1,624.58
$2,028.54 		$1,707.68
$1,815.04
$1,928.74
$2,332.70 		$304.16
Toc - Plan #45 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2312S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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 		$385.01
$436.99
$492.04
$687.63
$1,044.92 		$679.54
$731.52
$786.57
$982.16 		$974.07
$1,026.05
$1,081.10
$1,276.69 		$1,268.60
$1,320.58
$1,375.63
$1,571.22 		$294.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.02
$873.98
$984.08
$1,375.26
$2,089.84 		$1,064.55
$1,168.51
$1,278.61
$1,669.79 		$1,359.08
$1,463.04
$1,573.14
$1,964.32 		$1,653.61
$1,757.57
$1,867.67
$2,258.85 		$294.53
Toc - Plan #46 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2329 ($0 Virtual Visits / Multilingual Available / 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
$9,450 $18,900 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 		$417.47
$473.83
$533.53
$745.60
$1,133.01 		$736.83
$793.19
$852.89
$1,064.96 		$1,056.19
$1,112.55
$1,172.25
$1,384.32 		$1,375.55
$1,431.91
$1,491.61
$1,703.68 		$319.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.94
$947.66
$1,067.06
$1,491.20
$2,266.02 		$1,154.30
$1,267.02
$1,386.42
$1,810.56 		$1,473.66
$1,586.38
$1,705.78
$2,129.92 		$1,793.02
$1,905.74
$2,025.14
$2,449.28 		$319.36
Toc - Plan #47 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 24M06-50 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$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 		$475.96
$540.21
$608.28
$850.06
$1,291.76 		$840.07
$904.32
$972.39
$1,214.17 		$1,204.18
$1,268.43
$1,336.50
$1,578.28 		$1,568.29
$1,632.54
$1,700.61
$1,942.39 		$364.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$951.92
$1,080.42
$1,216.56
$1,700.12
$2,583.52 		$1,316.03
$1,444.53
$1,580.67
$2,064.23 		$1,680.14
$1,808.64
$1,944.78
$2,428.34 		$2,044.25
$2,172.75
$2,308.89
$2,792.45 		$364.11
Toc - Plan #48 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2313S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 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 		$471.20
$534.81
$602.19
$841.56
$1,278.84 		$831.67
$895.28
$962.66
$1,202.03 		$1,192.14
$1,255.75
$1,323.13
$1,562.50 		$1,552.61
$1,616.22
$1,683.60
$1,922.97 		$360.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942.40
$1,069.62
$1,204.38
$1,683.12
$2,557.68 		$1,302.87
$1,430.09
$1,564.85
$2,043.59 		$1,663.34
$1,790.56
$1,925.32
$2,404.06 		$2,023.81
$2,151.03
$2,285.79
$2,764.53 		$360.47
Toc - Plan #49 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 2314S ($30 PCP Visits / Multilingual Available / 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
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$542.66
$615.92
$693.52
$969.19
$1,472.78 		$957.79
$1,031.05
$1,108.65
$1,384.32 		$1,372.92
$1,446.18
$1,523.78
$1,799.45 		$1,788.05
$1,861.31
$1,938.91
$2,214.58 		$415.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,085.32
$1,231.84
$1,387.04
$1,938.38
$2,945.56 		$1,500.45
$1,646.97
$1,802.17
$2,353.51 		$1,915.58
$2,062.10
$2,217.30
$2,768.64 		$2,330.71
$2,477.23
$2,632.43
$3,183.77 		$415.13
Toc - Plan #50 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 24M05-74 ($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
$5,950 $11,900 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 		$570.43
$647.44
$729.01
$1,018.79
$1,548.15 		$1,006.81
$1,083.82
$1,165.39
$1,455.17 		$1,443.19
$1,520.20
$1,601.77
$1,891.55 		$1,879.57
$1,956.58
$2,038.15
$2,327.93 		$436.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,140.86
$1,294.88
$1,458.02
$2,037.58
$3,096.30 		$1,577.24
$1,731.26
$1,894.40
$2,473.96 		$2,013.62
$2,167.64
$2,330.78
$2,910.34 		$2,450.00
$2,604.02
$2,767.16
$3,346.72 		$436.38
Toc - Plan #51 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) myBlue Platinum 24M05-75 ($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 		$699.52
$793.96
$893.99
$1,249.34
$1,898.50 		$1,234.65
$1,329.09
$1,429.12
$1,784.47 		$1,769.78
$1,864.22
$1,964.25
$2,319.60 		$2,304.91
$2,399.35
$2,499.38
$2,854.73 		$535.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,399.04
$1,587.92
$1,787.98
$2,498.68
$3,797.00 		$1,934.17
$2,123.05
$2,323.11
$3,033.81 		$2,469.30
$2,658.18
$2,858.24
$3,568.94 		$3,004.43
$3,193.31
$3,393.37
$4,104.07 		$535.13
Toc - Plan #52 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 24M06-76 ($0 Virtual Visits / $10 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,200 $18,400 Maximum Out of Pocket Per 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 #53 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) myBlue Platinum 24M05-00S ($0 Deductible / $10 PCP Visits / Multilingual Available / 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
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$696.61
$790.65
$890.27
$1,244.15
$1,890.60 		$1,229.52
$1,323.56
$1,423.18
$1,777.06 		$1,762.43
$1,856.47
$1,956.09
$2,309.97 		$2,295.34
$2,389.38
$2,489.00
$2,842.88 		$532.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,393.22
$1,581.30
$1,780.54
$2,488.30
$3,781.20 		$1,926.13
$2,114.21
$2,313.45
$3,021.21 		$2,459.04
$2,647.12
$2,846.36
$3,554.12 		$2,991.95
$3,180.03
$3,379.27
$4,087.03 		$532.91
Toc - Plan #54 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237D ($0 Virtual Visits / $60 PCP Visits / Adult Dental / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$9,450 $18,900 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 		$455.44
$516.92
$582.05
$813.42
$1,236.06 		$803.85
$865.33
$930.46
$1,161.83 		$1,152.26
$1,213.74
$1,278.87
$1,510.24 		$1,500.67
$1,562.15
$1,627.28
$1,858.65 		$348.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.88
$1,033.84
$1,164.10
$1,626.84
$2,472.12 		$1,259.29
$1,382.25
$1,512.51
$1,975.25 		$1,607.70
$1,730.66
$1,860.92
$2,323.66 		$1,956.11
$2,079.07
$2,209.33
$2,672.07 		$348.41
Toc - Plan #55 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 24M06-76D ($0 Virtual Visits / Adult Dental / $10 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,200 $18,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$446.51
$506.79
$570.64
$797.47
$1,211.83 		$788.09
$848.37
$912.22
$1,139.05 		$1,129.67
$1,189.95
$1,253.80
$1,480.63 		$1,471.25
$1,531.53
$1,595.38
$1,822.21 		$341.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$893.02
$1,013.58
$1,141.28
$1,594.94
$2,423.66 		$1,234.60
$1,355.16
$1,482.86
$1,936.52 		$1,576.18
$1,696.74
$1,824.44
$2,278.10 		$1,917.76
$2,038.32
$2,166.02
$2,619.68 		$341.58
Toc - Plan #56 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K01-02 ($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
$8,000 $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 		$522.08
$592.56
$667.22
$932.43
$1,416.93 		$921.47
$991.95
$1,066.61
$1,331.82 		$1,320.86
$1,391.34
$1,466.00
$1,731.21 		$1,720.25
$1,790.73
$1,865.39
$2,130.60 		$399.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,044.16
$1,185.12
$1,334.44
$1,864.86
$2,833.86 		$1,443.55
$1,584.51
$1,733.83
$2,264.25 		$1,842.94
$1,983.90
$2,133.22
$2,663.64 		$2,242.33
$2,383.29
$2,532.61
$3,063.03 		$399.39
Toc - Plan #57 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K01-03 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$440.51
$499.98
$562.97
$786.75
$1,195.54 		$777.50
$836.97
$899.96
$1,123.74 		$1,114.49
$1,173.96
$1,236.95
$1,460.73 		$1,451.48
$1,510.95
$1,573.94
$1,797.72 		$336.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.02
$999.96
$1,125.94
$1,573.50
$2,391.08 		$1,218.01
$1,336.95
$1,462.93
$1,910.49 		$1,555.00
$1,673.94
$1,799.92
$2,247.48 		$1,891.99
$2,010.93
$2,136.91
$2,584.47 		$336.99
Toc - Plan #58 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K01-04 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$713.53
$809.86
$911.89
$1,274.36
$1,936.52 		$1,259.38
$1,355.71
$1,457.74
$1,820.21 		$1,805.23
$1,901.56
$2,003.59
$2,366.06 		$2,351.08
$2,447.41
$2,549.44
$2,911.91 		$545.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,427.06
$1,619.72
$1,823.78
$2,548.72
$3,873.04 		$1,972.91
$2,165.57
$2,369.63
$3,094.57 		$2,518.76
$2,711.42
$2,915.48
$3,640.42 		$3,064.61
$3,257.27
$3,461.33
$4,186.27 		$545.85
Toc - Plan #59 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(POS) BlueCare Bronze 24K01-05 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$9,450 $18,900 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 		$401.37
$455.55
$512.95
$716.85
$1,089.32 		$708.42
$762.60
$820.00
$1,023.90 		$1,015.47
$1,069.65
$1,127.05
$1,330.95 		$1,322.52
$1,376.70
$1,434.10
$1,638.00 		$307.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.74
$911.10
$1,025.90
$1,433.70
$2,178.64 		$1,109.79
$1,218.15
$1,332.95
$1,740.75 		$1,416.84
$1,525.20
$1,640.00
$2,047.80 		$1,723.89
$1,832.25
$1,947.05
$2,354.85 		$307.05
Toc - Plan #60 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K01-06 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$574.61
$652.18
$734.35
$1,026.25
$1,559.49 		$1,014.19
$1,091.76
$1,173.93
$1,465.83 		$1,453.77
$1,531.34
$1,613.51
$1,905.41 		$1,893.35
$1,970.92
$2,053.09
$2,344.99 		$439.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,149.22
$1,304.36
$1,468.70
$2,052.50
$3,118.98 		$1,588.80
$1,743.94
$1,908.28
$2,492.08 		$2,028.38
$2,183.52
$2,347.86
$2,931.66 		$2,467.96
$2,623.10
$2,787.44
$3,371.24 		$439.58
Toc - Plan #61 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K01-07 ($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 		$750.35
$851.65
$958.95
$1,340.13
$2,036.45 		$1,324.37
$1,425.67
$1,532.97
$1,914.15 		$1,898.39
$1,999.69
$2,106.99
$2,488.17 		$2,472.41
$2,573.71
$2,681.01
$3,062.19 		$574.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,500.70
$1,703.30
$1,917.90
$2,680.26
$4,072.90 		$2,074.72
$2,277.32
$2,491.92
$3,254.28 		$2,648.74
$2,851.34
$3,065.94
$3,828.30 		$3,222.76
$3,425.36
$3,639.96
$4,402.32 		$574.02
Toc - Plan #62 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K01-08 ($0 Virtual Visits / $20 PCP Visit / $15 Generic Meds / 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
$6,250 $12,500 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 		$649.11
$736.74
$829.56
$1,159.31
$1,761.68 		$1,145.68
$1,233.31
$1,326.13
$1,655.88 		$1,642.25
$1,729.88
$1,822.70
$2,152.45 		$2,138.82
$2,226.45
$2,319.27
$2,649.02 		$496.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,298.22
$1,473.48
$1,659.12
$2,318.62
$3,523.36 		$1,794.79
$1,970.05
$2,155.69
$2,815.19 		$2,291.36
$2,466.62
$2,652.26
$3,311.76 		$2,787.93
$2,963.19
$3,148.83
$3,808.33 		$496.57
Toc - Plan #63 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze (HSA) 24K01-09 (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
$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 		$421.83
$478.78
$539.10
$753.39
$1,144.85 		$744.53
$801.48
$861.80
$1,076.09 		$1,067.23
$1,124.18
$1,184.50
$1,398.79 		$1,389.93
$1,446.88
$1,507.20
$1,721.49 		$322.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.66
$957.56
$1,078.20
$1,506.78
$2,289.70 		$1,166.36
$1,280.26
$1,400.90
$1,829.48 		$1,489.06
$1,602.96
$1,723.60
$2,152.18 		$1,811.76
$1,925.66
$2,046.30
$2,474.88 		$322.70
Toc - Plan #64 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K01-10 ($0 Virtual Visits / $20 Labs / 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
$5,900 $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 		$622.72
$706.79
$795.84
$1,112.18
$1,690.06 		$1,099.10
$1,183.17
$1,272.22
$1,588.56 		$1,575.48
$1,659.55
$1,748.60
$2,064.94 		$2,051.86
$2,135.93
$2,224.98
$2,541.32 		$476.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,245.44
$1,413.58
$1,591.68
$2,224.36
$3,380.12 		$1,721.82
$1,889.96
$2,068.06
$2,700.74 		$2,198.20
$2,366.34
$2,544.44
$3,177.12 		$2,674.58
$2,842.72
$3,020.82
$3,653.50 		$476.38
Toc - Plan #65 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K01-25 ($0 Virtual Visits / $50 PCP Visit / $30 Generic Meds / 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
$9,450 $18,900 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 		$470.00
$533.45
$600.66
$839.42
$1,275.58 		$829.55
$893.00
$960.21
$1,198.97 		$1,189.10
$1,252.55
$1,319.76
$1,558.52 		$1,548.65
$1,612.10
$1,679.31
$1,918.07 		$359.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$940.00
$1,066.90
$1,201.32
$1,678.84
$2,551.16 		$1,299.55
$1,426.45
$1,560.87
$2,038.39 		$1,659.10
$1,786.00
$1,920.42
$2,397.94 		$2,018.65
$2,145.55
$2,279.97
$2,757.49 		$359.55
Toc - Plan #66 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K01-31S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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 		$429.16
$487.10
$548.47
$766.48
$1,164.74 		$757.47
$815.41
$876.78
$1,094.79 		$1,085.78
$1,143.72
$1,205.09
$1,423.10 		$1,414.09
$1,472.03
$1,533.40
$1,751.41 		$328.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.32
$974.20
$1,096.94
$1,532.96
$2,329.48 		$1,186.63
$1,302.51
$1,425.25
$1,861.27 		$1,514.94
$1,630.82
$1,753.56
$2,189.58 		$1,843.25
$1,959.13
$2,081.87
$2,517.89 		$328.31
Toc - Plan #67 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K01-32S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 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 		$552.89
$627.53
$706.59
$987.46
$1,500.54 		$975.85
$1,050.49
$1,129.55
$1,410.42 		$1,398.81
$1,473.45
$1,552.51
$1,833.38 		$1,821.77
$1,896.41
$1,975.47
$2,256.34 		$422.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,105.78
$1,255.06
$1,413.18
$1,974.92
$3,001.08 		$1,528.74
$1,678.02
$1,836.14
$2,397.88 		$1,951.70
$2,100.98
$2,259.10
$2,820.84 		$2,374.66
$2,523.94
$2,682.06
$3,243.80 		$422.96
Toc - Plan #68 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K01-33S ($30 PCP Visit / Multilingual Available/ 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
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$603.52
$685.00
$771.30
$1,077.89
$1,637.95 		$1,065.21
$1,146.69
$1,232.99
$1,539.58 		$1,526.90
$1,608.38
$1,694.68
$2,001.27 		$1,988.59
$2,070.07
$2,156.37
$2,462.96 		$461.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,207.04
$1,370.00
$1,542.60
$2,155.78
$3,275.90 		$1,668.73
$1,831.69
$2,004.29
$2,617.47 		$2,130.42
$2,293.38
$2,465.98
$3,079.16 		$2,592.11
$2,755.07
$2,927.67
$3,540.85 		$461.69
Toc - Plan #69 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K01-34S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / 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
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$747.97
$848.95
$955.91
$1,335.87
$2,029.99 		$1,320.17
$1,421.15
$1,528.11
$1,908.07 		$1,892.37
$1,993.35
$2,100.31
$2,480.27 		$2,464.57
$2,565.55
$2,672.51
$3,052.47 		$572.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,495.94
$1,697.90
$1,911.82
$2,671.74
$4,059.98 		$2,068.14
$2,270.10
$2,484.02
$3,243.94 		$2,640.34
$2,842.30
$3,056.22
$3,816.14 		$3,212.54
$3,414.50
$3,628.42
$4,388.34 		$572.20

‡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 Levy County here.

Levy County is in “Rating Area 37” of Florida.

Currently, there are 69 plans offered in Rating Area 37.

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2024 Obamacare Plans for Levy County, FL

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