Obamacare 2022 Rates for Caldwell County

Obamacare > Rates > Texas > Caldwell 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 Caldwell County, TX.

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, 96 Plans and 2022 Rates for Caldwell County, Texas

Below, you’ll find a summary of the 96 plans for Caldwell County, Texas 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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Oscar Insurance Company

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

Toc - Plan #1 Oscar Insurance Company
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 		$287.24
$326.01
$367.08
$513.00
$779.55 		$506.97
$545.74
$586.81
$732.73 		$726.70
$765.47
$806.54
$952.46 		$946.43
$985.20
$1,026.27
$1,172.19 		$219.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.48
$652.02
$734.16
$1,026.00
$1,559.10 		$794.21
$871.75
$953.89
$1,245.73 		$1,013.94
$1,091.48
$1,173.62
$1,465.46 		$1,233.67
$1,311.21
$1,393.35
$1,685.19 		$219.73
Toc - Plan #2 Oscar Insurance Company
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 		$291.95
$331.35
$373.10
$521.40
$792.32 		$515.28
$554.68
$596.43
$744.73 		$738.61
$778.01
$819.76
$968.06 		$961.94
$1,001.34
$1,043.09
$1,191.39 		$223.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.90
$662.70
$746.20
$1,042.80
$1,584.64 		$807.23
$886.03
$969.53
$1,266.13 		$1,030.56
$1,109.36
$1,192.86
$1,489.46 		$1,253.89
$1,332.69
$1,416.19
$1,712.79 		$223.33
Toc - Plan #3 Oscar Insurance Company
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 		$287.59
$326.40
$367.52
$513.61
$780.48 		$507.59
$546.40
$587.52
$733.61 		$727.59
$766.40
$807.52
$953.61 		$947.59
$986.40
$1,027.52
$1,173.61 		$220.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.18
$652.80
$735.04
$1,027.22
$1,560.96 		$795.18
$872.80
$955.04
$1,247.22 		$1,015.18
$1,092.80
$1,175.04
$1,467.22 		$1,235.18
$1,312.80
$1,395.04
$1,687.22 		$220.00
Toc - Plan #4 Oscar Insurance Company
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 		$344.00
$390.42
$439.61
$614.36
$933.58 		$607.15
$653.57
$702.76
$877.51 		$870.30
$916.72
$965.91
$1,140.66 		$1,133.45
$1,179.87
$1,229.06
$1,403.81 		$263.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.00
$780.84
$879.22
$1,228.72
$1,867.16 		$951.15
$1,043.99
$1,142.37
$1,491.87 		$1,214.30
$1,307.14
$1,405.52
$1,755.02 		$1,477.45
$1,570.29
$1,668.67
$2,018.17 		$263.15
Toc - Plan #5 Oscar Insurance Company
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 		$402.06
$456.33
$513.83
$718.07
$1,091.18 		$709.63
$763.90
$821.40
$1,025.64 		$1,017.20
$1,071.47
$1,128.97
$1,333.21 		$1,324.77
$1,379.04
$1,436.54
$1,640.78 		$307.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.12
$912.66
$1,027.66
$1,436.14
$2,182.36 		$1,111.69
$1,220.23
$1,335.23
$1,743.71 		$1,419.26
$1,527.80
$1,642.80
$2,051.28 		$1,726.83
$1,835.37
$1,950.37
$2,358.85 		$307.57
Toc - Plan #6 Oscar Insurance Company
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 		$393.94
$447.11
$503.44
$703.55
$1,069.12 		$695.29
$748.46
$804.79
$1,004.90 		$996.64
$1,049.81
$1,106.14
$1,306.25 		$1,297.99
$1,351.16
$1,407.49
$1,607.60 		$301.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.88
$894.22
$1,006.88
$1,407.10
$2,138.24 		$1,089.23
$1,195.57
$1,308.23
$1,708.45 		$1,390.58
$1,496.92
$1,609.58
$2,009.80 		$1,691.93
$1,798.27
$1,910.93
$2,311.15 		$301.35
Toc - Plan #7 Oscar Insurance Company
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 		$402.44
$456.75
$514.30
$718.73
$1,092.19 		$710.30
$764.61
$822.16
$1,026.59 		$1,018.16
$1,072.47
$1,130.02
$1,334.45 		$1,326.02
$1,380.33
$1,437.88
$1,642.31 		$307.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.88
$913.50
$1,028.60
$1,437.46
$2,184.38 		$1,112.74
$1,221.36
$1,336.46
$1,745.32 		$1,420.60
$1,529.22
$1,644.32
$2,053.18 		$1,728.46
$1,837.08
$1,952.18
$2,361.04 		$307.86
Toc - Plan #8 Oscar Insurance Company
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 		$237.69
$269.76
$303.75
$424.49
$645.06 		$419.51
$451.58
$485.57
$606.31 		$601.33
$633.40
$667.39
$788.13 		$783.15
$815.22
$849.21
$969.95 		$181.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$475.38
$539.52
$607.50
$848.98
$1,290.12 		$657.20
$721.34
$789.32
$1,030.80 		$839.02
$903.16
$971.14
$1,212.62 		$1,020.84
$1,084.98
$1,152.96
$1,394.44 		$181.82
Toc - Plan #9 Oscar Insurance Company
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 		$344.08
$390.52
$439.72
$614.50
$933.80 		$607.29
$653.73
$702.93
$877.71 		$870.50
$916.94
$966.14
$1,140.92 		$1,133.71
$1,180.15
$1,229.35
$1,404.13 		$263.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.16
$781.04
$879.44
$1,229.00
$1,867.60 		$951.37
$1,044.25
$1,142.65
$1,492.21 		$1,214.58
$1,307.46
$1,405.86
$1,755.42 		$1,477.79
$1,570.67
$1,669.07
$2,018.63 		$263.21
Toc - Plan #10 Oscar Insurance Company
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 		$396.52
$450.04
$506.74
$708.17
$1,076.13 		$699.85
$753.37
$810.07
$1,011.50 		$1,003.18
$1,056.70
$1,113.40
$1,314.83 		$1,306.51
$1,360.03
$1,416.73
$1,618.16 		$303.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.04
$900.08
$1,013.48
$1,416.34
$2,152.26 		$1,096.37
$1,203.41
$1,316.81
$1,719.67 		$1,399.70
$1,506.74
$1,620.14
$2,023.00 		$1,703.03
$1,810.07
$1,923.47
$2,326.33 		$303.33
Toc - Plan #11 Oscar Insurance Company
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 		$315.53
$358.11
$403.23
$563.51
$856.32 		$556.90
$599.48
$644.60
$804.88 		$798.27
$840.85
$885.97
$1,046.25 		$1,039.64
$1,082.22
$1,127.34
$1,287.62 		$241.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.06
$716.22
$806.46
$1,127.02
$1,712.64 		$872.43
$957.59
$1,047.83
$1,368.39 		$1,113.80
$1,198.96
$1,289.20
$1,609.76 		$1,355.17
$1,440.33
$1,530.57
$1,851.13 		$241.37
Toc - Plan #12 Oscar Insurance Company
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 		$394.39
$447.62
$504.01
$704.35
$1,070.33 		$696.09
$749.32
$805.71
$1,006.05 		$997.79
$1,051.02
$1,107.41
$1,307.75 		$1,299.49
$1,352.72
$1,409.11
$1,609.45 		$301.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.78
$895.24
$1,008.02
$1,408.70
$2,140.66 		$1,090.48
$1,196.94
$1,309.72
$1,710.40 		$1,392.18
$1,498.64
$1,611.42
$2,012.10 		$1,693.88
$1,800.34
$1,913.12
$2,313.80 		$301.70
Toc - Plan #13 Oscar Insurance Company
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 		$408.91
$464.10
$522.57
$730.29
$1,109.74 		$721.71
$776.90
$835.37
$1,043.09 		$1,034.51
$1,089.70
$1,148.17
$1,355.89 		$1,347.31
$1,402.50
$1,460.97
$1,668.69 		$312.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817.82
$928.20
$1,045.14
$1,460.58
$2,219.48 		$1,130.62
$1,241.00
$1,357.94
$1,773.38 		$1,443.42
$1,553.80
$1,670.74
$2,086.18 		$1,756.22
$1,866.60
$1,983.54
$2,398.98 		$312.80
Toc - Plan #14 Oscar Insurance Company
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 		$425.55
$482.99
$543.84
$760.02
$1,154.92 		$751.09
$808.53
$869.38
$1,085.56 		$1,076.63
$1,134.07
$1,194.92
$1,411.10 		$1,402.17
$1,459.61
$1,520.46
$1,736.64 		$325.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.10
$965.98
$1,087.68
$1,520.04
$2,309.84 		$1,176.64
$1,291.52
$1,413.22
$1,845.58 		$1,502.18
$1,617.06
$1,738.76
$2,171.12 		$1,827.72
$1,942.60
$2,064.30
$2,496.66 		$325.54
Toc - Plan #15 Oscar Insurance Company
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 		$404.84
$459.48
$517.37
$723.03
$1,098.71 		$714.54
$769.18
$827.07
$1,032.73 		$1,024.24
$1,078.88
$1,136.77
$1,342.43 		$1,333.94
$1,388.58
$1,446.47
$1,652.13 		$309.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.68
$918.96
$1,034.74
$1,446.06
$2,197.42 		$1,119.38
$1,228.66
$1,344.44
$1,755.76 		$1,429.08
$1,538.36
$1,654.14
$2,065.46 		$1,738.78
$1,848.06
$1,963.84
$2,375.16 		$309.70
Toc - Plan #16 Oscar Insurance Company
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 		$304.17
$345.23
$388.72
$543.24
$825.50 		$536.86
$577.92
$621.41
$775.93 		$769.55
$810.61
$854.10
$1,008.62 		$1,002.24
$1,043.30
$1,086.79
$1,241.31 		$232.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.34
$690.46
$777.44
$1,086.48
$1,651.00 		$841.03
$923.15
$1,010.13
$1,319.17 		$1,073.72
$1,155.84
$1,242.82
$1,551.86 		$1,306.41
$1,388.53
$1,475.51
$1,784.55 		$232.69
Toc - Plan #17 Oscar Insurance Company
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 		$330.33
$374.92
$422.15
$589.96
$896.50 		$583.03
$627.62
$674.85
$842.66 		$835.73
$880.32
$927.55
$1,095.36 		$1,088.43
$1,133.02
$1,180.25
$1,348.06 		$252.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$660.66
$749.84
$844.30
$1,179.92
$1,793.00 		$913.36
$1,002.54
$1,097.00
$1,432.62 		$1,166.06
$1,255.24
$1,349.70
$1,685.32 		$1,418.76
$1,507.94
$1,602.40
$1,938.02 		$252.70
Toc - Plan #18 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $3250 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 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 		$328.61
$372.96
$419.95
$586.87
$891.81 		$579.99
$624.34
$671.33
$838.25 		$831.37
$875.72
$922.71
$1,089.63 		$1,082.75
$1,127.10
$1,174.09
$1,341.01 		$251.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.22
$745.92
$839.90
$1,173.74
$1,783.62 		$908.60
$997.30
$1,091.28
$1,425.12 		$1,159.98
$1,248.68
$1,342.66
$1,676.50 		$1,411.36
$1,500.06
$1,594.04
$1,927.88 		$251.38
Toc - Plan #19 Oscar Insurance Company
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 		$303.12
$344.03
$387.37
$541.35
$822.63 		$535.00
$575.91
$619.25
$773.23 		$766.88
$807.79
$851.13
$1,005.11 		$998.76
$1,039.67
$1,083.01
$1,236.99 		$231.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.24
$688.06
$774.74
$1,082.70
$1,645.26 		$838.12
$919.94
$1,006.62
$1,314.58 		$1,070.00
$1,151.82
$1,238.50
$1,546.46 		$1,301.88
$1,383.70
$1,470.38
$1,778.34 		$231.88
Toc - Plan #20 Oscar Insurance Company
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
$8,375 $16,750 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.76
$442.37
$498.10
$696.09
$1,057.78 		$687.92
$740.53
$796.26
$994.25 		$986.08
$1,038.69
$1,094.42
$1,292.41 		$1,284.24
$1,336.85
$1,392.58
$1,590.57 		$298.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.52
$884.74
$996.20
$1,392.18
$2,115.56 		$1,077.68
$1,182.90
$1,294.36
$1,690.34 		$1,375.84
$1,481.06
$1,592.52
$1,988.50 		$1,674.00
$1,779.22
$1,890.68
$2,286.66 		$298.16
Toc - Plan #21 Oscar Insurance Company
Silver

(EPO) Silver Elite- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$421.38
$478.25
$538.51
$752.56
$1,143.59 		$743.73
$800.60
$860.86
$1,074.91 		$1,066.08
$1,122.95
$1,183.21
$1,397.26 		$1,388.43
$1,445.30
$1,505.56
$1,719.61 		$322.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.76
$956.50
$1,077.02
$1,505.12
$2,287.18 		$1,165.11
$1,278.85
$1,399.37
$1,827.47 		$1,487.46
$1,601.20
$1,721.72
$2,149.82 		$1,809.81
$1,923.55
$2,044.07
$2,472.17 		$322.35
Toc - Plan #22 Oscar Insurance Company
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 		$405.44
$460.16
$518.13
$724.09
$1,100.33 		$715.59
$770.31
$828.28
$1,034.24 		$1,025.74
$1,080.46
$1,138.43
$1,344.39 		$1,335.89
$1,390.61
$1,448.58
$1,654.54 		$310.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.88
$920.32
$1,036.26
$1,448.18
$2,200.66 		$1,121.03
$1,230.47
$1,346.41
$1,758.33 		$1,431.18
$1,540.62
$1,656.56
$2,068.48 		$1,741.33
$1,850.77
$1,966.71
$2,378.63 		$310.15
Toc - Plan #23 Oscar Insurance Company
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 		$418.60
$475.09
$534.95
$747.59
$1,136.04 		$738.82
$795.31
$855.17
$1,067.81 		$1,059.04
$1,115.53
$1,175.39
$1,388.03 		$1,379.26
$1,435.75
$1,495.61
$1,708.25 		$320.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.20
$950.18
$1,069.90
$1,495.18
$2,272.08 		$1,157.42
$1,270.40
$1,390.12
$1,815.40 		$1,477.64
$1,590.62
$1,710.34
$2,135.62 		$1,797.86
$1,910.84
$2,030.56
$2,455.84 		$320.22
Toc - Plan #24 Oscar Insurance Company
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 		$417.70
$474.08
$533.81
$746.00
$1,133.62 		$737.23
$793.61
$853.34
$1,065.53 		$1,056.76
$1,113.14
$1,172.87
$1,385.06 		$1,376.29
$1,432.67
$1,492.40
$1,704.59 		$319.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.40
$948.16
$1,067.62
$1,492.00
$2,267.24 		$1,154.93
$1,267.69
$1,387.15
$1,811.53 		$1,474.46
$1,587.22
$1,706.68
$2,131.06 		$1,793.99
$1,906.75
$2,026.21
$2,450.59 		$319.53
Toc - Plan #25 Oscar Insurance Company
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 		$413.66
$469.50
$528.65
$738.79
$1,122.66 		$730.11
$785.95
$845.10
$1,055.24 		$1,046.56
$1,102.40
$1,161.55
$1,371.69 		$1,363.01
$1,418.85
$1,478.00
$1,688.14 		$316.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.32
$939.00
$1,057.30
$1,477.58
$2,245.32 		$1,143.77
$1,255.45
$1,373.75
$1,794.03 		$1,460.22
$1,571.90
$1,690.20
$2,110.48 		$1,776.67
$1,888.35
$2,006.65
$2,426.93 		$316.45
Toc - Plan #26 Oscar Insurance Company
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 		$380.16
$431.46
$485.83
$678.94
$1,031.71 		$670.97
$722.27
$776.64
$969.75 		$961.78
$1,013.08
$1,067.45
$1,260.56 		$1,252.59
$1,303.89
$1,358.26
$1,551.37 		$290.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.32
$862.92
$971.66
$1,357.88
$2,063.42 		$1,051.13
$1,153.73
$1,262.47
$1,648.69 		$1,341.94
$1,444.54
$1,553.28
$1,939.50 		$1,632.75
$1,735.35
$1,844.09
$2,230.31 		$290.81
Toc - Plan #27 Oscar Insurance Company
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 		$387.59
$439.90
$495.32
$692.21
$1,051.88 		$684.09
$736.40
$791.82
$988.71 		$980.59
$1,032.90
$1,088.32
$1,285.21 		$1,277.09
$1,329.40
$1,384.82
$1,581.71 		$296.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.18
$879.80
$990.64
$1,384.42
$2,103.76 		$1,071.68
$1,176.30
$1,287.14
$1,680.92 		$1,368.18
$1,472.80
$1,583.64
$1,977.42 		$1,664.68
$1,769.30
$1,880.14
$2,273.92 		$296.50
Toc - Plan #28 Oscar Insurance Company
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 		$443.58
$503.45
$566.88
$792.22
$1,203.85 		$782.91
$842.78
$906.21
$1,131.55 		$1,122.24
$1,182.11
$1,245.54
$1,470.88 		$1,461.57
$1,521.44
$1,584.87
$1,810.21 		$339.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.16
$1,006.90
$1,133.76
$1,584.44
$2,407.70 		$1,226.49
$1,346.23
$1,473.09
$1,923.77 		$1,565.82
$1,685.56
$1,812.42
$2,263.10 		$1,905.15
$2,024.89
$2,151.75
$2,602.43 		$339.33
Toc - Plan #29 Oscar Insurance Company
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 		$419.24
$475.83
$535.78
$748.75
$1,137.79 		$739.95
$796.54
$856.49
$1,069.46 		$1,060.66
$1,117.25
$1,177.20
$1,390.17 		$1,381.37
$1,437.96
$1,497.91
$1,710.88 		$320.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.48
$951.66
$1,071.56
$1,497.50
$2,275.58 		$1,159.19
$1,272.37
$1,392.27
$1,818.21 		$1,479.90
$1,593.08
$1,712.98
$2,138.92 		$1,800.61
$1,913.79
$2,033.69
$2,459.63 		$320.71
Toc - Plan #30 Oscar Insurance Company
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 		$390.32
$443.00
$498.82
$697.09
$1,059.30 		$688.91
$741.59
$797.41
$995.68 		$987.50
$1,040.18
$1,096.00
$1,294.27 		$1,286.09
$1,338.77
$1,394.59
$1,592.86 		$298.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.64
$886.00
$997.64
$1,394.18
$2,118.60 		$1,079.23
$1,184.59
$1,296.23
$1,692.77 		$1,377.82
$1,483.18
$1,594.82
$1,991.36 		$1,676.41
$1,781.77
$1,893.41
$2,289.95 		$298.59
Toc - Plan #31 Oscar Insurance Company
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 		$327.52
$371.72
$418.56
$584.93
$888.86 		$578.07
$622.27
$669.11
$835.48 		$828.62
$872.82
$919.66
$1,086.03 		$1,079.17
$1,123.37
$1,170.21
$1,336.58 		$250.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.04
$743.44
$837.12
$1,169.86
$1,777.72 		$905.59
$993.99
$1,087.67
$1,420.41 		$1,156.14
$1,244.54
$1,338.22
$1,670.96 		$1,406.69
$1,495.09
$1,588.77
$1,921.51 		$250.55
Toc - Plan #32 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite

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
$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 		$336.56
$381.98
$430.11
$601.07
$913.39 		$594.02
$639.44
$687.57
$858.53 		$851.48
$896.90
$945.03
$1,115.99 		$1,108.94
$1,154.36
$1,202.49
$1,373.45 		$257.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$673.12
$763.96
$860.22
$1,202.14
$1,826.78 		$930.58
$1,021.42
$1,117.68
$1,459.60 		$1,188.04
$1,278.88
$1,375.14
$1,717.06 		$1,445.50
$1,536.34
$1,632.60
$1,974.52 		$257.46
Toc - Plan #33 Oscar Insurance Company
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 		$337.56
$383.11
$431.38
$602.86
$916.10 		$595.78
$641.33
$689.60
$861.08 		$854.00
$899.55
$947.82
$1,119.30 		$1,112.22
$1,157.77
$1,206.04
$1,377.52 		$258.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.12
$766.22
$862.76
$1,205.72
$1,832.20 		$933.34
$1,024.44
$1,120.98
$1,463.94 		$1,191.56
$1,282.66
$1,379.20
$1,722.16 		$1,449.78
$1,540.88
$1,637.42
$1,980.38 		$258.22
Toc - Plan #34 Oscar Insurance Company
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 		$398.32
$452.08
$509.03
$711.37
$1,081.00 		$703.02
$756.78
$813.73
$1,016.07 		$1,007.72
$1,061.48
$1,118.43
$1,320.77 		$1,312.42
$1,366.18
$1,423.13
$1,625.47 		$304.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.64
$904.16
$1,018.06
$1,422.74
$2,162.00 		$1,101.34
$1,208.86
$1,322.76
$1,727.44 		$1,406.04
$1,513.56
$1,627.46
$2,032.14 		$1,710.74
$1,818.26
$1,932.16
$2,336.84 		$304.70

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #35 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$471.33
$534.94
$602.34
$841.77
$1,279.15 		$831.89
$895.50
$962.90
$1,202.33 		$1,192.45
$1,256.06
$1,323.46
$1,562.89 		$1,553.01
$1,616.62
$1,684.02
$1,923.45 		$360.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942.66
$1,069.88
$1,204.68
$1,683.54
$2,558.30 		$1,303.22
$1,430.44
$1,565.24
$2,044.10 		$1,663.78
$1,791.00
$1,925.80
$2,404.66 		$2,024.34
$2,151.56
$2,286.36
$2,765.22 		$360.56
Toc - Plan #36 Ambetter from Superior HealthPlan
Bronze

(EPO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$394.88
$448.18
$504.64
$705.23
$1,071.67 		$696.95
$750.25
$806.71
$1,007.30 		$999.02
$1,052.32
$1,108.78
$1,309.37 		$1,301.09
$1,354.39
$1,410.85
$1,611.44 		$302.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.76
$896.36
$1,009.28
$1,410.46
$2,143.34 		$1,091.83
$1,198.43
$1,311.35
$1,712.53 		$1,393.90
$1,500.50
$1,613.42
$2,014.60 		$1,695.97
$1,802.57
$1,915.49
$2,316.67 		$302.07
Toc - Plan #37 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 10

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$417.03
$473.32
$532.95
$744.80
$1,131.79 		$736.05
$792.34
$851.97
$1,063.82 		$1,055.07
$1,111.36
$1,170.99
$1,382.84 		$1,374.09
$1,430.38
$1,490.01
$1,701.86 		$319.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.06
$946.64
$1,065.90
$1,489.60
$2,263.58 		$1,153.08
$1,265.66
$1,384.92
$1,808.62 		$1,472.10
$1,584.68
$1,703.94
$2,127.64 		$1,791.12
$1,903.70
$2,022.96
$2,446.66 		$319.02
Toc - Plan #38 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$618.80
$702.33
$790.81
$1,105.16
$1,679.40 		$1,092.17
$1,175.70
$1,264.18
$1,578.53 		$1,565.54
$1,649.07
$1,737.55
$2,051.90 		$2,038.91
$2,122.44
$2,210.92
$2,525.27 		$473.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,237.60
$1,404.66
$1,581.62
$2,210.32
$3,358.80 		$1,710.97
$1,878.03
$2,054.99
$2,683.69 		$2,184.34
$2,351.40
$2,528.36
$3,157.06 		$2,657.71
$2,824.77
$3,001.73
$3,630.43 		$473.37
Toc - Plan #39 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$431.59
$489.85
$551.56
$770.81
$1,171.32 		$761.75
$820.01
$881.72
$1,100.97 		$1,091.91
$1,150.17
$1,211.88
$1,431.13 		$1,422.07
$1,480.33
$1,542.04
$1,761.29 		$330.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.18
$979.70
$1,103.12
$1,541.62
$2,342.64 		$1,193.34
$1,309.86
$1,433.28
$1,871.78 		$1,523.50
$1,640.02
$1,763.44
$2,201.94 		$1,853.66
$1,970.18
$2,093.60
$2,532.10 		$330.16
Toc - Plan #40 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 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 		$473.96
$537.94
$605.71
$846.48
$1,286.31 		$836.54
$900.52
$968.29
$1,209.06 		$1,199.12
$1,263.10
$1,330.87
$1,571.64 		$1,561.70
$1,625.68
$1,693.45
$1,934.22 		$362.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$947.92
$1,075.88
$1,211.42
$1,692.96
$2,572.62 		$1,310.50
$1,438.46
$1,574.00
$2,055.54 		$1,673.08
$1,801.04
$1,936.58
$2,418.12 		$2,035.66
$2,163.62
$2,299.16
$2,780.70 		$362.58
Toc - Plan #41 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$464.96
$527.72
$594.21
$830.41
$1,261.88 		$820.65
$883.41
$949.90
$1,186.10 		$1,176.34
$1,239.10
$1,305.59
$1,541.79 		$1,532.03
$1,594.79
$1,661.28
$1,897.48 		$355.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.92
$1,055.44
$1,188.42
$1,660.82
$2,523.76 		$1,285.61
$1,411.13
$1,544.11
$2,016.51 		$1,641.30
$1,766.82
$1,899.80
$2,372.20 		$1,996.99
$2,122.51
$2,255.49
$2,727.89 		$355.69
Toc - Plan #42 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 29

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$458.93
$520.87
$586.50
$819.63
$1,245.51 		$810.00
$871.94
$937.57
$1,170.70 		$1,161.07
$1,223.01
$1,288.64
$1,521.77 		$1,512.14
$1,574.08
$1,639.71
$1,872.84 		$351.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.86
$1,041.74
$1,173.00
$1,639.26
$2,491.02 		$1,268.93
$1,392.81
$1,524.07
$1,990.33 		$1,620.00
$1,743.88
$1,875.14
$2,341.40 		$1,971.07
$2,094.95
$2,226.21
$2,692.47 		$351.07
Toc - Plan #43 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 22

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$458.46
$520.34
$585.90
$818.79
$1,244.23 		$809.17
$871.05
$936.61
$1,169.50 		$1,159.88
$1,221.76
$1,287.32
$1,520.21 		$1,510.59
$1,572.47
$1,638.03
$1,870.92 		$350.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$916.92
$1,040.68
$1,171.80
$1,637.58
$2,488.46 		$1,267.63
$1,391.39
$1,522.51
$1,988.29 		$1,618.34
$1,742.10
$1,873.22
$2,339.00 		$1,969.05
$2,092.81
$2,223.93
$2,689.71 		$350.71
Toc - Plan #44 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$469.82
$533.23
$600.41
$839.08
$1,275.06 		$829.22
$892.63
$959.81
$1,198.48 		$1,188.62
$1,252.03
$1,319.21
$1,557.88 		$1,548.02
$1,611.43
$1,678.61
$1,917.28 		$359.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.64
$1,066.46
$1,200.82
$1,678.16
$2,550.12 		$1,299.04
$1,425.86
$1,560.22
$2,037.56 		$1,658.44
$1,785.26
$1,919.62
$2,396.96 		$2,017.84
$2,144.66
$2,279.02
$2,756.36 		$359.40
Toc - Plan #45 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$495.65
$562.55
$633.42
$885.20
$1,345.15 		$874.81
$941.71
$1,012.58
$1,264.36 		$1,253.97
$1,320.87
$1,391.74
$1,643.52 		$1,633.13
$1,700.03
$1,770.90
$2,022.68 		$379.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.30
$1,125.10
$1,266.84
$1,770.40
$2,690.30 		$1,370.46
$1,504.26
$1,646.00
$2,149.56 		$1,749.62
$1,883.42
$2,025.16
$2,528.72 		$2,128.78
$2,262.58
$2,404.32
$2,907.88 		$379.16
Toc - Plan #46 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$435.32
$494.07
$556.32
$777.46
$1,181.42 		$768.33
$827.08
$889.33
$1,110.47 		$1,101.34
$1,160.09
$1,222.34
$1,443.48 		$1,434.35
$1,493.10
$1,555.35
$1,776.49 		$333.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.64
$988.14
$1,112.64
$1,554.92
$2,362.84 		$1,203.65
$1,321.15
$1,445.65
$1,887.93 		$1,536.66
$1,654.16
$1,778.66
$2,220.94 		$1,869.67
$1,987.17
$2,111.67
$2,553.95 		$333.01
Toc - Plan #47 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$435.93
$494.77
$557.11
$778.55
$1,183.09 		$769.41
$828.25
$890.59
$1,112.03 		$1,102.89
$1,161.73
$1,224.07
$1,445.51 		$1,436.37
$1,495.21
$1,557.55
$1,778.99 		$333.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.86
$989.54
$1,114.22
$1,557.10
$2,366.18 		$1,205.34
$1,323.02
$1,447.70
$1,890.58 		$1,538.82
$1,656.50
$1,781.18
$2,224.06 		$1,872.30
$1,989.98
$2,114.66
$2,557.54 		$333.48
Toc - Plan #48 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$450.02
$510.76
$575.12
$803.72
$1,221.33 		$794.28
$855.02
$919.38
$1,147.98 		$1,138.54
$1,199.28
$1,263.64
$1,492.24 		$1,482.80
$1,543.54
$1,607.90
$1,836.50 		$344.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.04
$1,021.52
$1,150.24
$1,607.44
$2,442.66 		$1,244.30
$1,365.78
$1,494.50
$1,951.70 		$1,588.56
$1,710.04
$1,838.76
$2,295.96 		$1,932.82
$2,054.30
$2,183.02
$2,640.22 		$344.26
Toc - Plan #49 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$578.83
$656.96
$739.74
$1,033.78
$1,570.92 		$1,021.63
$1,099.76
$1,182.54
$1,476.58 		$1,464.43
$1,542.56
$1,625.34
$1,919.38 		$1,907.23
$1,985.36
$2,068.14
$2,362.18 		$442.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,157.66
$1,313.92
$1,479.48
$2,067.56
$3,141.84 		$1,600.46
$1,756.72
$1,922.28
$2,510.36 		$2,043.26
$2,199.52
$2,365.08
$2,953.16 		$2,486.06
$2,642.32
$2,807.88
$3,395.96 		$442.80
Toc - Plan #50 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 5 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$624.97
$709.33
$798.70
$1,116.18
$1,696.15 		$1,103.07
$1,187.43
$1,276.80
$1,594.28 		$1,581.17
$1,665.53
$1,754.90
$2,072.38 		$2,059.27
$2,143.63
$2,233.00
$2,550.48 		$478.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,249.94
$1,418.66
$1,597.40
$2,232.36
$3,392.30 		$1,728.04
$1,896.76
$2,075.50
$2,710.46 		$2,206.14
$2,374.86
$2,553.60
$3,188.56 		$2,684.24
$2,852.96
$3,031.70
$3,666.66 		$478.10
Toc - Plan #51 Ambetter from Superior HealthPlan
Bronze

(EPO) Ambetter Essential Care 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$398.82
$452.65
$509.68
$712.27
$1,082.36 		$703.91
$757.74
$814.77
$1,017.36 		$1,009.00
$1,062.83
$1,119.86
$1,322.45 		$1,314.09
$1,367.92
$1,424.95
$1,627.54 		$305.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.64
$905.30
$1,019.36
$1,424.54
$2,164.72 		$1,102.73
$1,210.39
$1,324.45
$1,729.63 		$1,407.82
$1,515.48
$1,629.54
$2,034.72 		$1,712.91
$1,820.57
$1,934.63
$2,339.81 		$305.09
Toc - Plan #52 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 10 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$421.19
$478.04
$538.27
$752.23
$1,143.08 		$743.39
$800.24
$860.47
$1,074.43 		$1,065.59
$1,122.44
$1,182.67
$1,396.63 		$1,387.79
$1,444.64
$1,504.87
$1,718.83 		$322.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.38
$956.08
$1,076.54
$1,504.46
$2,286.16 		$1,164.58
$1,278.28
$1,398.74
$1,826.66 		$1,486.78
$1,600.48
$1,720.94
$2,148.86 		$1,808.98
$1,922.68
$2,043.14
$2,471.06 		$322.20
Toc - Plan #53 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 11 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$476.03
$540.28
$608.35
$850.17
$1,291.91 		$840.18
$904.43
$972.50
$1,214.32 		$1,204.33
$1,268.58
$1,336.65
$1,578.47 		$1,568.48
$1,632.73
$1,700.80
$1,942.62 		$364.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952.06
$1,080.56
$1,216.70
$1,700.34
$2,583.82 		$1,316.21
$1,444.71
$1,580.85
$2,064.49 		$1,680.36
$1,808.86
$1,945.00
$2,428.64 		$2,044.51
$2,173.01
$2,309.15
$2,792.79 		$364.15
Toc - Plan #54 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$435.90
$494.73
$557.07
$778.50
$1,183.00 		$769.35
$828.18
$890.52
$1,111.95 		$1,102.80
$1,161.63
$1,223.97
$1,445.40 		$1,436.25
$1,495.08
$1,557.42
$1,778.85 		$333.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.80
$989.46
$1,114.14
$1,557.00
$2,366.00 		$1,205.25
$1,322.91
$1,447.59
$1,890.45 		$1,538.70
$1,656.36
$1,781.04
$2,223.90 		$1,872.15
$1,989.81
$2,114.49
$2,557.35 		$333.45
Toc - Plan #55 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 5 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 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 		$478.69
$543.30
$611.76
$854.93
$1,299.14 		$844.88
$909.49
$977.95
$1,221.12 		$1,211.07
$1,275.68
$1,344.14
$1,587.31 		$1,577.26
$1,641.87
$1,710.33
$1,953.50 		$366.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.38
$1,086.60
$1,223.52
$1,709.86
$2,598.28 		$1,323.57
$1,452.79
$1,589.71
$2,076.05 		$1,689.76
$1,818.98
$1,955.90
$2,442.24 		$2,055.95
$2,185.17
$2,322.09
$2,808.43 		$366.19
Toc - Plan #56 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 12 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$469.60
$532.99
$600.14
$838.69
$1,274.47 		$828.84
$892.23
$959.38
$1,197.93 		$1,188.08
$1,251.47
$1,318.62
$1,557.17 		$1,547.32
$1,610.71
$1,677.86
$1,916.41 		$359.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.20
$1,065.98
$1,200.28
$1,677.38
$2,548.94 		$1,298.44
$1,425.22
$1,559.52
$2,036.62 		$1,657.68
$1,784.46
$1,918.76
$2,395.86 		$2,016.92
$2,143.70
$2,278.00
$2,755.10 		$359.24
Toc - Plan #57 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 22 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$463.03
$525.53
$591.74
$826.96
$1,256.64 		$817.24
$879.74
$945.95
$1,181.17 		$1,171.45
$1,233.95
$1,300.16
$1,535.38 		$1,525.66
$1,588.16
$1,654.37
$1,889.59 		$354.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$926.06
$1,051.06
$1,183.48
$1,653.92
$2,513.28 		$1,280.27
$1,405.27
$1,537.69
$2,008.13 		$1,634.48
$1,759.48
$1,891.90
$2,362.34 		$1,988.69
$2,113.69
$2,246.11
$2,716.55 		$354.21
Toc - Plan #58 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$474.50
$538.55
$606.40
$847.45
$1,287.78 		$837.49
$901.54
$969.39
$1,210.44 		$1,200.48
$1,264.53
$1,332.38
$1,573.43 		$1,563.47
$1,627.52
$1,695.37
$1,936.42 		$362.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$949.00
$1,077.10
$1,212.80
$1,694.90
$2,575.56 		$1,311.99
$1,440.09
$1,575.79
$2,057.89 		$1,674.98
$1,803.08
$1,938.78
$2,420.88 		$2,037.97
$2,166.07
$2,301.77
$2,783.87 		$362.99
Toc - Plan #59 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$500.59
$568.16
$639.74
$894.03
$1,358.57 		$883.53
$951.10
$1,022.68
$1,276.97 		$1,266.47
$1,334.04
$1,405.62
$1,659.91 		$1,649.41
$1,716.98
$1,788.56
$2,042.85 		$382.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,001.18
$1,136.32
$1,279.48
$1,788.06
$2,717.14 		$1,384.12
$1,519.26
$1,662.42
$2,171.00 		$1,767.06
$1,902.20
$2,045.36
$2,553.94 		$2,150.00
$2,285.14
$2,428.30
$2,936.88 		$382.94
Toc - Plan #60 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 31 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$440.28
$499.70
$562.66
$786.32
$1,194.89 		$777.08
$836.50
$899.46
$1,123.12 		$1,113.88
$1,173.30
$1,236.26
$1,459.92 		$1,450.68
$1,510.10
$1,573.06
$1,796.72 		$336.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.56
$999.40
$1,125.32
$1,572.64
$2,389.78 		$1,217.36
$1,336.20
$1,462.12
$1,909.44 		$1,554.16
$1,673.00
$1,798.92
$2,246.24 		$1,890.96
$2,009.80
$2,135.72
$2,583.04 		$336.80
Toc - Plan #61 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 32 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$454.51
$515.86
$580.85
$811.74
$1,233.52 		$802.20
$863.55
$928.54
$1,159.43 		$1,149.89
$1,211.24
$1,276.23
$1,507.12 		$1,497.58
$1,558.93
$1,623.92
$1,854.81 		$347.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.02
$1,031.72
$1,161.70
$1,623.48
$2,467.04 		$1,256.71
$1,379.41
$1,509.39
$1,971.17 		$1,604.40
$1,727.10
$1,857.08
$2,318.86 		$1,952.09
$2,074.79
$2,204.77
$2,666.55 		$347.69
Toc - Plan #62 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 20 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$584.61
$663.52
$747.11
$1,044.09
$1,586.59 		$1,031.83
$1,110.74
$1,194.33
$1,491.31 		$1,479.05
$1,557.96
$1,641.55
$1,938.53 		$1,926.27
$2,005.18
$2,088.77
$2,385.75 		$447.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,169.22
$1,327.04
$1,494.22
$2,088.18
$3,173.18 		$1,616.44
$1,774.26
$1,941.44
$2,535.40 		$2,063.66
$2,221.48
$2,388.66
$2,982.62 		$2,510.88
$2,668.70
$2,835.88
$3,429.84 		$447.22
Toc - Plan #63 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 29 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$463.51
$526.07
$592.35
$827.81
$1,257.93 		$818.09
$880.65
$946.93
$1,182.39 		$1,172.67
$1,235.23
$1,301.51
$1,536.97 		$1,527.25
$1,589.81
$1,656.09
$1,891.55 		$354.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.02
$1,052.14
$1,184.70
$1,655.62
$2,515.86 		$1,281.60
$1,406.72
$1,539.28
$2,010.20 		$1,636.18
$1,761.30
$1,893.86
$2,364.78 		$1,990.76
$2,115.88
$2,248.44
$2,719.36 		$354.58
Toc - Plan #64 Ambetter from Superior HealthPlan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$644.44
$731.43
$823.59
$1,150.96
$1,749.00 		$1,137.43
$1,224.42
$1,316.58
$1,643.95 		$1,630.42
$1,717.41
$1,809.57
$2,136.94 		$2,123.41
$2,210.40
$2,302.56
$2,629.93 		$492.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,288.88
$1,462.86
$1,647.18
$2,301.92
$3,498.00 		$1,781.87
$1,955.85
$2,140.17
$2,794.91 		$2,274.86
$2,448.84
$2,633.16
$3,287.90 		$2,767.85
$2,941.83
$3,126.15
$3,780.89 		$492.99
Toc - Plan #65 Ambetter from Superior HealthPlan
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$411.24
$466.75
$525.56
$734.46
$1,116.09 		$725.83
$781.34
$840.15
$1,049.05 		$1,040.42
$1,095.93
$1,154.74
$1,363.64 		$1,355.01
$1,410.52
$1,469.33
$1,678.23 		$314.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.48
$933.50
$1,051.12
$1,468.92
$2,232.18 		$1,137.07
$1,248.09
$1,365.71
$1,783.51 		$1,451.66
$1,562.68
$1,680.30
$2,098.10 		$1,766.25
$1,877.27
$1,994.89
$2,412.69 		$314.59
Toc - Plan #66 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 10 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$434.31
$492.93
$555.04
$775.66
$1,178.70 		$766.55
$825.17
$887.28
$1,107.90 		$1,098.79
$1,157.41
$1,219.52
$1,440.14 		$1,431.03
$1,489.65
$1,551.76
$1,772.38 		$332.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.62
$985.86
$1,110.08
$1,551.32
$2,357.40 		$1,200.86
$1,318.10
$1,442.32
$1,883.56 		$1,533.10
$1,650.34
$1,774.56
$2,215.80 		$1,865.34
$1,982.58
$2,106.80
$2,548.04 		$332.24
Toc - Plan #67 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$490.86
$557.11
$627.30
$876.65
$1,332.16 		$866.36
$932.61
$1,002.80
$1,252.15 		$1,241.86
$1,308.11
$1,378.30
$1,627.65 		$1,617.36
$1,683.61
$1,753.80
$2,003.15 		$375.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$981.72
$1,114.22
$1,254.60
$1,753.30
$2,664.32 		$1,357.22
$1,489.72
$1,630.10
$2,128.80 		$1,732.72
$1,865.22
$2,005.60
$2,504.30 		$2,108.22
$2,240.72
$2,381.10
$2,879.80 		$375.50
Toc - Plan #68 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$449.48
$510.15
$574.42
$802.75
$1,219.86 		$793.32
$853.99
$918.26
$1,146.59 		$1,137.16
$1,197.83
$1,262.10
$1,490.43 		$1,481.00
$1,541.67
$1,605.94
$1,834.27 		$343.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.96
$1,020.30
$1,148.84
$1,605.50
$2,439.72 		$1,242.80
$1,364.14
$1,492.68
$1,949.34 		$1,586.64
$1,707.98
$1,836.52
$2,293.18 		$1,930.48
$2,051.82
$2,180.36
$2,637.02 		$343.84
Toc - Plan #69 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 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 		$493.61
$560.23
$630.82
$881.56
$1,339.62 		$871.21
$937.83
$1,008.42
$1,259.16 		$1,248.81
$1,315.43
$1,386.02
$1,636.76 		$1,626.41
$1,693.03
$1,763.62
$2,014.36 		$377.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$987.22
$1,120.46
$1,261.64
$1,763.12
$2,679.24 		$1,364.82
$1,498.06
$1,639.24
$2,140.72 		$1,742.42
$1,875.66
$2,016.84
$2,518.32 		$2,120.02
$2,253.26
$2,394.44
$2,895.92 		$377.60
Toc - Plan #70 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$484.23
$549.59
$618.84
$864.82
$1,314.18 		$854.66
$920.02
$989.27
$1,235.25 		$1,225.09
$1,290.45
$1,359.70
$1,605.68 		$1,595.52
$1,660.88
$1,730.13
$1,976.11 		$370.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$968.46
$1,099.18
$1,237.68
$1,729.64
$2,628.36 		$1,338.89
$1,469.61
$1,608.11
$2,100.07 		$1,709.32
$1,840.04
$1,978.54
$2,470.50 		$2,079.75
$2,210.47
$2,348.97
$2,840.93 		$370.43
Toc - Plan #71 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$477.46
$541.90
$610.18
$852.72
$1,295.79 		$842.71
$907.15
$975.43
$1,217.97 		$1,207.96
$1,272.40
$1,340.68
$1,583.22 		$1,573.21
$1,637.65
$1,705.93
$1,948.47 		$365.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954.92
$1,083.80
$1,220.36
$1,705.44
$2,591.58 		$1,320.17
$1,449.05
$1,585.61
$2,070.69 		$1,685.42
$1,814.30
$1,950.86
$2,435.94 		$2,050.67
$2,179.55
$2,316.11
$2,801.19 		$365.25
Toc - Plan #72 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$489.29
$555.33
$625.30
$873.85
$1,327.90 		$863.59
$929.63
$999.60
$1,248.15 		$1,237.89
$1,303.93
$1,373.90
$1,622.45 		$1,612.19
$1,678.23
$1,748.20
$1,996.75 		$374.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$978.58
$1,110.66
$1,250.60
$1,747.70
$2,655.80 		$1,352.88
$1,484.96
$1,624.90
$2,122.00 		$1,727.18
$1,859.26
$1,999.20
$2,496.30 		$2,101.48
$2,233.56
$2,373.50
$2,870.60 		$374.30
Toc - Plan #73 Ambetter from Superior HealthPlan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$516.19
$585.86
$659.67
$921.89
$1,400.90 		$911.06
$980.73
$1,054.54
$1,316.76 		$1,305.93
$1,375.60
$1,449.41
$1,711.63 		$1,700.80
$1,770.47
$1,844.28
$2,106.50 		$394.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,032.38
$1,171.72
$1,319.34
$1,843.78
$2,801.80 		$1,427.25
$1,566.59
$1,714.21
$2,238.65 		$1,822.12
$1,961.46
$2,109.08
$2,633.52 		$2,216.99
$2,356.33
$2,503.95
$3,028.39 		$394.87
Toc - Plan #74 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$454.00
$515.27
$580.19
$810.82
$1,232.12 		$801.30
$862.57
$927.49
$1,158.12 		$1,148.60
$1,209.87
$1,274.79
$1,505.42 		$1,495.90
$1,557.17
$1,622.09
$1,852.72 		$347.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.00
$1,030.54
$1,160.38
$1,621.64
$2,464.24 		$1,255.30
$1,377.84
$1,507.68
$1,968.94 		$1,602.60
$1,725.14
$1,854.98
$2,316.24 		$1,949.90
$2,072.44
$2,202.28
$2,663.54 		$347.30
Toc - Plan #75 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$468.67
$531.93
$598.95
$837.03
$1,271.95 		$827.20
$890.46
$957.48
$1,195.56 		$1,185.73
$1,248.99
$1,316.01
$1,554.09 		$1,544.26
$1,607.52
$1,674.54
$1,912.62 		$358.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$937.34
$1,063.86
$1,197.90
$1,674.06
$2,543.90 		$1,295.87
$1,422.39
$1,556.43
$2,032.59 		$1,654.40
$1,780.92
$1,914.96
$2,391.12 		$2,012.93
$2,139.45
$2,273.49
$2,749.65 		$358.53
Toc - Plan #76 Ambetter from Superior HealthPlan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$602.82
$684.19
$770.39
$1,076.62
$1,636.03 		$1,063.97
$1,145.34
$1,231.54
$1,537.77 		$1,525.12
$1,606.49
$1,692.69
$1,998.92 		$1,986.27
$2,067.64
$2,153.84
$2,460.07 		$461.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,205.64
$1,368.38
$1,540.78
$2,153.24
$3,272.06 		$1,666.79
$1,829.53
$2,001.93
$2,614.39 		$2,127.94
$2,290.68
$2,463.08
$3,075.54 		$2,589.09
$2,751.83
$2,924.23
$3,536.69 		$461.15
Toc - Plan #77 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$477.95
$542.46
$610.81
$853.60
$1,297.13 		$843.57
$908.08
$976.43
$1,219.22 		$1,209.19
$1,273.70
$1,342.05
$1,584.84 		$1,574.81
$1,639.32
$1,707.67
$1,950.46 		$365.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$955.90
$1,084.92
$1,221.62
$1,707.20
$2,594.26 		$1,321.52
$1,450.54
$1,587.24
$2,072.82 		$1,687.14
$1,816.16
$1,952.86
$2,438.44 		$2,052.76
$2,181.78
$2,318.48
$2,804.06 		$365.62

ADVERTISEMENT

Blue Cross and Blue Shield of Texas

Local: 1-888-697-0683 | Toll Free: 1-888-697-0683 | TTY: 1-800-735-2989
Toc - Plan #78 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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 		$427.25
$484.93
$546.03
$763.07
$1,159.56 		$754.10
$811.78
$872.88
$1,089.92 		$1,080.95
$1,138.63
$1,199.73
$1,416.77 		$1,407.80
$1,465.48
$1,526.58
$1,743.62 		$326.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.50
$969.86
$1,092.06
$1,526.14
$2,319.12 		$1,181.35
$1,296.71
$1,418.91
$1,852.99 		$1,508.20
$1,623.56
$1,745.76
$2,179.84 		$1,835.05
$1,950.41
$2,072.61
$2,506.69 		$326.85
Toc - Plan #79 Blue Cross and Blue Shield of Texas
Catastrophic

(HMO) Blue Advantage Security HMO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$316.34
$359.05
$404.28
$564.98
$858.55 		$558.34
$601.05
$646.28
$806.98 		$800.34
$843.05
$888.28
$1,048.98 		$1,042.34
$1,085.05
$1,130.28
$1,290.98 		$242.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.68
$718.10
$808.56
$1,129.96
$1,717.10 		$874.68
$960.10
$1,050.56
$1,371.96 		$1,116.68
$1,202.10
$1,292.56
$1,613.96 		$1,358.68
$1,444.10
$1,534.56
$1,855.96 		$242.00
Toc - Plan #80 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$2,050 $6,150 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 		$454.05
$515.34
$580.27
$810.93
$1,232.29 		$801.40
$862.69
$927.62
$1,158.28 		$1,148.75
$1,210.04
$1,274.97
$1,505.63 		$1,496.10
$1,557.39
$1,622.32
$1,852.98 		$347.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.10
$1,030.68
$1,160.54
$1,621.86
$2,464.58 		$1,255.45
$1,378.03
$1,507.89
$1,969.21 		$1,602.80
$1,725.38
$1,855.24
$2,316.56 		$1,950.15
$2,072.73
$2,202.59
$2,663.91 		$347.35
Toc - Plan #81 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.30
$399.86
$450.24
$629.21
$956.15 		$621.81
$669.37
$719.75
$898.72 		$891.32
$938.88
$989.26
$1,168.23 		$1,160.83
$1,208.39
$1,258.77
$1,437.74 		$269.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.60
$799.72
$900.48
$1,258.42
$1,912.30 		$974.11
$1,069.23
$1,169.99
$1,527.93 		$1,243.62
$1,338.74
$1,439.50
$1,797.44 		$1,513.13
$1,608.25
$1,709.01
$2,066.95 		$269.51
Toc - Plan #82 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO? 301

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$342.58
$388.83
$437.82
$611.85
$929.77 		$604.66
$650.91
$699.90
$873.93 		$866.74
$912.99
$961.98
$1,136.01 		$1,128.82
$1,175.07
$1,224.06
$1,398.09 		$262.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.16
$777.66
$875.64
$1,223.70
$1,859.54 		$947.24
$1,039.74
$1,137.72
$1,485.78 		$1,209.32
$1,301.82
$1,399.80
$1,747.86 		$1,471.40
$1,563.90
$1,661.88
$2,009.94 		$262.08
Toc - Plan #83 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 603

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,500 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 		$450.65
$511.49
$575.94
$804.87
$1,223.07 		$795.40
$856.24
$920.69
$1,149.62 		$1,140.15
$1,200.99
$1,265.44
$1,494.37 		$1,484.90
$1,545.74
$1,610.19
$1,839.12 		$344.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901.30
$1,022.98
$1,151.88
$1,609.74
$2,446.14 		$1,246.05
$1,367.73
$1,496.63
$1,954.49 		$1,590.80
$1,712.48
$1,841.38
$2,299.24 		$1,935.55
$2,057.23
$2,186.13
$2,643.99 		$344.75
Toc - Plan #84 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Plus Gold? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$850 $2,550 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 		$497.70
$564.89
$636.06
$888.89
$1,350.75 		$878.44
$945.63
$1,016.80
$1,269.63 		$1,259.18
$1,326.37
$1,397.54
$1,650.37 		$1,639.92
$1,707.11
$1,778.28
$2,031.11 		$380.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$995.40
$1,129.78
$1,272.12
$1,777.78
$2,701.50 		$1,376.14
$1,510.52
$1,652.86
$2,158.52 		$1,756.88
$1,891.26
$2,033.60
$2,539.26 		$2,137.62
$2,272.00
$2,414.34
$2,920.00 		$380.74
Toc - Plan #85 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$530.30
$601.89
$677.72
$947.12
$1,439.23 		$935.98
$1,007.57
$1,083.40
$1,352.80 		$1,341.66
$1,413.25
$1,489.08
$1,758.48 		$1,747.34
$1,818.93
$1,894.76
$2,164.16 		$405.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,060.60
$1,203.78
$1,355.44
$1,894.24
$2,878.46 		$1,466.28
$1,609.46
$1,761.12
$2,299.92 		$1,871.96
$2,015.14
$2,166.80
$2,705.60 		$2,277.64
$2,420.82
$2,572.48
$3,111.28 		$405.68
Toc - Plan #86 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Plus Bronze? 303

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$5,500 $16,500 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 		$410.42
$465.83
$524.52
$733.02
$1,113.89 		$724.39
$779.80
$838.49
$1,046.99 		$1,038.36
$1,093.77
$1,152.46
$1,360.96 		$1,352.33
$1,407.74
$1,466.43
$1,674.93 		$313.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.84
$931.66
$1,049.04
$1,466.04
$2,227.78 		$1,134.81
$1,245.63
$1,363.01
$1,780.01 		$1,448.78
$1,559.60
$1,676.98
$2,093.98 		$1,762.75
$1,873.57
$1,990.95
$2,407.95 		$313.97
Toc - Plan #87 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Plus Bronze? 305

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$6,100 $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 		$371.89
$422.09
$475.27
$664.19
$1,009.30 		$656.38
$706.58
$759.76
$948.68 		$940.87
$991.07
$1,044.25
$1,233.17 		$1,225.36
$1,275.56
$1,328.74
$1,517.66 		$284.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.78
$844.18
$950.54
$1,328.38
$2,018.60 		$1,028.27
$1,128.67
$1,235.03
$1,612.87 		$1,312.76
$1,413.16
$1,519.52
$1,897.36 		$1,597.25
$1,697.65
$1,804.01
$2,181.85 		$284.49
Toc - Plan #88 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 605

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$539.36
$612.17
$689.30
$963.29
$1,463.82 		$951.97
$1,024.78
$1,101.91
$1,375.90 		$1,364.58
$1,437.39
$1,514.52
$1,788.51 		$1,777.19
$1,850.00
$1,927.13
$2,201.12 		$412.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,078.72
$1,224.34
$1,378.60
$1,926.58
$2,927.64 		$1,491.33
$1,636.95
$1,791.21
$2,339.19 		$1,903.94
$2,049.56
$2,203.82
$2,751.80 		$2,316.55
$2,462.17
$2,616.43
$3,164.41 		$412.61

ADVERTISEMENT

Sendero Health Plans, Local Nonprofit

Local: 1-844-800-4693 | Toll Free: 1-844-800-4693 | TTY: 1-800-855-2880
Toc - Plan #89 Sendero Health Plans, Local Nonprofit
Silver

(HMO) Sendero IdealCare Silver / $20 PCP / $10 Gen Rx + Free Wellness & Preventive Screening + Free Dedicated Healthcare

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$4,250 $8,500 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 		$466.53
$529.51
$596.23
$833.22
$1,266.16 		$823.43
$886.41
$953.13
$1,190.12 		$1,180.33
$1,243.31
$1,310.03
$1,547.02 		$1,537.23
$1,600.21
$1,666.93
$1,903.92 		$356.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$933.06
$1,059.02
$1,192.46
$1,666.44
$2,532.32 		$1,289.96
$1,415.92
$1,549.36
$2,023.34 		$1,646.86
$1,772.82
$1,906.26
$2,380.24 		$2,003.76
$2,129.72
$2,263.16
$2,737.14 		$356.90
Toc - Plan #90 Sendero Health Plans, Local Nonprofit
Gold

(HMO) Sendero IdealCare Gold / Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + Free 24/7 Virtual

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$350 $700 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 		$467.25
$530.33
$597.15
$834.51
$1,268.12 		$824.70
$887.78
$954.60
$1,191.96 		$1,182.15
$1,245.23
$1,312.05
$1,549.41 		$1,539.60
$1,602.68
$1,669.50
$1,906.86 		$357.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.50
$1,060.66
$1,194.30
$1,669.02
$2,536.24 		$1,291.95
$1,418.11
$1,551.75
$2,026.47 		$1,649.40
$1,775.56
$1,909.20
$2,383.92 		$2,006.85
$2,133.01
$2,266.65
$2,741.37 		$357.45
Toc - Plan #91 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero IdealCare Bronze / $25 PCP / $11 Gen Rx + Free Wellness & Preventive Screening + Free Dedicated Healthcare

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$324.71
$368.55
$414.98
$579.93
$881.26 		$573.11
$616.95
$663.38
$828.33 		$821.51
$865.35
$911.78
$1,076.73 		$1,069.91
$1,113.75
$1,160.18
$1,325.13 		$248.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.42
$737.10
$829.96
$1,159.86
$1,762.52 		$897.82
$985.50
$1,078.36
$1,408.26 		$1,146.22
$1,233.90
$1,326.76
$1,656.66 		$1,394.62
$1,482.30
$1,575.16
$1,905.06 		$248.40
Toc - Plan #92 Sendero Health Plans, Local Nonprofit
Bronze

(HMO) Sendero IdealCare Bronze High Deductible / Free Wellness & Preventive Screening + Free Dedicated Healthcare Team +

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$309.22
$350.96
$395.18
$552.27
$839.22 		$545.77
$587.51
$631.73
$788.82 		$782.32
$824.06
$868.28
$1,025.37 		$1,018.87
$1,060.61
$1,104.83
$1,261.92 		$236.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.44
$701.92
$790.36
$1,104.54
$1,678.44 		$854.99
$938.47
$1,026.91
$1,341.09 		$1,091.54
$1,175.02
$1,263.46
$1,577.64 		$1,328.09
$1,411.57
$1,500.01
$1,814.19 		$236.55
Toc - Plan #93 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero IdealCare Bronze / $25 PCP / $75 Specialist + Free Wellness & Preventive Screening + Free Dedicated Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$334.27
$379.40
$427.20
$597.01
$907.21 		$589.99
$635.12
$682.92
$852.73 		$845.71
$890.84
$938.64
$1,108.45 		$1,101.43
$1,146.56
$1,194.36
$1,364.17 		$255.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.54
$758.80
$854.40
$1,194.02
$1,814.42 		$924.26
$1,014.52
$1,110.12
$1,449.74 		$1,179.98
$1,270.24
$1,365.84
$1,705.46 		$1,435.70
$1,525.96
$1,621.56
$1,961.18 		$255.72

ADVERTISEMENT

Ambetter from Superior Healthplan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-877-941-9237
Toc - Plan #94 Ambetter from Superior Healthplan
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$422.69
$479.74
$540.18
$754.90
$1,147.15 		$746.04
$803.09
$863.53
$1,078.25 		$1,069.39
$1,126.44
$1,186.88
$1,401.60 		$1,392.74
$1,449.79
$1,510.23
$1,724.95 		$323.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.38
$959.48
$1,080.36
$1,509.80
$2,294.30 		$1,168.73
$1,282.83
$1,403.71
$1,833.15 		$1,492.08
$1,606.18
$1,727.06
$2,156.50 		$1,815.43
$1,929.53
$2,050.41
$2,479.85 		$323.35
Toc - Plan #95 Ambetter from Superior Healthplan
Silver

(HMO) Ambetter Virtual Access Silver ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$454.72
$516.09
$581.12
$812.11
$1,234.08 		$802.57
$863.94
$928.97
$1,159.96 		$1,150.42
$1,211.79
$1,276.82
$1,507.81 		$1,498.27
$1,559.64
$1,624.67
$1,855.66 		$347.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.44
$1,032.18
$1,162.24
$1,624.22
$2,468.16 		$1,257.29
$1,380.03
$1,510.09
$1,972.07 		$1,605.14
$1,727.88
$1,857.94
$2,319.92 		$1,952.99
$2,075.73
$2,205.79
$2,667.77 		$347.85
Toc - Plan #96 Ambetter from Superior Healthplan
Gold

(HMO) Ambetter Virtual Access Gold ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 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 		$604.55
$686.16
$772.61
$1,079.72
$1,640.73 		$1,067.03
$1,148.64
$1,235.09
$1,542.20 		$1,529.51
$1,611.12
$1,697.57
$2,004.68 		$1,991.99
$2,073.60
$2,160.05
$2,467.16 		$462.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,209.10
$1,372.32
$1,545.22
$2,159.44
$3,281.46 		$1,671.58
$1,834.80
$2,007.70
$2,621.92 		$2,134.06
$2,297.28
$2,470.18
$3,084.40 		$2,596.54
$2,759.76
$2,932.66
$3,546.88 		$462.48

‡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 Caldwell County here.

Caldwell County is in “Rating Area 3” of Texas.

Currently, there are 96 plans offered in Rating Area 3.

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2022 Obamacare Plans for Caldwell County, TX

Plan Browser: 96 Plans
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