Obamacare 2022 Rates for Alachua County

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

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

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

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

Obamacare Providers, 117 Plans and 2022 Rates for Alachua County, Florida

Below, you’ll find a summary of the 117 plans for Alachua County, Florida and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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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

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$676.72
$768.08
$864.85
$1,208.62
$1,836.62 		$1,194.41
$1,285.77
$1,382.54
$1,726.31 		$1,712.10
$1,803.46
$1,900.23
$2,244.00 		$2,229.79
$2,321.15
$2,417.92
$2,761.69 		$517.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,353.44
$1,536.16
$1,729.70
$2,417.24
$3,673.24 		$1,871.13
$2,053.85
$2,247.39
$2,934.93 		$2,388.82
$2,571.54
$2,765.08
$3,452.62 		$2,906.51
$3,089.23
$3,282.77
$3,970.31 		$517.69
Toc - Plan #2 Florida Blue (BlueCross BlueShield FL)
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$422.20
$479.20
$539.57
$754.05
$1,145.85 		$745.18
$802.18
$862.55
$1,077.03 		$1,068.16
$1,125.16
$1,185.53
$1,400.01 		$1,391.14
$1,448.14
$1,508.51
$1,722.99 		$322.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$844.40
$958.40
$1,079.14
$1,508.10
$2,291.70 		$1,167.38
$1,281.38
$1,402.12
$1,831.08 		$1,490.36
$1,604.36
$1,725.10
$2,154.06 		$1,813.34
$1,927.34
$2,048.08
$2,477.04 		$322.98
Toc - Plan #3 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$692.49
$785.98
$885.00
$1,236.79
$1,879.42 		$1,222.24
$1,315.73
$1,414.75
$1,766.54 		$1,751.99
$1,845.48
$1,944.50
$2,296.29 		$2,281.74
$2,375.23
$2,474.25
$2,826.04 		$529.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,384.98
$1,571.96
$1,770.00
$2,473.58
$3,758.84 		$1,914.73
$2,101.71
$2,299.75
$3,003.33 		$2,444.48
$2,631.46
$2,829.50
$3,533.08 		$2,974.23
$3,161.21
$3,359.25
$4,062.83 		$529.75
Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$843.61
$957.50
$1,078.13
$1,506.69
$2,289.56 		$1,488.97
$1,602.86
$1,723.49
$2,152.05 		$2,134.33
$2,248.22
$2,368.85
$2,797.41 		$2,779.69
$2,893.58
$3,014.21
$3,442.77 		$645.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,687.22
$1,915.00
$2,156.26
$3,013.38
$4,579.12 		$2,332.58
$2,560.36
$2,801.62
$3,658.74 		$2,977.94
$3,205.72
$3,446.98
$4,304.10 		$3,623.30
$3,851.08
$4,092.34
$4,949.46 		$645.36
Toc - Plan #5 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$453.64
$514.88
$579.75
$810.20
$1,231.18 		$800.67
$861.91
$926.78
$1,157.23 		$1,147.70
$1,208.94
$1,273.81
$1,504.26 		$1,494.73
$1,555.97
$1,620.84
$1,851.29 		$347.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$907.28
$1,029.76
$1,159.50
$1,620.40
$2,462.36 		$1,254.31
$1,376.79
$1,506.53
$1,967.43 		$1,601.34
$1,723.82
$1,853.56
$2,314.46 		$1,948.37
$2,070.85
$2,200.59
$2,661.49 		$347.03
Toc - Plan #6 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$889.96
$1,010.10
$1,137.37
$1,589.47
$2,415.35 		$1,570.78
$1,690.92
$1,818.19
$2,270.29 		$2,251.60
$2,371.74
$2,499.01
$2,951.11 		$2,932.42
$3,052.56
$3,179.83
$3,631.93 		$680.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,779.92
$2,020.20
$2,274.74
$3,178.94
$4,830.70 		$2,460.74
$2,701.02
$2,955.56
$3,859.76 		$3,141.56
$3,381.84
$3,636.38
$4,540.58 		$3,822.38
$4,062.66
$4,317.20
$5,221.40 		$680.82
Toc - Plan #7 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$625.39
$709.82
$799.25
$1,116.95
$1,697.31 		$1,103.81
$1,188.24
$1,277.67
$1,595.37 		$1,582.23
$1,666.66
$1,756.09
$2,073.79 		$2,060.65
$2,145.08
$2,234.51
$2,552.21 		$478.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,250.78
$1,419.64
$1,598.50
$2,233.90
$3,394.62 		$1,729.20
$1,898.06
$2,076.92
$2,712.32 		$2,207.62
$2,376.48
$2,555.34
$3,190.74 		$2,686.04
$2,854.90
$3,033.76
$3,669.16 		$478.42
Toc - Plan #8 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$713.92
$810.30
$912.39
$1,275.06
$1,937.58 		$1,260.07
$1,356.45
$1,458.54
$1,821.21 		$1,806.22
$1,902.60
$2,004.69
$2,367.36 		$2,352.37
$2,448.75
$2,550.84
$2,913.51 		$546.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,427.84
$1,620.60
$1,824.78
$2,550.12
$3,875.16 		$1,973.99
$2,166.75
$2,370.93
$3,096.27 		$2,520.14
$2,712.90
$2,917.08
$3,642.42 		$3,066.29
$3,259.05
$3,463.23
$4,188.57 		$546.15
Toc - Plan #9 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$441.07
$500.61
$563.69
$787.75
$1,197.06 		$778.49
$838.03
$901.11
$1,125.17 		$1,115.91
$1,175.45
$1,238.53
$1,462.59 		$1,453.33
$1,512.87
$1,575.95
$1,800.01 		$337.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$882.14
$1,001.22
$1,127.38
$1,575.50
$2,394.12 		$1,219.56
$1,338.64
$1,464.80
$1,912.92 		$1,556.98
$1,676.06
$1,802.22
$2,250.34 		$1,894.40
$2,013.48
$2,139.64
$2,587.76 		$337.42
Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$687.86
$780.72
$879.09
$1,228.52
$1,866.85 		$1,214.07
$1,306.93
$1,405.30
$1,754.73 		$1,740.28
$1,833.14
$1,931.51
$2,280.94 		$2,266.49
$2,359.35
$2,457.72
$2,807.15 		$526.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,375.72
$1,561.44
$1,758.18
$2,457.04
$3,733.70 		$1,901.93
$2,087.65
$2,284.39
$2,983.25 		$2,428.14
$2,613.86
$2,810.60
$3,509.46 		$2,954.35
$3,140.07
$3,336.81
$4,035.67 		$526.21
Toc - Plan #11 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$453.07
$514.23
$579.02
$809.18
$1,229.63 		$799.67
$860.83
$925.62
$1,155.78 		$1,146.27
$1,207.43
$1,272.22
$1,502.38 		$1,492.87
$1,554.03
$1,618.82
$1,848.98 		$346.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$906.14
$1,028.46
$1,158.04
$1,618.36
$2,459.26 		$1,252.74
$1,375.06
$1,504.64
$1,964.96 		$1,599.34
$1,721.66
$1,851.24
$2,311.56 		$1,945.94
$2,068.26
$2,197.84
$2,658.16 		$346.60
Toc - Plan #12 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$689.69
$782.80
$881.42
$1,231.79
$1,871.82 		$1,217.30
$1,310.41
$1,409.03
$1,759.40 		$1,744.91
$1,838.02
$1,936.64
$2,287.01 		$2,272.52
$2,365.63
$2,464.25
$2,814.62 		$527.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,379.38
$1,565.60
$1,762.84
$2,463.58
$3,743.64 		$1,906.99
$2,093.21
$2,290.45
$2,991.19 		$2,434.60
$2,620.82
$2,818.06
$3,518.80 		$2,962.21
$3,148.43
$3,345.67
$4,046.41 		$527.61
Toc - Plan #13 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$482.79
$547.97
$617.01
$862.26
$1,310.29 		$852.12
$917.30
$986.34
$1,231.59 		$1,221.45
$1,286.63
$1,355.67
$1,600.92 		$1,590.78
$1,655.96
$1,725.00
$1,970.25 		$369.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$965.58
$1,095.94
$1,234.02
$1,724.52
$2,620.58 		$1,334.91
$1,465.27
$1,603.35
$2,093.85 		$1,704.24
$1,834.60
$1,972.68
$2,463.18 		$2,073.57
$2,203.93
$2,342.01
$2,832.51 		$369.33

ADVERTISEMENT

AvMed

Local: 1-800-477-8768 | Toll Free: 

Toc - Plan #14 AvMed
Gold

(HMO) AvMed Entrust Gold 125 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$456.49
$518.12
$583.40
$815.30
$1,238.93 		$805.71
$867.34
$932.62
$1,164.52 		$1,154.93
$1,216.56
$1,281.84
$1,513.74 		$1,504.15
$1,565.78
$1,631.06
$1,862.96 		$349.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$912.98
$1,036.24
$1,166.80
$1,630.60
$2,477.86 		$1,262.20
$1,385.46
$1,516.02
$1,979.82 		$1,611.42
$1,734.68
$1,865.24
$2,329.04 		$1,960.64
$2,083.90
$2,214.46
$2,678.26 		$349.22
Toc - Plan #15 AvMed
Silver

(HMO) AvMed Entrust Silver 300 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$445.49
$505.63
$569.33
$795.64
$1,209.05 		$786.29
$846.43
$910.13
$1,136.44 		$1,127.09
$1,187.23
$1,250.93
$1,477.24 		$1,467.89
$1,528.03
$1,591.73
$1,818.04 		$340.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.98
$1,011.26
$1,138.66
$1,591.28
$2,418.10 		$1,231.78
$1,352.06
$1,479.46
$1,932.08 		$1,572.58
$1,692.86
$1,820.26
$2,272.88 		$1,913.38
$2,033.66
$2,161.06
$2,613.68 		$340.80
Toc - Plan #16 AvMed
Silver

(HMO) AvMed Entrust Silver 350 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$419.46
$476.08
$536.07
$749.15
$1,138.41 		$740.35
$796.97
$856.96
$1,070.04 		$1,061.24
$1,117.86
$1,177.85
$1,390.93 		$1,382.13
$1,438.75
$1,498.74
$1,711.82 		$320.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.92
$952.16
$1,072.14
$1,498.30
$2,276.82 		$1,159.81
$1,273.05
$1,393.03
$1,819.19 		$1,480.70
$1,593.94
$1,713.92
$2,140.08 		$1,801.59
$1,914.83
$2,034.81
$2,460.97 		$320.89
Toc - Plan #17 AvMed
Silver

(HMO) AvMed Entrust Silver 500 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.88
$477.70
$537.88
$751.69
$1,142.26 		$742.85
$799.67
$859.85
$1,073.66 		$1,064.82
$1,121.64
$1,181.82
$1,395.63 		$1,386.79
$1,443.61
$1,503.79
$1,717.60 		$321.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.76
$955.40
$1,075.76
$1,503.38
$2,284.52 		$1,163.73
$1,277.37
$1,397.73
$1,825.35 		$1,485.70
$1,599.34
$1,719.70
$2,147.32 		$1,807.67
$1,921.31
$2,041.67
$2,469.29 		$321.97
Toc - Plan #18 AvMed
Silver

(HMO) AvMed Entrust Silver 550 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.83
$470.83
$530.15
$740.88
$1,125.84 		$732.17
$788.17
$847.49
$1,058.22 		$1,049.51
$1,105.51
$1,164.83
$1,375.56 		$1,366.85
$1,422.85
$1,482.17
$1,692.90 		$317.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.66
$941.66
$1,060.30
$1,481.76
$2,251.68 		$1,147.00
$1,259.00
$1,377.64
$1,799.10 		$1,464.34
$1,576.34
$1,694.98
$2,116.44 		$1,781.68
$1,893.68
$2,012.32
$2,433.78 		$317.34
Toc - Plan #19 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 600 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336.14
$381.51
$429.58
$600.34
$912.27 		$593.28
$638.65
$686.72
$857.48 		$850.42
$895.79
$943.86
$1,114.62 		$1,107.56
$1,152.93
$1,201.00
$1,371.76 		$257.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.28
$763.02
$859.16
$1,200.68
$1,824.54 		$929.42
$1,020.16
$1,116.30
$1,457.82 		$1,186.56
$1,277.30
$1,373.44
$1,714.96 		$1,443.70
$1,534.44
$1,630.58
$1,972.10 		$257.14
Toc - Plan #20 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 650 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321.50
$364.90
$410.87
$574.20
$872.55 		$567.45
$610.85
$656.82
$820.15 		$813.40
$856.80
$902.77
$1,066.10 		$1,059.35
$1,102.75
$1,148.72
$1,312.05 		$245.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.00
$729.80
$821.74
$1,148.40
$1,745.10 		$888.95
$975.75
$1,067.69
$1,394.35 		$1,134.90
$1,221.70
$1,313.64
$1,640.30 		$1,380.85
$1,467.65
$1,559.59
$1,886.25 		$245.95
Toc - Plan #21 AvMed
Catastrophic

(HMO) AvMed Entrust Catastrophic 100 (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$296.02
$335.98
$378.31
$528.69
$803.40 		$522.48
$562.44
$604.77
$755.15 		$748.94
$788.90
$831.23
$981.61 		$975.40
$1,015.36
$1,057.69
$1,208.07 		$226.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.04
$671.96
$756.62
$1,057.38
$1,606.80 		$818.50
$898.42
$983.08
$1,283.84 		$1,044.96
$1,124.88
$1,209.54
$1,510.30 		$1,271.42
$1,351.34
$1,436.00
$1,736.76 		$226.46
Toc - Plan #22 AvMed
Gold

(HMO) AvMed Entrust Gold 125 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$461.19
$523.46
$589.41
$823.69
$1,251.68 		$814.00
$876.27
$942.22
$1,176.50 		$1,166.81
$1,229.08
$1,295.03
$1,529.31 		$1,519.62
$1,581.89
$1,647.84
$1,882.12 		$352.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.38
$1,046.92
$1,178.82
$1,647.38
$2,503.36 		$1,275.19
$1,399.73
$1,531.63
$2,000.19 		$1,628.00
$1,752.54
$1,884.44
$2,353.00 		$1,980.81
$2,105.35
$2,237.25
$2,705.81 		$352.81
Toc - Plan #23 AvMed
Silver

(HMO) AvMed Entrust Silver 300 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$450.19
$510.97
$575.35
$804.05
$1,221.83 		$794.59
$855.37
$919.75
$1,148.45 		$1,138.99
$1,199.77
$1,264.15
$1,492.85 		$1,483.39
$1,544.17
$1,608.55
$1,837.25 		$344.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.38
$1,021.94
$1,150.70
$1,608.10
$2,443.66 		$1,244.78
$1,366.34
$1,495.10
$1,952.50 		$1,589.18
$1,710.74
$1,839.50
$2,296.90 		$1,933.58
$2,055.14
$2,183.90
$2,641.30 		$344.40
Toc - Plan #24 AvMed
Silver

(HMO) AvMed Entrust Silver 350 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$424.16
$481.42
$542.07
$757.55
$1,151.16 		$748.64
$805.90
$866.55
$1,082.03 		$1,073.12
$1,130.38
$1,191.03
$1,406.51 		$1,397.60
$1,454.86
$1,515.51
$1,730.99 		$324.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.32
$962.84
$1,084.14
$1,515.10
$2,302.32 		$1,172.80
$1,287.32
$1,408.62
$1,839.58 		$1,497.28
$1,611.80
$1,733.10
$2,164.06 		$1,821.76
$1,936.28
$2,057.58
$2,488.54 		$324.48
Toc - Plan #25 AvMed
Silver

(HMO) AvMed Entrust Silver 500 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.58
$483.03
$543.89
$760.08
$1,155.02 		$751.15
$808.60
$869.46
$1,085.65 		$1,076.72
$1,134.17
$1,195.03
$1,411.22 		$1,402.29
$1,459.74
$1,520.60
$1,736.79 		$325.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.16
$966.06
$1,087.78
$1,520.16
$2,310.04 		$1,176.73
$1,291.63
$1,413.35
$1,845.73 		$1,502.30
$1,617.20
$1,738.92
$2,171.30 		$1,827.87
$1,942.77
$2,064.49
$2,496.87 		$325.57
Toc - Plan #26 AvMed
Silver

(HMO) AvMed Entrust Silver 550 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$419.53
$476.16
$536.16
$749.28
$1,138.60 		$740.47
$797.10
$857.10
$1,070.22 		$1,061.41
$1,118.04
$1,178.04
$1,391.16 		$1,382.35
$1,438.98
$1,498.98
$1,712.10 		$320.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.06
$952.32
$1,072.32
$1,498.56
$2,277.20 		$1,160.00
$1,273.26
$1,393.26
$1,819.50 		$1,480.94
$1,594.20
$1,714.20
$2,140.44 		$1,801.88
$1,915.14
$2,035.14
$2,461.38 		$320.94
Toc - Plan #27 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 625 Dental+Vision (2022)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,350 $16,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.67
$477.46
$537.61
$751.31
$1,141.69 		$742.48
$799.27
$859.42
$1,073.12 		$1,064.29
$1,121.08
$1,181.23
$1,394.93 		$1,386.10
$1,442.89
$1,503.04
$1,716.74 		$321.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.34
$954.92
$1,075.22
$1,502.62
$2,283.38 		$1,163.15
$1,276.73
$1,397.03
$1,824.43 		$1,484.96
$1,598.54
$1,718.84
$2,146.24 		$1,806.77
$1,920.35
$2,040.65
$2,468.05 		$321.81

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #28 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 5

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$427.70
$485.43
$546.59
$763.86
$1,160.75 		$754.88
$812.61
$873.77
$1,091.04 		$1,082.06
$1,139.79
$1,200.95
$1,418.22 		$1,409.24
$1,466.97
$1,528.13
$1,745.40 		$327.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.40
$970.86
$1,093.18
$1,527.72
$2,321.50 		$1,182.58
$1,298.04
$1,420.36
$1,854.90 		$1,509.76
$1,625.22
$1,747.54
$2,182.08 		$1,836.94
$1,952.40
$2,074.72
$2,509.26 		$327.18
Toc - Plan #29 Ambetter from Sunshine Health
Bronze

(EPO) Ambetter Essential Care 1

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.92
$341.53
$384.56
$537.43
$816.67 		$531.12
$571.73
$614.76
$767.63 		$761.32
$801.93
$844.96
$997.83 		$991.52
$1,032.13
$1,075.16
$1,228.03 		$230.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.84
$683.06
$769.12
$1,074.86
$1,633.34 		$832.04
$913.26
$999.32
$1,305.06 		$1,062.24
$1,143.46
$1,229.52
$1,535.26 		$1,292.44
$1,373.66
$1,459.72
$1,765.46 		$230.20
Toc - Plan #30 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$330.90
$375.56
$422.88
$590.97
$898.04 		$584.03
$628.69
$676.01
$844.10 		$837.16
$881.82
$929.14
$1,097.23 		$1,090.29
$1,134.95
$1,182.27
$1,350.36 		$253.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$661.80
$751.12
$845.76
$1,181.94
$1,796.08 		$914.93
$1,004.25
$1,098.89
$1,435.07 		$1,168.06
$1,257.38
$1,352.02
$1,688.20 		$1,421.19
$1,510.51
$1,605.15
$1,941.33 		$253.13
Toc - Plan #31 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 11

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.51
$477.27
$537.40
$751.01
$1,141.24 		$742.19
$798.95
$859.08
$1,072.69 		$1,063.87
$1,120.63
$1,180.76
$1,394.37 		$1,385.55
$1,442.31
$1,502.44
$1,716.05 		$321.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.02
$954.54
$1,074.80
$1,502.02
$2,282.48 		$1,162.70
$1,276.22
$1,396.48
$1,823.70 		$1,484.38
$1,597.90
$1,718.16
$2,145.38 		$1,806.06
$1,919.58
$2,039.84
$2,467.06 		$321.68
Toc - Plan #32 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 12

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.71
$470.68
$529.98
$740.65
$1,125.49 		$731.95
$787.92
$847.22
$1,057.89 		$1,049.19
$1,105.16
$1,164.46
$1,375.13 		$1,366.43
$1,422.40
$1,481.70
$1,692.37 		$317.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.42
$941.36
$1,059.96
$1,481.30
$2,250.98 		$1,146.66
$1,258.60
$1,377.20
$1,798.54 		$1,463.90
$1,575.84
$1,694.44
$2,115.78 		$1,781.14
$1,893.08
$2,011.68
$2,433.02 		$317.24
Toc - Plan #33 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 24

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$428.00
$485.76
$546.97
$764.38
$1,161.55 		$755.41
$813.17
$874.38
$1,091.79 		$1,082.82
$1,140.58
$1,201.79
$1,419.20 		$1,410.23
$1,467.99
$1,529.20
$1,746.61 		$327.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.00
$971.52
$1,093.94
$1,528.76
$2,323.10 		$1,183.41
$1,298.93
$1,421.35
$1,856.17 		$1,510.82
$1,626.34
$1,748.76
$2,183.58 		$1,838.23
$1,953.75
$2,076.17
$2,510.99 		$327.41
Toc - Plan #34 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 29

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.87
$465.19
$523.80
$732.01
$1,112.37 		$723.41
$778.73
$837.34
$1,045.55 		$1,036.95
$1,092.27
$1,150.88
$1,359.09 		$1,350.49
$1,405.81
$1,464.42
$1,672.63 		$313.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.74
$930.38
$1,047.60
$1,464.02
$2,224.74 		$1,133.28
$1,243.92
$1,361.14
$1,777.56 		$1,446.82
$1,557.46
$1,674.68
$2,091.10 		$1,760.36
$1,871.00
$1,988.22
$2,404.64 		$313.54
Toc - Plan #35 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 5

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$327.33
$371.51
$418.31
$584.59
$888.34 		$577.73
$621.91
$668.71
$834.99 		$828.13
$872.31
$919.11
$1,085.39 		$1,078.53
$1,122.71
$1,169.51
$1,335.79 		$250.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.66
$743.02
$836.62
$1,169.18
$1,776.68 		$905.06
$993.42
$1,087.02
$1,419.58 		$1,155.46
$1,243.82
$1,337.42
$1,669.98 		$1,405.86
$1,494.22
$1,587.82
$1,920.38 		$250.40
Toc - Plan #36 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 22

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.03
$397.28
$447.33
$625.14
$949.97 		$617.80
$665.05
$715.10
$892.91 		$885.57
$932.82
$982.87
$1,160.68 		$1,153.34
$1,200.59
$1,250.64
$1,428.45 		$267.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.06
$794.56
$894.66
$1,250.28
$1,899.94 		$967.83
$1,062.33
$1,162.43
$1,518.05 		$1,235.60
$1,330.10
$1,430.20
$1,785.82 		$1,503.37
$1,597.87
$1,697.97
$2,053.59 		$267.77
Toc - Plan #37 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.62
$408.16
$459.58
$642.27
$975.99 		$634.72
$683.26
$734.68
$917.37 		$909.82
$958.36
$1,009.78
$1,192.47 		$1,184.92
$1,233.46
$1,284.88
$1,467.57 		$275.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.24
$816.32
$919.16
$1,284.54
$1,951.98 		$994.34
$1,091.42
$1,194.26
$1,559.64 		$1,269.44
$1,366.52
$1,469.36
$1,834.74 		$1,544.54
$1,641.62
$1,744.46
$2,109.84 		$275.10
Toc - Plan #38 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$381.57
$433.07
$487.64
$681.47
$1,035.56 		$673.47
$724.97
$779.54
$973.37 		$965.37
$1,016.87
$1,071.44
$1,265.27 		$1,257.27
$1,308.77
$1,363.34
$1,557.17 		$291.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.14
$866.14
$975.28
$1,362.94
$2,071.12 		$1,055.04
$1,158.04
$1,267.18
$1,654.84 		$1,346.94
$1,449.94
$1,559.08
$1,946.74 		$1,638.84
$1,741.84
$1,850.98
$2,238.64 		$291.90
Toc - Plan #39 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 30

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.43
$446.53
$502.79
$702.65
$1,067.74 		$694.40
$747.50
$803.76
$1,003.62 		$995.37
$1,048.47
$1,104.73
$1,304.59 		$1,296.34
$1,349.44
$1,405.70
$1,605.56 		$300.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.86
$893.06
$1,005.58
$1,405.30
$2,135.48 		$1,087.83
$1,194.03
$1,306.55
$1,706.27 		$1,388.80
$1,495.00
$1,607.52
$2,007.24 		$1,689.77
$1,795.97
$1,908.49
$2,308.21 		$300.97
Toc - Plan #40 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 31

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.27
$447.49
$503.87
$704.15
$1,070.03 		$695.88
$749.10
$805.48
$1,005.76 		$997.49
$1,050.71
$1,107.09
$1,307.37 		$1,299.10
$1,352.32
$1,408.70
$1,608.98 		$301.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.54
$894.98
$1,007.74
$1,408.30
$2,140.06 		$1,090.15
$1,196.59
$1,309.35
$1,709.91 		$1,391.76
$1,498.20
$1,610.96
$2,011.52 		$1,693.37
$1,799.81
$1,912.57
$2,313.13 		$301.61
Toc - Plan #41 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 32

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$400.83
$454.93
$512.25
$715.87
$1,087.83 		$707.46
$761.56
$818.88
$1,022.50 		$1,014.09
$1,068.19
$1,125.51
$1,329.13 		$1,320.72
$1,374.82
$1,432.14
$1,635.76 		$306.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.66
$909.86
$1,024.50
$1,431.74
$2,175.66 		$1,108.29
$1,216.49
$1,331.13
$1,738.37 		$1,414.92
$1,523.12
$1,637.76
$2,045.00 		$1,721.55
$1,829.75
$1,944.39
$2,351.63 		$306.63
Toc - Plan #42 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 20

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.99
$453.98
$511.17
$714.36
$1,085.55 		$705.97
$759.96
$817.15
$1,020.34 		$1,011.95
$1,065.94
$1,123.13
$1,326.32 		$1,317.93
$1,371.92
$1,429.11
$1,632.30 		$305.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.98
$907.96
$1,022.34
$1,428.72
$2,171.10 		$1,105.96
$1,213.94
$1,328.32
$1,734.70 		$1,411.94
$1,519.92
$1,634.30
$2,040.68 		$1,717.92
$1,825.90
$1,940.28
$2,346.66 		$305.98
Toc - Plan #43 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$429.50
$487.47
$548.89
$767.07
$1,165.63 		$758.06
$816.03
$877.45
$1,095.63 		$1,086.62
$1,144.59
$1,206.01
$1,424.19 		$1,415.18
$1,473.15
$1,534.57
$1,752.75 		$328.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.00
$974.94
$1,097.78
$1,534.14
$2,331.26 		$1,187.56
$1,303.50
$1,426.34
$1,862.70 		$1,516.12
$1,632.06
$1,754.90
$2,191.26 		$1,844.68
$1,960.62
$2,083.46
$2,519.82 		$328.56
Toc - Plan #44 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$342.70
$388.96
$437.96
$612.05
$930.07 		$604.86
$651.12
$700.12
$874.21 		$867.02
$913.28
$962.28
$1,136.37 		$1,129.18
$1,175.44
$1,224.44
$1,398.53 		$262.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.40
$777.92
$875.92
$1,224.10
$1,860.14 		$947.56
$1,040.08
$1,138.08
$1,486.26 		$1,209.72
$1,302.24
$1,400.24
$1,748.42 		$1,471.88
$1,564.40
$1,662.40
$2,010.58 		$262.16
Toc - Plan #45 Ambetter from Sunshine Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$442.95
$502.74
$566.08
$791.10
$1,202.15 		$781.80
$841.59
$904.93
$1,129.95 		$1,120.65
$1,180.44
$1,243.78
$1,468.80 		$1,459.50
$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 		$885.90
$1,005.48
$1,132.16
$1,582.20
$2,404.30 		$1,224.75
$1,344.33
$1,471.01
$1,921.05 		$1,563.60
$1,683.18
$1,809.86
$2,259.90 		$1,902.45
$2,022.03
$2,148.71
$2,598.75 		$338.85
Toc - Plan #46 Ambetter from Sunshine Health
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.65
$353.71
$398.28
$556.59
$845.80 		$550.06
$592.12
$636.69
$795.00 		$788.47
$830.53
$875.10
$1,033.41 		$1,026.88
$1,068.94
$1,113.51
$1,271.82 		$238.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.30
$707.42
$796.56
$1,113.18
$1,691.60 		$861.71
$945.83
$1,034.97
$1,351.59 		$1,100.12
$1,184.24
$1,273.38
$1,590.00 		$1,338.53
$1,422.65
$1,511.79
$1,828.41 		$238.41
Toc - Plan #47 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$435.51
$494.29
$556.57
$777.80
$1,181.94 		$768.67
$827.45
$889.73
$1,110.96 		$1,101.83
$1,160.61
$1,222.89
$1,444.12 		$1,434.99
$1,493.77
$1,556.05
$1,777.28 		$333.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.02
$988.58
$1,113.14
$1,555.60
$2,363.88 		$1,204.18
$1,321.74
$1,446.30
$1,888.76 		$1,537.34
$1,654.90
$1,779.46
$2,221.92 		$1,870.50
$1,988.06
$2,112.62
$2,555.08 		$333.16
Toc - Plan #48 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$443.26
$503.09
$566.47
$791.64
$1,202.98 		$782.35
$842.18
$905.56
$1,130.73 		$1,121.44
$1,181.27
$1,244.65
$1,469.82 		$1,460.53
$1,520.36
$1,583.74
$1,808.91 		$339.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.52
$1,006.18
$1,132.94
$1,583.28
$2,405.96 		$1,225.61
$1,345.27
$1,472.03
$1,922.37 		$1,564.70
$1,684.36
$1,811.12
$2,261.46 		$1,903.79
$2,023.45
$2,150.21
$2,600.55 		$339.09
Toc - Plan #49 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$339.00
$384.76
$433.23
$605.44
$920.02 		$598.33
$644.09
$692.56
$864.77 		$857.66
$903.42
$951.89
$1,124.10 		$1,116.99
$1,162.75
$1,211.22
$1,383.43 		$259.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.00
$769.52
$866.46
$1,210.88
$1,840.04 		$937.33
$1,028.85
$1,125.79
$1,470.21 		$1,196.66
$1,288.18
$1,385.12
$1,729.54 		$1,455.99
$1,547.51
$1,644.45
$1,988.87 		$259.33
Toc - Plan #50 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.52
$411.45
$463.29
$647.44
$983.85 		$639.84
$688.77
$740.61
$924.76 		$917.16
$966.09
$1,017.93
$1,202.08 		$1,194.48
$1,243.41
$1,295.25
$1,479.40 		$277.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.04
$822.90
$926.58
$1,294.88
$1,967.70 		$1,002.36
$1,100.22
$1,203.90
$1,572.20 		$1,279.68
$1,377.54
$1,481.22
$1,849.52 		$1,557.00
$1,654.86
$1,758.54
$2,126.84 		$277.32
Toc - Plan #51 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.45
$422.72
$475.98
$665.17
$1,010.80 		$657.36
$707.63
$760.89
$950.08 		$942.27
$992.54
$1,045.80
$1,234.99 		$1,227.18
$1,277.45
$1,330.71
$1,519.90 		$284.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.90
$845.44
$951.96
$1,330.34
$2,021.60 		$1,029.81
$1,130.35
$1,236.87
$1,615.25 		$1,314.72
$1,415.26
$1,521.78
$1,900.16 		$1,599.63
$1,700.17
$1,806.69
$2,185.07 		$284.91
Toc - Plan #52 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.18
$448.52
$505.03
$705.77
$1,072.49 		$697.49
$750.83
$807.34
$1,008.08 		$999.80
$1,053.14
$1,109.65
$1,310.39 		$1,302.11
$1,355.45
$1,411.96
$1,612.70 		$302.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.36
$897.04
$1,010.06
$1,411.54
$2,144.98 		$1,092.67
$1,199.35
$1,312.37
$1,713.85 		$1,394.98
$1,501.66
$1,614.68
$2,016.16 		$1,697.29
$1,803.97
$1,916.99
$2,318.47 		$302.31
Toc - Plan #53 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408.33
$463.45
$521.84
$729.26
$1,108.19 		$720.70
$775.82
$834.21
$1,041.63 		$1,033.07
$1,088.19
$1,146.58
$1,354.00 		$1,345.44
$1,400.56
$1,458.95
$1,666.37 		$312.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.66
$926.90
$1,043.68
$1,458.52
$2,216.38 		$1,129.03
$1,239.27
$1,356.05
$1,770.89 		$1,441.40
$1,551.64
$1,668.42
$2,083.26 		$1,753.77
$1,864.01
$1,980.79
$2,395.63 		$312.37
Toc - Plan #54 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$415.13
$471.16
$530.52
$741.40
$1,126.63 		$732.69
$788.72
$848.08
$1,058.96 		$1,050.25
$1,106.28
$1,165.64
$1,376.52 		$1,367.81
$1,423.84
$1,483.20
$1,694.08 		$317.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.26
$942.32
$1,061.04
$1,482.80
$2,253.26 		$1,147.82
$1,259.88
$1,378.60
$1,800.36 		$1,465.38
$1,577.44
$1,696.16
$2,117.92 		$1,782.94
$1,895.00
$2,013.72
$2,435.48 		$317.56
Toc - Plan #55 Ambetter from Sunshine Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.26
$470.17
$529.41
$739.84
$1,124.26 		$731.16
$787.07
$846.31
$1,056.74 		$1,048.06
$1,103.97
$1,163.21
$1,373.64 		$1,364.96
$1,420.87
$1,480.11
$1,690.54 		$316.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.52
$940.34
$1,058.82
$1,479.68
$2,248.52 		$1,145.42
$1,257.24
$1,375.72
$1,796.58 		$1,462.32
$1,574.14
$1,692.62
$2,113.48 		$1,779.22
$1,891.04
$2,009.52
$2,430.38 		$316.90
Toc - Plan #56 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$424.49
$481.78
$542.49
$758.12
$1,152.04 		$749.22
$806.51
$867.22
$1,082.85 		$1,073.95
$1,131.24
$1,191.95
$1,407.58 		$1,398.68
$1,455.97
$1,516.68
$1,732.31 		$324.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.98
$963.56
$1,084.98
$1,516.24
$2,304.08 		$1,173.71
$1,288.29
$1,409.71
$1,840.97 		$1,498.44
$1,613.02
$1,734.44
$2,165.70 		$1,823.17
$1,937.75
$2,059.17
$2,490.43 		$324.73

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 #57 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$524.74
$595.58
$670.62
$937.19
$1,424.14 		$926.17
$997.01
$1,072.05
$1,338.62 		$1,327.60
$1,398.44
$1,473.48
$1,740.05 		$1,729.03
$1,799.87
$1,874.91
$2,141.48 		$401.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,049.48
$1,191.16
$1,341.24
$1,874.38
$2,848.28 		$1,450.91
$1,592.59
$1,742.67
$2,275.81 		$1,852.34
$1,994.02
$2,144.10
$2,677.24 		$2,253.77
$2,395.45
$2,545.53
$3,078.67 		$401.43
Toc - Plan #58 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.47
$397.78
$447.90
$625.94
$951.18 		$618.58
$665.89
$716.01
$894.05 		$886.69
$934.00
$984.12
$1,162.16 		$1,154.80
$1,202.11
$1,252.23
$1,430.27 		$268.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.94
$795.56
$895.80
$1,251.88
$1,902.36 		$969.05
$1,063.67
$1,163.91
$1,519.99 		$1,237.16
$1,331.78
$1,432.02
$1,788.10 		$1,505.27
$1,599.89
$1,700.13
$2,056.21 		$268.11
Toc - Plan #59 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$547.90
$621.87
$700.22
$978.55
$1,487.00 		$967.04
$1,041.01
$1,119.36
$1,397.69 		$1,386.18
$1,460.15
$1,538.50
$1,816.83 		$1,805.32
$1,879.29
$1,957.64
$2,235.97 		$419.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,095.80
$1,243.74
$1,400.44
$1,957.10
$2,974.00 		$1,514.94
$1,662.88
$1,819.58
$2,376.24 		$1,934.08
$2,082.02
$2,238.72
$2,795.38 		$2,353.22
$2,501.16
$2,657.86
$3,214.52 		$419.14
Toc - Plan #60 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$611.79
$694.38
$781.87
$1,092.66
$1,660.40 		$1,079.81
$1,162.40
$1,249.89
$1,560.68 		$1,547.83
$1,630.42
$1,717.91
$2,028.70 		$2,015.85
$2,098.44
$2,185.93
$2,496.72 		$468.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,223.58
$1,388.76
$1,563.74
$2,185.32
$3,320.80 		$1,691.60
$1,856.78
$2,031.76
$2,653.34 		$2,159.62
$2,324.80
$2,499.78
$3,121.36 		$2,627.64
$2,792.82
$2,967.80
$3,589.38 		$468.02
Toc - Plan #61 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$387.96
$440.33
$495.81
$692.90
$1,052.92 		$684.75
$737.12
$792.60
$989.69 		$981.54
$1,033.91
$1,089.39
$1,286.48 		$1,278.33
$1,330.70
$1,386.18
$1,583.27 		$296.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.92
$880.66
$991.62
$1,385.80
$2,105.84 		$1,072.71
$1,177.45
$1,288.41
$1,682.59 		$1,369.50
$1,474.24
$1,585.20
$1,979.38 		$1,666.29
$1,771.03
$1,881.99
$2,276.17 		$296.79
Toc - Plan #62 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$656.48
$745.10
$838.98
$1,172.47
$1,781.69 		$1,158.69
$1,247.31
$1,341.19
$1,674.68 		$1,660.90
$1,749.52
$1,843.40
$2,176.89 		$2,163.11
$2,251.73
$2,345.61
$2,679.10 		$502.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,312.96
$1,490.20
$1,677.96
$2,344.94
$3,563.38 		$1,815.17
$1,992.41
$2,180.17
$2,847.15 		$2,317.38
$2,494.62
$2,682.38
$3,349.36 		$2,819.59
$2,996.83
$3,184.59
$3,851.57 		$502.21
Toc - Plan #63 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$473.27
$537.16
$604.84
$845.26
$1,284.45 		$835.32
$899.21
$966.89
$1,207.31 		$1,197.37
$1,261.26
$1,328.94
$1,569.36 		$1,559.42
$1,623.31
$1,690.99
$1,931.41 		$362.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$946.54
$1,074.32
$1,209.68
$1,690.52
$2,568.90 		$1,308.59
$1,436.37
$1,571.73
$2,052.57 		$1,670.64
$1,798.42
$1,933.78
$2,414.62 		$2,032.69
$2,160.47
$2,295.83
$2,776.67 		$362.05
Toc - Plan #64 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$564.71
$640.95
$721.70
$1,008.57
$1,532.62 		$996.71
$1,072.95
$1,153.70
$1,440.57 		$1,428.71
$1,504.95
$1,585.70
$1,872.57 		$1,860.71
$1,936.95
$2,017.70
$2,304.57 		$432.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,129.42
$1,281.90
$1,443.40
$2,017.14
$3,065.24 		$1,561.42
$1,713.90
$1,875.40
$2,449.14 		$1,993.42
$2,145.90
$2,307.40
$2,881.14 		$2,425.42
$2,577.90
$2,739.40
$3,313.14 		$432.00
Toc - Plan #65 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.54
$420.56
$473.55
$661.78
$1,005.65 		$654.00
$704.02
$757.01
$945.24 		$937.46
$987.48
$1,040.47
$1,228.70 		$1,220.92
$1,270.94
$1,323.93
$1,512.16 		$283.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.08
$841.12
$947.10
$1,323.56
$2,011.30 		$1,024.54
$1,124.58
$1,230.56
$1,607.02 		$1,308.00
$1,408.04
$1,514.02
$1,890.48 		$1,591.46
$1,691.50
$1,797.48
$2,173.94 		$283.46
Toc - Plan #66 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$538.30
$610.97
$687.95
$961.40
$1,460.95 		$950.10
$1,022.77
$1,099.75
$1,373.20 		$1,361.90
$1,434.57
$1,511.55
$1,785.00 		$1,773.70
$1,846.37
$1,923.35
$2,196.80 		$411.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,076.60
$1,221.94
$1,375.90
$1,922.80
$2,921.90 		$1,488.40
$1,633.74
$1,787.70
$2,334.60 		$1,900.20
$2,045.54
$2,199.50
$2,746.40 		$2,312.00
$2,457.34
$2,611.30
$3,158.20 		$411.80
Toc - Plan #67 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$386.55
$438.73
$494.01
$690.38
$1,049.10 		$682.26
$734.44
$789.72
$986.09 		$977.97
$1,030.15
$1,085.43
$1,281.80 		$1,273.68
$1,325.86
$1,381.14
$1,577.51 		$295.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.10
$877.46
$988.02
$1,380.76
$2,098.20 		$1,068.81
$1,173.17
$1,283.73
$1,676.47 		$1,364.52
$1,468.88
$1,579.44
$1,972.18 		$1,660.23
$1,764.59
$1,875.15
$2,267.89 		$295.71
Toc - Plan #68 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$539.71
$612.57
$689.75
$963.92
$1,464.77 		$952.59
$1,025.45
$1,102.63
$1,376.80 		$1,365.47
$1,438.33
$1,515.51
$1,789.68 		$1,778.35
$1,851.21
$1,928.39
$2,202.56 		$412.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,079.42
$1,225.14
$1,379.50
$1,927.84
$2,929.54 		$1,492.30
$1,638.02
$1,792.38
$2,340.72 		$1,905.18
$2,050.90
$2,205.26
$2,753.60 		$2,318.06
$2,463.78
$2,618.14
$3,166.48 		$412.88
Toc - Plan #69 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$421.69
$478.62
$538.92
$753.14
$1,144.47 		$744.28
$801.21
$861.51
$1,075.73 		$1,066.87
$1,123.80
$1,184.10
$1,398.32 		$1,389.46
$1,446.39
$1,506.69
$1,720.91 		$322.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.38
$957.24
$1,077.84
$1,506.28
$2,288.94 		$1,165.97
$1,279.83
$1,400.43
$1,828.87 		$1,488.56
$1,602.42
$1,723.02
$2,151.46 		$1,811.15
$1,925.01
$2,045.61
$2,474.05 		$322.59
Toc - Plan #70 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$357.67
$405.96
$457.10
$638.80
$970.72 		$631.29
$679.58
$730.72
$912.42 		$904.91
$953.20
$1,004.34
$1,186.04 		$1,178.53
$1,226.82
$1,277.96
$1,459.66 		$273.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.34
$811.92
$914.20
$1,277.60
$1,941.44 		$988.96
$1,085.54
$1,187.82
$1,551.22 		$1,262.58
$1,359.16
$1,461.44
$1,824.84 		$1,536.20
$1,632.78
$1,735.06
$2,098.46 		$273.62
Toc - Plan #71 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317.92
$360.84
$406.30
$567.81
$862.83 		$561.13
$604.05
$649.51
$811.02 		$804.34
$847.26
$892.72
$1,054.23 		$1,047.55
$1,090.47
$1,135.93
$1,297.44 		$243.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.84
$721.68
$812.60
$1,135.62
$1,725.66 		$879.05
$964.89
$1,055.81
$1,378.83 		$1,122.26
$1,208.10
$1,299.02
$1,622.04 		$1,365.47
$1,451.31
$1,542.23
$1,865.25 		$243.21
Toc - Plan #72 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1603 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$454.47
$515.82
$580.81
$811.68
$1,233.43 		$802.14
$863.49
$928.48
$1,159.35 		$1,149.81
$1,211.16
$1,276.15
$1,507.02 		$1,497.48
$1,558.83
$1,623.82
$1,854.69 		$347.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.94
$1,031.64
$1,161.62
$1,623.36
$2,466.86 		$1,256.61
$1,379.31
$1,509.29
$1,971.03 		$1,604.28
$1,726.98
$1,856.96
$2,318.70 		$1,951.95
$2,074.65
$2,204.63
$2,666.37 		$347.67
Toc - Plan #73 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1604 ($0 Labs / $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
$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 		$430.11
$488.17
$549.68
$768.18
$1,167.32 		$759.14
$817.20
$878.71
$1,097.21 		$1,088.17
$1,146.23
$1,207.74
$1,426.24 		$1,417.20
$1,475.26
$1,536.77
$1,755.27 		$329.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.22
$976.34
$1,099.36
$1,536.36
$2,334.64 		$1,189.25
$1,305.37
$1,428.39
$1,865.39 		$1,518.28
$1,634.40
$1,757.42
$2,194.42 		$1,847.31
$1,963.43
$2,086.45
$2,523.45 		$329.03
Toc - Plan #74 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 1605 ($0 Labs / $0 Virtual Visits / 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 		$477.59
$542.06
$610.36
$852.98
$1,296.18 		$842.95
$907.42
$975.72
$1,218.34 		$1,208.31
$1,272.78
$1,341.08
$1,583.70 		$1,573.67
$1,638.14
$1,706.44
$1,949.06 		$365.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$955.18
$1,084.12
$1,220.72
$1,705.96
$2,592.36 		$1,320.54
$1,449.48
$1,586.08
$2,071.32 		$1,685.90
$1,814.84
$1,951.44
$2,436.68 		$2,051.26
$2,180.20
$2,316.80
$2,802.04 		$365.36
Toc - Plan #75 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1710 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$467.49
$530.60
$597.45
$834.94
$1,268.77 		$825.12
$888.23
$955.08
$1,192.57 		$1,182.75
$1,245.86
$1,312.71
$1,550.20 		$1,540.38
$1,603.49
$1,670.34
$1,907.83 		$357.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.98
$1,061.20
$1,194.90
$1,669.88
$2,537.54 		$1,292.61
$1,418.83
$1,552.53
$2,027.51 		$1,650.24
$1,776.46
$1,910.16
$2,385.14 		$2,007.87
$2,134.09
$2,267.79
$2,742.77 		$357.63
Toc - Plan #76 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1711S ($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
$7,800 $15,600 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 		$355.63
$403.64
$454.50
$635.16
$965.18 		$627.69
$675.70
$726.56
$907.22 		$899.75
$947.76
$998.62
$1,179.28 		$1,171.81
$1,219.82
$1,270.68
$1,451.34 		$272.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.26
$807.28
$909.00
$1,270.32
$1,930.36 		$983.32
$1,079.34
$1,181.06
$1,542.38 		$1,255.38
$1,351.40
$1,453.12
$1,814.44 		$1,527.44
$1,623.46
$1,725.18
$2,086.50 		$272.06
Toc - Plan #77 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1712S ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$3,950 $7,900 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$462.68
$525.14
$591.31
$826.35
$1,255.71 		$816.63
$879.09
$945.26
$1,180.30 		$1,170.58
$1,233.04
$1,299.21
$1,534.25 		$1,524.53
$1,586.99
$1,653.16
$1,888.20 		$353.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.36
$1,050.28
$1,182.62
$1,652.70
$2,511.42 		$1,279.31
$1,404.23
$1,536.57
$2,006.65 		$1,633.26
$1,758.18
$1,890.52
$2,360.60 		$1,987.21
$2,112.13
$2,244.47
$2,714.55 		$353.95
Toc - Plan #78 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$422.66
$479.72
$540.16
$754.87
$1,147.10 		$745.99
$803.05
$863.49
$1,078.20 		$1,069.32
$1,126.38
$1,186.82
$1,401.53 		$1,392.65
$1,449.71
$1,510.15
$1,724.86 		$323.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.32
$959.44
$1,080.32
$1,509.74
$2,294.20 		$1,168.65
$1,282.77
$1,403.65
$1,833.07 		$1,491.98
$1,606.10
$1,726.98
$2,156.40 		$1,815.31
$1,929.43
$2,050.31
$2,479.73 		$323.33
Toc - Plan #79 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

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 		$413.21
$468.99
$528.08
$737.99
$1,121.45 		$729.32
$785.10
$844.19
$1,054.10 		$1,045.43
$1,101.21
$1,160.30
$1,370.21 		$1,361.54
$1,417.32
$1,476.41
$1,686.32 		$316.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.42
$937.98
$1,056.16
$1,475.98
$2,242.90 		$1,142.53
$1,254.09
$1,372.27
$1,792.09 		$1,458.64
$1,570.20
$1,688.38
$2,108.20 		$1,774.75
$1,886.31
$2,004.49
$2,424.31 		$316.11
Toc - Plan #80 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Deductible / $0 Virtual Visits / $35 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$387.68
$440.02
$495.46
$692.40
$1,052.16 		$684.26
$736.60
$792.04
$988.98 		$980.84
$1,033.18
$1,088.62
$1,285.56 		$1,277.42
$1,329.76
$1,385.20
$1,582.14 		$296.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.36
$880.04
$990.92
$1,384.80
$2,104.32 		$1,071.94
$1,176.62
$1,287.50
$1,681.38 		$1,368.52
$1,473.20
$1,584.08
$1,977.96 		$1,665.10
$1,769.78
$1,880.66
$2,274.54 		$296.58
Toc - Plan #81 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 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 		$357.62
$405.90
$457.04
$638.71
$970.58 		$631.20
$679.48
$730.62
$912.29 		$904.78
$953.06
$1,004.20
$1,185.87 		$1,178.36
$1,226.64
$1,277.78
$1,459.45 		$273.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.24
$811.80
$914.08
$1,277.42
$1,941.16 		$988.82
$1,085.38
$1,187.66
$1,551.00 		$1,262.40
$1,358.96
$1,461.24
$1,824.58 		$1,535.98
$1,632.54
$1,734.82
$2,098.16 		$273.58
Toc - Plan #82 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$8,650 $17,300 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 		$399.76
$453.73
$510.89
$713.97
$1,084.95 		$705.58
$759.55
$816.71
$1,019.79 		$1,011.40
$1,065.37
$1,122.53
$1,325.61 		$1,317.22
$1,371.19
$1,428.35
$1,631.43 		$305.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.52
$907.46
$1,021.78
$1,427.94
$2,169.90 		$1,105.34
$1,213.28
$1,327.60
$1,733.76 		$1,411.16
$1,519.10
$1,633.42
$2,039.58 		$1,716.98
$1,824.92
$1,939.24
$2,345.40 		$305.82
Toc - Plan #83 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
$2,700 $5,400 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 		$348.37
$395.40
$445.22
$622.19
$945.48 		$614.87
$661.90
$711.72
$888.69 		$881.37
$928.40
$978.22
$1,155.19 		$1,147.87
$1,194.90
$1,244.72
$1,421.69 		$266.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.74
$790.80
$890.44
$1,244.38
$1,890.96 		$963.24
$1,057.30
$1,156.94
$1,510.88 		$1,229.74
$1,323.80
$1,423.44
$1,777.38 		$1,496.24
$1,590.30
$1,689.94
$2,043.88 		$266.50
Toc - Plan #84 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2266 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.36
$396.52
$446.48
$623.96
$948.16 		$616.62
$663.78
$713.74
$891.22 		$883.88
$931.04
$981.00
$1,158.48 		$1,151.14
$1,198.30
$1,248.26
$1,425.74 		$267.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.72
$793.04
$892.96
$1,247.92
$1,896.32 		$965.98
$1,060.30
$1,160.22
$1,515.18 		$1,233.24
$1,327.56
$1,427.48
$1,782.44 		$1,500.50
$1,594.82
$1,694.74
$2,049.70 		$267.26
Toc - Plan #85 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$8,650 $17,300 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 		$408.84
$464.03
$522.50
$730.19
$1,109.59 		$721.60
$776.79
$835.26
$1,042.95 		$1,034.36
$1,089.55
$1,148.02
$1,355.71 		$1,347.12
$1,402.31
$1,460.78
$1,668.47 		$312.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817.68
$928.06
$1,045.00
$1,460.38
$2,219.18 		$1,130.44
$1,240.82
$1,357.76
$1,773.14 		$1,443.20
$1,553.58
$1,670.52
$2,085.90 		$1,755.96
$1,866.34
$1,983.28
$2,398.66 		$312.76

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #86 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$310.88
$352.84
$397.29
$555.21
$843.70 		$548.70
$590.66
$635.11
$793.03 		$786.52
$828.48
$872.93
$1,030.85 		$1,024.34
$1,066.30
$1,110.75
$1,268.67 		$237.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.76
$705.68
$794.58
$1,110.42
$1,687.40 		$859.58
$943.50
$1,032.40
$1,348.24 		$1,097.40
$1,181.32
$1,270.22
$1,586.06 		$1,335.22
$1,419.14
$1,508.04
$1,823.88 		$237.82
Toc - Plan #87 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319.45
$362.57
$408.25
$570.52
$866.96 		$563.82
$606.94
$652.62
$814.89 		$808.19
$851.31
$896.99
$1,059.26 		$1,052.56
$1,095.68
$1,141.36
$1,303.63 		$244.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.90
$725.14
$816.50
$1,141.04
$1,733.92 		$883.27
$969.51
$1,060.87
$1,385.41 		$1,127.64
$1,213.88
$1,305.24
$1,629.78 		$1,372.01
$1,458.25
$1,549.61
$1,874.15 		$244.37
Toc - Plan #88 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.73
$353.80
$398.37
$556.72
$846.00 		$550.19
$592.26
$636.83
$795.18 		$788.65
$830.72
$875.29
$1,033.64 		$1,027.11
$1,069.18
$1,113.75
$1,272.10 		$238.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.46
$707.60
$796.74
$1,113.44
$1,692.00 		$861.92
$946.06
$1,035.20
$1,351.90 		$1,100.38
$1,184.52
$1,273.66
$1,590.36 		$1,338.84
$1,422.98
$1,512.12
$1,828.82 		$238.46
Toc - Plan #89 Oscar Insurance Company of Florida
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.89
$413.00
$465.04
$649.89
$987.56 		$642.26
$691.37
$743.41
$928.26 		$920.63
$969.74
$1,021.78
$1,206.63 		$1,199.00
$1,248.11
$1,300.15
$1,485.00 		$278.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.78
$826.00
$930.08
$1,299.78
$1,975.12 		$1,006.15
$1,104.37
$1,208.45
$1,578.15 		$1,284.52
$1,382.74
$1,486.82
$1,856.52 		$1,562.89
$1,661.11
$1,765.19
$2,134.89 		$278.37
Toc - Plan #90 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$404.51
$459.11
$516.96
$722.44
$1,097.82 		$713.96
$768.56
$826.41
$1,031.89 		$1,023.41
$1,078.01
$1,135.86
$1,341.34 		$1,332.86
$1,387.46
$1,445.31
$1,650.79 		$309.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.02
$918.22
$1,033.92
$1,444.88
$2,195.64 		$1,118.47
$1,227.67
$1,343.37
$1,754.33 		$1,427.92
$1,537.12
$1,652.82
$2,063.78 		$1,737.37
$1,846.57
$1,962.27
$2,373.23 		$309.45
Toc - Plan #91 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$402.36
$456.67
$514.21
$718.60
$1,091.98 		$710.16
$764.47
$822.01
$1,026.40 		$1,017.96
$1,072.27
$1,129.81
$1,334.20 		$1,325.76
$1,380.07
$1,437.61
$1,642.00 		$307.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.72
$913.34
$1,028.42
$1,437.20
$2,183.96 		$1,112.52
$1,221.14
$1,336.22
$1,745.00 		$1,420.32
$1,528.94
$1,644.02
$2,052.80 		$1,728.12
$1,836.74
$1,951.82
$2,360.60 		$307.80
Toc - Plan #92 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$404.87
$459.51
$517.41
$723.07
$1,098.78 		$714.58
$769.22
$827.12
$1,032.78 		$1,024.29
$1,078.93
$1,136.83
$1,342.49 		$1,334.00
$1,388.64
$1,446.54
$1,652.20 		$309.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.74
$919.02
$1,034.82
$1,446.14
$2,197.56 		$1,119.45
$1,228.73
$1,344.53
$1,755.85 		$1,429.16
$1,538.44
$1,654.24
$2,065.56 		$1,738.87
$1,848.15
$1,963.95
$2,375.27 		$309.71
Toc - Plan #93 Oscar Insurance Company of Florida
Catastrophic

(EPO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$241.27
$273.83
$308.32
$430.88
$654.77 		$425.83
$458.39
$492.88
$615.44 		$610.39
$642.95
$677.44
$800.00 		$794.95
$827.51
$862.00
$984.56 		$184.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$482.54
$547.66
$616.64
$861.76
$1,309.54 		$667.10
$732.22
$801.20
$1,046.32 		$851.66
$916.78
$985.76
$1,230.88 		$1,036.22
$1,101.34
$1,170.32
$1,415.44 		$184.56
Toc - Plan #94 Oscar Insurance Company of Florida
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.07
$413.21
$465.27
$650.22
$988.07 		$642.58
$691.72
$743.78
$928.73 		$921.09
$970.23
$1,022.29
$1,207.24 		$1,199.60
$1,248.74
$1,300.80
$1,485.75 		$278.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.14
$826.42
$930.54
$1,300.44
$1,976.14 		$1,006.65
$1,104.93
$1,209.05
$1,578.95 		$1,285.16
$1,383.44
$1,487.56
$1,857.46 		$1,563.67
$1,661.95
$1,766.07
$2,135.97 		$278.51
Toc - Plan #95 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$433.92
$492.48
$554.53
$774.96
$1,177.62 		$765.86
$824.42
$886.47
$1,106.90 		$1,097.80
$1,156.36
$1,218.41
$1,438.84 		$1,429.74
$1,488.30
$1,550.35
$1,770.78 		$331.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.84
$984.96
$1,109.06
$1,549.92
$2,355.24 		$1,199.78
$1,316.90
$1,441.00
$1,881.86 		$1,531.72
$1,648.84
$1,772.94
$2,213.80 		$1,863.66
$1,980.78
$2,104.88
$2,545.74 		$331.94
Toc - Plan #96 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336.06
$381.41
$429.47
$600.18
$912.03 		$593.13
$638.48
$686.54
$857.25 		$850.20
$895.55
$943.61
$1,114.32 		$1,107.27
$1,152.62
$1,200.68
$1,371.39 		$257.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.12
$762.82
$858.94
$1,200.36
$1,824.06 		$929.19
$1,019.89
$1,116.01
$1,457.43 		$1,186.26
$1,276.96
$1,373.08
$1,714.50 		$1,443.33
$1,534.03
$1,630.15
$1,971.57 		$257.07
Toc - Plan #97 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.22
$455.37
$512.75
$716.56
$1,088.89 		$708.15
$762.30
$819.68
$1,023.49 		$1,015.08
$1,069.23
$1,126.61
$1,330.42 		$1,322.01
$1,376.16
$1,433.54
$1,637.35 		$306.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.44
$910.74
$1,025.50
$1,433.12
$2,177.78 		$1,109.37
$1,217.67
$1,332.43
$1,740.05 		$1,416.30
$1,524.60
$1,639.36
$2,046.98 		$1,723.23
$1,831.53
$1,946.29
$2,353.91 		$306.93
Toc - Plan #98 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.64
$464.93
$523.51
$731.61
$1,111.75 		$723.01
$778.30
$836.88
$1,044.98 		$1,036.38
$1,091.67
$1,150.25
$1,358.35 		$1,349.75
$1,405.04
$1,463.62
$1,671.72 		$313.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.28
$929.86
$1,047.02
$1,463.22
$2,223.50 		$1,132.65
$1,243.23
$1,360.39
$1,776.59 		$1,446.02
$1,556.60
$1,673.76
$2,089.96 		$1,759.39
$1,869.97
$1,987.13
$2,403.33 		$313.37
Toc - Plan #99 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.13
$467.76
$526.69
$736.05
$1,118.50 		$727.40
$783.03
$841.96
$1,051.32 		$1,042.67
$1,098.30
$1,157.23
$1,366.59 		$1,357.94
$1,413.57
$1,472.50
$1,681.86 		$315.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.26
$935.52
$1,053.38
$1,472.10
$2,237.00 		$1,139.53
$1,250.79
$1,368.65
$1,787.37 		$1,454.80
$1,566.06
$1,683.92
$2,102.64 		$1,770.07
$1,881.33
$1,999.19
$2,417.91 		$315.27
Toc - Plan #100 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- Low Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$434.98
$493.70
$555.90
$776.86
$1,180.52 		$767.74
$826.46
$888.66
$1,109.62 		$1,100.50
$1,159.22
$1,221.42
$1,442.38 		$1,433.26
$1,491.98
$1,554.18
$1,775.14 		$332.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869.96
$987.40
$1,111.80
$1,553.72
$2,361.04 		$1,202.72
$1,320.16
$1,444.56
$1,886.48 		$1,535.48
$1,652.92
$1,777.32
$2,219.24 		$1,868.24
$1,985.68
$2,110.08
$2,552.00 		$332.76
Toc - Plan #101 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.04
$372.31
$419.22
$585.86
$890.27 		$578.98
$623.25
$670.16
$836.80 		$829.92
$874.19
$921.10
$1,087.74 		$1,080.86
$1,125.13
$1,172.04
$1,338.68 		$250.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$656.08
$744.62
$838.44
$1,171.72
$1,780.54 		$907.02
$995.56
$1,089.38
$1,422.66 		$1,157.96
$1,246.50
$1,340.32
$1,673.60 		$1,408.90
$1,497.44
$1,591.26
$1,924.54 		$250.94
Toc - Plan #102 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.55
$396.73
$446.71
$624.28
$948.66 		$616.95
$664.13
$714.11
$891.68 		$884.35
$931.53
$981.51
$1,159.08 		$1,151.75
$1,198.93
$1,248.91
$1,426.48 		$267.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$699.10
$793.46
$893.42
$1,248.56
$1,897.32 		$966.50
$1,060.86
$1,160.82
$1,515.96 		$1,233.90
$1,328.26
$1,428.22
$1,783.36 		$1,501.30
$1,595.66
$1,695.62
$2,050.76 		$267.40
Toc - Plan #103 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$333.87
$378.93
$426.67
$596.27
$906.09 		$589.27
$634.33
$682.07
$851.67 		$844.67
$889.73
$937.47
$1,107.07 		$1,100.07
$1,145.13
$1,192.87
$1,362.47 		$255.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.74
$757.86
$853.34
$1,192.54
$1,812.18 		$923.14
$1,013.26
$1,108.74
$1,447.94 		$1,178.54
$1,268.66
$1,364.14
$1,703.34 		$1,433.94
$1,524.06
$1,619.54
$1,958.74 		$255.40
Toc - Plan #104 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$397.98
$451.70
$508.61
$710.78
$1,080.09 		$702.43
$756.15
$813.06
$1,015.23 		$1,006.88
$1,060.60
$1,117.51
$1,319.68 		$1,311.33
$1,365.05
$1,421.96
$1,624.13 		$304.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.96
$903.40
$1,017.22
$1,421.56
$2,160.18 		$1,100.41
$1,207.85
$1,321.67
$1,726.01 		$1,404.86
$1,512.30
$1,626.12
$2,030.46 		$1,709.31
$1,816.75
$1,930.57
$2,334.91 		$304.45
Toc - Plan #105 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- Low Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.55
$458.02
$515.72
$720.72
$1,095.21 		$712.26
$766.73
$824.43
$1,029.43 		$1,020.97
$1,075.44
$1,133.14
$1,338.14 		$1,329.68
$1,384.15
$1,441.85
$1,646.85 		$308.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.10
$916.04
$1,031.44
$1,441.44
$2,190.42 		$1,115.81
$1,224.75
$1,340.15
$1,750.15 		$1,424.52
$1,533.46
$1,648.86
$2,058.86 		$1,733.23
$1,842.17
$1,957.57
$2,367.57 		$308.71
Toc - Plan #106 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- $0 PCP

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$413.87
$469.74
$528.92
$739.16
$1,123.23 		$730.48
$786.35
$845.53
$1,055.77 		$1,047.09
$1,102.96
$1,162.14
$1,372.38 		$1,363.70
$1,419.57
$1,478.75
$1,688.99 		$316.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.74
$939.48
$1,057.84
$1,478.32
$2,246.46 		$1,144.35
$1,256.09
$1,374.45
$1,794.93 		$1,460.96
$1,572.70
$1,691.06
$2,111.54 		$1,777.57
$1,889.31
$2,007.67
$2,428.15 		$316.61
Toc - Plan #107 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408.11
$463.19
$521.55
$728.87
$1,107.58 		$720.31
$775.39
$833.75
$1,041.07 		$1,032.51
$1,087.59
$1,145.95
$1,353.27 		$1,344.71
$1,399.79
$1,458.15
$1,665.47 		$312.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.22
$926.38
$1,043.10
$1,457.74
$2,215.16 		$1,128.42
$1,238.58
$1,355.30
$1,769.94 		$1,440.62
$1,550.78
$1,667.50
$2,082.14 		$1,752.82
$1,862.98
$1,979.70
$2,394.34 		$312.20
Toc - Plan #108 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$404.97
$459.63
$517.54
$723.26
$1,099.07 		$714.77
$769.43
$827.34
$1,033.06 		$1,024.57
$1,079.23
$1,137.14
$1,342.86 		$1,334.37
$1,389.03
$1,446.94
$1,652.66 		$309.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.94
$919.26
$1,035.08
$1,446.52
$2,198.14 		$1,119.74
$1,229.06
$1,344.88
$1,756.32 		$1,429.54
$1,538.86
$1,654.68
$2,066.12 		$1,739.34
$1,848.66
$1,964.48
$2,375.92 		$309.80
Toc - Plan #109 Oscar Insurance Company of Florida
Gold

(EPO) Gold Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.26
$474.72
$534.53
$747.00
$1,135.13 		$738.22
$794.68
$854.49
$1,066.96 		$1,058.18
$1,114.64
$1,174.45
$1,386.92 		$1,378.14
$1,434.60
$1,494.41
$1,706.88 		$319.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.52
$949.44
$1,069.06
$1,494.00
$2,270.26 		$1,156.48
$1,269.40
$1,389.02
$1,813.96 		$1,476.44
$1,589.36
$1,708.98
$2,133.92 		$1,796.40
$1,909.32
$2,028.94
$2,453.88 		$319.96
Toc - Plan #110 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- $0 PCP

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.37
$482.78
$543.60
$759.69
$1,154.42 		$750.77
$808.18
$869.00
$1,085.09 		$1,076.17
$1,133.58
$1,194.40
$1,410.49 		$1,401.57
$1,458.98
$1,519.80
$1,735.89 		$325.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.74
$965.56
$1,087.20
$1,519.38
$2,308.84 		$1,176.14
$1,290.96
$1,412.60
$1,844.78 		$1,501.54
$1,616.36
$1,738.00
$2,170.18 		$1,826.94
$1,941.76
$2,063.40
$2,495.58 		$325.40
Toc - Plan #111 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$467.18
$530.24
$597.04
$834.36
$1,267.89 		$824.56
$887.62
$954.42
$1,191.74 		$1,181.94
$1,245.00
$1,311.80
$1,549.12 		$1,539.32
$1,602.38
$1,669.18
$1,906.50 		$357.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.36
$1,060.48
$1,194.08
$1,668.72
$2,535.78 		$1,291.74
$1,417.86
$1,551.46
$2,026.10 		$1,649.12
$1,775.24
$1,908.84
$2,383.48 		$2,006.50
$2,132.62
$2,266.22
$2,740.86 		$357.38
Toc - Plan #112 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$443.72
$503.61
$567.06
$792.46
$1,204.22 		$783.16
$843.05
$906.50
$1,131.90 		$1,122.60
$1,182.49
$1,245.94
$1,471.34 		$1,462.04
$1,521.93
$1,585.38
$1,810.78 		$339.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.44
$1,007.22
$1,134.12
$1,584.92
$2,408.44 		$1,226.88
$1,346.66
$1,473.56
$1,924.36 		$1,566.32
$1,686.10
$1,813.00
$2,263.80 		$1,905.76
$2,025.54
$2,152.44
$2,603.24 		$339.44
Toc - Plan #113 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.15
$473.46
$533.11
$745.02
$1,132.13 		$736.26
$792.57
$852.22
$1,064.13 		$1,055.37
$1,111.68
$1,171.33
$1,383.24 		$1,374.48
$1,430.79
$1,490.44
$1,702.35 		$319.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.30
$946.92
$1,066.22
$1,490.04
$2,264.26 		$1,153.41
$1,266.03
$1,385.33
$1,809.15 		$1,472.52
$1,585.14
$1,704.44
$2,128.26 		$1,791.63
$1,904.25
$2,023.55
$2,447.37 		$319.11
Toc - Plan #114 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- $4000 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$351.23
$398.63
$448.85
$627.27
$953.20 		$619.91
$667.31
$717.53
$895.95 		$888.59
$935.99
$986.21
$1,164.63 		$1,157.27
$1,204.67
$1,254.89
$1,433.31 		$268.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.46
$797.26
$897.70
$1,254.54
$1,906.40 		$971.14
$1,065.94
$1,166.38
$1,523.22 		$1,239.82
$1,334.62
$1,435.06
$1,791.90 		$1,508.50
$1,603.30
$1,703.74
$2,060.58 		$268.68
Toc - Plan #115 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- $1000 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.21
$407.70
$459.06
$641.54
$974.88 		$634.00
$682.49
$733.85
$916.33 		$908.79
$957.28
$1,008.64
$1,191.12 		$1,183.58
$1,232.07
$1,283.43
$1,465.91 		$274.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.42
$815.40
$918.12
$1,283.08
$1,949.76 		$993.21
$1,090.19
$1,192.91
$1,557.87 		$1,268.00
$1,364.98
$1,467.70
$1,832.66 		$1,542.79
$1,639.77
$1,742.49
$2,107.45 		$274.79
Toc - Plan #116 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.38
$409.02
$460.56
$643.62
$978.05 		$636.06
$684.70
$736.24
$919.30 		$911.74
$960.38
$1,011.92
$1,194.98 		$1,187.42
$1,236.06
$1,287.60
$1,470.66 		$275.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.76
$818.04
$921.12
$1,287.24
$1,956.10 		$996.44
$1,093.72
$1,196.80
$1,562.92 		$1,272.12
$1,369.40
$1,472.48
$1,838.60 		$1,547.80
$1,645.08
$1,748.16
$2,114.28 		$275.68
Toc - Plan #117 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.52
$457.99
$515.69
$720.68
$1,095.14 		$712.21
$766.68
$824.38
$1,029.37 		$1,020.90
$1,075.37
$1,133.07
$1,338.06 		$1,329.59
$1,384.06
$1,441.76
$1,646.75 		$308.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.04
$915.98
$1,031.38
$1,441.36
$2,190.28 		$1,115.73
$1,224.67
$1,340.07
$1,750.05 		$1,424.42
$1,533.36
$1,648.76
$2,058.74 		$1,733.11
$1,842.05
$1,957.45
$2,367.43 		$308.69

‡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 Alachua County here.

Alachua County is in “Rating Area 1” of Florida.

Currently, there are 117 plans offered in Rating Area 1.

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2022 Obamacare Plans for Alachua County, FL

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