Obamacare 2022 Rates for Dallas County

Obamacare > Rates > Texas > Dallas 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 Dallas 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, 169 Plans and 2022 Rates for Dallas County, Texas

Below, you’ll find a summary of the 169 plans for Dallas 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 		$262.34
$297.74
$335.25
$468.52
$711.96 		$463.02
$498.42
$535.93
$669.20 		$663.70
$699.10
$736.61
$869.88 		$864.38
$899.78
$937.29
$1,070.56 		$200.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524.68
$595.48
$670.50
$937.04
$1,423.92 		$725.36
$796.16
$871.18
$1,137.72 		$926.04
$996.84
$1,071.86
$1,338.40 		$1,126.72
$1,197.52
$1,272.54
$1,539.08 		$200.68
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 		$266.64
$302.62
$340.75
$476.19
$723.62 		$470.61
$506.59
$544.72
$680.16 		$674.58
$710.56
$748.69
$884.13 		$878.55
$914.53
$952.66
$1,088.10 		$203.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$533.28
$605.24
$681.50
$952.38
$1,447.24 		$737.25
$809.21
$885.47
$1,156.35 		$941.22
$1,013.18
$1,089.44
$1,360.32 		$1,145.19
$1,217.15
$1,293.41
$1,564.29 		$203.97
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 		$262.65
$298.10
$335.66
$469.08
$712.81 		$463.57
$499.02
$536.58
$670.00 		$664.49
$699.94
$737.50
$870.92 		$865.41
$900.86
$938.42
$1,071.84 		$200.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$525.30
$596.20
$671.32
$938.16
$1,425.62 		$726.22
$797.12
$872.24
$1,139.08 		$927.14
$998.04
$1,073.16
$1,340.00 		$1,128.06
$1,198.96
$1,274.08
$1,540.92 		$200.92
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 		$314.17
$356.57
$401.50
$561.09
$852.63 		$554.50
$596.90
$641.83
$801.42 		$794.83
$837.23
$882.16
$1,041.75 		$1,035.16
$1,077.56
$1,122.49
$1,282.08 		$240.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.34
$713.14
$803.00
$1,122.18
$1,705.26 		$868.67
$953.47
$1,043.33
$1,362.51 		$1,109.00
$1,193.80
$1,283.66
$1,602.84 		$1,349.33
$1,434.13
$1,523.99
$1,843.17 		$240.33
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 		$367.20
$416.77
$469.27
$655.81
$996.57 		$648.10
$697.67
$750.17
$936.71 		$929.00
$978.57
$1,031.07
$1,217.61 		$1,209.90
$1,259.47
$1,311.97
$1,498.51 		$280.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.40
$833.54
$938.54
$1,311.62
$1,993.14 		$1,015.30
$1,114.44
$1,219.44
$1,592.52 		$1,296.20
$1,395.34
$1,500.34
$1,873.42 		$1,577.10
$1,676.24
$1,781.24
$2,154.32 		$280.90
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 		$359.78
$408.34
$459.79
$642.55
$976.42 		$635.00
$683.56
$735.01
$917.77 		$910.22
$958.78
$1,010.23
$1,192.99 		$1,185.44
$1,234.00
$1,285.45
$1,468.21 		$275.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.56
$816.68
$919.58
$1,285.10
$1,952.84 		$994.78
$1,091.90
$1,194.80
$1,560.32 		$1,270.00
$1,367.12
$1,470.02
$1,835.54 		$1,545.22
$1,642.34
$1,745.24
$2,110.76 		$275.22
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 		$367.55
$417.15
$469.71
$656.42
$997.49 		$648.71
$698.31
$750.87
$937.58 		$929.87
$979.47
$1,032.03
$1,218.74 		$1,211.03
$1,260.63
$1,313.19
$1,499.90 		$281.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.10
$834.30
$939.42
$1,312.84
$1,994.98 		$1,016.26
$1,115.46
$1,220.58
$1,594.00 		$1,297.42
$1,396.62
$1,501.74
$1,875.16 		$1,578.58
$1,677.78
$1,782.90
$2,156.32 		$281.16
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 		$217.08
$246.38
$277.42
$387.69
$589.13 		$383.14
$412.44
$443.48
$553.75 		$549.20
$578.50
$609.54
$719.81 		$715.26
$744.56
$775.60
$885.87 		$166.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$434.16
$492.76
$554.84
$775.38
$1,178.26 		$600.22
$658.82
$720.90
$941.44 		$766.28
$824.88
$886.96
$1,107.50 		$932.34
$990.94
$1,053.02
$1,273.56 		$166.06
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 		$314.25
$356.66
$401.59
$561.22
$852.83 		$554.64
$597.05
$641.98
$801.61 		$795.03
$837.44
$882.37
$1,042.00 		$1,035.42
$1,077.83
$1,122.76
$1,282.39 		$240.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.50
$713.32
$803.18
$1,122.44
$1,705.66 		$868.89
$953.71
$1,043.57
$1,362.83 		$1,109.28
$1,194.10
$1,283.96
$1,603.22 		$1,349.67
$1,434.49
$1,524.35
$1,843.61 		$240.39
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 		$362.14
$411.02
$462.81
$646.77
$982.83 		$639.17
$688.05
$739.84
$923.80 		$916.20
$965.08
$1,016.87
$1,200.83 		$1,193.23
$1,242.11
$1,293.90
$1,477.86 		$277.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.28
$822.04
$925.62
$1,293.54
$1,965.66 		$1,001.31
$1,099.07
$1,202.65
$1,570.57 		$1,278.34
$1,376.10
$1,479.68
$1,847.60 		$1,555.37
$1,653.13
$1,756.71
$2,124.63 		$277.03
Toc - Plan #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 		$288.17
$327.06
$368.27
$514.66
$782.07 		$508.61
$547.50
$588.71
$735.10 		$729.05
$767.94
$809.15
$955.54 		$949.49
$988.38
$1,029.59
$1,175.98 		$220.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.34
$654.12
$736.54
$1,029.32
$1,564.14 		$796.78
$874.56
$956.98
$1,249.76 		$1,017.22
$1,095.00
$1,177.42
$1,470.20 		$1,237.66
$1,315.44
$1,397.86
$1,690.64 		$220.44
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 		$360.19
$408.81
$460.31
$643.28
$977.53 		$635.73
$684.35
$735.85
$918.82 		$911.27
$959.89
$1,011.39
$1,194.36 		$1,186.81
$1,235.43
$1,286.93
$1,469.90 		$275.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.38
$817.62
$920.62
$1,286.56
$1,955.06 		$995.92
$1,093.16
$1,196.16
$1,562.10 		$1,271.46
$1,368.70
$1,471.70
$1,837.64 		$1,547.00
$1,644.24
$1,747.24
$2,113.18 		$275.54
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 		$373.45
$423.86
$477.26
$666.97
$1,013.52 		$659.13
$709.54
$762.94
$952.65 		$944.81
$995.22
$1,048.62
$1,238.33 		$1,230.49
$1,280.90
$1,334.30
$1,524.01 		$285.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.90
$847.72
$954.52
$1,333.94
$2,027.04 		$1,032.58
$1,133.40
$1,240.20
$1,619.62 		$1,318.26
$1,419.08
$1,525.88
$1,905.30 		$1,603.94
$1,704.76
$1,811.56
$2,190.98 		$285.68
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 		$388.66
$441.11
$496.69
$694.12
$1,054.79 		$685.97
$738.42
$794.00
$991.43 		$983.28
$1,035.73
$1,091.31
$1,288.74 		$1,280.59
$1,333.04
$1,388.62
$1,586.05 		$297.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.32
$882.22
$993.38
$1,388.24
$2,109.58 		$1,074.63
$1,179.53
$1,290.69
$1,685.55 		$1,371.94
$1,476.84
$1,588.00
$1,982.86 		$1,669.25
$1,774.15
$1,885.31
$2,280.17 		$297.31
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 		$369.74
$419.64
$472.52
$660.34
$1,003.45 		$652.58
$702.48
$755.36
$943.18 		$935.42
$985.32
$1,038.20
$1,226.02 		$1,218.26
$1,268.16
$1,321.04
$1,508.86 		$282.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.48
$839.28
$945.04
$1,320.68
$2,006.90 		$1,022.32
$1,122.12
$1,227.88
$1,603.52 		$1,305.16
$1,404.96
$1,510.72
$1,886.36 		$1,588.00
$1,687.80
$1,793.56
$2,169.20 		$282.84
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 		$277.80
$315.29
$355.02
$496.14
$753.93 		$490.31
$527.80
$567.53
$708.65 		$702.82
$740.31
$780.04
$921.16 		$915.33
$952.82
$992.55
$1,133.67 		$212.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.60
$630.58
$710.04
$992.28
$1,507.86 		$768.11
$843.09
$922.55
$1,204.79 		$980.62
$1,055.60
$1,135.06
$1,417.30 		$1,193.13
$1,268.11
$1,347.57
$1,629.81 		$212.51
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 		$301.69
$342.41
$385.55
$538.81
$818.77 		$532.48
$573.20
$616.34
$769.60 		$763.27
$803.99
$847.13
$1,000.39 		$994.06
$1,034.78
$1,077.92
$1,231.18 		$230.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.38
$684.82
$771.10
$1,077.62
$1,637.54 		$834.17
$915.61
$1,001.89
$1,308.41 		$1,064.96
$1,146.40
$1,232.68
$1,539.20 		$1,295.75
$1,377.19
$1,463.47
$1,769.99 		$230.79
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 		$300.12
$340.62
$383.54
$535.99
$814.49 		$529.70
$570.20
$613.12
$765.57 		$759.28
$799.78
$842.70
$995.15 		$988.86
$1,029.36
$1,072.28
$1,224.73 		$229.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.24
$681.24
$767.08
$1,071.98
$1,628.98 		$829.82
$910.82
$996.66
$1,301.56 		$1,059.40
$1,140.40
$1,226.24
$1,531.14 		$1,288.98
$1,369.98
$1,455.82
$1,760.72 		$229.58
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 		$276.84
$314.20
$353.79
$494.41
$751.31 		$488.61
$525.97
$565.56
$706.18 		$700.38
$737.74
$777.33
$917.95 		$912.15
$949.51
$989.10
$1,129.72 		$211.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.68
$628.40
$707.58
$988.82
$1,502.62 		$765.45
$840.17
$919.35
$1,200.59 		$977.22
$1,051.94
$1,131.12
$1,412.36 		$1,188.99
$1,263.71
$1,342.89
$1,624.13 		$211.77
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 		$355.97
$404.01
$454.91
$635.74
$966.07 		$628.28
$676.32
$727.22
$908.05 		$900.59
$948.63
$999.53
$1,180.36 		$1,172.90
$1,220.94
$1,271.84
$1,452.67 		$272.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.94
$808.02
$909.82
$1,271.48
$1,932.14 		$984.25
$1,080.33
$1,182.13
$1,543.79 		$1,256.56
$1,352.64
$1,454.44
$1,816.10 		$1,528.87
$1,624.95
$1,726.75
$2,088.41 		$272.31
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 		$384.84
$436.79
$491.82
$687.31
$1,044.44 		$679.24
$731.19
$786.22
$981.71 		$973.64
$1,025.59
$1,080.62
$1,276.11 		$1,268.04
$1,319.99
$1,375.02
$1,570.51 		$294.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.68
$873.58
$983.64
$1,374.62
$2,088.88 		$1,064.08
$1,167.98
$1,278.04
$1,669.02 		$1,358.48
$1,462.38
$1,572.44
$1,963.42 		$1,652.88
$1,756.78
$1,866.84
$2,257.82 		$294.40
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 		$370.28
$420.26
$473.21
$661.31
$1,004.92 		$653.54
$703.52
$756.47
$944.57 		$936.80
$986.78
$1,039.73
$1,227.83 		$1,220.06
$1,270.04
$1,322.99
$1,511.09 		$283.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.56
$840.52
$946.42
$1,322.62
$2,009.84 		$1,023.82
$1,123.78
$1,229.68
$1,605.88 		$1,307.08
$1,407.04
$1,512.94
$1,889.14 		$1,590.34
$1,690.30
$1,796.20
$2,172.40 		$283.26
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 		$382.30
$433.90
$488.57
$682.78
$1,037.54 		$674.75
$726.35
$781.02
$975.23 		$967.20
$1,018.80
$1,073.47
$1,267.68 		$1,259.65
$1,311.25
$1,365.92
$1,560.13 		$292.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.60
$867.80
$977.14
$1,365.56
$2,075.08 		$1,057.05
$1,160.25
$1,269.59
$1,658.01 		$1,349.50
$1,452.70
$1,562.04
$1,950.46 		$1,641.95
$1,745.15
$1,854.49
$2,242.91 		$292.45
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 		$381.49
$432.98
$487.53
$681.32
$1,035.33 		$673.32
$724.81
$779.36
$973.15 		$965.15
$1,016.64
$1,071.19
$1,264.98 		$1,256.98
$1,308.47
$1,363.02
$1,556.81 		$291.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.98
$865.96
$975.06
$1,362.64
$2,070.66 		$1,054.81
$1,157.79
$1,266.89
$1,654.47 		$1,346.64
$1,449.62
$1,558.72
$1,946.30 		$1,638.47
$1,741.45
$1,850.55
$2,238.13 		$291.83
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 		$377.80
$428.79
$482.81
$674.73
$1,025.32 		$666.81
$717.80
$771.82
$963.74 		$955.82
$1,006.81
$1,060.83
$1,252.75 		$1,244.83
$1,295.82
$1,349.84
$1,541.76 		$289.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.60
$857.58
$965.62
$1,349.46
$2,050.64 		$1,044.61
$1,146.59
$1,254.63
$1,638.47 		$1,333.62
$1,435.60
$1,543.64
$1,927.48 		$1,622.63
$1,724.61
$1,832.65
$2,216.49 		$289.01
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 		$347.20
$394.06
$443.70
$620.07
$942.26 		$612.80
$659.66
$709.30
$885.67 		$878.40
$925.26
$974.90
$1,151.27 		$1,144.00
$1,190.86
$1,240.50
$1,416.87 		$265.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.40
$788.12
$887.40
$1,240.14
$1,884.52 		$960.00
$1,053.72
$1,153.00
$1,505.74 		$1,225.60
$1,319.32
$1,418.60
$1,771.34 		$1,491.20
$1,584.92
$1,684.20
$2,036.94 		$265.60
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 		$353.98
$401.76
$452.38
$632.19
$960.68 		$624.77
$672.55
$723.17
$902.98 		$895.56
$943.34
$993.96
$1,173.77 		$1,166.35
$1,214.13
$1,264.75
$1,444.56 		$270.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.96
$803.52
$904.76
$1,264.38
$1,921.36 		$978.75
$1,074.31
$1,175.55
$1,535.17 		$1,249.54
$1,345.10
$1,446.34
$1,805.96 		$1,520.33
$1,615.89
$1,717.13
$2,076.75 		$270.79
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 		$405.12
$459.80
$517.73
$723.53
$1,099.47 		$715.03
$769.71
$827.64
$1,033.44 		$1,024.94
$1,079.62
$1,137.55
$1,343.35 		$1,334.85
$1,389.53
$1,447.46
$1,653.26 		$309.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.24
$919.60
$1,035.46
$1,447.06
$2,198.94 		$1,120.15
$1,229.51
$1,345.37
$1,756.97 		$1,430.06
$1,539.42
$1,655.28
$2,066.88 		$1,739.97
$1,849.33
$1,965.19
$2,376.79 		$309.91
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 		$382.89
$434.57
$489.32
$683.83
$1,039.14 		$675.79
$727.47
$782.22
$976.73 		$968.69
$1,020.37
$1,075.12
$1,269.63 		$1,261.59
$1,313.27
$1,368.02
$1,562.53 		$292.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.78
$869.14
$978.64
$1,367.66
$2,078.28 		$1,058.68
$1,162.04
$1,271.54
$1,660.56 		$1,351.58
$1,454.94
$1,564.44
$1,953.46 		$1,644.48
$1,747.84
$1,857.34
$2,246.36 		$292.90
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 		$356.48
$404.59
$455.57
$636.65
$967.46 		$629.18
$677.29
$728.27
$909.35 		$901.88
$949.99
$1,000.97
$1,182.05 		$1,174.58
$1,222.69
$1,273.67
$1,454.75 		$272.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.96
$809.18
$911.14
$1,273.30
$1,934.92 		$985.66
$1,081.88
$1,183.84
$1,546.00 		$1,258.36
$1,354.58
$1,456.54
$1,818.70 		$1,531.06
$1,627.28
$1,729.24
$2,091.40 		$272.70
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 		$299.12
$339.49
$382.27
$534.22
$811.79 		$527.94
$568.31
$611.09
$763.04 		$756.76
$797.13
$839.91
$991.86 		$985.58
$1,025.95
$1,068.73
$1,220.68 		$228.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.24
$678.98
$764.54
$1,068.44
$1,623.58 		$827.06
$907.80
$993.36
$1,297.26 		$1,055.88
$1,136.62
$1,222.18
$1,526.08 		$1,284.70
$1,365.44
$1,451.00
$1,754.90 		$228.82
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 		$307.38
$348.86
$392.81
$548.96
$834.19 		$542.52
$584.00
$627.95
$784.10 		$777.66
$819.14
$863.09
$1,019.24 		$1,012.80
$1,054.28
$1,098.23
$1,254.38 		$235.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.76
$697.72
$785.62
$1,097.92
$1,668.38 		$849.90
$932.86
$1,020.76
$1,333.06 		$1,085.04
$1,168.00
$1,255.90
$1,568.20 		$1,320.18
$1,403.14
$1,491.04
$1,803.34 		$235.14
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 		$308.29
$349.90
$393.98
$550.59
$836.67 		$544.12
$585.73
$629.81
$786.42 		$779.95
$821.56
$865.64
$1,022.25 		$1,015.78
$1,057.39
$1,101.47
$1,258.08 		$235.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.58
$699.80
$787.96
$1,101.18
$1,673.34 		$852.41
$935.63
$1,023.79
$1,337.01 		$1,088.24
$1,171.46
$1,259.62
$1,572.84 		$1,324.07
$1,407.29
$1,495.45
$1,808.67 		$235.83
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 		$363.78
$412.88
$464.90
$649.69
$987.27 		$642.06
$691.16
$743.18
$927.97 		$920.34
$969.44
$1,021.46
$1,206.25 		$1,198.62
$1,247.72
$1,299.74
$1,484.53 		$278.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.56
$825.76
$929.80
$1,299.38
$1,974.54 		$1,005.84
$1,104.04
$1,208.08
$1,577.66 		$1,284.12
$1,382.32
$1,486.36
$1,855.94 		$1,562.40
$1,660.60
$1,764.64
$2,134.22 		$278.28

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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
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 		$357.41
$405.65
$456.76
$638.32
$969.99 		$630.82
$679.06
$730.17
$911.73 		$904.23
$952.47
$1,003.58
$1,185.14 		$1,177.64
$1,225.88
$1,276.99
$1,458.55 		$273.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.82
$811.30
$913.52
$1,276.64
$1,939.98 		$988.23
$1,084.71
$1,186.93
$1,550.05 		$1,261.64
$1,358.12
$1,460.34
$1,823.46 		$1,535.05
$1,631.53
$1,733.75
$2,096.87 		$273.41
Toc - Plan #36 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 		$426.61
$484.19
$545.19
$761.90
$1,157.78 		$752.96
$810.54
$871.54
$1,088.25 		$1,079.31
$1,136.89
$1,197.89
$1,414.60 		$1,405.66
$1,463.24
$1,524.24
$1,740.95 		$326.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.22
$968.38
$1,090.38
$1,523.80
$2,315.56 		$1,179.57
$1,294.73
$1,416.73
$1,850.15 		$1,505.92
$1,621.08
$1,743.08
$2,176.50 		$1,832.27
$1,947.43
$2,069.43
$2,502.85 		$326.35
Toc - Plan #37 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 		$428.99
$486.90
$548.24
$766.17
$1,164.26 		$757.16
$815.07
$876.41
$1,094.34 		$1,085.33
$1,143.24
$1,204.58
$1,422.51 		$1,413.50
$1,471.41
$1,532.75
$1,750.68 		$328.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.98
$973.80
$1,096.48
$1,532.34
$2,328.52 		$1,186.15
$1,301.97
$1,424.65
$1,860.51 		$1,514.32
$1,630.14
$1,752.82
$2,188.68 		$1,842.49
$1,958.31
$2,080.99
$2,516.85 		$328.17
Toc - Plan #38 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 		$377.46
$428.41
$482.38
$674.13
$1,024.40 		$666.21
$717.16
$771.13
$962.88 		$954.96
$1,005.91
$1,059.88
$1,251.63 		$1,243.71
$1,294.66
$1,348.63
$1,540.38 		$288.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.92
$856.82
$964.76
$1,348.26
$2,048.80 		$1,043.67
$1,145.57
$1,253.51
$1,637.01 		$1,332.42
$1,434.32
$1,542.26
$1,925.76 		$1,621.17
$1,723.07
$1,831.01
$2,214.51 		$288.75
Toc - Plan #39 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 		$560.09
$635.69
$715.78
$1,000.30
$1,520.05 		$988.55
$1,064.15
$1,144.24
$1,428.76 		$1,417.01
$1,492.61
$1,572.70
$1,857.22 		$1,845.47
$1,921.07
$2,001.16
$2,285.68 		$428.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,120.18
$1,271.38
$1,431.56
$2,000.60
$3,040.10 		$1,548.64
$1,699.84
$1,860.02
$2,429.06 		$1,977.10
$2,128.30
$2,288.48
$2,857.52 		$2,405.56
$2,556.76
$2,716.94
$3,285.98 		$428.46
Toc - Plan #40 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 		$390.64
$443.37
$499.23
$697.67
$1,060.18 		$689.47
$742.20
$798.06
$996.50 		$988.30
$1,041.03
$1,096.89
$1,295.33 		$1,287.13
$1,339.86
$1,395.72
$1,594.16 		$298.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.28
$886.74
$998.46
$1,395.34
$2,120.36 		$1,080.11
$1,185.57
$1,297.29
$1,694.17 		$1,378.94
$1,484.40
$1,596.12
$1,993.00 		$1,677.77
$1,783.23
$1,894.95
$2,291.83 		$298.83
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 		$420.85
$477.65
$537.83
$751.61
$1,142.15 		$742.79
$799.59
$859.77
$1,073.55 		$1,064.73
$1,121.53
$1,181.71
$1,395.49 		$1,386.67
$1,443.47
$1,503.65
$1,717.43 		$321.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.70
$955.30
$1,075.66
$1,503.22
$2,284.30 		$1,163.64
$1,277.24
$1,397.60
$1,825.16 		$1,485.58
$1,599.18
$1,719.54
$2,147.10 		$1,807.52
$1,921.12
$2,041.48
$2,469.04 		$321.94
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 		$415.39
$471.45
$530.85
$741.86
$1,127.33 		$733.15
$789.21
$848.61
$1,059.62 		$1,050.91
$1,106.97
$1,166.37
$1,377.38 		$1,368.67
$1,424.73
$1,484.13
$1,695.14 		$317.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.78
$942.90
$1,061.70
$1,483.72
$2,254.66 		$1,148.54
$1,260.66
$1,379.46
$1,801.48 		$1,466.30
$1,578.42
$1,697.22
$2,119.24 		$1,784.06
$1,896.18
$2,014.98
$2,437.00 		$317.76
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 		$414.96
$470.97
$530.31
$741.10
$1,126.17 		$732.40
$788.41
$847.75
$1,058.54 		$1,049.84
$1,105.85
$1,165.19
$1,375.98 		$1,367.28
$1,423.29
$1,482.63
$1,693.42 		$317.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.92
$941.94
$1,060.62
$1,482.20
$2,252.34 		$1,147.36
$1,259.38
$1,378.06
$1,799.64 		$1,464.80
$1,576.82
$1,695.50
$2,117.08 		$1,782.24
$1,894.26
$2,012.94
$2,434.52 		$317.44
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 		$425.24
$482.64
$543.44
$759.46
$1,154.07 		$750.54
$807.94
$868.74
$1,084.76 		$1,075.84
$1,133.24
$1,194.04
$1,410.06 		$1,401.14
$1,458.54
$1,519.34
$1,735.36 		$325.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.48
$965.28
$1,086.88
$1,518.92
$2,308.14 		$1,175.78
$1,290.58
$1,412.18
$1,844.22 		$1,501.08
$1,615.88
$1,737.48
$2,169.52 		$1,826.38
$1,941.18
$2,062.78
$2,494.82 		$325.30
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 		$448.62
$509.17
$573.32
$801.21
$1,217.52 		$791.80
$852.35
$916.50
$1,144.39 		$1,134.98
$1,195.53
$1,259.68
$1,487.57 		$1,478.16
$1,538.71
$1,602.86
$1,830.75 		$343.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$897.24
$1,018.34
$1,146.64
$1,602.42
$2,435.04 		$1,240.42
$1,361.52
$1,489.82
$1,945.60 		$1,583.60
$1,704.70
$1,833.00
$2,288.78 		$1,926.78
$2,047.88
$2,176.18
$2,631.96 		$343.18
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 		$394.01
$447.19
$503.54
$703.69
$1,069.33 		$695.42
$748.60
$804.95
$1,005.10 		$996.83
$1,050.01
$1,106.36
$1,306.51 		$1,298.24
$1,351.42
$1,407.77
$1,607.92 		$301.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.02
$894.38
$1,007.08
$1,407.38
$2,138.66 		$1,089.43
$1,195.79
$1,308.49
$1,708.79 		$1,390.84
$1,497.20
$1,609.90
$2,010.20 		$1,692.25
$1,798.61
$1,911.31
$2,311.61 		$301.41
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 		$394.57
$447.82
$504.25
$704.68
$1,070.83 		$696.41
$749.66
$806.09
$1,006.52 		$998.25
$1,051.50
$1,107.93
$1,308.36 		$1,300.09
$1,353.34
$1,409.77
$1,610.20 		$301.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.14
$895.64
$1,008.50
$1,409.36
$2,141.66 		$1,090.98
$1,197.48
$1,310.34
$1,711.20 		$1,392.82
$1,499.32
$1,612.18
$2,013.04 		$1,694.66
$1,801.16
$1,914.02
$2,314.88 		$301.84
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 		$407.32
$462.30
$520.55
$727.46
$1,105.45 		$718.91
$773.89
$832.14
$1,039.05 		$1,030.50
$1,085.48
$1,143.73
$1,350.64 		$1,342.09
$1,397.07
$1,455.32
$1,662.23 		$311.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.64
$924.60
$1,041.10
$1,454.92
$2,210.90 		$1,126.23
$1,236.19
$1,352.69
$1,766.51 		$1,437.82
$1,547.78
$1,664.28
$2,078.10 		$1,749.41
$1,859.37
$1,975.87
$2,389.69 		$311.59
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 		$523.91
$594.63
$669.55
$935.69
$1,421.87 		$924.69
$995.41
$1,070.33
$1,336.47 		$1,325.47
$1,396.19
$1,471.11
$1,737.25 		$1,726.25
$1,796.97
$1,871.89
$2,138.03 		$400.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,047.82
$1,189.26
$1,339.10
$1,871.38
$2,843.74 		$1,448.60
$1,590.04
$1,739.88
$2,272.16 		$1,849.38
$1,990.82
$2,140.66
$2,672.94 		$2,250.16
$2,391.60
$2,541.44
$3,073.72 		$400.78
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 		$565.67
$642.03
$722.92
$1,010.28
$1,535.21 		$998.40
$1,074.76
$1,155.65
$1,443.01 		$1,431.13
$1,507.49
$1,588.38
$1,875.74 		$1,863.86
$1,940.22
$2,021.11
$2,308.47 		$432.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,131.34
$1,284.06
$1,445.84
$2,020.56
$3,070.42 		$1,564.07
$1,716.79
$1,878.57
$2,453.29 		$1,996.80
$2,149.52
$2,311.30
$2,886.02 		$2,429.53
$2,582.25
$2,744.03
$3,318.75 		$432.73
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 		$360.98
$409.70
$461.32
$644.69
$979.66 		$637.12
$685.84
$737.46
$920.83 		$913.26
$961.98
$1,013.60
$1,196.97 		$1,189.40
$1,238.12
$1,289.74
$1,473.11 		$276.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.96
$819.40
$922.64
$1,289.38
$1,959.32 		$998.10
$1,095.54
$1,198.78
$1,565.52 		$1,274.24
$1,371.68
$1,474.92
$1,841.66 		$1,550.38
$1,647.82
$1,751.06
$2,117.80 		$276.14
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 		$381.23
$432.68
$487.19
$680.85
$1,034.62 		$672.86
$724.31
$778.82
$972.48 		$964.49
$1,015.94
$1,070.45
$1,264.11 		$1,256.12
$1,307.57
$1,362.08
$1,555.74 		$291.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.46
$865.36
$974.38
$1,361.70
$2,069.24 		$1,054.09
$1,156.99
$1,266.01
$1,653.33 		$1,345.72
$1,448.62
$1,557.64
$1,944.96 		$1,637.35
$1,740.25
$1,849.27
$2,236.59 		$291.63
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 		$430.86
$489.02
$550.63
$769.50
$1,169.33 		$760.46
$818.62
$880.23
$1,099.10 		$1,090.06
$1,148.22
$1,209.83
$1,428.70 		$1,419.66
$1,477.82
$1,539.43
$1,758.30 		$329.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.72
$978.04
$1,101.26
$1,539.00
$2,338.66 		$1,191.32
$1,307.64
$1,430.86
$1,868.60 		$1,520.92
$1,637.24
$1,760.46
$2,198.20 		$1,850.52
$1,966.84
$2,090.06
$2,527.80 		$329.60
Toc - Plan #54 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 		$433.27
$491.75
$553.71
$773.81
$1,175.88 		$764.72
$823.20
$885.16
$1,105.26 		$1,096.17
$1,154.65
$1,216.61
$1,436.71 		$1,427.62
$1,486.10
$1,548.06
$1,768.16 		$331.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.54
$983.50
$1,107.42
$1,547.62
$2,351.76 		$1,197.99
$1,314.95
$1,438.87
$1,879.07 		$1,529.44
$1,646.40
$1,770.32
$2,210.52 		$1,860.89
$1,977.85
$2,101.77
$2,541.97 		$331.45
Toc - Plan #55 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 		$394.54
$447.79
$504.21
$704.63
$1,070.75 		$696.36
$749.61
$806.03
$1,006.45 		$998.18
$1,051.43
$1,107.85
$1,308.27 		$1,300.00
$1,353.25
$1,409.67
$1,610.09 		$301.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.08
$895.58
$1,008.42
$1,409.26
$2,141.50 		$1,090.90
$1,197.40
$1,310.24
$1,711.08 		$1,392.72
$1,499.22
$1,612.06
$2,012.90 		$1,694.54
$1,801.04
$1,913.88
$2,314.72 		$301.82
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 		$425.04
$482.41
$543.19
$759.11
$1,153.54 		$750.19
$807.56
$868.34
$1,084.26 		$1,075.34
$1,132.71
$1,193.49
$1,409.41 		$1,400.49
$1,457.86
$1,518.64
$1,734.56 		$325.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.08
$964.82
$1,086.38
$1,518.22
$2,307.08 		$1,175.23
$1,289.97
$1,411.53
$1,843.37 		$1,500.38
$1,615.12
$1,736.68
$2,168.52 		$1,825.53
$1,940.27
$2,061.83
$2,493.67 		$325.15
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 		$419.10
$475.67
$535.59
$748.49
$1,137.41 		$739.70
$796.27
$856.19
$1,069.09 		$1,060.30
$1,116.87
$1,176.79
$1,389.69 		$1,380.90
$1,437.47
$1,497.39
$1,710.29 		$320.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.20
$951.34
$1,071.18
$1,496.98
$2,274.82 		$1,158.80
$1,271.94
$1,391.78
$1,817.58 		$1,479.40
$1,592.54
$1,712.38
$2,138.18 		$1,800.00
$1,913.14
$2,032.98
$2,458.78 		$320.60
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 		$429.48
$487.45
$548.86
$767.04
$1,165.59 		$758.03
$816.00
$877.41
$1,095.59 		$1,086.58
$1,144.55
$1,205.96
$1,424.14 		$1,415.13
$1,473.10
$1,534.51
$1,752.69 		$328.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.96
$974.90
$1,097.72
$1,534.08
$2,331.18 		$1,187.51
$1,303.45
$1,426.27
$1,862.63 		$1,516.06
$1,632.00
$1,754.82
$2,191.18 		$1,844.61
$1,960.55
$2,083.37
$2,519.73 		$328.55
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 		$453.09
$514.25
$579.04
$809.21
$1,229.67 		$799.70
$860.86
$925.65
$1,155.82 		$1,146.31
$1,207.47
$1,272.26
$1,502.43 		$1,492.92
$1,554.08
$1,618.87
$1,849.04 		$346.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$906.18
$1,028.50
$1,158.08
$1,618.42
$2,459.34 		$1,252.79
$1,375.11
$1,504.69
$1,965.03 		$1,599.40
$1,721.72
$1,851.30
$2,311.64 		$1,946.01
$2,068.33
$2,197.91
$2,658.25 		$346.61
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 		$398.50
$452.29
$509.27
$711.71
$1,081.51 		$703.35
$757.14
$814.12
$1,016.56 		$1,008.20
$1,061.99
$1,118.97
$1,321.41 		$1,313.05
$1,366.84
$1,423.82
$1,626.26 		$304.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.00
$904.58
$1,018.54
$1,423.42
$2,163.02 		$1,101.85
$1,209.43
$1,323.39
$1,728.27 		$1,406.70
$1,514.28
$1,628.24
$2,033.12 		$1,711.55
$1,819.13
$1,933.09
$2,337.97 		$304.85
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 		$411.39
$466.91
$525.74
$734.72
$1,116.47 		$726.09
$781.61
$840.44
$1,049.42 		$1,040.79
$1,096.31
$1,155.14
$1,364.12 		$1,355.49
$1,411.01
$1,469.84
$1,678.82 		$314.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.78
$933.82
$1,051.48
$1,469.44
$2,232.94 		$1,137.48
$1,248.52
$1,366.18
$1,784.14 		$1,452.18
$1,563.22
$1,680.88
$2,098.84 		$1,766.88
$1,877.92
$1,995.58
$2,413.54 		$314.70
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 		$529.14
$600.56
$676.23
$945.02
$1,436.05 		$933.92
$1,005.34
$1,081.01
$1,349.80 		$1,338.70
$1,410.12
$1,485.79
$1,754.58 		$1,743.48
$1,814.90
$1,890.57
$2,159.36 		$404.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,058.28
$1,201.12
$1,352.46
$1,890.04
$2,872.10 		$1,463.06
$1,605.90
$1,757.24
$2,294.82 		$1,867.84
$2,010.68
$2,162.02
$2,699.60 		$2,272.62
$2,415.46
$2,566.80
$3,104.38 		$404.78
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 		$419.53
$476.15
$536.15
$749.26
$1,138.58 		$740.46
$797.08
$857.08
$1,070.19 		$1,061.39
$1,118.01
$1,178.01
$1,391.12 		$1,382.32
$1,438.94
$1,498.94
$1,712.05 		$320.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.06
$952.30
$1,072.30
$1,498.52
$2,277.16 		$1,159.99
$1,273.23
$1,393.23
$1,819.45 		$1,480.92
$1,594.16
$1,714.16
$2,140.38 		$1,801.85
$1,915.09
$2,035.09
$2,461.31 		$320.93
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 		$583.30
$662.03
$745.44
$1,041.75
$1,583.04 		$1,029.52
$1,108.25
$1,191.66
$1,487.97 		$1,475.74
$1,554.47
$1,637.88
$1,934.19 		$1,921.96
$2,000.69
$2,084.10
$2,380.41 		$446.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,166.60
$1,324.06
$1,490.88
$2,083.50
$3,166.08 		$1,612.82
$1,770.28
$1,937.10
$2,529.72 		$2,059.04
$2,216.50
$2,383.32
$2,975.94 		$2,505.26
$2,662.72
$2,829.54
$3,422.16 		$446.22
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 		$372.22
$422.46
$475.69
$664.77
$1,010.19 		$656.96
$707.20
$760.43
$949.51 		$941.70
$991.94
$1,045.17
$1,234.25 		$1,226.44
$1,276.68
$1,329.91
$1,518.99 		$284.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.44
$844.92
$951.38
$1,329.54
$2,020.38 		$1,029.18
$1,129.66
$1,236.12
$1,614.28 		$1,313.92
$1,414.40
$1,520.86
$1,899.02 		$1,598.66
$1,699.14
$1,805.60
$2,183.76 		$284.74
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 		$393.10
$446.16
$502.37
$702.07
$1,066.86 		$693.82
$746.88
$803.09
$1,002.79 		$994.54
$1,047.60
$1,103.81
$1,303.51 		$1,295.26
$1,348.32
$1,404.53
$1,604.23 		$300.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.20
$892.32
$1,004.74
$1,404.14
$2,133.72 		$1,086.92
$1,193.04
$1,305.46
$1,704.86 		$1,387.64
$1,493.76
$1,606.18
$2,005.58 		$1,688.36
$1,794.48
$1,906.90
$2,306.30 		$300.72
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 		$444.28
$504.25
$567.78
$793.47
$1,205.76 		$784.15
$844.12
$907.65
$1,133.34 		$1,124.02
$1,183.99
$1,247.52
$1,473.21 		$1,463.89
$1,523.86
$1,587.39
$1,813.08 		$339.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.56
$1,008.50
$1,135.56
$1,586.94
$2,411.52 		$1,228.43
$1,348.37
$1,475.43
$1,926.81 		$1,568.30
$1,688.24
$1,815.30
$2,266.68 		$1,908.17
$2,028.11
$2,155.17
$2,606.55 		$339.87
Toc - Plan #68 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 		$446.77
$507.08
$570.96
$797.92
$1,212.51 		$788.54
$848.85
$912.73
$1,139.69 		$1,130.31
$1,190.62
$1,254.50
$1,481.46 		$1,472.08
$1,532.39
$1,596.27
$1,823.23 		$341.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$893.54
$1,014.16
$1,141.92
$1,595.84
$2,425.02 		$1,235.31
$1,355.93
$1,483.69
$1,937.61 		$1,577.08
$1,697.70
$1,825.46
$2,279.38 		$1,918.85
$2,039.47
$2,167.23
$2,621.15 		$341.77
Toc - Plan #69 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 		$406.83
$461.74
$519.92
$726.58
$1,104.12 		$718.05
$772.96
$831.14
$1,037.80 		$1,029.27
$1,084.18
$1,142.36
$1,349.02 		$1,340.49
$1,395.40
$1,453.58
$1,660.24 		$311.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.66
$923.48
$1,039.84
$1,453.16
$2,208.24 		$1,124.88
$1,234.70
$1,351.06
$1,764.38 		$1,436.10
$1,545.92
$1,662.28
$2,075.60 		$1,747.32
$1,857.14
$1,973.50
$2,386.82 		$311.22
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 		$438.29
$497.44
$560.12
$782.76
$1,189.48 		$773.57
$832.72
$895.40
$1,118.04 		$1,108.85
$1,168.00
$1,230.68
$1,453.32 		$1,444.13
$1,503.28
$1,565.96
$1,788.60 		$335.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$876.58
$994.88
$1,120.24
$1,565.52
$2,378.96 		$1,211.86
$1,330.16
$1,455.52
$1,900.80 		$1,547.14
$1,665.44
$1,790.80
$2,236.08 		$1,882.42
$2,000.72
$2,126.08
$2,571.36 		$335.28
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 		$432.16
$490.49
$552.28
$771.81
$1,172.84 		$762.75
$821.08
$882.87
$1,102.40 		$1,093.34
$1,151.67
$1,213.46
$1,432.99 		$1,423.93
$1,482.26
$1,544.05
$1,763.58 		$330.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$864.32
$980.98
$1,104.56
$1,543.62
$2,345.68 		$1,194.91
$1,311.57
$1,435.15
$1,874.21 		$1,525.50
$1,642.16
$1,765.74
$2,204.80 		$1,856.09
$1,972.75
$2,096.33
$2,535.39 		$330.59
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 		$442.86
$502.64
$565.97
$790.94
$1,201.90 		$781.64
$841.42
$904.75
$1,129.72 		$1,120.42
$1,180.20
$1,243.53
$1,468.50 		$1,459.20
$1,518.98
$1,582.31
$1,807.28 		$338.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$885.72
$1,005.28
$1,131.94
$1,581.88
$2,403.80 		$1,224.50
$1,344.06
$1,470.72
$1,920.66 		$1,563.28
$1,682.84
$1,809.50
$2,259.44 		$1,902.06
$2,021.62
$2,148.28
$2,598.22 		$338.78
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 		$467.21
$530.27
$597.08
$834.42
$1,267.98 		$824.62
$887.68
$954.49
$1,191.83 		$1,182.03
$1,245.09
$1,311.90
$1,549.24 		$1,539.44
$1,602.50
$1,669.31
$1,906.65 		$357.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.42
$1,060.54
$1,194.16
$1,668.84
$2,535.96 		$1,291.83
$1,417.95
$1,551.57
$2,026.25 		$1,649.24
$1,775.36
$1,908.98
$2,383.66 		$2,006.65
$2,132.77
$2,266.39
$2,741.07 		$357.41
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 		$410.92
$466.38
$525.14
$733.88
$1,115.21 		$725.27
$780.73
$839.49
$1,048.23 		$1,039.62
$1,095.08
$1,153.84
$1,362.58 		$1,353.97
$1,409.43
$1,468.19
$1,676.93 		$314.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.84
$932.76
$1,050.28
$1,467.76
$2,230.42 		$1,136.19
$1,247.11
$1,364.63
$1,782.11 		$1,450.54
$1,561.46
$1,678.98
$2,096.46 		$1,764.89
$1,875.81
$1,993.33
$2,410.81 		$314.35
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 		$424.20
$481.46
$542.12
$757.61
$1,151.26 		$748.71
$805.97
$866.63
$1,082.12 		$1,073.22
$1,130.48
$1,191.14
$1,406.63 		$1,397.73
$1,454.99
$1,515.65
$1,731.14 		$324.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.40
$962.92
$1,084.24
$1,515.22
$2,302.52 		$1,172.91
$1,287.43
$1,408.75
$1,839.73 		$1,497.42
$1,611.94
$1,733.26
$2,164.24 		$1,821.93
$1,936.45
$2,057.77
$2,488.75 		$324.51
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 		$545.62
$619.27
$697.29
$974.47
$1,480.80 		$963.01
$1,036.66
$1,114.68
$1,391.86 		$1,380.40
$1,454.05
$1,532.07
$1,809.25 		$1,797.79
$1,871.44
$1,949.46
$2,226.64 		$417.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,091.24
$1,238.54
$1,394.58
$1,948.94
$2,961.60 		$1,508.63
$1,655.93
$1,811.97
$2,366.33 		$1,926.02
$2,073.32
$2,229.36
$2,783.72 		$2,343.41
$2,490.71
$2,646.75
$3,201.11 		$417.39
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 		$432.60
$490.99
$552.85
$772.61
$1,174.05 		$763.53
$821.92
$883.78
$1,103.54 		$1,094.46
$1,152.85
$1,214.71
$1,434.47 		$1,425.39
$1,483.78
$1,545.64
$1,765.40 		$330.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$865.20
$981.98
$1,105.70
$1,545.22
$2,348.10 		$1,196.13
$1,312.91
$1,436.63
$1,876.15 		$1,527.06
$1,643.84
$1,767.56
$2,207.08 		$1,857.99
$1,974.77
$2,098.49
$2,538.01 		$330.93

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 		$405.57
$460.33
$518.32
$724.36
$1,100.73 		$715.83
$770.59
$828.58
$1,034.62 		$1,026.09
$1,080.85
$1,138.84
$1,344.88 		$1,336.35
$1,391.11
$1,449.10
$1,655.14 		$310.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.14
$920.66
$1,036.64
$1,448.72
$2,201.46 		$1,121.40
$1,230.92
$1,346.90
$1,758.98 		$1,431.66
$1,541.18
$1,657.16
$2,069.24 		$1,741.92
$1,851.44
$1,967.42
$2,379.50 		$310.26
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 		$301.66
$342.39
$385.53
$538.77
$818.72 		$532.43
$573.16
$616.30
$769.54 		$763.20
$803.93
$847.07
$1,000.31 		$993.97
$1,034.70
$1,077.84
$1,231.08 		$230.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.32
$684.78
$771.06
$1,077.54
$1,637.44 		$834.09
$915.55
$1,001.83
$1,308.31 		$1,064.86
$1,146.32
$1,232.60
$1,539.08 		$1,295.63
$1,377.09
$1,463.37
$1,769.85 		$230.77
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 		$431.63
$489.90
$551.63
$770.90
$1,171.46 		$761.83
$820.10
$881.83
$1,101.10 		$1,092.03
$1,150.30
$1,212.03
$1,431.30 		$1,422.23
$1,480.50
$1,542.23
$1,761.50 		$330.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.26
$979.80
$1,103.26
$1,541.80
$2,342.92 		$1,193.46
$1,310.00
$1,433.46
$1,872.00 		$1,523.66
$1,640.20
$1,763.66
$2,202.20 		$1,853.86
$1,970.40
$2,093.86
$2,532.40 		$330.20
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 		$334.95
$380.17
$428.07
$598.22
$909.06 		$591.19
$636.41
$684.31
$854.46 		$847.43
$892.65
$940.55
$1,110.70 		$1,103.67
$1,148.89
$1,196.79
$1,366.94 		$256.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.90
$760.34
$856.14
$1,196.44
$1,818.12 		$926.14
$1,016.58
$1,112.38
$1,452.68 		$1,182.38
$1,272.82
$1,368.62
$1,708.92 		$1,438.62
$1,529.06
$1,624.86
$1,965.16 		$256.24
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 		$326.65
$370.75
$417.46
$583.40
$886.53 		$576.54
$620.64
$667.35
$833.29 		$826.43
$870.53
$917.24
$1,083.18 		$1,076.32
$1,120.42
$1,167.13
$1,333.07 		$249.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.30
$741.50
$834.92
$1,166.80
$1,773.06 		$903.19
$991.39
$1,084.81
$1,416.69 		$1,153.08
$1,241.28
$1,334.70
$1,666.58 		$1,402.97
$1,491.17
$1,584.59
$1,916.47 		$249.89
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 		$428.09
$485.89
$547.10
$764.58
$1,161.85 		$755.58
$813.38
$874.59
$1,092.07 		$1,083.07
$1,140.87
$1,202.08
$1,419.56 		$1,410.56
$1,468.36
$1,529.57
$1,747.05 		$327.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.18
$971.78
$1,094.20
$1,529.16
$2,323.70 		$1,183.67
$1,299.27
$1,421.69
$1,856.65 		$1,511.16
$1,626.76
$1,749.18
$2,184.14 		$1,838.65
$1,954.25
$2,076.67
$2,511.63 		$327.49
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 		$448.81
$509.40
$573.57
$801.57
$1,218.06 		$792.15
$852.74
$916.91
$1,144.91 		$1,135.49
$1,196.08
$1,260.25
$1,488.25 		$1,478.83
$1,539.42
$1,603.59
$1,831.59 		$343.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$897.62
$1,018.80
$1,147.14
$1,603.14
$2,436.12 		$1,240.96
$1,362.14
$1,490.48
$1,946.48 		$1,584.30
$1,705.48
$1,833.82
$2,289.82 		$1,927.64
$2,048.82
$2,177.16
$2,633.16 		$343.34
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 		$478.78
$543.41
$611.88
$855.10
$1,299.40 		$845.05
$909.68
$978.15
$1,221.37 		$1,211.32
$1,275.95
$1,344.42
$1,587.64 		$1,577.59
$1,642.22
$1,710.69
$1,953.91 		$366.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.56
$1,086.82
$1,223.76
$1,710.20
$2,598.80 		$1,323.83
$1,453.09
$1,590.03
$2,076.47 		$1,690.10
$1,819.36
$1,956.30
$2,442.74 		$2,056.37
$2,185.63
$2,322.57
$2,809.01 		$366.27
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 		$370.70
$420.75
$473.76
$662.08
$1,006.09 		$654.29
$704.34
$757.35
$945.67 		$937.88
$987.93
$1,040.94
$1,229.26 		$1,221.47
$1,271.52
$1,324.53
$1,512.85 		$283.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.40
$841.50
$947.52
$1,324.16
$2,012.18 		$1,024.99
$1,125.09
$1,231.11
$1,607.75 		$1,308.58
$1,408.68
$1,514.70
$1,891.34 		$1,592.17
$1,692.27
$1,798.29
$2,174.93 		$283.59
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 		$336.34
$381.74
$429.84
$600.70
$912.82 		$593.64
$639.04
$687.14
$858.00 		$850.94
$896.34
$944.44
$1,115.30 		$1,108.24
$1,153.64
$1,201.74
$1,372.60 		$257.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.68
$763.48
$859.68
$1,201.40
$1,825.64 		$929.98
$1,020.78
$1,116.98
$1,458.70 		$1,187.28
$1,278.08
$1,374.28
$1,716.00 		$1,444.58
$1,535.38
$1,631.58
$1,973.30 		$257.30
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 		$486.96
$552.71
$622.34
$869.72
$1,321.62 		$859.49
$925.24
$994.87
$1,242.25 		$1,232.02
$1,297.77
$1,367.40
$1,614.78 		$1,604.55
$1,670.30
$1,739.93
$1,987.31 		$372.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$973.92
$1,105.42
$1,244.68
$1,739.44
$2,643.24 		$1,346.45
$1,477.95
$1,617.21
$2,111.97 		$1,718.98
$1,850.48
$1,989.74
$2,484.50 		$2,091.51
$2,223.01
$2,362.27
$2,857.03 		$372.53
Toc - Plan #89 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) MyBlue Health Bronze? 402

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $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 		$263.12
$298.64
$336.26
$469.93
$714.10 		$464.40
$499.92
$537.54
$671.21 		$665.68
$701.20
$738.82
$872.49 		$866.96
$902.48
$940.10
$1,073.77 		$201.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.24
$597.28
$672.52
$939.86
$1,428.20 		$727.52
$798.56
$873.80
$1,141.14 		$928.80
$999.84
$1,075.08
$1,342.42 		$1,130.08
$1,201.12
$1,276.36
$1,543.70 		$201.28
Toc - Plan #90 Blue Cross and Blue Shield of Texas
Gold

(HMO) MyBlue Health Gold? 403

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

Annual Out of Pocket Expenses:

Individual Family
$1,100 $3,300 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$315.74
$358.37
$403.52
$563.91
$856.92 		$557.28
$599.91
$645.06
$805.45 		$798.82
$841.45
$886.60
$1,046.99 		$1,040.36
$1,082.99
$1,128.14
$1,288.53 		$241.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.48
$716.74
$807.04
$1,127.82
$1,713.84 		$873.02
$958.28
$1,048.58
$1,369.36 		$1,114.56
$1,199.82
$1,290.12
$1,610.90 		$1,356.10
$1,441.36
$1,531.66
$1,852.44 		$241.54
Toc - Plan #91 Blue Cross and Blue Shield of Texas
Silver

(HMO) MyBlue Health Silver? 405

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

Annual Out of Pocket Expenses:

Individual Family
$3,550 $10,650 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$332.28
$377.14
$424.66
$593.46
$901.82 		$586.48
$631.34
$678.86
$847.66 		$840.68
$885.54
$933.06
$1,101.86 		$1,094.88
$1,139.74
$1,187.26
$1,356.06 		$254.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.56
$754.28
$849.32
$1,186.92
$1,803.64 		$918.76
$1,008.48
$1,103.52
$1,441.12 		$1,172.96
$1,262.68
$1,357.72
$1,695.32 		$1,427.16
$1,516.88
$1,611.92
$1,949.52 		$254.20

ADVERTISEMENT

UnitedHealthcare

Local: 1-866-811-2704 | Toll Free: 1-866-811-2704 | TTY: 1-866-811-2704
Toc - Plan #92 UnitedHealthcare
Gold

(HMO) UHC Gold Value+ ($1 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$339.45
$385.27
$433.81
$606.25
$921.25 		$599.13
$644.95
$693.49
$865.93 		$858.81
$904.63
$953.17
$1,125.61 		$1,118.49
$1,164.31
$1,212.85
$1,385.29 		$259.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.90
$770.54
$867.62
$1,212.50
$1,842.50 		$938.58
$1,030.22
$1,127.30
$1,472.18 		$1,198.26
$1,289.90
$1,386.98
$1,731.86 		$1,457.94
$1,549.58
$1,646.66
$1,991.54 		$259.68
Toc - Plan #93 UnitedHealthcare
Gold

(HMO) UHC Gold Value+

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 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 		$343.33
$389.67
$438.77
$613.18
$931.78 		$605.97
$652.31
$701.41
$875.82 		$868.61
$914.95
$964.05
$1,138.46 		$1,131.25
$1,177.59
$1,226.69
$1,401.10 		$262.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.66
$779.34
$877.54
$1,226.36
$1,863.56 		$949.30
$1,041.98
$1,140.18
$1,489.00 		$1,211.94
$1,304.62
$1,402.82
$1,751.64 		$1,474.58
$1,567.26
$1,665.46
$2,014.28 		$262.64
Toc - Plan #94 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($1 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$341.67
$387.79
$436.65
$610.22
$927.29 		$603.05
$649.17
$698.03
$871.60 		$864.43
$910.55
$959.41
$1,132.98 		$1,125.81
$1,171.93
$1,220.79
$1,394.36 		$261.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.34
$775.58
$873.30
$1,220.44
$1,854.58 		$944.72
$1,036.96
$1,134.68
$1,481.82 		$1,206.10
$1,298.34
$1,396.06
$1,743.20 		$1,467.48
$1,559.72
$1,657.44
$2,004.58 		$261.38
Toc - Plan #95 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ Extra ($1 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$2,250 $4,500 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 		$353.52
$401.25
$451.80
$631.39
$959.45 		$623.96
$671.69
$722.24
$901.83 		$894.40
$942.13
$992.68
$1,172.27 		$1,164.84
$1,212.57
$1,263.12
$1,442.71 		$270.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.04
$802.50
$903.60
$1,262.78
$1,918.90 		$977.48
$1,072.94
$1,174.04
$1,533.22 		$1,247.92
$1,343.38
$1,444.48
$1,803.66 		$1,518.36
$1,613.82
$1,714.92
$2,074.10 		$270.44
Toc - Plan #96 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($5 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 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 		$345.66
$392.33
$441.76
$617.35
$938.13 		$610.09
$656.76
$706.19
$881.78 		$874.52
$921.19
$970.62
$1,146.21 		$1,138.95
$1,185.62
$1,235.05
$1,410.64 		$264.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.32
$784.66
$883.52
$1,234.70
$1,876.26 		$955.75
$1,049.09
$1,147.95
$1,499.13 		$1,220.18
$1,313.52
$1,412.38
$1,763.56 		$1,484.61
$1,577.95
$1,676.81
$2,027.99 		$264.43
Toc - Plan #97 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ (HSA)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$348.20
$395.20
$445.00
$621.88
$945.01 		$614.57
$661.57
$711.37
$888.25 		$880.94
$927.94
$977.74
$1,154.62 		$1,147.31
$1,194.31
$1,244.11
$1,420.99 		$266.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.40
$790.40
$890.00
$1,243.76
$1,890.02 		$962.77
$1,056.77
$1,156.37
$1,510.13 		$1,229.14
$1,323.14
$1,422.74
$1,776.50 		$1,495.51
$1,589.51
$1,689.11
$2,042.87 		$266.37
Toc - Plan #98 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First ($3 Rx + Unlimited Free App-based Care) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$336.48
$381.91
$430.02
$600.96
$913.21 		$593.89
$639.32
$687.43
$858.37 		$851.30
$896.73
$944.84
$1,115.78 		$1,108.71
$1,154.14
$1,202.25
$1,373.19 		$257.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.96
$763.82
$860.04
$1,201.92
$1,826.42 		$930.37
$1,021.23
$1,117.45
$1,459.33 		$1,187.78
$1,278.64
$1,374.86
$1,716.74 		$1,445.19
$1,536.05
$1,632.27
$1,974.15 		$257.41
Toc - Plan #99 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$348.32
$395.34
$445.15
$622.10
$945.34 		$614.78
$661.80
$711.61
$888.56 		$881.24
$928.26
$978.07
$1,155.02 		$1,147.70
$1,194.72
$1,244.53
$1,421.48 		$266.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.64
$790.68
$890.30
$1,244.20
$1,890.68 		$963.10
$1,057.14
$1,156.76
$1,510.66 		$1,229.56
$1,323.60
$1,423.22
$1,777.12 		$1,496.02
$1,590.06
$1,689.68
$2,043.58 		$266.46
Toc - Plan #100 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ Extra ($3 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$363.90
$413.02
$465.06
$649.92
$987.61 		$642.28
$691.40
$743.44
$928.30 		$920.66
$969.78
$1,021.82
$1,206.68 		$1,199.04
$1,248.16
$1,300.20
$1,485.06 		$278.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.80
$826.04
$930.12
$1,299.84
$1,975.22 		$1,006.18
$1,104.42
$1,208.50
$1,578.22 		$1,284.56
$1,382.80
$1,486.88
$1,856.60 		$1,562.94
$1,661.18
$1,765.26
$2,134.98 		$278.38
Toc - Plan #101 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$258.52
$293.42
$330.39
$461.72
$701.63 		$456.29
$491.19
$528.16
$659.49 		$654.06
$688.96
$725.93
$857.26 		$851.83
$886.73
$923.70
$1,055.03 		$197.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$517.04
$586.84
$660.78
$923.44
$1,403.26 		$714.81
$784.61
$858.55
$1,121.21 		$912.58
$982.38
$1,056.32
$1,318.98 		$1,110.35
$1,180.15
$1,254.09
$1,516.75 		$197.77
Toc - Plan #102 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential+ (Low Premium)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$242.97
$275.78
$310.52
$433.95
$659.43 		$428.85
$461.66
$496.40
$619.83 		$614.73
$647.54
$682.28
$805.71 		$800.61
$833.42
$868.16
$991.59 		$185.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$485.94
$551.56
$621.04
$867.90
$1,318.86 		$671.82
$737.44
$806.92
$1,053.78 		$857.70
$923.32
$992.80
$1,239.66 		$1,043.58
$1,109.20
$1,178.68
$1,425.54 		$185.88
Toc - Plan #103 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First ($3 Rx + Unlimited Free App-based Care) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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 		$252.47
$286.56
$322.66
$450.92
$685.22 		$445.61
$479.70
$515.80
$644.06 		$638.75
$672.84
$708.94
$837.20 		$831.89
$865.98
$902.08
$1,030.34 		$193.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.94
$573.12
$645.32
$901.84
$1,370.44 		$698.08
$766.26
$838.46
$1,094.98 		$891.22
$959.40
$1,031.60
$1,288.12 		$1,084.36
$1,152.54
$1,224.74
$1,481.26 		$193.14
Toc - Plan #104 UnitedHealthcare
Gold

(HMO) UHC Gold Value+ ($5 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$368.40
$418.14
$470.82
$657.97
$999.85 		$650.23
$699.97
$752.65
$939.80 		$932.06
$981.80
$1,034.48
$1,221.63 		$1,213.89
$1,263.63
$1,316.31
$1,503.46 		$281.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.80
$836.28
$941.64
$1,315.94
$1,999.70 		$1,018.63
$1,118.11
$1,223.47
$1,597.77 		$1,300.46
$1,399.94
$1,505.30
$1,879.60 		$1,582.29
$1,681.77
$1,787.13
$2,161.43 		$281.83

ADVERTISEMENT

Scott and White Health Plan

Local: 1-844-633-5325 | Toll Free: 1-844-633-5325 | TTY: 1-800-735-2989
Toc - Plan #105 Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$370.51
$420.53
$473.52
$661.74
$1,005.57 		$653.95
$703.97
$756.96
$945.18 		$937.39
$987.41
$1,040.40
$1,228.62 		$1,220.83
$1,270.85
$1,323.84
$1,512.06 		$283.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.02
$841.06
$947.04
$1,323.48
$2,011.14 		$1,024.46
$1,124.50
$1,230.48
$1,606.92 		$1,307.90
$1,407.94
$1,513.92
$1,890.36 		$1,591.34
$1,691.38
$1,797.36
$2,173.80 		$283.44
Toc - Plan #106 Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 003 ($0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$373.07
$423.44
$476.79
$666.31
$1,012.52 		$658.47
$708.84
$762.19
$951.71 		$943.87
$994.24
$1,047.59
$1,237.11 		$1,229.27
$1,279.64
$1,332.99
$1,522.51 		$285.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.14
$846.88
$953.58
$1,332.62
$2,025.04 		$1,031.54
$1,132.28
$1,238.98
$1,618.02 		$1,316.94
$1,417.68
$1,524.38
$1,903.42 		$1,602.34
$1,703.08
$1,809.78
$2,188.82 		$285.40
Toc - Plan #107 Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 004 ($0 deductible, $15 PCP visit, $0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$406.13
$460.95
$519.03
$725.34
$1,102.23 		$716.82
$771.64
$829.72
$1,036.03 		$1,027.51
$1,082.33
$1,140.41
$1,346.72 		$1,338.20
$1,393.02
$1,451.10
$1,657.41 		$310.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.26
$921.90
$1,038.06
$1,450.68
$2,204.46 		$1,122.95
$1,232.59
$1,348.75
$1,761.37 		$1,433.64
$1,543.28
$1,659.44
$2,072.06 		$1,744.33
$1,853.97
$1,970.13
$2,382.75 		$310.69
Toc - Plan #108 Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 005 ($0 deductible copay only, $0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$384.86
$436.81
$491.85
$687.35
$1,044.50 		$679.27
$731.22
$786.26
$981.76 		$973.68
$1,025.63
$1,080.67
$1,276.17 		$1,268.09
$1,320.04
$1,375.08
$1,570.58 		$294.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.72
$873.62
$983.70
$1,374.70
$2,089.00 		$1,064.13
$1,168.03
$1,278.11
$1,669.11 		$1,358.54
$1,462.44
$1,572.52
$1,963.52 		$1,652.95
$1,756.85
$1,866.93
$2,257.93 		$294.41
Toc - Plan #109 Scott and White Health Plan
Expanded Bronze

(HMO) BSW Savers Bronze HMO H S A 006 ($0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$297.57
$337.74
$380.29
$531.45
$807.60 		$525.21
$565.38
$607.93
$759.09 		$752.85
$793.02
$835.57
$986.73 		$980.49
$1,020.66
$1,063.21
$1,214.37 		$227.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$595.14
$675.48
$760.58
$1,062.90
$1,615.20 		$822.78
$903.12
$988.22
$1,290.54 		$1,050.42
$1,130.76
$1,215.86
$1,518.18 		$1,278.06
$1,358.40
$1,443.50
$1,745.82 		$227.64
Toc - Plan #110 Scott and White Health Plan
Expanded Bronze

(HMO) BSW Vital Bronze HMO 007 ($20 Generic Rx Drugs, $0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$307.36
$348.86
$392.81
$548.95
$834.18 		$542.49
$583.99
$627.94
$784.08 		$777.62
$819.12
$863.07
$1,019.21 		$1,012.75
$1,054.25
$1,098.20
$1,254.34 		$235.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.72
$697.72
$785.62
$1,097.90
$1,668.36 		$849.85
$932.85
$1,020.75
$1,333.03 		$1,084.98
$1,167.98
$1,255.88
$1,568.16 		$1,320.11
$1,403.11
$1,491.01
$1,803.29 		$235.13
Toc - Plan #111 Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 008 ($35 PCP visit, $0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$352.99
$400.65
$451.13
$630.45
$958.03 		$623.03
$670.69
$721.17
$900.49 		$893.07
$940.73
$991.21
$1,170.53 		$1,163.11
$1,210.77
$1,261.25
$1,440.57 		$270.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.98
$801.30
$902.26
$1,260.90
$1,916.06 		$976.02
$1,071.34
$1,172.30
$1,530.94 		$1,246.06
$1,341.38
$1,442.34
$1,800.98 		$1,516.10
$1,611.42
$1,712.38
$2,071.02 		$270.04
Toc - Plan #112 Scott and White Health Plan
Expanded Bronze

(HMO) BSW Vital Bronze HMO 009 (No limit on PCP visit copay, $0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 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 		$291.87
$331.28
$373.02
$521.29
$792.15 		$515.15
$554.56
$596.30
$744.57 		$738.43
$777.84
$819.58
$967.85 		$961.71
$1,001.12
$1,042.86
$1,191.13 		$223.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.74
$662.56
$746.04
$1,042.58
$1,584.30 		$807.02
$885.84
$969.32
$1,265.86 		$1,030.30
$1,109.12
$1,192.60
$1,489.14 		$1,253.58
$1,332.40
$1,415.88
$1,712.42 		$223.28
Toc - Plan #113 Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 012 ($0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.82
$414.07
$466.24
$651.57
$990.12 		$643.91
$693.16
$745.33
$930.66 		$923.00
$972.25
$1,024.42
$1,209.75 		$1,202.09
$1,251.34
$1,303.51
$1,488.84 		$279.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.64
$828.14
$932.48
$1,303.14
$1,980.24 		$1,008.73
$1,107.23
$1,211.57
$1,582.23 		$1,287.82
$1,386.32
$1,490.66
$1,861.32 		$1,566.91
$1,665.41
$1,769.75
$2,140.41 		$279.09

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-2025 | Toll Free: 1-888-560-2025

Toc - Plan #114 Molina Healthcare
Gold

(HMO) Molina Gold 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$383.60
$435.38
$490.24
$685.10
$1,041.08 		$677.05
$728.83
$783.69
$978.55 		$970.50
$1,022.28
$1,077.14
$1,272.00 		$1,263.95
$1,315.73
$1,370.59
$1,565.45 		$293.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.20
$870.76
$980.48
$1,370.20
$2,082.16 		$1,060.65
$1,164.21
$1,273.93
$1,663.65 		$1,354.10
$1,457.66
$1,567.38
$1,957.10 		$1,647.55
$1,751.11
$1,860.83
$2,250.55 		$293.45
Toc - Plan #115 Molina Healthcare
Silver

(HMO) Molina Silver 3 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$371.05
$421.14
$474.20
$662.69
$1,007.02 		$654.90
$704.99
$758.05
$946.54 		$938.75
$988.84
$1,041.90
$1,230.39 		$1,222.60
$1,272.69
$1,325.75
$1,514.24 		$283.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.10
$842.28
$948.40
$1,325.38
$2,014.04 		$1,025.95
$1,126.13
$1,232.25
$1,609.23 		$1,309.80
$1,409.98
$1,516.10
$1,893.08 		$1,593.65
$1,693.83
$1,799.95
$2,176.93 		$283.85
Toc - Plan #116 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

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 		$392.18
$445.12
$501.21
$700.43
$1,064.38 		$692.20
$745.14
$801.23
$1,000.45 		$992.22
$1,045.16
$1,101.25
$1,300.47 		$1,292.24
$1,345.18
$1,401.27
$1,600.49 		$300.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784.36
$890.24
$1,002.42
$1,400.86
$2,128.76 		$1,084.38
$1,190.26
$1,302.44
$1,700.88 		$1,384.40
$1,490.28
$1,602.46
$2,000.90 		$1,684.42
$1,790.30
$1,902.48
$2,300.92 		$300.02
Toc - Plan #117 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

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 		$371.36
$421.49
$474.60
$663.25
$1,007.87 		$655.45
$705.58
$758.69
$947.34 		$939.54
$989.67
$1,042.78
$1,231.43 		$1,223.63
$1,273.76
$1,326.87
$1,515.52 		$284.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.72
$842.98
$949.20
$1,326.50
$2,015.74 		$1,026.81
$1,127.07
$1,233.29
$1,610.59 		$1,310.90
$1,411.16
$1,517.38
$1,894.68 		$1,594.99
$1,695.25
$1,801.47
$2,178.77 		$284.09
Toc - Plan #118 Molina Healthcare
Silver

(HMO) Constant Care Silver 2 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

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 		$373.15
$423.52
$476.88
$666.44
$1,012.72 		$658.61
$708.98
$762.34
$951.90 		$944.07
$994.44
$1,047.80
$1,237.36 		$1,229.53
$1,279.90
$1,333.26
$1,522.82 		$285.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.30
$847.04
$953.76
$1,332.88
$2,025.44 		$1,031.76
$1,132.50
$1,239.22
$1,618.34 		$1,317.22
$1,417.96
$1,524.68
$1,903.80 		$1,602.68
$1,703.42
$1,810.14
$2,189.26 		$285.46
Toc - Plan #119 Molina Healthcare
Silver

(HMO) Constant Care Silver 4 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

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 		$367.55
$417.17
$469.73
$656.45
$997.54 		$648.73
$698.35
$750.91
$937.63 		$929.91
$979.53
$1,032.09
$1,218.81 		$1,211.09
$1,260.71
$1,313.27
$1,499.99 		$281.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.10
$834.34
$939.46
$1,312.90
$1,995.08 		$1,016.28
$1,115.52
$1,220.64
$1,594.08 		$1,297.46
$1,396.70
$1,501.82
$1,875.26 		$1,578.64
$1,677.88
$1,783.00
$2,156.44 		$281.18
Toc - Plan #120 Molina Healthcare
Silver

(HMO) Constant Care Silver 7 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

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 		$363.88
$413.00
$465.03
$649.88
$987.56 		$642.25
$691.37
$743.40
$928.25 		$920.62
$969.74
$1,021.77
$1,206.62 		$1,198.99
$1,248.11
$1,300.14
$1,484.99 		$278.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.76
$826.00
$930.06
$1,299.76
$1,975.12 		$1,006.13
$1,104.37
$1,208.43
$1,578.13 		$1,284.50
$1,382.74
$1,486.80
$1,856.50 		$1,562.87
$1,661.11
$1,765.17
$2,134.87 		$278.37
Toc - Plan #121 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

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 		$396.67
$450.22
$506.94
$708.45
$1,076.56 		$700.12
$753.67
$810.39
$1,011.90 		$1,003.57
$1,057.12
$1,113.84
$1,315.35 		$1,307.02
$1,360.57
$1,417.29
$1,618.80 		$303.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.34
$900.44
$1,013.88
$1,416.90
$2,153.12 		$1,096.79
$1,203.89
$1,317.33
$1,720.35 		$1,400.24
$1,507.34
$1,620.78
$2,023.80 		$1,703.69
$1,810.79
$1,924.23
$2,327.25 		$303.45
Toc - Plan #122 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

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 		$374.41
$424.95
$478.49
$668.69
$1,016.15 		$660.83
$711.37
$764.91
$955.11 		$947.25
$997.79
$1,051.33
$1,241.53 		$1,233.67
$1,284.21
$1,337.75
$1,527.95 		$286.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748.82
$849.90
$956.98
$1,337.38
$2,032.30 		$1,035.24
$1,136.32
$1,243.40
$1,623.80 		$1,321.66
$1,422.74
$1,529.82
$1,910.22 		$1,608.08
$1,709.16
$1,816.24
$2,196.64 		$286.42

ADVERTISEMENT

Friday Health Plans

Local: 1-844-451-4444 | Toll Free: 1-844-451-4444 | TTY: 1-800-659-2656
Toc - Plan #123 Friday Health Plans
Catastrophic

(EPO) Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

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 		$200.73
$227.83
$256.54
$358.51
$544.79 		$354.29
$381.39
$410.10
$512.07 		$507.85
$534.95
$563.66
$665.63 		$661.41
$688.51
$717.22
$819.19 		$153.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$401.46
$455.66
$513.08
$717.02
$1,089.58 		$555.02
$609.22
$666.64
$870.58 		$708.58
$762.78
$820.20
$1,024.14 		$862.14
$916.34
$973.76
$1,177.70 		$153.56
Toc - Plan #124 Friday Health Plans
Bronze

(EPO) Friday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

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 		$220.79
$250.59
$282.16
$394.32
$599.21 		$389.69
$419.49
$451.06
$563.22 		$558.59
$588.39
$619.96
$732.12 		$727.49
$757.29
$788.86
$901.02 		$168.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$441.58
$501.18
$564.32
$788.64
$1,198.42 		$610.48
$670.08
$733.22
$957.54 		$779.38
$838.98
$902.12
$1,126.44 		$948.28
$1,007.88
$1,071.02
$1,295.34 		$168.90
Toc - Plan #125 Friday Health Plans
Expanded Bronze

(EPO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

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 		$225.75
$256.23
$288.51
$403.20
$612.70 		$398.45
$428.93
$461.21
$575.90 		$571.15
$601.63
$633.91
$748.60 		$743.85
$774.33
$806.61
$921.30 		$172.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$451.50
$512.46
$577.02
$806.40
$1,225.40 		$624.20
$685.16
$749.72
$979.10 		$796.90
$857.86
$922.42
$1,151.80 		$969.60
$1,030.56
$1,095.12
$1,324.50 		$172.70
Toc - Plan #126 Friday Health Plans
Expanded Bronze

(EPO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$232.41
$263.78
$297.02
$415.08
$630.75 		$410.20
$441.57
$474.81
$592.87 		$587.99
$619.36
$652.60
$770.66 		$765.78
$797.15
$830.39
$948.45 		$177.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$464.82
$527.56
$594.04
$830.16
$1,261.50 		$642.61
$705.35
$771.83
$1,007.95 		$820.40
$883.14
$949.62
$1,185.74 		$998.19
$1,060.93
$1,127.41
$1,363.53 		$177.79
Toc - Plan #127 Friday Health Plans
Silver

(EPO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.49
$351.27
$395.52
$552.74
$839.95 		$546.25
$588.03
$632.28
$789.50 		$783.01
$824.79
$869.04
$1,026.26 		$1,019.77
$1,061.55
$1,105.80
$1,263.02 		$236.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.98
$702.54
$791.04
$1,105.48
$1,679.90 		$855.74
$939.30
$1,027.80
$1,342.24 		$1,092.50
$1,176.06
$1,264.56
$1,579.00 		$1,329.26
$1,412.82
$1,501.32
$1,815.76 		$236.76
Toc - Plan #128 Friday Health Plans
Gold

(EPO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$292.28
$331.74
$373.53
$522.01
$793.24 		$515.87
$555.33
$597.12
$745.60 		$739.46
$778.92
$820.71
$969.19 		$963.05
$1,002.51
$1,044.30
$1,192.78 		$223.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.56
$663.48
$747.06
$1,044.02
$1,586.48 		$808.15
$887.07
$970.65
$1,267.61 		$1,031.74
$1,110.66
$1,194.24
$1,491.20 		$1,255.33
$1,334.25
$1,417.83
$1,714.79 		$223.59
Toc - Plan #129 Friday Health Plans
Expanded Bronze

(EPO) Friday Bronze Plus Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

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 		$227.81
$258.56
$291.14
$406.86
$618.27 		$402.08
$432.83
$465.41
$581.13 		$576.35
$607.10
$639.68
$755.40 		$750.62
$781.37
$813.95
$929.67 		$174.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$455.62
$517.12
$582.28
$813.72
$1,236.54 		$629.89
$691.39
$756.55
$987.99 		$804.16
$865.66
$930.82
$1,162.26 		$978.43
$1,039.93
$1,105.09
$1,336.53 		$174.27
Toc - Plan #130 Friday Health Plans
Silver

(EPO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.44
$355.76
$400.58
$559.81
$850.69 		$553.22
$595.54
$640.36
$799.59 		$793.00
$835.32
$880.14
$1,039.37 		$1,032.78
$1,075.10
$1,119.92
$1,279.15 		$239.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.88
$711.52
$801.16
$1,119.62
$1,701.38 		$866.66
$951.30
$1,040.94
$1,359.40 		$1,106.44
$1,191.08
$1,280.72
$1,599.18 		$1,346.22
$1,430.86
$1,520.50
$1,838.96 		$239.78
Toc - Plan #131 Friday Health Plans
Gold

(EPO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.61
$346.86
$390.57
$545.82
$829.42 		$539.40
$580.65
$624.36
$779.61 		$773.19
$814.44
$858.15
$1,013.40 		$1,006.98
$1,048.23
$1,091.94
$1,247.19 		$233.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.22
$693.72
$781.14
$1,091.64
$1,658.84 		$845.01
$927.51
$1,014.93
$1,325.43 		$1,078.80
$1,161.30
$1,248.72
$1,559.22 		$1,312.59
$1,395.09
$1,482.51
$1,793.01 		$233.79

ADVERTISEMENT

Ambetter from Superior Healthplan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-877-941-9237
Toc - Plan #132 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 		$382.57
$434.20
$488.91
$683.25
$1,038.26 		$675.23
$726.86
$781.57
$975.91 		$967.89
$1,019.52
$1,074.23
$1,268.57 		$1,260.55
$1,312.18
$1,366.89
$1,561.23 		$292.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.14
$868.40
$977.82
$1,366.50
$2,076.52 		$1,057.80
$1,161.06
$1,270.48
$1,659.16 		$1,350.46
$1,453.72
$1,563.14
$1,951.82 		$1,643.12
$1,746.38
$1,855.80
$2,244.48 		$292.66
Toc - Plan #133 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 		$411.56
$467.11
$525.96
$735.03
$1,116.94 		$726.39
$781.94
$840.79
$1,049.86 		$1,041.22
$1,096.77
$1,155.62
$1,364.69 		$1,356.05
$1,411.60
$1,470.45
$1,679.52 		$314.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.12
$934.22
$1,051.92
$1,470.06
$2,233.88 		$1,137.95
$1,249.05
$1,366.75
$1,784.89 		$1,452.78
$1,563.88
$1,681.58
$2,099.72 		$1,767.61
$1,878.71
$1,996.41
$2,414.55 		$314.83
Toc - Plan #134 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 		$547.17
$621.03
$699.28
$977.23
$1,485.00 		$965.75
$1,039.61
$1,117.86
$1,395.81 		$1,384.33
$1,458.19
$1,536.44
$1,814.39 		$1,802.91
$1,876.77
$1,955.02
$2,232.97 		$418.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,094.34
$1,242.06
$1,398.56
$1,954.46
$2,970.00 		$1,512.92
$1,660.64
$1,817.14
$2,373.04 		$1,931.50
$2,079.22
$2,235.72
$2,791.62 		$2,350.08
$2,497.80
$2,654.30
$3,210.20 		$418.58
Toc - Plan #135 Ambetter from Superior Healthplan
Silver

(HMO) Ambetter Value Silver 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 		$356.62
$404.75
$455.75
$636.90
$967.83 		$629.43
$677.56
$728.56
$909.71 		$902.24
$950.37
$1,001.37
$1,182.52 		$1,175.05
$1,223.18
$1,274.18
$1,455.33 		$272.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.24
$809.50
$911.50
$1,273.80
$1,935.66 		$986.05
$1,082.31
$1,184.31
$1,546.61 		$1,258.86
$1,355.12
$1,457.12
$1,819.42 		$1,531.67
$1,627.93
$1,729.93
$2,092.23 		$272.81
Toc - Plan #136 Ambetter from Superior Healthplan
Silver

(HMO) Ambetter Value Silver 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 		$329.37
$373.82
$420.92
$588.23
$893.87 		$581.33
$625.78
$672.88
$840.19 		$833.29
$877.74
$924.84
$1,092.15 		$1,085.25
$1,129.70
$1,176.80
$1,344.11 		$251.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658.74
$747.64
$841.84
$1,176.46
$1,787.74 		$910.70
$999.60
$1,093.80
$1,428.42 		$1,162.66
$1,251.56
$1,345.76
$1,680.38 		$1,414.62
$1,503.52
$1,597.72
$1,932.34 		$251.96
Toc - Plan #137 Ambetter from Superior Healthplan
Silver

(HMO) Ambetter Value Silver 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 		$329.84
$374.35
$421.52
$589.07
$895.15 		$582.16
$626.67
$673.84
$841.39 		$834.48
$878.99
$926.16
$1,093.71 		$1,086.80
$1,131.31
$1,178.48
$1,346.03 		$252.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.68
$748.70
$843.04
$1,178.14
$1,790.30 		$912.00
$1,001.02
$1,095.36
$1,430.46 		$1,164.32
$1,253.34
$1,347.68
$1,682.78 		$1,416.64
$1,505.66
$1,600.00
$1,935.10 		$252.32
Toc - Plan #138 Ambetter from Superior Healthplan
Silver

(HMO) Ambetter Value Silver 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 		$340.51
$386.47
$435.16
$608.14
$924.12 		$600.99
$646.95
$695.64
$868.62 		$861.47
$907.43
$956.12
$1,129.10 		$1,121.95
$1,167.91
$1,216.60
$1,389.58 		$260.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.02
$772.94
$870.32
$1,216.28
$1,848.24 		$941.50
$1,033.42
$1,130.80
$1,476.76 		$1,201.98
$1,293.90
$1,391.28
$1,737.24 		$1,462.46
$1,554.38
$1,651.76
$1,997.72 		$260.48
Toc - Plan #139 Ambetter from Superior Healthplan
Gold

(HMO) Ambetter Value Gold 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 		$437.98
$497.10
$559.73
$782.21
$1,188.65 		$773.03
$832.15
$894.78
$1,117.26 		$1,108.08
$1,167.20
$1,229.83
$1,452.31 		$1,443.13
$1,502.25
$1,564.88
$1,787.36 		$335.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$875.96
$994.20
$1,119.46
$1,564.42
$2,377.30 		$1,211.01
$1,329.25
$1,454.51
$1,899.47 		$1,546.06
$1,664.30
$1,789.56
$2,234.52 		$1,881.11
$1,999.35
$2,124.61
$2,569.57 		$335.05

ADVERTISEMENT

Bright HealthCare

Local:  | Toll Free: 

Toc - Plan #140 Bright HealthCare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$341.80
$387.94
$436.81
$610.45
$927.63 		$603.27
$649.41
$698.28
$871.92 		$864.74
$910.88
$959.75
$1,133.39 		$1,126.21
$1,172.35
$1,221.22
$1,394.86 		$261.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.60
$775.88
$873.62
$1,220.90
$1,855.26 		$945.07
$1,037.35
$1,135.09
$1,482.37 		$1,206.54
$1,298.82
$1,396.56
$1,743.84 		$1,468.01
$1,560.29
$1,658.03
$2,005.31 		$261.47
Toc - Plan #141 Bright HealthCare
Gold

(HMO) 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:

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 		$383.79
$435.60
$490.48
$685.45
$1,041.60 		$677.39
$729.20
$784.08
$979.05 		$970.99
$1,022.80
$1,077.68
$1,272.65 		$1,264.59
$1,316.40
$1,371.28
$1,566.25 		$293.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.58
$871.20
$980.96
$1,370.90
$2,083.20 		$1,061.18
$1,164.80
$1,274.56
$1,664.50 		$1,354.78
$1,458.40
$1,568.16
$1,958.10 		$1,648.38
$1,752.00
$1,861.76
$2,251.70 		$293.60
Toc - Plan #142 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$350.84
$398.21
$448.38
$626.61
$952.19 		$619.24
$666.61
$716.78
$895.01 		$887.64
$935.01
$985.18
$1,163.41 		$1,156.04
$1,203.41
$1,253.58
$1,431.81 		$268.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$701.68
$796.42
$896.76
$1,253.22
$1,904.38 		$970.08
$1,064.82
$1,165.16
$1,521.62 		$1,238.48
$1,333.22
$1,433.56
$1,790.02 		$1,506.88
$1,601.62
$1,701.96
$2,058.42 		$268.40
Toc - Plan #143 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$353.56
$401.29
$451.85
$631.46
$959.56 		$624.03
$671.76
$722.32
$901.93 		$894.50
$942.23
$992.79
$1,172.40 		$1,164.97
$1,212.70
$1,263.26
$1,442.87 		$270.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.12
$802.58
$903.70
$1,262.92
$1,919.12 		$977.59
$1,073.05
$1,174.17
$1,533.39 		$1,248.06
$1,343.52
$1,444.64
$1,803.86 		$1,518.53
$1,613.99
$1,715.11
$2,074.33 		$270.47
Toc - Plan #144 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$365.26
$414.57
$466.80
$652.35
$991.31 		$644.68
$693.99
$746.22
$931.77 		$924.10
$973.41
$1,025.64
$1,211.19 		$1,203.52
$1,252.83
$1,305.06
$1,490.61 		$279.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.52
$829.14
$933.60
$1,304.70
$1,982.62 		$1,009.94
$1,108.56
$1,213.02
$1,584.12 		$1,289.36
$1,387.98
$1,492.44
$1,863.54 		$1,568.78
$1,667.40
$1,771.86
$2,142.96 		$279.42
Toc - Plan #145 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$357.11
$405.32
$456.39
$637.80
$969.20 		$630.30
$678.51
$729.58
$910.99 		$903.49
$951.70
$1,002.77
$1,184.18 		$1,176.68
$1,224.89
$1,275.96
$1,457.37 		$273.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.22
$810.64
$912.78
$1,275.60
$1,938.40 		$987.41
$1,083.83
$1,185.97
$1,548.79 		$1,260.60
$1,357.02
$1,459.16
$1,821.98 		$1,533.79
$1,630.21
$1,732.35
$2,095.17 		$273.19
Toc - Plan #146 Bright HealthCare
Silver

(HMO) 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:

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 		$364.42
$413.61
$465.72
$650.85
$989.03 		$643.20
$692.39
$744.50
$929.63 		$921.98
$971.17
$1,023.28
$1,208.41 		$1,200.76
$1,249.95
$1,302.06
$1,487.19 		$278.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.84
$827.22
$931.44
$1,301.70
$1,978.06 		$1,007.62
$1,106.00
$1,210.22
$1,580.48 		$1,286.40
$1,384.78
$1,489.00
$1,859.26 		$1,565.18
$1,663.56
$1,767.78
$2,138.04 		$278.78
Toc - Plan #147 Bright HealthCare
Expanded Bronze

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

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 		$256.65
$291.30
$328.00
$458.37
$696.54 		$452.99
$487.64
$524.34
$654.71 		$649.33
$683.98
$720.68
$851.05 		$845.67
$880.32
$917.02
$1,047.39 		$196.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$513.30
$582.60
$656.00
$916.74
$1,393.08 		$709.64
$778.94
$852.34
$1,113.08 		$905.98
$975.28
$1,048.68
$1,309.42 		$1,102.32
$1,171.62
$1,245.02
$1,505.76 		$196.34
Toc - Plan #148 Bright HealthCare
Expanded Bronze

(HMO) Bronze 5300 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$277.49
$314.95
$354.63
$495.59
$753.10 		$489.77
$527.23
$566.91
$707.87 		$702.05
$739.51
$779.19
$920.15 		$914.33
$951.79
$991.47
$1,132.43 		$212.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.98
$629.90
$709.26
$991.18
$1,506.20 		$767.26
$842.18
$921.54
$1,203.46 		$979.54
$1,054.46
$1,133.82
$1,415.74 		$1,191.82
$1,266.74
$1,346.10
$1,628.02 		$212.28
Toc - Plan #149 Bright HealthCare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$264.98
$300.75
$338.65
$473.26
$719.16 		$467.69
$503.46
$541.36
$675.97 		$670.40
$706.17
$744.07
$878.68 		$873.11
$908.88
$946.78
$1,081.39 		$202.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$529.96
$601.50
$677.30
$946.52
$1,438.32 		$732.67
$804.21
$880.01
$1,149.23 		$935.38
$1,006.92
$1,082.72
$1,351.94 		$1,138.09
$1,209.63
$1,285.43
$1,554.65 		$202.71
Toc - Plan #150 Bright HealthCare
Expanded Bronze

(HMO) 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:

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 		$296.10
$336.07
$378.41
$528.83
$803.61 		$522.61
$562.58
$604.92
$755.34 		$749.12
$789.09
$831.43
$981.85 		$975.63
$1,015.60
$1,057.94
$1,208.36 		$226.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.20
$672.14
$756.82
$1,057.66
$1,607.22 		$818.71
$898.65
$983.33
$1,284.17 		$1,045.22
$1,125.16
$1,209.84
$1,510.68 		$1,271.73
$1,351.67
$1,436.35
$1,737.19 		$226.51
Toc - Plan #151 Bright HealthCare
Expanded Bronze

(HMO) 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:

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 		$272.29
$309.05
$347.98
$486.31
$738.99 		$480.59
$517.35
$556.28
$694.61 		$688.89
$725.65
$764.58
$902.91 		$897.19
$933.95
$972.88
$1,111.21 		$208.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$544.58
$618.10
$695.96
$972.62
$1,477.98 		$752.88
$826.40
$904.26
$1,180.92 		$961.18
$1,034.70
$1,112.56
$1,389.22 		$1,169.48
$1,243.00
$1,320.86
$1,597.52 		$208.30
Toc - Plan #152 Bright HealthCare
Catastrophic

(HMO) Catastrophic 8700 ($0 Primary Care)

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 		$219.82
$249.49
$280.93
$392.60
$596.59 		$387.98
$417.65
$449.09
$560.76 		$556.14
$585.81
$617.25
$728.92 		$724.30
$753.97
$785.41
$897.08 		$168.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$439.64
$498.98
$561.86
$785.20
$1,193.18 		$607.80
$667.14
$730.02
$953.36 		$775.96
$835.30
$898.18
$1,121.52 		$944.12
$1,003.46
$1,066.34
$1,289.68 		$168.16
Toc - Plan #153 Bright HealthCare
Gold

(HMO) Super Gold 1 ($0 Primary Care + $0 Telehealth + $0 Specialist + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$300.78
$341.39
$384.40
$537.19
$816.32 		$530.88
$571.49
$614.50
$767.29 		$760.98
$801.59
$844.60
$997.39 		$991.08
$1,031.69
$1,074.70
$1,227.49 		$230.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.56
$682.78
$768.80
$1,074.38
$1,632.64 		$831.66
$912.88
$998.90
$1,304.48 		$1,061.76
$1,142.98
$1,229.00
$1,534.58 		$1,291.86
$1,373.08
$1,459.10
$1,764.68 		$230.10
Toc - Plan #154 Bright HealthCare
Gold

(HMO) Super Gold 2 + Adult Dental & Vision ($0 Primary Care + $0 Telehealth + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$338.61
$384.32
$432.75
$604.76
$918.99 		$597.65
$643.36
$691.79
$863.80 		$856.69
$902.40
$950.83
$1,122.84 		$1,115.73
$1,161.44
$1,209.87
$1,381.88 		$259.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677.22
$768.64
$865.50
$1,209.52
$1,837.98 		$936.26
$1,027.68
$1,124.54
$1,468.56 		$1,195.30
$1,286.72
$1,383.58
$1,727.60 		$1,454.34
$1,545.76
$1,642.62
$1,986.64 		$259.04
Toc - Plan #155 Bright HealthCare
Silver

(HMO) Super Silver 1 ($0 Primary Care + $0 Telehealth + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$308.74
$350.42
$394.57
$551.42
$837.93 		$544.93
$586.61
$630.76
$787.61 		$781.12
$822.80
$866.95
$1,023.80 		$1,017.31
$1,058.99
$1,103.14
$1,259.99 		$236.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.48
$700.84
$789.14
$1,102.84
$1,675.86 		$853.67
$937.03
$1,025.33
$1,339.03 		$1,089.86
$1,173.22
$1,261.52
$1,575.22 		$1,326.05
$1,409.41
$1,497.71
$1,811.41 		$236.19
Toc - Plan #156 Bright HealthCare
Silver

(HMO) Super Silver 2 ($0 Primary Care + $0 Telehealth + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$311.13
$353.13
$397.63
$555.68
$844.41 		$549.15
$591.15
$635.65
$793.70 		$787.17
$829.17
$873.67
$1,031.72 		$1,025.19
$1,067.19
$1,111.69
$1,269.74 		$238.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.26
$706.26
$795.26
$1,111.36
$1,688.82 		$860.28
$944.28
$1,033.28
$1,349.38 		$1,098.30
$1,182.30
$1,271.30
$1,587.40 		$1,336.32
$1,420.32
$1,509.32
$1,825.42 		$238.02
Toc - Plan #157 Bright HealthCare
Silver

(HMO) Super Silver 5 ($0 Primary Care + $0 Telehealth + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$321.43
$364.82
$410.78
$574.07
$872.35 		$567.32
$610.71
$656.67
$819.96 		$813.21
$856.60
$902.56
$1,065.85 		$1,059.10
$1,102.49
$1,148.45
$1,311.74 		$245.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.86
$729.64
$821.56
$1,148.14
$1,744.70 		$888.75
$975.53
$1,067.45
$1,394.03 		$1,134.64
$1,221.42
$1,313.34
$1,639.92 		$1,380.53
$1,467.31
$1,559.23
$1,885.81 		$245.89
Toc - Plan #158 Bright HealthCare
Silver

(HMO) Super Silver 3 ($0 Primary Care + $0 Telehealth + $0 Specialist + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$314.26
$356.68
$401.62
$561.26
$852.89 		$554.67
$597.09
$642.03
$801.67 		$795.08
$837.50
$882.44
$1,042.08 		$1,035.49
$1,077.91
$1,122.85
$1,282.49 		$240.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.52
$713.36
$803.24
$1,122.52
$1,705.78 		$868.93
$953.77
$1,043.65
$1,362.93 		$1,109.34
$1,194.18
$1,284.06
$1,603.34 		$1,349.75
$1,434.59
$1,524.47
$1,843.75 		$240.41
Toc - Plan #159 Bright HealthCare
Silver

(HMO) Super Silver 4 + Adult Dental & Vision ($0 Primary Care + $0 Telehealth + $0 Specialist + $0 Mental Health + $0 Pr

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$321.56
$364.97
$410.96
$574.31
$872.72 		$567.56
$610.97
$656.96
$820.31 		$813.56
$856.97
$902.96
$1,066.31 		$1,059.56
$1,102.97
$1,148.96
$1,312.31 		$246.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.12
$729.94
$821.92
$1,148.62
$1,745.44 		$889.12
$975.94
$1,067.92
$1,394.62 		$1,135.12
$1,221.94
$1,313.92
$1,640.62 		$1,381.12
$1,467.94
$1,559.92
$1,886.62 		$246.00
Toc - Plan #160 Bright HealthCare
Expanded Bronze

(HMO) Super Bronze 1 ($0 Primary Care + $0 Telehealth + $0 Mental Health + $0 Prescription List)

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 		$225.85
$256.34
$288.64
$403.37
$612.96 		$398.63
$429.12
$461.42
$576.15 		$571.41
$601.90
$634.20
$748.93 		$744.19
$774.68
$806.98
$921.71 		$172.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$451.70
$512.68
$577.28
$806.74
$1,225.92 		$624.48
$685.46
$750.06
$979.52 		$797.26
$858.24
$922.84
$1,152.30 		$970.04
$1,031.02
$1,095.62
$1,325.08 		$172.78
Toc - Plan #161 Bright HealthCare
Expanded Bronze

(HMO) Super Bronze 5 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$244.19
$277.15
$312.07
$436.12
$662.73 		$430.99
$463.95
$498.87
$622.92 		$617.79
$650.75
$685.67
$809.72 		$804.59
$837.55
$872.47
$996.52 		$186.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$488.38
$554.30
$624.14
$872.24
$1,325.46 		$675.18
$741.10
$810.94
$1,059.04 		$861.98
$927.90
$997.74
$1,245.84 		$1,048.78
$1,114.70
$1,184.54
$1,432.64 		$186.80
Toc - Plan #162 Bright HealthCare
Expanded Bronze

(HMO) Super Bronze 2 ($0 Primary Care + $0 Telehealth + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$233.18
$264.66
$298.01
$416.47
$632.86 		$411.57
$443.05
$476.40
$594.86 		$589.96
$621.44
$654.79
$773.25 		$768.35
$799.83
$833.18
$951.64 		$178.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$466.36
$529.32
$596.02
$832.94
$1,265.72 		$644.75
$707.71
$774.41
$1,011.33 		$823.14
$886.10
$952.80
$1,189.72 		$1,001.53
$1,064.49
$1,131.19
$1,368.11 		$178.39
Toc - Plan #163 Bright HealthCare
Expanded Bronze

(HMO) Super Bronze 4 ($0 Primary Care + $0 Telehealth + $0 Specialist + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$260.57
$295.74
$333.00
$465.37
$707.17 		$459.90
$495.07
$532.33
$664.70 		$659.23
$694.40
$731.66
$864.03 		$858.56
$893.73
$930.99
$1,063.36 		$199.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.14
$591.48
$666.00
$930.74
$1,414.34 		$720.47
$790.81
$865.33
$1,130.07 		$919.80
$990.14
$1,064.66
$1,329.40 		$1,119.13
$1,189.47
$1,263.99
$1,528.73 		$199.33
Toc - Plan #164 Bright HealthCare
Expanded Bronze

(HMO) Super Bronze 3 + Adult Dental & Vision ($0 Primary Care + $0 Telehealth + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$240.49
$272.96
$307.35
$429.52
$652.69 		$424.46
$456.93
$491.32
$613.49 		$608.43
$640.90
$675.29
$797.46 		$792.40
$824.87
$859.26
$981.43 		$183.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$480.98
$545.92
$614.70
$859.04
$1,305.38 		$664.95
$729.89
$798.67
$1,043.01 		$848.92
$913.86
$982.64
$1,226.98 		$1,032.89
$1,097.83
$1,166.61
$1,410.95 		$183.97
Toc - Plan #165 Bright HealthCare
Catastrophic

(HMO) Super Catastrophic 1 ($0 Primary Care)

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 		$193.44
$219.55
$247.22
$345.48
$525.00 		$341.42
$367.53
$395.20
$493.46 		$489.40
$515.51
$543.18
$641.44 		$637.38
$663.49
$691.16
$789.42 		$147.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$386.88
$439.10
$494.44
$690.96
$1,050.00 		$534.86
$587.08
$642.42
$838.94 		$682.84
$735.06
$790.40
$986.92 		$830.82
$883.04
$938.38
$1,134.90 		$147.98
Toc - Plan #166 Bright HealthCare
Expanded Bronze

(HMO) Bronze 8700 ($25 Generic)

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 		$253.20
$287.38
$323.59
$452.21
$687.18 		$446.90
$481.08
$517.29
$645.91 		$640.60
$674.78
$710.99
$839.61 		$834.30
$868.48
$904.69
$1,033.31 		$193.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$506.40
$574.76
$647.18
$904.42
$1,374.36 		$700.10
$768.46
$840.88
$1,098.12 		$893.80
$962.16
$1,034.58
$1,291.82 		$1,087.50
$1,155.86
$1,228.28
$1,485.52 		$193.70
Toc - Plan #167 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$346.21
$392.95
$442.46
$618.34
$939.62 		$611.06
$657.80
$707.31
$883.19 		$875.91
$922.65
$972.16
$1,148.04 		$1,140.76
$1,187.50
$1,237.01
$1,412.89 		$264.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.42
$785.90
$884.92
$1,236.68
$1,879.24 		$957.27
$1,050.75
$1,149.77
$1,501.53 		$1,222.12
$1,315.60
$1,414.62
$1,766.38 		$1,486.97
$1,580.45
$1,679.47
$2,031.23 		$264.85
Toc - Plan #168 Bright HealthCare
Expanded Bronze

(HMO) Super Bronze 6

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 		$222.81
$252.89
$284.76
$397.95
$604.72 		$393.26
$423.34
$455.21
$568.40 		$563.71
$593.79
$625.66
$738.85 		$734.16
$764.24
$796.11
$909.30 		$170.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$445.62
$505.78
$569.52
$795.90
$1,209.44 		$616.07
$676.23
$739.97
$966.35 		$786.52
$846.68
$910.42
$1,136.80 		$956.97
$1,017.13
$1,080.87
$1,307.25 		$170.45
Toc - Plan #169 Bright HealthCare
Silver

(HMO) Super Silver 7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$304.67
$345.80
$389.36
$544.14
$826.87 		$537.74
$578.87
$622.43
$777.21 		$770.81
$811.94
$855.50
$1,010.28 		$1,003.88
$1,045.01
$1,088.57
$1,243.35 		$233.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.34
$691.60
$778.72
$1,088.28
$1,653.74 		$842.41
$924.67
$1,011.79
$1,321.35 		$1,075.48
$1,157.74
$1,244.86
$1,554.42 		$1,308.55
$1,390.81
$1,477.93
$1,787.49 		$233.07

‡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 Dallas County here.

Dallas County is in “Rating Area 8” of Texas.

Currently, there are 169 plans offered in Rating Area 8.

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2022 Obamacare Plans for Dallas County, TX

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