Obamacare 2022 Rates for Duval County

Obamacare > Rates > Florida > Duval 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 Duval 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, 147 Plans and 2022 Rates for Duval County, Florida

Below, you’ll find a summary of the 147 plans for Duval County, Florida and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Bright HealthCare

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

Toc - Plan #1 Bright HealthCare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$392.36
$445.32
$501.43
$700.75
$1,064.86 		$692.51
$745.47
$801.58
$1,000.90 		$992.66
$1,045.62
$1,101.73
$1,301.05 		$1,292.81
$1,345.77
$1,401.88
$1,601.20 		$300.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784.72
$890.64
$1,002.86
$1,401.50
$2,129.72 		$1,084.87
$1,190.79
$1,303.01
$1,701.65 		$1,385.02
$1,490.94
$1,603.16
$2,001.80 		$1,685.17
$1,791.09
$1,903.31
$2,301.95 		$300.15
Toc - Plan #2 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.94
$417.61
$470.22
$657.14
$998.58 		$649.41
$699.08
$751.69
$938.61 		$930.88
$980.55
$1,033.16
$1,220.08 		$1,212.35
$1,262.02
$1,314.63
$1,501.55 		$281.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.88
$835.22
$940.44
$1,314.28
$1,997.16 		$1,017.35
$1,116.69
$1,221.91
$1,595.75 		$1,298.82
$1,398.16
$1,503.38
$1,877.22 		$1,580.29
$1,679.63
$1,784.85
$2,158.69 		$281.47
Toc - Plan #3 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.16
$426.94
$480.73
$671.82
$1,020.90 		$663.92
$714.70
$768.49
$959.58 		$951.68
$1,002.46
$1,056.25
$1,247.34 		$1,239.44
$1,290.22
$1,344.01
$1,535.10 		$287.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.32
$853.88
$961.46
$1,343.64
$2,041.80 		$1,040.08
$1,141.64
$1,249.22
$1,631.40 		$1,327.84
$1,429.40
$1,536.98
$1,919.16 		$1,615.60
$1,717.16
$1,824.74
$2,206.92 		$287.76
Toc - Plan #4 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.77
$465.08
$523.68
$731.84
$1,112.10 		$723.24
$778.55
$837.15
$1,045.31 		$1,036.71
$1,092.02
$1,150.62
$1,358.78 		$1,350.18
$1,405.49
$1,464.09
$1,672.25 		$313.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.54
$930.16
$1,047.36
$1,463.68
$2,224.20 		$1,133.01
$1,243.63
$1,360.83
$1,777.15 		$1,446.48
$1,557.10
$1,674.30
$2,090.62 		$1,759.95
$1,870.57
$1,987.77
$2,404.09 		$313.47
Toc - Plan #5 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.28
$427.08
$480.88
$672.03
$1,021.22 		$664.13
$714.93
$768.73
$959.88 		$951.98
$1,002.78
$1,056.58
$1,247.73 		$1,239.83
$1,290.63
$1,344.43
$1,535.58 		$287.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.56
$854.16
$961.76
$1,344.06
$2,042.44 		$1,040.41
$1,142.01
$1,249.61
$1,631.91 		$1,328.26
$1,429.86
$1,537.46
$1,919.76 		$1,616.11
$1,717.71
$1,825.31
$2,207.61 		$287.85
Toc - Plan #6 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$275.62
$312.83
$352.24
$492.25
$748.03 		$486.47
$523.68
$563.09
$703.10 		$697.32
$734.53
$773.94
$913.95 		$908.17
$945.38
$984.79
$1,124.80 		$210.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.24
$625.66
$704.48
$984.50
$1,496.06 		$762.09
$836.51
$915.33
$1,195.35 		$972.94
$1,047.36
$1,126.18
$1,406.20 		$1,183.79
$1,258.21
$1,337.03
$1,617.05 		$210.85
Toc - Plan #7 Bright HealthCare
Expanded Bronze

(EPO) Bronze 5300 HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$304.25
$345.32
$388.83
$543.39
$825.73 		$537.00
$578.07
$621.58
$776.14 		$769.75
$810.82
$854.33
$1,008.89 		$1,002.50
$1,043.57
$1,087.08
$1,241.64 		$232.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.50
$690.64
$777.66
$1,086.78
$1,651.46 		$841.25
$923.39
$1,010.41
$1,319.53 		$1,074.00
$1,156.14
$1,243.16
$1,552.28 		$1,306.75
$1,388.89
$1,475.91
$1,785.03 		$232.75
Toc - Plan #8 Bright HealthCare
Catastrophic

(EPO) Catastrophic 8700 ($0 Primary Care)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$202.78
$230.16
$259.15
$362.17
$550.35 		$357.91
$385.29
$414.28
$517.30 		$513.04
$540.42
$569.41
$672.43 		$668.17
$695.55
$724.54
$827.56 		$155.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$405.56
$460.32
$518.30
$724.34
$1,100.70 		$560.69
$615.45
$673.43
$879.47 		$715.82
$770.58
$828.56
$1,034.60 		$870.95
$925.71
$983.69
$1,189.73 		$155.13
Toc - Plan #9 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$287.06
$325.81
$366.86
$512.69
$779.08 		$506.66
$545.41
$586.46
$732.29 		$726.26
$765.01
$806.06
$951.89 		$945.86
$984.61
$1,025.66
$1,171.49 		$219.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.12
$651.62
$733.72
$1,025.38
$1,558.16 		$793.72
$871.22
$953.32
$1,244.98 		$1,013.32
$1,090.82
$1,172.92
$1,464.58 		$1,232.92
$1,310.42
$1,392.52
$1,684.18 		$219.60
Toc - Plan #10 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.33
$363.58
$409.39
$572.12
$869.39 		$565.39
$608.64
$654.45
$817.18 		$810.45
$853.70
$899.51
$1,062.24 		$1,055.51
$1,098.76
$1,144.57
$1,307.30 		$245.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.66
$727.16
$818.78
$1,144.24
$1,738.78 		$885.72
$972.22
$1,063.84
$1,389.30 		$1,130.78
$1,217.28
$1,308.90
$1,634.36 		$1,375.84
$1,462.34
$1,553.96
$1,879.42 		$245.06
Toc - Plan #11 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$291.61
$330.98
$372.68
$520.82
$791.44 		$514.69
$554.06
$595.76
$743.90 		$737.77
$777.14
$818.84
$966.98 		$960.85
$1,000.22
$1,041.92
$1,190.06 		$223.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.22
$661.96
$745.36
$1,041.64
$1,582.88 		$806.30
$885.04
$968.44
$1,264.72 		$1,029.38
$1,108.12
$1,191.52
$1,487.80 		$1,252.46
$1,331.20
$1,414.60
$1,710.88 		$223.08
Toc - Plan #12 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$380.83
$432.25
$486.71
$680.17
$1,033.58 		$672.17
$723.59
$778.05
$971.51 		$963.51
$1,014.93
$1,069.39
$1,262.85 		$1,254.85
$1,306.27
$1,360.73
$1,554.19 		$291.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.66
$864.50
$973.42
$1,360.34
$2,067.16 		$1,053.00
$1,155.84
$1,264.76
$1,651.68 		$1,344.34
$1,447.18
$1,556.10
$1,943.02 		$1,635.68
$1,738.52
$1,847.44
$2,234.36 		$291.34
Toc - Plan #13 Bright HealthCare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.33
$482.75
$543.57
$759.64
$1,154.35 		$750.71
$808.13
$868.95
$1,085.02 		$1,076.09
$1,133.51
$1,194.33
$1,410.40 		$1,401.47
$1,458.89
$1,519.71
$1,735.78 		$325.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.66
$965.50
$1,087.14
$1,519.28
$2,308.70 		$1,176.04
$1,290.88
$1,412.52
$1,844.66 		$1,501.42
$1,616.26
$1,737.90
$2,170.04 		$1,826.80
$1,941.64
$2,063.28
$2,495.42 		$325.38
Toc - Plan #14 Bright HealthCare
Expanded Bronze

(EPO) Bronze 8700 ($25 Generic)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$270.79
$307.35
$346.07
$483.63
$734.92 		$477.94
$514.50
$553.22
$690.78 		$685.09
$721.65
$760.37
$897.93 		$892.24
$928.80
$967.52
$1,105.08 		$207.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541.58
$614.70
$692.14
$967.26
$1,469.84 		$748.73
$821.85
$899.29
$1,174.41 		$955.88
$1,029.00
$1,106.44
$1,381.56 		$1,163.03
$1,236.15
$1,313.59
$1,588.71 		$207.15
Toc - Plan #15 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.87
$397.11
$447.14
$624.88
$949.56 		$617.52
$664.76
$714.79
$892.53 		$885.17
$932.41
$982.44
$1,160.18 		$1,152.82
$1,200.06
$1,250.09
$1,427.83 		$267.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$699.74
$794.22
$894.28
$1,249.76
$1,899.12 		$967.39
$1,061.87
$1,161.93
$1,517.41 		$1,235.04
$1,329.52
$1,429.58
$1,785.06 		$1,502.69
$1,597.17
$1,697.23
$2,052.71 		$267.65

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Florida Blue (BlueCross BlueShield FL)

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

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$665.85
$755.74
$850.96
$1,189.21
$1,807.12 		$1,175.23
$1,265.12
$1,360.34
$1,698.59 		$1,684.61
$1,774.50
$1,869.72
$2,207.97 		$2,193.99
$2,283.88
$2,379.10
$2,717.35 		$509.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,331.70
$1,511.48
$1,701.92
$2,378.42
$3,614.24 		$1,841.08
$2,020.86
$2,211.30
$2,887.80 		$2,350.46
$2,530.24
$2,720.68
$3,397.18 		$2,859.84
$3,039.62
$3,230.06
$3,906.56 		$509.38
Toc - Plan #17 Florida Blue (BlueCross BlueShield FL)
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$415.43
$471.51
$530.92
$741.96
$1,127.48 		$733.23
$789.31
$848.72
$1,059.76 		$1,051.03
$1,107.11
$1,166.52
$1,377.56 		$1,368.83
$1,424.91
$1,484.32
$1,695.36 		$317.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.86
$943.02
$1,061.84
$1,483.92
$2,254.96 		$1,148.66
$1,260.82
$1,379.64
$1,801.72 		$1,466.46
$1,578.62
$1,697.44
$2,119.52 		$1,784.26
$1,896.42
$2,015.24
$2,437.32 		$317.80
Toc - Plan #18 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$681.37
$773.35
$870.79
$1,216.93
$1,849.24 		$1,202.62
$1,294.60
$1,392.04
$1,738.18 		$1,723.87
$1,815.85
$1,913.29
$2,259.43 		$2,245.12
$2,337.10
$2,434.54
$2,780.68 		$521.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,362.74
$1,546.70
$1,741.58
$2,433.86
$3,698.48 		$1,883.99
$2,067.95
$2,262.83
$2,955.11 		$2,405.24
$2,589.20
$2,784.08
$3,476.36 		$2,926.49
$3,110.45
$3,305.33
$3,997.61 		$521.25
Toc - Plan #19 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$830.06
$942.12
$1,060.82
$1,482.49
$2,252.78 		$1,465.06
$1,577.12
$1,695.82
$2,117.49 		$2,100.06
$2,212.12
$2,330.82
$2,752.49 		$2,735.06
$2,847.12
$2,965.82
$3,387.49 		$635.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,660.12
$1,884.24
$2,121.64
$2,964.98
$4,505.56 		$2,295.12
$2,519.24
$2,756.64
$3,599.98 		$2,930.12
$3,154.24
$3,391.64
$4,234.98 		$3,565.12
$3,789.24
$4,026.64
$4,869.98 		$635.00
Toc - Plan #20 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$446.36
$506.62
$570.45
$797.20
$1,211.42 		$787.83
$848.09
$911.92
$1,138.67 		$1,129.30
$1,189.56
$1,253.39
$1,480.14 		$1,470.77
$1,531.03
$1,594.86
$1,821.61 		$341.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.72
$1,013.24
$1,140.90
$1,594.40
$2,422.84 		$1,234.19
$1,354.71
$1,482.37
$1,935.87 		$1,575.66
$1,696.18
$1,823.84
$2,277.34 		$1,917.13
$2,037.65
$2,165.31
$2,618.81 		$341.47
Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$875.67
$993.89
$1,119.11
$1,563.95
$2,376.57 		$1,545.56
$1,663.78
$1,789.00
$2,233.84 		$2,215.45
$2,333.67
$2,458.89
$2,903.73 		$2,885.34
$3,003.56
$3,128.78
$3,573.62 		$669.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,751.34
$1,987.78
$2,238.22
$3,127.90
$4,753.14 		$2,421.23
$2,657.67
$2,908.11
$3,797.79 		$3,091.12
$3,327.56
$3,578.00
$4,467.68 		$3,761.01
$3,997.45
$4,247.89
$5,137.57 		$669.89
Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$615.35
$698.42
$786.42
$1,099.02
$1,670.06 		$1,086.09
$1,169.16
$1,257.16
$1,569.76 		$1,556.83
$1,639.90
$1,727.90
$2,040.50 		$2,027.57
$2,110.64
$2,198.64
$2,511.24 		$470.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,230.70
$1,396.84
$1,572.84
$2,198.04
$3,340.12 		$1,701.44
$1,867.58
$2,043.58
$2,668.78 		$2,172.18
$2,338.32
$2,514.32
$3,139.52 		$2,642.92
$2,809.06
$2,985.06
$3,610.26 		$470.74
Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$702.46
$797.29
$897.74
$1,254.59
$1,906.48 		$1,239.84
$1,334.67
$1,435.12
$1,791.97 		$1,777.22
$1,872.05
$1,972.50
$2,329.35 		$2,314.60
$2,409.43
$2,509.88
$2,866.73 		$537.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,404.92
$1,594.58
$1,795.48
$2,509.18
$3,812.96 		$1,942.30
$2,131.96
$2,332.86
$3,046.56 		$2,479.68
$2,669.34
$2,870.24
$3,583.94 		$3,017.06
$3,206.72
$3,407.62
$4,121.32 		$537.38
Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$433.98
$492.57
$554.63
$775.09
$1,177.82 		$765.97
$824.56
$886.62
$1,107.08 		$1,097.96
$1,156.55
$1,218.61
$1,439.07 		$1,429.95
$1,488.54
$1,550.60
$1,771.06 		$331.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.96
$985.14
$1,109.26
$1,550.18
$2,355.64 		$1,199.95
$1,317.13
$1,441.25
$1,882.17 		$1,531.94
$1,649.12
$1,773.24
$2,214.16 		$1,863.93
$1,981.11
$2,105.23
$2,546.15 		$331.99
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$676.82
$768.19
$864.98
$1,208.80
$1,836.89 		$1,194.59
$1,285.96
$1,382.75
$1,726.57 		$1,712.36
$1,803.73
$1,900.52
$2,244.34 		$2,230.13
$2,321.50
$2,418.29
$2,762.11 		$517.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,353.64
$1,536.38
$1,729.96
$2,417.60
$3,673.78 		$1,871.41
$2,054.15
$2,247.73
$2,935.37 		$2,389.18
$2,571.92
$2,765.50
$3,453.14 		$2,906.95
$3,089.69
$3,283.27
$3,970.91 		$517.77
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$445.79
$505.97
$569.72
$796.18
$1,209.87 		$786.82
$847.00
$910.75
$1,137.21 		$1,127.85
$1,188.03
$1,251.78
$1,478.24 		$1,468.88
$1,529.06
$1,592.81
$1,819.27 		$341.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$891.58
$1,011.94
$1,139.44
$1,592.36
$2,419.74 		$1,232.61
$1,352.97
$1,480.47
$1,933.39 		$1,573.64
$1,694.00
$1,821.50
$2,274.42 		$1,914.67
$2,035.03
$2,162.53
$2,615.45 		$341.03
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$678.62
$770.23
$867.28
$1,212.02
$1,841.77 		$1,197.76
$1,289.37
$1,386.42
$1,731.16 		$1,716.90
$1,808.51
$1,905.56
$2,250.30 		$2,236.04
$2,327.65
$2,424.70
$2,769.44 		$519.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,357.24
$1,540.46
$1,734.56
$2,424.04
$3,683.54 		$1,876.38
$2,059.60
$2,253.70
$2,943.18 		$2,395.52
$2,578.74
$2,772.84
$3,462.32 		$2,914.66
$3,097.88
$3,291.98
$3,981.46 		$519.14
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$475.04
$539.17
$607.10
$848.42
$1,289.26 		$838.45
$902.58
$970.51
$1,211.83 		$1,201.86
$1,265.99
$1,333.92
$1,575.24 		$1,565.27
$1,629.40
$1,697.33
$1,938.65 		$363.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$950.08
$1,078.34
$1,214.20
$1,696.84
$2,578.52 		$1,313.49
$1,441.75
$1,577.61
$2,060.25 		$1,676.90
$1,805.16
$1,941.02
$2,423.66 		$2,040.31
$2,168.57
$2,304.43
$2,787.07 		$363.41
Toc - Plan #29 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1456 ($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 		$433.19
$491.67
$553.62
$773.68
$1,175.68 		$764.58
$823.06
$885.01
$1,105.07 		$1,095.97
$1,154.45
$1,216.40
$1,436.46 		$1,427.36
$1,485.84
$1,547.79
$1,767.85 		$331.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.38
$983.34
$1,107.24
$1,547.36
$2,351.36 		$1,197.77
$1,314.73
$1,438.63
$1,878.75 		$1,529.16
$1,646.12
$1,770.02
$2,210.14 		$1,860.55
$1,977.51
$2,101.41
$2,541.53 		$331.39
Toc - Plan #30 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueSelect Bronze 1452 ($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 		$311.91
$354.02
$398.62
$557.07
$846.52 		$550.52
$592.63
$637.23
$795.68 		$789.13
$831.24
$875.84
$1,034.29 		$1,027.74
$1,069.85
$1,114.45
$1,272.90 		$238.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.82
$708.04
$797.24
$1,114.14
$1,693.04 		$862.43
$946.65
$1,035.85
$1,352.75 		$1,101.04
$1,185.26
$1,274.46
$1,591.36 		$1,339.65
$1,423.87
$1,513.07
$1,829.97 		$238.61
Toc - Plan #31 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1464 ($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 		$443.30
$503.15
$566.54
$791.73
$1,203.12 		$782.42
$842.27
$905.66
$1,130.85 		$1,121.54
$1,181.39
$1,244.78
$1,469.97 		$1,460.66
$1,520.51
$1,583.90
$1,809.09 		$339.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.60
$1,006.30
$1,133.08
$1,583.46
$2,406.24 		$1,225.72
$1,345.42
$1,472.20
$1,922.58 		$1,564.84
$1,684.54
$1,811.32
$2,261.70 		$1,903.96
$2,023.66
$2,150.44
$2,600.82 		$339.12
Toc - Plan #32 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1451 ($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 		$541.59
$614.70
$692.15
$967.28
$1,469.88 		$955.91
$1,029.02
$1,106.47
$1,381.60 		$1,370.23
$1,443.34
$1,520.79
$1,795.92 		$1,784.55
$1,857.66
$1,935.11
$2,210.24 		$414.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,083.18
$1,229.40
$1,384.30
$1,934.56
$2,939.76 		$1,497.50
$1,643.72
$1,798.62
$2,348.88 		$1,911.82
$2,058.04
$2,212.94
$2,763.20 		$2,326.14
$2,472.36
$2,627.26
$3,177.52 		$414.32
Toc - Plan #33 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($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 		$335.11
$380.35
$428.27
$598.51
$909.49 		$591.47
$636.71
$684.63
$854.87 		$847.83
$893.07
$940.99
$1,111.23 		$1,104.19
$1,149.43
$1,197.35
$1,367.59 		$256.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.22
$760.70
$856.54
$1,197.02
$1,818.98 		$926.58
$1,017.06
$1,112.90
$1,453.38 		$1,182.94
$1,273.42
$1,369.26
$1,709.74 		$1,439.30
$1,529.78
$1,625.62
$1,966.10 		$256.36
Toc - Plan #34 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1457 ($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 		$570.96
$648.04
$729.69
$1,019.73
$1,549.59 		$1,007.74
$1,084.82
$1,166.47
$1,456.51 		$1,444.52
$1,521.60
$1,603.25
$1,893.29 		$1,881.30
$1,958.38
$2,040.03
$2,330.07 		$436.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,141.92
$1,296.08
$1,459.38
$2,039.46
$3,099.18 		$1,578.70
$1,732.86
$1,896.16
$2,476.24 		$2,015.48
$2,169.64
$2,332.94
$2,913.02 		$2,452.26
$2,606.42
$2,769.72
$3,349.80 		$436.78
Toc - Plan #35 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1443 ($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 		$400.36
$454.41
$511.66
$715.04
$1,086.58 		$706.64
$760.69
$817.94
$1,021.32 		$1,012.92
$1,066.97
$1,124.22
$1,327.60 		$1,319.20
$1,373.25
$1,430.50
$1,633.88 		$306.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800.72
$908.82
$1,023.32
$1,430.08
$2,173.16 		$1,107.00
$1,215.10
$1,329.60
$1,736.36 		$1,413.28
$1,521.38
$1,635.88
$2,042.64 		$1,719.56
$1,827.66
$1,942.16
$2,348.92 		$306.28
Toc - Plan #36 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1535 ($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 		$464.84
$527.59
$594.07
$830.20
$1,261.58 		$820.44
$883.19
$949.67
$1,185.80 		$1,176.04
$1,238.79
$1,305.27
$1,541.40 		$1,531.64
$1,594.39
$1,660.87
$1,897.00 		$355.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.68
$1,055.18
$1,188.14
$1,660.40
$2,523.16 		$1,285.28
$1,410.78
$1,543.74
$2,016.00 		$1,640.88
$1,766.38
$1,899.34
$2,371.60 		$1,996.48
$2,121.98
$2,254.94
$2,727.20 		$355.60
Toc - Plan #37 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze (HSA) 1735 (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 		$325.81
$369.79
$416.39
$581.90
$884.25 		$575.05
$619.03
$665.63
$831.14 		$824.29
$868.27
$914.87
$1,080.38 		$1,073.53
$1,117.51
$1,164.11
$1,329.62 		$249.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.62
$739.58
$832.78
$1,163.80
$1,768.50 		$900.86
$988.82
$1,082.02
$1,413.04 		$1,150.10
$1,238.06
$1,331.26
$1,662.28 		$1,399.34
$1,487.30
$1,580.50
$1,911.52 		$249.24
Toc - Plan #38 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1736S ($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 		$440.34
$499.79
$562.75
$786.45
$1,195.08 		$777.20
$836.65
$899.61
$1,123.31 		$1,114.06
$1,173.51
$1,236.47
$1,460.17 		$1,450.92
$1,510.37
$1,573.33
$1,797.03 		$336.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.68
$999.58
$1,125.50
$1,572.90
$2,390.16 		$1,217.54
$1,336.44
$1,462.36
$1,909.76 		$1,554.40
$1,673.30
$1,799.22
$2,246.62 		$1,891.26
$2,010.16
$2,136.08
$2,583.48 		$336.86
Toc - Plan #39 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1737S ($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 		$334.71
$379.90
$427.76
$597.79
$908.40 		$590.76
$635.95
$683.81
$853.84 		$846.81
$892.00
$939.86
$1,109.89 		$1,102.86
$1,148.05
$1,195.91
$1,365.94 		$256.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.42
$759.80
$855.52
$1,195.58
$1,816.80 		$925.47
$1,015.85
$1,111.57
$1,451.63 		$1,181.52
$1,271.90
$1,367.62
$1,707.68 		$1,437.57
$1,527.95
$1,623.67
$1,963.73 		$256.05
Toc - Plan #40 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1835 ($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 		$449.76
$510.48
$574.79
$803.27
$1,220.65 		$793.83
$854.55
$918.86
$1,147.34 		$1,137.90
$1,198.62
$1,262.93
$1,491.41 		$1,481.97
$1,542.69
$1,607.00
$1,835.48 		$344.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$899.52
$1,020.96
$1,149.58
$1,606.54
$2,441.30 		$1,243.59
$1,365.03
$1,493.65
$1,950.61 		$1,587.66
$1,709.10
$1,837.72
$2,294.68 		$1,931.73
$2,053.17
$2,181.79
$2,638.75 		$344.07
Toc - Plan #41 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2139 ($0 Deductible / $50 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$356.32
$404.42
$455.38
$636.39
$967.05 		$628.90
$677.00
$727.96
$908.97 		$901.48
$949.58
$1,000.54
$1,181.55 		$1,174.06
$1,222.16
$1,273.12
$1,454.13 		$272.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.64
$808.84
$910.76
$1,272.78
$1,934.10 		$985.22
$1,081.42
$1,183.34
$1,545.36 		$1,257.80
$1,354.00
$1,455.92
$1,817.94 		$1,530.38
$1,626.58
$1,728.50
$2,090.52 		$272.58

ADVERTISEMENT

AvMed

Local: 1-800-477-8768 | Toll Free: 

Toc - Plan #42 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 		$430.79
$488.95
$550.55
$769.39
$1,169.17 		$760.35
$818.51
$880.11
$1,098.95 		$1,089.91
$1,148.07
$1,209.67
$1,428.51 		$1,419.47
$1,477.63
$1,539.23
$1,758.07 		$329.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.58
$977.90
$1,101.10
$1,538.78
$2,338.34 		$1,191.14
$1,307.46
$1,430.66
$1,868.34 		$1,520.70
$1,637.02
$1,760.22
$2,197.90 		$1,850.26
$1,966.58
$2,089.78
$2,527.46 		$329.56
Toc - Plan #43 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 		$420.40
$477.16
$537.27
$750.84
$1,140.97 		$742.01
$798.77
$858.88
$1,072.45 		$1,063.62
$1,120.38
$1,180.49
$1,394.06 		$1,385.23
$1,441.99
$1,502.10
$1,715.67 		$321.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.80
$954.32
$1,074.54
$1,501.68
$2,281.94 		$1,162.41
$1,275.93
$1,396.15
$1,823.29 		$1,484.02
$1,597.54
$1,717.76
$2,144.90 		$1,805.63
$1,919.15
$2,039.37
$2,466.51 		$321.61
Toc - Plan #44 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 		$395.84
$449.28
$505.88
$706.97
$1,074.31 		$698.66
$752.10
$808.70
$1,009.79 		$1,001.48
$1,054.92
$1,111.52
$1,312.61 		$1,304.30
$1,357.74
$1,414.34
$1,615.43 		$302.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.68
$898.56
$1,011.76
$1,413.94
$2,148.62 		$1,094.50
$1,201.38
$1,314.58
$1,716.76 		$1,397.32
$1,504.20
$1,617.40
$2,019.58 		$1,700.14
$1,807.02
$1,920.22
$2,322.40 		$302.82
Toc - Plan #45 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 		$397.18
$450.80
$507.60
$709.36
$1,077.95 		$701.02
$754.64
$811.44
$1,013.20 		$1,004.86
$1,058.48
$1,115.28
$1,317.04 		$1,308.70
$1,362.32
$1,419.12
$1,620.88 		$303.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.36
$901.60
$1,015.20
$1,418.72
$2,155.90 		$1,098.20
$1,205.44
$1,319.04
$1,722.56 		$1,402.04
$1,509.28
$1,622.88
$2,026.40 		$1,705.88
$1,813.12
$1,926.72
$2,330.24 		$303.84
Toc - Plan #46 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 		$391.47
$444.32
$500.30
$699.17
$1,062.45 		$690.95
$743.80
$799.78
$998.65 		$990.43
$1,043.28
$1,099.26
$1,298.13 		$1,289.91
$1,342.76
$1,398.74
$1,597.61 		$299.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.94
$888.64
$1,000.60
$1,398.34
$2,124.90 		$1,082.42
$1,188.12
$1,300.08
$1,697.82 		$1,381.90
$1,487.60
$1,599.56
$1,997.30 		$1,681.38
$1,787.08
$1,899.04
$2,296.78 		$299.48
Toc - Plan #47 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 		$317.21
$360.03
$405.39
$566.54
$860.91 		$559.88
$602.70
$648.06
$809.21 		$802.55
$845.37
$890.73
$1,051.88 		$1,045.22
$1,088.04
$1,133.40
$1,294.55 		$242.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.42
$720.06
$810.78
$1,133.08
$1,721.82 		$877.09
$962.73
$1,053.45
$1,375.75 		$1,119.76
$1,205.40
$1,296.12
$1,618.42 		$1,362.43
$1,448.07
$1,538.79
$1,861.09 		$242.67
Toc - Plan #48 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 		$303.40
$344.35
$387.74
$541.86
$823.42 		$535.50
$576.45
$619.84
$773.96 		$767.60
$808.55
$851.94
$1,006.06 		$999.70
$1,040.65
$1,084.04
$1,238.16 		$232.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.80
$688.70
$775.48
$1,083.72
$1,646.84 		$838.90
$920.80
$1,007.58
$1,315.82 		$1,071.00
$1,152.90
$1,239.68
$1,547.92 		$1,303.10
$1,385.00
$1,471.78
$1,780.02 		$232.10
Toc - Plan #49 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 		$279.35
$317.07
$357.01
$498.92
$758.16 		$493.05
$530.77
$570.71
$712.62 		$706.75
$744.47
$784.41
$926.32 		$920.45
$958.17
$998.11
$1,140.02 		$213.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558.70
$634.14
$714.02
$997.84
$1,516.32 		$772.40
$847.84
$927.72
$1,211.54 		$986.10
$1,061.54
$1,141.42
$1,425.24 		$1,199.80
$1,275.24
$1,355.12
$1,638.94 		$213.70
Toc - Plan #50 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 		$435.23
$493.98
$556.22
$777.31
$1,181.20 		$768.18
$826.93
$889.17
$1,110.26 		$1,101.13
$1,159.88
$1,222.12
$1,443.21 		$1,434.08
$1,492.83
$1,555.07
$1,776.16 		$332.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.46
$987.96
$1,112.44
$1,554.62
$2,362.40 		$1,203.41
$1,320.91
$1,445.39
$1,887.57 		$1,536.36
$1,653.86
$1,778.34
$2,220.52 		$1,869.31
$1,986.81
$2,111.29
$2,553.47 		$332.95
Toc - Plan #51 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 		$424.85
$482.20
$542.95
$758.78
$1,153.03 		$749.86
$807.21
$867.96
$1,083.79 		$1,074.87
$1,132.22
$1,192.97
$1,408.80 		$1,399.88
$1,457.23
$1,517.98
$1,733.81 		$325.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.70
$964.40
$1,085.90
$1,517.56
$2,306.06 		$1,174.71
$1,289.41
$1,410.91
$1,842.57 		$1,499.72
$1,614.42
$1,735.92
$2,167.58 		$1,824.73
$1,939.43
$2,060.93
$2,492.59 		$325.01
Toc - Plan #52 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 		$400.28
$454.31
$511.55
$714.89
$1,086.35 		$706.49
$760.52
$817.76
$1,021.10 		$1,012.70
$1,066.73
$1,123.97
$1,327.31 		$1,318.91
$1,372.94
$1,430.18
$1,633.52 		$306.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800.56
$908.62
$1,023.10
$1,429.78
$2,172.70 		$1,106.77
$1,214.83
$1,329.31
$1,735.99 		$1,412.98
$1,521.04
$1,635.52
$2,042.20 		$1,719.19
$1,827.25
$1,941.73
$2,348.41 		$306.21
Toc - Plan #53 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 		$401.62
$455.83
$513.26
$717.28
$1,089.98 		$708.86
$763.07
$820.50
$1,024.52 		$1,016.10
$1,070.31
$1,127.74
$1,331.76 		$1,323.34
$1,377.55
$1,434.98
$1,639.00 		$307.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.24
$911.66
$1,026.52
$1,434.56
$2,179.96 		$1,110.48
$1,218.90
$1,333.76
$1,741.80 		$1,417.72
$1,526.14
$1,641.00
$2,049.04 		$1,724.96
$1,833.38
$1,948.24
$2,356.28 		$307.24
Toc - Plan #54 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 		$395.91
$449.35
$505.97
$707.09
$1,074.49 		$698.78
$752.22
$808.84
$1,009.96 		$1,001.65
$1,055.09
$1,111.71
$1,312.83 		$1,304.52
$1,357.96
$1,414.58
$1,615.70 		$302.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.82
$898.70
$1,011.94
$1,414.18
$2,148.98 		$1,094.69
$1,201.57
$1,314.81
$1,717.05 		$1,397.56
$1,504.44
$1,617.68
$2,019.92 		$1,700.43
$1,807.31
$1,920.55
$2,322.79 		$302.87
Toc - Plan #55 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 		$396.98
$450.57
$507.34
$709.01
$1,077.41 		$700.67
$754.26
$811.03
$1,012.70 		$1,004.36
$1,057.95
$1,114.72
$1,316.39 		$1,308.05
$1,361.64
$1,418.41
$1,620.08 		$303.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.96
$901.14
$1,014.68
$1,418.02
$2,154.82 		$1,097.65
$1,204.83
$1,318.37
$1,721.71 		$1,401.34
$1,508.52
$1,622.06
$2,025.40 		$1,705.03
$1,812.21
$1,925.75
$2,329.09 		$303.69

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #56 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 		$372.27
$422.52
$475.75
$664.86
$1,010.32 		$657.05
$707.30
$760.53
$949.64 		$941.83
$992.08
$1,045.31
$1,234.42 		$1,226.61
$1,276.86
$1,330.09
$1,519.20 		$284.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.54
$845.04
$951.50
$1,329.72
$2,020.64 		$1,029.32
$1,129.82
$1,236.28
$1,614.50 		$1,314.10
$1,414.60
$1,521.06
$1,899.28 		$1,598.88
$1,699.38
$1,805.84
$2,184.06 		$284.78
Toc - Plan #57 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 		$261.92
$297.27
$334.72
$467.78
$710.83 		$462.28
$497.63
$535.08
$668.14 		$662.64
$697.99
$735.44
$868.50 		$863.00
$898.35
$935.80
$1,068.86 		$200.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523.84
$594.54
$669.44
$935.56
$1,421.66 		$724.20
$794.90
$869.80
$1,135.92 		$924.56
$995.26
$1,070.16
$1,336.28 		$1,124.92
$1,195.62
$1,270.52
$1,536.64 		$200.36
Toc - Plan #58 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 		$288.02
$326.89
$368.07
$514.38
$781.65 		$508.35
$547.22
$588.40
$734.71 		$728.68
$767.55
$808.73
$955.04 		$949.01
$987.88
$1,029.06
$1,175.37 		$220.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.04
$653.78
$736.14
$1,028.76
$1,563.30 		$796.37
$874.11
$956.47
$1,249.09 		$1,016.70
$1,094.44
$1,176.80
$1,469.42 		$1,237.03
$1,314.77
$1,397.13
$1,689.75 		$220.33
Toc - Plan #59 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 		$366.01
$415.41
$467.75
$653.68
$993.33 		$646.00
$695.40
$747.74
$933.67 		$925.99
$975.39
$1,027.73
$1,213.66 		$1,205.98
$1,255.38
$1,307.72
$1,493.65 		$279.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.02
$830.82
$935.50
$1,307.36
$1,986.66 		$1,012.01
$1,110.81
$1,215.49
$1,587.35 		$1,292.00
$1,390.80
$1,495.48
$1,867.34 		$1,571.99
$1,670.79
$1,775.47
$2,147.33 		$279.99
Toc - Plan #60 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 		$360.96
$409.68
$461.30
$644.66
$979.63 		$637.09
$685.81
$737.43
$920.79 		$913.22
$961.94
$1,013.56
$1,196.92 		$1,189.35
$1,238.07
$1,289.69
$1,473.05 		$276.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.92
$819.36
$922.60
$1,289.32
$1,959.26 		$998.05
$1,095.49
$1,198.73
$1,565.45 		$1,274.18
$1,371.62
$1,474.86
$1,841.58 		$1,550.31
$1,647.75
$1,750.99
$2,117.71 		$276.13
Toc - Plan #61 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 		$372.53
$422.81
$476.08
$665.32
$1,011.02 		$657.51
$707.79
$761.06
$950.30 		$942.49
$992.77
$1,046.04
$1,235.28 		$1,227.47
$1,277.75
$1,331.02
$1,520.26 		$284.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.06
$845.62
$952.16
$1,330.64
$2,022.04 		$1,030.04
$1,130.60
$1,237.14
$1,615.62 		$1,315.02
$1,415.58
$1,522.12
$1,900.60 		$1,600.00
$1,700.56
$1,807.10
$2,185.58 		$284.98
Toc - Plan #62 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 		$356.75
$404.90
$455.92
$637.14
$968.20 		$629.66
$677.81
$728.83
$910.05 		$902.57
$950.72
$1,001.74
$1,182.96 		$1,175.48
$1,223.63
$1,274.65
$1,455.87 		$272.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.50
$809.80
$911.84
$1,274.28
$1,936.40 		$986.41
$1,082.71
$1,184.75
$1,547.19 		$1,259.32
$1,355.62
$1,457.66
$1,820.10 		$1,532.23
$1,628.53
$1,730.57
$2,093.01 		$272.91
Toc - Plan #63 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 		$284.91
$323.36
$364.10
$508.83
$773.21 		$502.86
$541.31
$582.05
$726.78 		$720.81
$759.26
$800.00
$944.73 		$938.76
$977.21
$1,017.95
$1,162.68 		$217.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569.82
$646.72
$728.20
$1,017.66
$1,546.42 		$787.77
$864.67
$946.15
$1,235.61 		$1,005.72
$1,082.62
$1,164.10
$1,453.56 		$1,223.67
$1,300.57
$1,382.05
$1,671.51 		$217.95
Toc - Plan #64 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 		$304.67
$345.79
$389.36
$544.13
$826.85 		$537.74
$578.86
$622.43
$777.20 		$770.81
$811.93
$855.50
$1,010.27 		$1,003.88
$1,045.00
$1,088.57
$1,243.34 		$233.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.34
$691.58
$778.72
$1,088.26
$1,653.70 		$842.41
$924.65
$1,011.79
$1,321.33 		$1,075.48
$1,157.72
$1,244.86
$1,554.40 		$1,308.55
$1,390.79
$1,477.93
$1,787.47 		$233.07
Toc - Plan #65 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 		$313.02
$355.26
$400.02
$559.03
$849.50 		$552.47
$594.71
$639.47
$798.48 		$791.92
$834.16
$878.92
$1,037.93 		$1,031.37
$1,073.61
$1,118.37
$1,277.38 		$239.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.04
$710.52
$800.04
$1,118.06
$1,699.00 		$865.49
$949.97
$1,039.49
$1,357.51 		$1,104.94
$1,189.42
$1,278.94
$1,596.96 		$1,344.39
$1,428.87
$1,518.39
$1,836.41 		$239.45
Toc - Plan #66 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 		$332.12
$376.95
$424.44
$593.15
$901.35 		$586.19
$631.02
$678.51
$847.22 		$840.26
$885.09
$932.58
$1,101.29 		$1,094.33
$1,139.16
$1,186.65
$1,355.36 		$254.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.24
$753.90
$848.88
$1,186.30
$1,802.70 		$918.31
$1,007.97
$1,102.95
$1,440.37 		$1,172.38
$1,262.04
$1,357.02
$1,694.44 		$1,426.45
$1,516.11
$1,611.09
$1,948.51 		$254.07
Toc - Plan #67 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 		$342.44
$388.66
$437.63
$611.59
$929.36 		$604.40
$650.62
$699.59
$873.55 		$866.36
$912.58
$961.55
$1,135.51 		$1,128.32
$1,174.54
$1,223.51
$1,397.47 		$261.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.88
$777.32
$875.26
$1,223.18
$1,858.72 		$946.84
$1,039.28
$1,137.22
$1,485.14 		$1,208.80
$1,301.24
$1,399.18
$1,747.10 		$1,470.76
$1,563.20
$1,661.14
$2,009.06 		$261.96
Toc - Plan #68 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 		$343.17
$389.49
$438.56
$612.89
$931.35 		$605.69
$652.01
$701.08
$875.41 		$868.21
$914.53
$963.60
$1,137.93 		$1,130.73
$1,177.05
$1,226.12
$1,400.45 		$262.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.34
$778.98
$877.12
$1,225.78
$1,862.70 		$948.86
$1,041.50
$1,139.64
$1,488.30 		$1,211.38
$1,304.02
$1,402.16
$1,750.82 		$1,473.90
$1,566.54
$1,664.68
$2,013.34 		$262.52
Toc - Plan #69 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 		$348.88
$395.97
$445.86
$623.09
$946.85 		$615.77
$662.86
$712.75
$889.98 		$882.66
$929.75
$979.64
$1,156.87 		$1,149.55
$1,196.64
$1,246.53
$1,423.76 		$266.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.76
$791.94
$891.72
$1,246.18
$1,893.70 		$964.65
$1,058.83
$1,158.61
$1,513.07 		$1,231.54
$1,325.72
$1,425.50
$1,779.96 		$1,498.43
$1,592.61
$1,692.39
$2,046.85 		$266.89
Toc - Plan #70 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 		$348.15
$395.14
$444.93
$621.78
$944.86 		$614.48
$661.47
$711.26
$888.11 		$880.81
$927.80
$977.59
$1,154.44 		$1,147.14
$1,194.13
$1,243.92
$1,420.77 		$266.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.30
$790.28
$889.86
$1,243.56
$1,889.72 		$962.63
$1,056.61
$1,156.19
$1,509.89 		$1,228.96
$1,322.94
$1,422.52
$1,776.22 		$1,495.29
$1,589.27
$1,688.85
$2,042.55 		$266.33
Toc - Plan #71 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 		$373.84
$424.29
$477.75
$667.65
$1,014.56 		$659.82
$710.27
$763.73
$953.63 		$945.80
$996.25
$1,049.71
$1,239.61 		$1,231.78
$1,282.23
$1,335.69
$1,525.59 		$285.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.68
$848.58
$955.50
$1,335.30
$2,029.12 		$1,033.66
$1,134.56
$1,241.48
$1,621.28 		$1,319.64
$1,420.54
$1,527.46
$1,907.26 		$1,605.62
$1,706.52
$1,813.44
$2,193.24 		$285.98
Toc - Plan #72 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 		$298.29
$338.55
$381.20
$532.73
$809.53 		$526.47
$566.73
$609.38
$760.91 		$754.65
$794.91
$837.56
$989.09 		$982.83
$1,023.09
$1,065.74
$1,217.27 		$228.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596.58
$677.10
$762.40
$1,065.46
$1,619.06 		$824.76
$905.28
$990.58
$1,293.64 		$1,052.94
$1,133.46
$1,218.76
$1,521.82 		$1,281.12
$1,361.64
$1,446.94
$1,750.00 		$228.18
Toc - Plan #73 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 		$385.55
$437.59
$492.72
$688.57
$1,046.35 		$680.49
$732.53
$787.66
$983.51 		$975.43
$1,027.47
$1,082.60
$1,278.45 		$1,270.37
$1,322.41
$1,377.54
$1,573.39 		$294.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.10
$875.18
$985.44
$1,377.14
$2,092.70 		$1,066.04
$1,170.12
$1,280.38
$1,672.08 		$1,360.98
$1,465.06
$1,575.32
$1,967.02 		$1,655.92
$1,760.00
$1,870.26
$2,261.96 		$294.94
Toc - Plan #74 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 		$271.26
$307.87
$346.66
$484.46
$736.18 		$478.77
$515.38
$554.17
$691.97 		$686.28
$722.89
$761.68
$899.48 		$893.79
$930.40
$969.19
$1,106.99 		$207.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$542.52
$615.74
$693.32
$968.92
$1,472.36 		$750.03
$823.25
$900.83
$1,176.43 		$957.54
$1,030.76
$1,108.34
$1,383.94 		$1,165.05
$1,238.27
$1,315.85
$1,591.45 		$207.51
Toc - Plan #75 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 		$379.07
$430.23
$484.43
$677.00
$1,028.76 		$669.05
$720.21
$774.41
$966.98 		$959.03
$1,010.19
$1,064.39
$1,256.96 		$1,249.01
$1,300.17
$1,354.37
$1,546.94 		$289.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.14
$860.46
$968.86
$1,354.00
$2,057.52 		$1,048.12
$1,150.44
$1,258.84
$1,643.98 		$1,338.10
$1,440.42
$1,548.82
$1,933.96 		$1,628.08
$1,730.40
$1,838.80
$2,223.94 		$289.98
Toc - Plan #76 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 		$385.81
$437.89
$493.06
$689.05
$1,047.07 		$680.95
$733.03
$788.20
$984.19 		$976.09
$1,028.17
$1,083.34
$1,279.33 		$1,271.23
$1,323.31
$1,378.48
$1,574.47 		$295.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.62
$875.78
$986.12
$1,378.10
$2,094.14 		$1,066.76
$1,170.92
$1,281.26
$1,673.24 		$1,361.90
$1,466.06
$1,576.40
$1,968.38 		$1,657.04
$1,761.20
$1,871.54
$2,263.52 		$295.14
Toc - Plan #77 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 		$295.07
$334.89
$377.08
$526.97
$800.79 		$520.79
$560.61
$602.80
$752.69 		$746.51
$786.33
$828.52
$978.41 		$972.23
$1,012.05
$1,054.24
$1,204.13 		$225.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$590.14
$669.78
$754.16
$1,053.94
$1,601.58 		$815.86
$895.50
$979.88
$1,279.66 		$1,041.58
$1,121.22
$1,205.60
$1,505.38 		$1,267.30
$1,346.94
$1,431.32
$1,731.10 		$225.72
Toc - Plan #78 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 		$315.54
$358.12
$403.24
$563.53
$856.34 		$556.92
$599.50
$644.62
$804.91 		$798.30
$840.88
$886.00
$1,046.29 		$1,039.68
$1,082.26
$1,127.38
$1,287.67 		$241.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.08
$716.24
$806.48
$1,127.06
$1,712.68 		$872.46
$957.62
$1,047.86
$1,368.44 		$1,113.84
$1,199.00
$1,289.24
$1,609.82 		$1,355.22
$1,440.38
$1,530.62
$1,851.20 		$241.38
Toc - Plan #79 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 		$324.18
$367.93
$414.29
$578.97
$879.80 		$572.17
$615.92
$662.28
$826.96 		$820.16
$863.91
$910.27
$1,074.95 		$1,068.15
$1,111.90
$1,158.26
$1,322.94 		$247.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.36
$735.86
$828.58
$1,157.94
$1,759.60 		$896.35
$983.85
$1,076.57
$1,405.93 		$1,144.34
$1,231.84
$1,324.56
$1,653.92 		$1,392.33
$1,479.83
$1,572.55
$1,901.91 		$247.99
Toc - Plan #80 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 		$343.97
$390.39
$439.58
$614.31
$933.50 		$607.10
$653.52
$702.71
$877.44 		$870.23
$916.65
$965.84
$1,140.57 		$1,133.36
$1,179.78
$1,228.97
$1,403.70 		$263.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687.94
$780.78
$879.16
$1,228.62
$1,867.00 		$951.07
$1,043.91
$1,142.29
$1,491.75 		$1,214.20
$1,307.04
$1,405.42
$1,754.88 		$1,477.33
$1,570.17
$1,668.55
$2,018.01 		$263.13
Toc - Plan #81 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 		$355.41
$403.38
$454.21
$634.75
$964.57 		$627.29
$675.26
$726.09
$906.63 		$899.17
$947.14
$997.97
$1,178.51 		$1,171.05
$1,219.02
$1,269.85
$1,450.39 		$271.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.82
$806.76
$908.42
$1,269.50
$1,929.14 		$982.70
$1,078.64
$1,180.30
$1,541.38 		$1,254.58
$1,350.52
$1,452.18
$1,813.26 		$1,526.46
$1,622.40
$1,724.06
$2,085.14 		$271.88
Toc - Plan #82 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 		$361.33
$410.10
$461.76
$645.31
$980.61 		$637.74
$686.51
$738.17
$921.72 		$914.15
$962.92
$1,014.58
$1,198.13 		$1,190.56
$1,239.33
$1,290.99
$1,474.54 		$276.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.66
$820.20
$923.52
$1,290.62
$1,961.22 		$999.07
$1,096.61
$1,199.93
$1,567.03 		$1,275.48
$1,373.02
$1,476.34
$1,843.44 		$1,551.89
$1,649.43
$1,752.75
$2,119.85 		$276.41
Toc - Plan #83 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 		$360.57
$409.23
$460.79
$643.96
$978.56 		$636.40
$685.06
$736.62
$919.79 		$912.23
$960.89
$1,012.45
$1,195.62 		$1,188.06
$1,236.72
$1,288.28
$1,471.45 		$275.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.14
$818.46
$921.58
$1,287.92
$1,957.12 		$996.97
$1,094.29
$1,197.41
$1,563.75 		$1,272.80
$1,370.12
$1,473.24
$1,839.58 		$1,548.63
$1,645.95
$1,749.07
$2,115.41 		$275.83
Toc - Plan #84 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 		$369.48
$419.34
$472.18
$659.87
$1,002.73 		$652.12
$701.98
$754.82
$942.51 		$934.76
$984.62
$1,037.46
$1,225.15 		$1,217.40
$1,267.26
$1,320.10
$1,507.79 		$282.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.96
$838.68
$944.36
$1,319.74
$2,005.46 		$1,021.60
$1,121.32
$1,227.00
$1,602.38 		$1,304.24
$1,403.96
$1,509.64
$1,885.02 		$1,586.88
$1,686.60
$1,792.28
$2,167.66 		$282.64

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 #85 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 2151 ($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 		$760.73
$863.43
$972.21
$1,358.66
$2,064.62 		$1,342.69
$1,445.39
$1,554.17
$1,940.62 		$1,924.65
$2,027.35
$2,136.13
$2,522.58 		$2,506.61
$2,609.31
$2,718.09
$3,104.54 		$581.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,521.46
$1,726.86
$1,944.42
$2,717.32
$4,129.24 		$2,103.42
$2,308.82
$2,526.38
$3,299.28 		$2,685.38
$2,890.78
$3,108.34
$3,881.24 		$3,267.34
$3,472.74
$3,690.30
$4,463.20 		$581.96
Toc - Plan #86 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2153 ($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 		$449.56
$510.25
$574.54
$802.91
$1,220.11 		$793.47
$854.16
$918.45
$1,146.82 		$1,137.38
$1,198.07
$1,262.36
$1,490.73 		$1,481.29
$1,541.98
$1,606.27
$1,834.64 		$343.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$899.12
$1,020.50
$1,149.08
$1,605.82
$2,440.22 		$1,243.03
$1,364.41
$1,492.99
$1,949.73 		$1,586.94
$1,708.32
$1,836.90
$2,293.64 		$1,930.85
$2,052.23
$2,180.81
$2,637.55 		$343.91
Toc - Plan #87 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) BlueCare Bronze 2154 ($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 		$406.13
$460.96
$519.03
$725.35
$1,102.24 		$716.82
$771.65
$829.72
$1,036.04 		$1,027.51
$1,082.34
$1,140.41
$1,346.73 		$1,338.20
$1,393.03
$1,451.10
$1,657.42 		$310.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.26
$921.92
$1,038.06
$1,450.70
$2,204.48 		$1,122.95
$1,232.61
$1,348.75
$1,761.39 		$1,433.64
$1,543.30
$1,659.44
$2,072.08 		$1,744.33
$1,853.99
$1,970.13
$2,382.77 		$310.69
Toc - Plan #88 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 2156 ($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 		$654.38
$742.72
$836.30
$1,168.72
$1,775.99 		$1,154.98
$1,243.32
$1,336.90
$1,669.32 		$1,655.58
$1,743.92
$1,837.50
$2,169.92 		$2,156.18
$2,244.52
$2,338.10
$2,670.52 		$500.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,308.76
$1,485.44
$1,672.60
$2,337.44
$3,551.98 		$1,809.36
$1,986.04
$2,173.20
$2,838.04 		$2,309.96
$2,486.64
$2,673.80
$3,338.64 		$2,810.56
$2,987.24
$3,174.40
$3,839.24 		$500.60
Toc - Plan #89 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 2157 ($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 		$544.59
$618.11
$695.99
$972.64
$1,478.02 		$961.20
$1,034.72
$1,112.60
$1,389.25 		$1,377.81
$1,451.33
$1,529.21
$1,805.86 		$1,794.42
$1,867.94
$1,945.82
$2,222.47 		$416.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,089.18
$1,236.22
$1,391.98
$1,945.28
$2,956.04 		$1,505.79
$1,652.83
$1,808.59
$2,361.89 		$1,922.40
$2,069.44
$2,225.20
$2,778.50 		$2,339.01
$2,486.05
$2,641.81
$3,195.11 		$416.61
Toc - Plan #90 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2159 ($0 Deductible / $50 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$488.65
$554.62
$624.49
$872.73
$1,326.20 		$862.47
$928.44
$998.31
$1,246.55 		$1,236.29
$1,302.26
$1,372.13
$1,620.37 		$1,610.11
$1,676.08
$1,745.95
$1,994.19 		$373.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$977.30
$1,109.24
$1,248.98
$1,745.46
$2,652.40 		$1,351.12
$1,483.06
$1,622.80
$2,119.28 		$1,724.94
$1,856.88
$1,996.62
$2,493.10 		$2,098.76
$2,230.70
$2,370.44
$2,866.92 		$373.82
Toc - Plan #91 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 		$311.47
$353.52
$398.06
$556.29
$845.33 		$549.74
$591.79
$636.33
$794.56 		$788.01
$830.06
$874.60
$1,032.83 		$1,026.28
$1,068.33
$1,112.87
$1,271.10 		$238.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.94
$707.04
$796.12
$1,112.58
$1,690.66 		$861.21
$945.31
$1,034.39
$1,350.85 		$1,099.48
$1,183.58
$1,272.66
$1,589.12 		$1,337.75
$1,421.85
$1,510.93
$1,827.39 		$238.27
Toc - Plan #92 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 		$276.86
$314.24
$353.83
$494.47
$751.40 		$488.66
$526.04
$565.63
$706.27 		$700.46
$737.84
$777.43
$918.07 		$912.26
$949.64
$989.23
$1,129.87 		$211.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.72
$628.48
$707.66
$988.94
$1,502.80 		$765.52
$840.28
$919.46
$1,200.74 		$977.32
$1,052.08
$1,131.26
$1,412.54 		$1,189.12
$1,263.88
$1,343.06
$1,624.34 		$211.80
Toc - Plan #93 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 		$395.76
$449.19
$505.78
$706.83
$1,074.09 		$698.52
$751.95
$808.54
$1,009.59 		$1,001.28
$1,054.71
$1,111.30
$1,312.35 		$1,304.04
$1,357.47
$1,414.06
$1,615.11 		$302.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.52
$898.38
$1,011.56
$1,413.66
$2,148.18 		$1,094.28
$1,201.14
$1,314.32
$1,716.42 		$1,397.04
$1,503.90
$1,617.08
$2,019.18 		$1,699.80
$1,806.66
$1,919.84
$2,321.94 		$302.76
Toc - Plan #94 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 		$374.55
$425.11
$478.67
$668.95
$1,016.53 		$661.08
$711.64
$765.20
$955.48 		$947.61
$998.17
$1,051.73
$1,242.01 		$1,234.14
$1,284.70
$1,338.26
$1,528.54 		$286.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.10
$850.22
$957.34
$1,337.90
$2,033.06 		$1,035.63
$1,136.75
$1,243.87
$1,624.43 		$1,322.16
$1,423.28
$1,530.40
$1,910.96 		$1,608.69
$1,709.81
$1,816.93
$2,197.49 		$286.53
Toc - Plan #95 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 		$415.90
$472.05
$531.52
$742.80
$1,128.75 		$734.06
$790.21
$849.68
$1,060.96 		$1,052.22
$1,108.37
$1,167.84
$1,379.12 		$1,370.38
$1,426.53
$1,486.00
$1,697.28 		$318.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.80
$944.10
$1,063.04
$1,485.60
$2,257.50 		$1,149.96
$1,262.26
$1,381.20
$1,803.76 		$1,468.12
$1,580.42
$1,699.36
$2,121.92 		$1,786.28
$1,898.58
$2,017.52
$2,440.08 		$318.16
Toc - Plan #96 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 		$407.10
$462.06
$520.27
$727.08
$1,104.87 		$718.53
$773.49
$831.70
$1,038.51 		$1,029.96
$1,084.92
$1,143.13
$1,349.94 		$1,341.39
$1,396.35
$1,454.56
$1,661.37 		$311.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.20
$924.12
$1,040.54
$1,454.16
$2,209.74 		$1,125.63
$1,235.55
$1,351.97
$1,765.59 		$1,437.06
$1,546.98
$1,663.40
$2,077.02 		$1,748.49
$1,858.41
$1,974.83
$2,388.45 		$311.43
Toc - Plan #97 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 		$309.69
$351.50
$395.78
$553.11
$840.50 		$546.60
$588.41
$632.69
$790.02 		$783.51
$825.32
$869.60
$1,026.93 		$1,020.42
$1,062.23
$1,106.51
$1,263.84 		$236.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.38
$703.00
$791.56
$1,106.22
$1,681.00 		$856.29
$939.91
$1,028.47
$1,343.13 		$1,093.20
$1,176.82
$1,265.38
$1,580.04 		$1,330.11
$1,413.73
$1,502.29
$1,816.95 		$236.91
Toc - Plan #98 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 		$402.91
$457.30
$514.92
$719.60
$1,093.50 		$711.14
$765.53
$823.15
$1,027.83 		$1,019.37
$1,073.76
$1,131.38
$1,336.06 		$1,327.60
$1,381.99
$1,439.61
$1,644.29 		$308.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.82
$914.60
$1,029.84
$1,439.20
$2,187.00 		$1,114.05
$1,222.83
$1,338.07
$1,747.43 		$1,422.28
$1,531.06
$1,646.30
$2,055.66 		$1,730.51
$1,839.29
$1,954.53
$2,363.89 		$308.23
Toc - Plan #99 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 		$368.06
$417.75
$470.38
$657.36
$998.91 		$649.63
$699.32
$751.95
$938.93 		$931.20
$980.89
$1,033.52
$1,220.50 		$1,212.77
$1,262.46
$1,315.09
$1,502.07 		$281.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.12
$835.50
$940.76
$1,314.72
$1,997.82 		$1,017.69
$1,117.07
$1,222.33
$1,596.29 		$1,299.26
$1,398.64
$1,503.90
$1,877.86 		$1,580.83
$1,680.21
$1,785.47
$2,159.43 		$281.57
Toc - Plan #100 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 		$359.84
$408.42
$459.88
$642.67
$976.61 		$635.12
$683.70
$735.16
$917.95 		$910.40
$958.98
$1,010.44
$1,193.23 		$1,185.68
$1,234.26
$1,285.72
$1,468.51 		$275.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.68
$816.84
$919.76
$1,285.34
$1,953.22 		$994.96
$1,092.12
$1,195.04
$1,560.62 		$1,270.24
$1,367.40
$1,470.32
$1,835.90 		$1,545.52
$1,642.68
$1,745.60
$2,111.18 		$275.28
Toc - Plan #101 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 		$337.60
$383.18
$431.45
$602.95
$916.25 		$595.86
$641.44
$689.71
$861.21 		$854.12
$899.70
$947.97
$1,119.47 		$1,112.38
$1,157.96
$1,206.23
$1,377.73 		$258.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.20
$766.36
$862.90
$1,205.90
$1,832.50 		$933.46
$1,024.62
$1,121.16
$1,464.16 		$1,191.72
$1,282.88
$1,379.42
$1,722.42 		$1,449.98
$1,541.14
$1,637.68
$1,980.68 		$258.26
Toc - Plan #102 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 		$311.42
$353.46
$397.99
$556.20
$845.19 		$549.66
$591.70
$636.23
$794.44 		$787.90
$829.94
$874.47
$1,032.68 		$1,026.14
$1,068.18
$1,112.71
$1,270.92 		$238.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.84
$706.92
$795.98
$1,112.40
$1,690.38 		$861.08
$945.16
$1,034.22
$1,350.64 		$1,099.32
$1,183.40
$1,272.46
$1,588.88 		$1,337.56
$1,421.64
$1,510.70
$1,827.12 		$238.24
Toc - Plan #103 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 		$348.12
$395.12
$444.90
$621.74
$944.80 		$614.43
$661.43
$711.21
$888.05 		$880.74
$927.74
$977.52
$1,154.36 		$1,147.05
$1,194.05
$1,243.83
$1,420.67 		$266.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.24
$790.24
$889.80
$1,243.48
$1,889.60 		$962.55
$1,056.55
$1,156.11
$1,509.79 		$1,228.86
$1,322.86
$1,422.42
$1,776.10 		$1,495.17
$1,589.17
$1,688.73
$2,042.41 		$266.31
Toc - Plan #104 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 		$303.37
$344.32
$387.71
$541.82
$823.35 		$535.45
$576.40
$619.79
$773.90 		$767.53
$808.48
$851.87
$1,005.98 		$999.61
$1,040.56
$1,083.95
$1,238.06 		$232.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.74
$688.64
$775.42
$1,083.64
$1,646.70 		$838.82
$920.72
$1,007.50
$1,315.72 		$1,070.90
$1,152.80
$1,239.58
$1,547.80 		$1,302.98
$1,384.88
$1,471.66
$1,779.88 		$232.08
Toc - Plan #105 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 		$304.23
$345.30
$388.81
$543.35
$825.68 		$536.97
$578.04
$621.55
$776.09 		$769.71
$810.78
$854.29
$1,008.83 		$1,002.45
$1,043.52
$1,087.03
$1,241.57 		$232.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.46
$690.60
$777.62
$1,086.70
$1,651.36 		$841.20
$923.34
$1,010.36
$1,319.44 		$1,073.94
$1,156.08
$1,243.10
$1,552.18 		$1,306.68
$1,388.82
$1,475.84
$1,784.92 		$232.74
Toc - Plan #106 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 		$356.03
$404.09
$455.01
$635.87
$966.27 		$628.39
$676.45
$727.37
$908.23 		$900.75
$948.81
$999.73
$1,180.59 		$1,173.11
$1,221.17
$1,272.09
$1,452.95 		$272.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.06
$808.18
$910.02
$1,271.74
$1,932.54 		$984.42
$1,080.54
$1,182.38
$1,544.10 		$1,256.78
$1,352.90
$1,454.74
$1,816.46 		$1,529.14
$1,625.26
$1,727.10
$2,088.82 		$272.36

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #107 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 		$309.78
$351.59
$395.88
$553.24
$840.71 		$546.75
$588.56
$632.85
$790.21 		$783.72
$825.53
$869.82
$1,027.18 		$1,020.69
$1,062.50
$1,106.79
$1,264.15 		$236.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.56
$703.18
$791.76
$1,106.48
$1,681.42 		$856.53
$940.15
$1,028.73
$1,343.45 		$1,093.50
$1,177.12
$1,265.70
$1,580.42 		$1,330.47
$1,414.09
$1,502.67
$1,817.39 		$236.97
Toc - Plan #108 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 		$318.32
$361.28
$406.80
$568.50
$863.89 		$561.83
$604.79
$650.31
$812.01 		$805.34
$848.30
$893.82
$1,055.52 		$1,048.85
$1,091.81
$1,137.33
$1,299.03 		$243.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.64
$722.56
$813.60
$1,137.00
$1,727.78 		$880.15
$966.07
$1,057.11
$1,380.51 		$1,123.66
$1,209.58
$1,300.62
$1,624.02 		$1,367.17
$1,453.09
$1,544.13
$1,867.53 		$243.51
Toc - Plan #109 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 		$310.62
$352.54
$396.96
$554.75
$842.99 		$548.24
$590.16
$634.58
$792.37 		$785.86
$827.78
$872.20
$1,029.99 		$1,023.48
$1,065.40
$1,109.82
$1,267.61 		$237.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.24
$705.08
$793.92
$1,109.50
$1,685.98 		$858.86
$942.70
$1,031.54
$1,347.12 		$1,096.48
$1,180.32
$1,269.16
$1,584.74 		$1,334.10
$1,417.94
$1,506.78
$1,822.36 		$237.62
Toc - Plan #110 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 		$362.60
$411.54
$463.39
$647.58
$984.06 		$639.98
$688.92
$740.77
$924.96 		$917.36
$966.30
$1,018.15
$1,202.34 		$1,194.74
$1,243.68
$1,295.53
$1,479.72 		$277.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.20
$823.08
$926.78
$1,295.16
$1,968.12 		$1,002.58
$1,100.46
$1,204.16
$1,572.54 		$1,279.96
$1,377.84
$1,481.54
$1,849.92 		$1,557.34
$1,655.22
$1,758.92
$2,127.30 		$277.38
Toc - Plan #111 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 		$403.08
$457.48
$515.12
$719.88
$1,093.93 		$711.43
$765.83
$823.47
$1,028.23 		$1,019.78
$1,074.18
$1,131.82
$1,336.58 		$1,328.13
$1,382.53
$1,440.17
$1,644.93 		$308.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.16
$914.96
$1,030.24
$1,439.76
$2,187.86 		$1,114.51
$1,223.31
$1,338.59
$1,748.11 		$1,422.86
$1,531.66
$1,646.94
$2,056.46 		$1,731.21
$1,840.01
$1,955.29
$2,364.81 		$308.35
Toc - Plan #112 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 		$400.93
$455.05
$512.38
$716.05
$1,088.11 		$707.64
$761.76
$819.09
$1,022.76 		$1,014.35
$1,068.47
$1,125.80
$1,329.47 		$1,321.06
$1,375.18
$1,432.51
$1,636.18 		$306.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.86
$910.10
$1,024.76
$1,432.10
$2,176.22 		$1,108.57
$1,216.81
$1,331.47
$1,738.81 		$1,415.28
$1,523.52
$1,638.18
$2,045.52 		$1,721.99
$1,830.23
$1,944.89
$2,352.23 		$306.71
Toc - Plan #113 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 		$403.43
$457.88
$515.57
$720.51
$1,094.88 		$712.05
$766.50
$824.19
$1,029.13 		$1,020.67
$1,075.12
$1,132.81
$1,337.75 		$1,329.29
$1,383.74
$1,441.43
$1,646.37 		$308.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.86
$915.76
$1,031.14
$1,441.02
$2,189.76 		$1,115.48
$1,224.38
$1,339.76
$1,749.64 		$1,424.10
$1,533.00
$1,648.38
$2,058.26 		$1,732.72
$1,841.62
$1,957.00
$2,366.88 		$308.62
Toc - Plan #114 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 		$240.41
$272.85
$307.23
$429.35
$652.44 		$424.32
$456.76
$491.14
$613.26 		$608.23
$640.67
$675.05
$797.17 		$792.14
$824.58
$858.96
$981.08 		$183.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$480.82
$545.70
$614.46
$858.70
$1,304.88 		$664.73
$729.61
$798.37
$1,042.61 		$848.64
$913.52
$982.28
$1,226.52 		$1,032.55
$1,097.43
$1,166.19
$1,410.43 		$183.91
Toc - Plan #115 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 		$362.78
$411.74
$463.62
$647.91
$984.56 		$640.30
$689.26
$741.14
$925.43 		$917.82
$966.78
$1,018.66
$1,202.95 		$1,195.34
$1,244.30
$1,296.18
$1,480.47 		$277.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.56
$823.48
$927.24
$1,295.82
$1,969.12 		$1,003.08
$1,101.00
$1,204.76
$1,573.34 		$1,280.60
$1,378.52
$1,482.28
$1,850.86 		$1,558.12
$1,656.04
$1,759.80
$2,128.38 		$277.52
Toc - Plan #116 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 		$432.38
$490.74
$552.56
$772.21
$1,173.44 		$763.14
$821.50
$883.32
$1,102.97 		$1,093.90
$1,152.26
$1,214.08
$1,433.73 		$1,424.66
$1,483.02
$1,544.84
$1,764.49 		$330.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$864.76
$981.48
$1,105.12
$1,544.42
$2,346.88 		$1,195.52
$1,312.24
$1,435.88
$1,875.18 		$1,526.28
$1,643.00
$1,766.64
$2,205.94 		$1,857.04
$1,973.76
$2,097.40
$2,536.70 		$330.76
Toc - Plan #117 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 		$334.86
$380.06
$427.94
$598.05
$908.79 		$591.02
$636.22
$684.10
$854.21 		$847.18
$892.38
$940.26
$1,110.37 		$1,103.34
$1,148.54
$1,196.42
$1,366.53 		$256.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.72
$760.12
$855.88
$1,196.10
$1,817.58 		$925.88
$1,016.28
$1,112.04
$1,452.26 		$1,182.04
$1,272.44
$1,368.20
$1,708.42 		$1,438.20
$1,528.60
$1,624.36
$1,964.58 		$256.16
Toc - Plan #118 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 		$399.80
$453.76
$510.93
$714.02
$1,085.02 		$705.64
$759.60
$816.77
$1,019.86 		$1,011.48
$1,065.44
$1,122.61
$1,325.70 		$1,317.32
$1,371.28
$1,428.45
$1,631.54 		$305.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.60
$907.52
$1,021.86
$1,428.04
$2,170.04 		$1,105.44
$1,213.36
$1,327.70
$1,733.88 		$1,411.28
$1,519.20
$1,633.54
$2,039.72 		$1,717.12
$1,825.04
$1,939.38
$2,345.56 		$305.84
Toc - Plan #119 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 		$408.19
$463.28
$521.65
$729.01
$1,107.80 		$720.45
$775.54
$833.91
$1,041.27 		$1,032.71
$1,087.80
$1,146.17
$1,353.53 		$1,344.97
$1,400.06
$1,458.43
$1,665.79 		$312.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.38
$926.56
$1,043.30
$1,458.02
$2,215.60 		$1,128.64
$1,238.82
$1,355.56
$1,770.28 		$1,440.90
$1,551.08
$1,667.82
$2,082.54 		$1,753.16
$1,863.34
$1,980.08
$2,394.80 		$312.26
Toc - Plan #120 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 		$410.67
$466.10
$524.82
$733.44
$1,114.53 		$724.82
$780.25
$838.97
$1,047.59 		$1,038.97
$1,094.40
$1,153.12
$1,361.74 		$1,353.12
$1,408.55
$1,467.27
$1,675.89 		$314.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.34
$932.20
$1,049.64
$1,466.88
$2,229.06 		$1,135.49
$1,246.35
$1,363.79
$1,781.03 		$1,449.64
$1,560.50
$1,677.94
$2,095.18 		$1,763.79
$1,874.65
$1,992.09
$2,409.33 		$314.15
Toc - Plan #121 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 		$433.44
$491.94
$553.92
$774.11
$1,176.33 		$765.01
$823.51
$885.49
$1,105.68 		$1,096.58
$1,155.08
$1,217.06
$1,437.25 		$1,428.15
$1,486.65
$1,548.63
$1,768.82 		$331.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.88
$983.88
$1,107.84
$1,548.22
$2,352.66 		$1,198.45
$1,315.45
$1,439.41
$1,879.79 		$1,530.02
$1,647.02
$1,770.98
$2,211.36 		$1,861.59
$1,978.59
$2,102.55
$2,542.93 		$331.57
Toc - Plan #122 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 		$326.87
$370.99
$417.73
$583.78
$887.11 		$576.92
$621.04
$667.78
$833.83 		$826.97
$871.09
$917.83
$1,083.88 		$1,077.02
$1,121.14
$1,167.88
$1,333.93 		$250.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.74
$741.98
$835.46
$1,167.56
$1,774.22 		$903.79
$992.03
$1,085.51
$1,417.61 		$1,153.84
$1,242.08
$1,335.56
$1,667.66 		$1,403.89
$1,492.13
$1,585.61
$1,917.71 		$250.05
Toc - Plan #123 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 		$348.31
$395.32
$445.13
$622.07
$945.29 		$614.76
$661.77
$711.58
$888.52 		$881.21
$928.22
$978.03
$1,154.97 		$1,147.66
$1,194.67
$1,244.48
$1,421.42 		$266.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.62
$790.64
$890.26
$1,244.14
$1,890.58 		$963.07
$1,057.09
$1,156.71
$1,510.59 		$1,229.52
$1,323.54
$1,423.16
$1,777.04 		$1,495.97
$1,589.99
$1,689.61
$2,043.49 		$266.45
Toc - Plan #124 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 		$332.68
$377.58
$425.16
$594.15
$902.88 		$587.18
$632.08
$679.66
$848.65 		$841.68
$886.58
$934.16
$1,103.15 		$1,096.18
$1,141.08
$1,188.66
$1,357.65 		$254.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.36
$755.16
$850.32
$1,188.30
$1,805.76 		$919.86
$1,009.66
$1,104.82
$1,442.80 		$1,174.36
$1,264.16
$1,359.32
$1,697.30 		$1,428.86
$1,518.66
$1,613.82
$1,951.80 		$254.50
Toc - Plan #125 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 		$396.57
$450.09
$506.80
$708.25
$1,076.26 		$699.94
$753.46
$810.17
$1,011.62 		$1,003.31
$1,056.83
$1,113.54
$1,314.99 		$1,306.68
$1,360.20
$1,416.91
$1,618.36 		$303.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.14
$900.18
$1,013.60
$1,416.50
$2,152.52 		$1,096.51
$1,203.55
$1,316.97
$1,719.87 		$1,399.88
$1,506.92
$1,620.34
$2,023.24 		$1,703.25
$1,810.29
$1,923.71
$2,326.61 		$303.37
Toc - Plan #126 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 		$402.12
$456.39
$513.89
$718.17
$1,091.32 		$709.73
$764.00
$821.50
$1,025.78 		$1,017.34
$1,071.61
$1,129.11
$1,333.39 		$1,324.95
$1,379.22
$1,436.72
$1,641.00 		$307.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.24
$912.78
$1,027.78
$1,436.34
$2,182.64 		$1,111.85
$1,220.39
$1,335.39
$1,743.95 		$1,419.46
$1,528.00
$1,643.00
$2,051.56 		$1,727.07
$1,835.61
$1,950.61
$2,359.17 		$307.61
Toc - Plan #127 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 		$412.41
$468.07
$527.04
$736.54
$1,119.24 		$727.89
$783.55
$842.52
$1,052.02 		$1,043.37
$1,099.03
$1,158.00
$1,367.50 		$1,358.85
$1,414.51
$1,473.48
$1,682.98 		$315.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.82
$936.14
$1,054.08
$1,473.08
$2,238.48 		$1,140.30
$1,251.62
$1,369.56
$1,788.56 		$1,455.78
$1,567.10
$1,685.04
$2,104.04 		$1,771.26
$1,882.58
$2,000.52
$2,419.52 		$315.48
Toc - Plan #128 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 		$406.66
$461.55
$519.70
$726.28
$1,103.65 		$717.75
$772.64
$830.79
$1,037.37 		$1,028.84
$1,083.73
$1,141.88
$1,348.46 		$1,339.93
$1,394.82
$1,452.97
$1,659.55 		$311.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.32
$923.10
$1,039.40
$1,452.56
$2,207.30 		$1,124.41
$1,234.19
$1,350.49
$1,763.65 		$1,435.50
$1,545.28
$1,661.58
$2,074.74 		$1,746.59
$1,856.37
$1,972.67
$2,385.83 		$311.09
Toc - Plan #129 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 		$403.53
$458.00
$515.70
$720.69
$1,095.17 		$712.23
$766.70
$824.40
$1,029.39 		$1,020.93
$1,075.40
$1,133.10
$1,338.09 		$1,329.63
$1,384.10
$1,441.80
$1,646.79 		$308.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.06
$916.00
$1,031.40
$1,441.38
$2,190.34 		$1,115.76
$1,224.70
$1,340.10
$1,750.08 		$1,424.46
$1,533.40
$1,648.80
$2,058.78 		$1,733.16
$1,842.10
$1,957.50
$2,367.48 		$308.70
Toc - Plan #130 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 		$416.78
$473.03
$532.63
$744.35
$1,131.10 		$735.61
$791.86
$851.46
$1,063.18 		$1,054.44
$1,110.69
$1,170.29
$1,382.01 		$1,373.27
$1,429.52
$1,489.12
$1,700.84 		$318.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$833.56
$946.06
$1,065.26
$1,488.70
$2,262.20 		$1,152.39
$1,264.89
$1,384.09
$1,807.53 		$1,471.22
$1,583.72
$1,702.92
$2,126.36 		$1,790.05
$1,902.55
$2,021.75
$2,445.19 		$318.83
Toc - Plan #131 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 		$423.86
$481.07
$541.67
$756.99
$1,150.32 		$748.10
$805.31
$865.91
$1,081.23 		$1,072.34
$1,129.55
$1,190.15
$1,405.47 		$1,396.58
$1,453.79
$1,514.39
$1,729.71 		$324.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$847.72
$962.14
$1,083.34
$1,513.98
$2,300.64 		$1,171.96
$1,286.38
$1,407.58
$1,838.22 		$1,496.20
$1,610.62
$1,731.82
$2,162.46 		$1,820.44
$1,934.86
$2,056.06
$2,486.70 		$324.24
Toc - Plan #132 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 		$465.52
$528.35
$594.92
$831.40
$1,263.39 		$821.64
$884.47
$951.04
$1,187.52 		$1,177.76
$1,240.59
$1,307.16
$1,543.64 		$1,533.88
$1,596.71
$1,663.28
$1,899.76 		$356.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$931.04
$1,056.70
$1,189.84
$1,662.80
$2,526.78 		$1,287.16
$1,412.82
$1,545.96
$2,018.92 		$1,643.28
$1,768.94
$1,902.08
$2,375.04 		$1,999.40
$2,125.06
$2,258.20
$2,731.16 		$356.12
Toc - Plan #133 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 		$442.14
$501.82
$565.04
$789.65
$1,199.94 		$780.37
$840.05
$903.27
$1,127.88 		$1,118.60
$1,178.28
$1,241.50
$1,466.11 		$1,456.83
$1,516.51
$1,579.73
$1,804.34 		$338.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.28
$1,003.64
$1,130.08
$1,579.30
$2,399.88 		$1,222.51
$1,341.87
$1,468.31
$1,917.53 		$1,560.74
$1,680.10
$1,806.54
$2,255.76 		$1,898.97
$2,018.33
$2,144.77
$2,593.99 		$338.23
Toc - Plan #134 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 		$415.67
$471.78
$531.22
$742.37
$1,128.11 		$733.65
$789.76
$849.20
$1,060.35 		$1,051.63
$1,107.74
$1,167.18
$1,378.33 		$1,369.61
$1,425.72
$1,485.16
$1,696.31 		$317.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.34
$943.56
$1,062.44
$1,484.74
$2,256.22 		$1,149.32
$1,261.54
$1,380.42
$1,802.72 		$1,467.30
$1,579.52
$1,698.40
$2,120.70 		$1,785.28
$1,897.50
$2,016.38
$2,438.68 		$317.98
Toc - Plan #135 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 		$349.98
$397.22
$447.26
$625.05
$949.82 		$617.71
$664.95
$714.99
$892.78 		$885.44
$932.68
$982.72
$1,160.51 		$1,153.17
$1,200.41
$1,250.45
$1,428.24 		$267.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$699.96
$794.44
$894.52
$1,250.10
$1,899.64 		$967.69
$1,062.17
$1,162.25
$1,517.83 		$1,235.42
$1,329.90
$1,429.98
$1,785.56 		$1,503.15
$1,597.63
$1,697.71
$2,053.29 		$267.73
Toc - Plan #136 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 		$357.94
$406.25
$457.43
$639.26
$971.42 		$631.76
$680.07
$731.25
$913.08 		$905.58
$953.89
$1,005.07
$1,186.90 		$1,179.40
$1,227.71
$1,278.89
$1,460.72 		$273.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.88
$812.50
$914.86
$1,278.52
$1,942.84 		$989.70
$1,086.32
$1,188.68
$1,552.34 		$1,263.52
$1,360.14
$1,462.50
$1,826.16 		$1,537.34
$1,633.96
$1,736.32
$2,099.98 		$273.82
Toc - Plan #137 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 		$359.10
$407.57
$458.92
$641.34
$974.58 		$633.81
$682.28
$733.63
$916.05 		$908.52
$956.99
$1,008.34
$1,190.76 		$1,183.23
$1,231.70
$1,283.05
$1,465.47 		$274.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.20
$815.14
$917.84
$1,282.68
$1,949.16 		$992.91
$1,089.85
$1,192.55
$1,557.39 		$1,267.62
$1,364.56
$1,467.26
$1,832.10 		$1,542.33
$1,639.27
$1,741.97
$2,106.81 		$274.71
Toc - Plan #138 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 		$402.09
$456.36
$513.86
$718.12
$1,091.25 		$709.68
$763.95
$821.45
$1,025.71 		$1,017.27
$1,071.54
$1,129.04
$1,333.30 		$1,324.86
$1,379.13
$1,436.63
$1,640.89 		$307.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.18
$912.72
$1,027.72
$1,436.24
$2,182.50 		$1,111.77
$1,220.31
$1,335.31
$1,743.83 		$1,419.36
$1,527.90
$1,642.90
$2,051.42 		$1,726.95
$1,835.49
$1,950.49
$2,359.01 		$307.59

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-5716 | Toll Free: 1-888-560-5716 | TTY: 1-800-955-8771
Toc - Plan #139 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$407.70
$462.74
$521.04
$728.15
$1,106.50 		$719.59
$774.63
$832.93
$1,040.04 		$1,031.48
$1,086.52
$1,144.82
$1,351.93 		$1,343.37
$1,398.41
$1,456.71
$1,663.82 		$311.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.40
$925.48
$1,042.08
$1,456.30
$2,213.00 		$1,127.29
$1,237.37
$1,353.97
$1,768.19 		$1,439.18
$1,549.26
$1,665.86
$2,080.08 		$1,751.07
$1,861.15
$1,977.75
$2,391.97 		$311.89
Toc - Plan #140 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.78
$411.75
$463.63
$647.92
$984.57 		$640.30
$689.27
$741.15
$925.44 		$917.82
$966.79
$1,018.67
$1,202.96 		$1,195.34
$1,244.31
$1,296.19
$1,480.48 		$277.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.56
$823.50
$927.26
$1,295.84
$1,969.14 		$1,003.08
$1,101.02
$1,204.78
$1,573.36 		$1,280.60
$1,378.54
$1,482.30
$1,850.88 		$1,558.12
$1,656.06
$1,759.82
$2,128.40 		$277.52
Toc - Plan #141 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$274.86
$311.97
$351.27
$490.90
$745.97 		$485.13
$522.24
$561.54
$701.17 		$695.40
$732.51
$771.81
$911.44 		$905.67
$942.78
$982.08
$1,121.71 		$210.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.72
$623.94
$702.54
$981.80
$1,491.94 		$759.99
$834.21
$912.81
$1,192.07 		$970.26
$1,044.48
$1,123.08
$1,402.34 		$1,180.53
$1,254.75
$1,333.35
$1,612.61 		$210.27
Toc - Plan #142 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

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 		$359.15
$407.63
$458.99
$641.44
$974.73 		$633.90
$682.38
$733.74
$916.19 		$908.65
$957.13
$1,008.49
$1,190.94 		$1,183.40
$1,231.88
$1,283.24
$1,465.69 		$274.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.30
$815.26
$917.98
$1,282.88
$1,949.46 		$993.05
$1,090.01
$1,192.73
$1,557.63 		$1,267.80
$1,364.76
$1,467.48
$1,832.38 		$1,542.55
$1,639.51
$1,742.23
$2,107.13 		$274.75
Toc - Plan #143 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$306.62
$348.01
$391.86
$547.62
$832.17 		$541.18
$582.57
$626.42
$782.18 		$775.74
$817.13
$860.98
$1,016.74 		$1,010.30
$1,051.69
$1,095.54
$1,251.30 		$234.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.24
$696.02
$783.72
$1,095.24
$1,664.34 		$847.80
$930.58
$1,018.28
$1,329.80 		$1,082.36
$1,165.14
$1,252.84
$1,564.36 		$1,316.92
$1,399.70
$1,487.40
$1,798.92 		$234.56
Toc - Plan #144 Molina Healthcare
Silver

(HMO) Constant Care Silver 7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$355.20
$403.15
$453.94
$634.38
$964.00 		$626.92
$674.87
$725.66
$906.10 		$898.64
$946.59
$997.38
$1,177.82 		$1,170.36
$1,218.31
$1,269.10
$1,449.54 		$271.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.40
$806.30
$907.88
$1,268.76
$1,928.00 		$982.12
$1,078.02
$1,179.60
$1,540.48 		$1,253.84
$1,349.74
$1,451.32
$1,812.20 		$1,525.56
$1,621.46
$1,723.04
$2,083.92 		$271.72
Toc - Plan #145 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$412.41
$468.09
$527.06
$736.57
$1,119.28 		$727.90
$783.58
$842.55
$1,052.06 		$1,043.39
$1,099.07
$1,158.04
$1,367.55 		$1,358.88
$1,414.56
$1,473.53
$1,683.04 		$315.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.82
$936.18
$1,054.12
$1,473.14
$2,238.56 		$1,140.31
$1,251.67
$1,369.61
$1,788.63 		$1,455.80
$1,567.16
$1,685.10
$2,104.12 		$1,771.29
$1,882.65
$2,000.59
$2,419.61 		$315.49
Toc - Plan #146 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$365.84
$415.23
$467.54
$653.39
$992.89 		$645.71
$695.10
$747.41
$933.26 		$925.58
$974.97
$1,027.28
$1,213.13 		$1,205.45
$1,254.84
$1,307.15
$1,493.00 		$279.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.68
$830.46
$935.08
$1,306.78
$1,985.78 		$1,011.55
$1,110.33
$1,214.95
$1,586.65 		$1,291.42
$1,390.20
$1,494.82
$1,866.52 		$1,571.29
$1,670.07
$1,774.69
$2,146.39 		$279.87
Toc - Plan #147 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 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 		$360.78
$409.49
$461.08
$644.36
$979.16 		$636.78
$685.49
$737.08
$920.36 		$912.78
$961.49
$1,013.08
$1,196.36 		$1,188.78
$1,237.49
$1,289.08
$1,472.36 		$276.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.56
$818.98
$922.16
$1,288.72
$1,958.32 		$997.56
$1,094.98
$1,198.16
$1,564.72 		$1,273.56
$1,370.98
$1,474.16
$1,840.72 		$1,549.56
$1,646.98
$1,750.16
$2,116.72 		$276.00

‡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 Duval County here.

Duval County is in “Rating Area 15” of Florida.

Currently, there are 147 plans offered in Rating Area 15.

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2022 Obamacare Plans for Duval County, FL

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