Obamacare 2022 Rates for Montgomery County

Obamacare > Rates > Texas > Montgomery 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 Montgomery 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, 189 Plans and 2022 Rates for Montgomery County, Texas

Below, you’ll find a summary of the 189 plans for Montgomery 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 		$259.67
$294.71
$331.84
$463.75
$704.72 		$458.31
$493.35
$530.48
$662.39 		$656.95
$691.99
$729.12
$861.03 		$855.59
$890.63
$927.76
$1,059.67 		$198.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519.34
$589.42
$663.68
$927.50
$1,409.44 		$717.98
$788.06
$862.32
$1,126.14 		$916.62
$986.70
$1,060.96
$1,324.78 		$1,115.26
$1,185.34
$1,259.60
$1,523.42 		$198.64
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 		$263.92
$299.54
$337.28
$471.35
$716.26 		$465.81
$501.43
$539.17
$673.24 		$667.70
$703.32
$741.06
$875.13 		$869.59
$905.21
$942.95
$1,077.02 		$201.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$527.84
$599.08
$674.56
$942.70
$1,432.52 		$729.73
$800.97
$876.45
$1,144.59 		$931.62
$1,002.86
$1,078.34
$1,346.48 		$1,133.51
$1,204.75
$1,280.23
$1,548.37 		$201.89
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 		$259.98
$295.07
$332.24
$464.31
$705.56 		$458.86
$493.95
$531.12
$663.19 		$657.74
$692.83
$730.00
$862.07 		$856.62
$891.71
$928.88
$1,060.95 		$198.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519.96
$590.14
$664.48
$928.62
$1,411.12 		$718.84
$789.02
$863.36
$1,127.50 		$917.72
$987.90
$1,062.24
$1,326.38 		$1,116.60
$1,186.78
$1,261.12
$1,525.26 		$198.88
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 		$310.98
$352.95
$397.41
$555.39
$843.96 		$548.87
$590.84
$635.30
$793.28 		$786.76
$828.73
$873.19
$1,031.17 		$1,024.65
$1,066.62
$1,111.08
$1,269.06 		$237.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.96
$705.90
$794.82
$1,110.78
$1,687.92 		$859.85
$943.79
$1,032.71
$1,348.67 		$1,097.74
$1,181.68
$1,270.60
$1,586.56 		$1,335.63
$1,419.57
$1,508.49
$1,824.45 		$237.89
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 		$363.47
$412.53
$464.50
$649.14
$986.43 		$641.52
$690.58
$742.55
$927.19 		$919.57
$968.63
$1,020.60
$1,205.24 		$1,197.62
$1,246.68
$1,298.65
$1,483.29 		$278.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.94
$825.06
$929.00
$1,298.28
$1,972.86 		$1,004.99
$1,103.11
$1,207.05
$1,576.33 		$1,283.04
$1,381.16
$1,485.10
$1,854.38 		$1,561.09
$1,659.21
$1,763.15
$2,132.43 		$278.05
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 		$356.12
$404.19
$455.11
$636.02
$966.49 		$628.55
$676.62
$727.54
$908.45 		$900.98
$949.05
$999.97
$1,180.88 		$1,173.41
$1,221.48
$1,272.40
$1,453.31 		$272.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.24
$808.38
$910.22
$1,272.04
$1,932.98 		$984.67
$1,080.81
$1,182.65
$1,544.47 		$1,257.10
$1,353.24
$1,455.08
$1,816.90 		$1,529.53
$1,625.67
$1,727.51
$2,089.33 		$272.43
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 		$363.81
$412.91
$464.93
$649.74
$987.34 		$642.11
$691.21
$743.23
$928.04 		$920.41
$969.51
$1,021.53
$1,206.34 		$1,198.71
$1,247.81
$1,299.83
$1,484.64 		$278.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.62
$825.82
$929.86
$1,299.48
$1,974.68 		$1,005.92
$1,104.12
$1,208.16
$1,577.78 		$1,284.22
$1,382.42
$1,486.46
$1,856.08 		$1,562.52
$1,660.72
$1,764.76
$2,134.38 		$278.30
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 		$214.87
$243.87
$274.59
$383.74
$583.14 		$379.24
$408.24
$438.96
$548.11 		$543.61
$572.61
$603.33
$712.48 		$707.98
$736.98
$767.70
$876.85 		$164.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$429.74
$487.74
$549.18
$767.48
$1,166.28 		$594.11
$652.11
$713.55
$931.85 		$758.48
$816.48
$877.92
$1,096.22 		$922.85
$980.85
$1,042.29
$1,260.59 		$164.37
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 		$311.05
$353.03
$397.51
$555.52
$844.16 		$548.99
$590.97
$635.45
$793.46 		$786.93
$828.91
$873.39
$1,031.40 		$1,024.87
$1,066.85
$1,111.33
$1,269.34 		$237.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.10
$706.06
$795.02
$1,111.04
$1,688.32 		$860.04
$944.00
$1,032.96
$1,348.98 		$1,097.98
$1,181.94
$1,270.90
$1,586.92 		$1,335.92
$1,419.88
$1,508.84
$1,824.86 		$237.94
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 		$358.46
$406.84
$458.10
$640.19
$972.83 		$632.67
$681.05
$732.31
$914.40 		$906.88
$955.26
$1,006.52
$1,188.61 		$1,181.09
$1,229.47
$1,280.73
$1,462.82 		$274.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.92
$813.68
$916.20
$1,280.38
$1,945.66 		$991.13
$1,087.89
$1,190.41
$1,554.59 		$1,265.34
$1,362.10
$1,464.62
$1,828.80 		$1,539.55
$1,636.31
$1,738.83
$2,103.01 		$274.21
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 		$285.24
$323.74
$364.52
$509.42
$774.12 		$503.44
$541.94
$582.72
$727.62 		$721.64
$760.14
$800.92
$945.82 		$939.84
$978.34
$1,019.12
$1,164.02 		$218.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.48
$647.48
$729.04
$1,018.84
$1,548.24 		$788.68
$865.68
$947.24
$1,237.04 		$1,006.88
$1,083.88
$1,165.44
$1,455.24 		$1,225.08
$1,302.08
$1,383.64
$1,673.44 		$218.20
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 		$356.53
$404.65
$455.63
$636.74
$967.59 		$629.27
$677.39
$728.37
$909.48 		$902.01
$950.13
$1,001.11
$1,182.22 		$1,174.75
$1,222.87
$1,273.85
$1,454.96 		$272.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.06
$809.30
$911.26
$1,273.48
$1,935.18 		$985.80
$1,082.04
$1,184.00
$1,546.22 		$1,258.54
$1,354.78
$1,456.74
$1,818.96 		$1,531.28
$1,627.52
$1,729.48
$2,091.70 		$272.74
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 		$369.65
$419.55
$472.40
$660.18
$1,003.21 		$652.43
$702.33
$755.18
$942.96 		$935.21
$985.11
$1,037.96
$1,225.74 		$1,217.99
$1,267.89
$1,320.74
$1,508.52 		$282.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.30
$839.10
$944.80
$1,320.36
$2,006.42 		$1,022.08
$1,121.88
$1,227.58
$1,603.14 		$1,304.86
$1,404.66
$1,510.36
$1,885.92 		$1,587.64
$1,687.44
$1,793.14
$2,168.70 		$282.78
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 		$384.70
$436.63
$491.64
$687.06
$1,044.06 		$678.99
$730.92
$785.93
$981.35 		$973.28
$1,025.21
$1,080.22
$1,275.64 		$1,267.57
$1,319.50
$1,374.51
$1,569.93 		$294.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.40
$873.26
$983.28
$1,374.12
$2,088.12 		$1,063.69
$1,167.55
$1,277.57
$1,668.41 		$1,357.98
$1,461.84
$1,571.86
$1,962.70 		$1,652.27
$1,756.13
$1,866.15
$2,256.99 		$294.29
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 		$365.98
$415.38
$467.71
$653.62
$993.24 		$645.95
$695.35
$747.68
$933.59 		$925.92
$975.32
$1,027.65
$1,213.56 		$1,205.89
$1,255.29
$1,307.62
$1,493.53 		$279.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.96
$830.76
$935.42
$1,307.24
$1,986.48 		$1,011.93
$1,110.73
$1,215.39
$1,587.21 		$1,291.90
$1,390.70
$1,495.36
$1,867.18 		$1,571.87
$1,670.67
$1,775.33
$2,147.15 		$279.97
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 		$274.98
$312.09
$351.41
$491.09
$746.26 		$485.33
$522.44
$561.76
$701.44 		$695.68
$732.79
$772.11
$911.79 		$906.03
$943.14
$982.46
$1,122.14 		$210.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.96
$624.18
$702.82
$982.18
$1,492.52 		$760.31
$834.53
$913.17
$1,192.53 		$970.66
$1,044.88
$1,123.52
$1,402.88 		$1,181.01
$1,255.23
$1,333.87
$1,613.23 		$210.35
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 		$298.63
$338.93
$381.63
$533.33
$810.44 		$527.07
$567.37
$610.07
$761.77 		$755.51
$795.81
$838.51
$990.21 		$983.95
$1,024.25
$1,066.95
$1,218.65 		$228.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.26
$677.86
$763.26
$1,066.66
$1,620.88 		$825.70
$906.30
$991.70
$1,295.10 		$1,054.14
$1,134.74
$1,220.14
$1,523.54 		$1,282.58
$1,363.18
$1,448.58
$1,751.98 		$228.44
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 		$297.06
$337.16
$379.63
$530.54
$806.20 		$524.31
$564.41
$606.88
$757.79 		$751.56
$791.66
$834.13
$985.04 		$978.81
$1,018.91
$1,061.38
$1,212.29 		$227.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$594.12
$674.32
$759.26
$1,061.08
$1,612.40 		$821.37
$901.57
$986.51
$1,288.33 		$1,048.62
$1,128.82
$1,213.76
$1,515.58 		$1,275.87
$1,356.07
$1,441.01
$1,742.83 		$227.25
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 		$274.02
$311.00
$350.19
$489.38
$743.67 		$483.64
$520.62
$559.81
$699.00 		$693.26
$730.24
$769.43
$908.62 		$902.88
$939.86
$979.05
$1,118.24 		$209.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.04
$622.00
$700.38
$978.76
$1,487.34 		$757.66
$831.62
$910.00
$1,188.38 		$967.28
$1,041.24
$1,119.62
$1,398.00 		$1,176.90
$1,250.86
$1,329.24
$1,607.62 		$209.62
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 		$352.35
$399.90
$450.29
$629.27
$956.24 		$621.89
$669.44
$719.83
$898.81 		$891.43
$938.98
$989.37
$1,168.35 		$1,160.97
$1,208.52
$1,258.91
$1,437.89 		$269.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.70
$799.80
$900.58
$1,258.54
$1,912.48 		$974.24
$1,069.34
$1,170.12
$1,528.08 		$1,243.78
$1,338.88
$1,439.66
$1,797.62 		$1,513.32
$1,608.42
$1,709.20
$2,067.16 		$269.54
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 		$380.93
$432.34
$486.81
$680.32
$1,033.81 		$672.33
$723.74
$778.21
$971.72 		$963.73
$1,015.14
$1,069.61
$1,263.12 		$1,255.13
$1,306.54
$1,361.01
$1,554.52 		$291.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.86
$864.68
$973.62
$1,360.64
$2,067.62 		$1,053.26
$1,156.08
$1,265.02
$1,652.04 		$1,344.66
$1,447.48
$1,556.42
$1,943.44 		$1,636.06
$1,738.88
$1,847.82
$2,234.84 		$291.40
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 		$366.52
$415.99
$468.40
$654.58
$994.70 		$646.90
$696.37
$748.78
$934.96 		$927.28
$976.75
$1,029.16
$1,215.34 		$1,207.66
$1,257.13
$1,309.54
$1,495.72 		$280.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.04
$831.98
$936.80
$1,309.16
$1,989.40 		$1,013.42
$1,112.36
$1,217.18
$1,589.54 		$1,293.80
$1,392.74
$1,497.56
$1,869.92 		$1,574.18
$1,673.12
$1,777.94
$2,150.30 		$280.38
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 		$378.41
$429.49
$483.60
$675.83
$1,026.99 		$667.89
$718.97
$773.08
$965.31 		$957.37
$1,008.45
$1,062.56
$1,254.79 		$1,246.85
$1,297.93
$1,352.04
$1,544.27 		$289.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.82
$858.98
$967.20
$1,351.66
$2,053.98 		$1,046.30
$1,148.46
$1,256.68
$1,641.14 		$1,335.78
$1,437.94
$1,546.16
$1,930.62 		$1,625.26
$1,727.42
$1,835.64
$2,220.10 		$289.48
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 		$377.61
$428.57
$482.57
$674.39
$1,024.80 		$666.47
$717.43
$771.43
$963.25 		$955.33
$1,006.29
$1,060.29
$1,252.11 		$1,244.19
$1,295.15
$1,349.15
$1,540.97 		$288.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.22
$857.14
$965.14
$1,348.78
$2,049.60 		$1,044.08
$1,146.00
$1,254.00
$1,637.64 		$1,332.94
$1,434.86
$1,542.86
$1,926.50 		$1,621.80
$1,723.72
$1,831.72
$2,215.36 		$288.86
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 		$373.96
$424.43
$477.90
$667.87
$1,014.89 		$660.03
$710.50
$763.97
$953.94 		$946.10
$996.57
$1,050.04
$1,240.01 		$1,232.17
$1,282.64
$1,336.11
$1,526.08 		$286.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.92
$848.86
$955.80
$1,335.74
$2,029.78 		$1,033.99
$1,134.93
$1,241.87
$1,621.81 		$1,320.06
$1,421.00
$1,527.94
$1,907.88 		$1,606.13
$1,707.07
$1,814.01
$2,193.95 		$286.07
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 		$343.66
$390.05
$439.19
$613.77
$932.68 		$606.56
$652.95
$702.09
$876.67 		$869.46
$915.85
$964.99
$1,139.57 		$1,132.36
$1,178.75
$1,227.89
$1,402.47 		$262.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687.32
$780.10
$878.38
$1,227.54
$1,865.36 		$950.22
$1,043.00
$1,141.28
$1,490.44 		$1,213.12
$1,305.90
$1,404.18
$1,753.34 		$1,476.02
$1,568.80
$1,667.08
$2,016.24 		$262.90
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 		$350.38
$397.67
$447.77
$625.76
$950.91 		$618.41
$665.70
$715.80
$893.79 		$886.44
$933.73
$983.83
$1,161.82 		$1,154.47
$1,201.76
$1,251.86
$1,429.85 		$268.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.76
$795.34
$895.54
$1,251.52
$1,901.82 		$968.79
$1,063.37
$1,163.57
$1,519.55 		$1,236.82
$1,331.40
$1,431.60
$1,787.58 		$1,504.85
$1,599.43
$1,699.63
$2,055.61 		$268.03
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 		$401.00
$455.12
$512.47
$716.17
$1,088.29 		$707.76
$761.88
$819.23
$1,022.93 		$1,014.52
$1,068.64
$1,125.99
$1,329.69 		$1,321.28
$1,375.40
$1,432.75
$1,636.45 		$306.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.00
$910.24
$1,024.94
$1,432.34
$2,176.58 		$1,108.76
$1,217.00
$1,331.70
$1,739.10 		$1,415.52
$1,523.76
$1,638.46
$2,045.86 		$1,722.28
$1,830.52
$1,945.22
$2,352.62 		$306.76
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 		$379.00
$430.15
$484.35
$676.87
$1,028.57 		$668.93
$720.08
$774.28
$966.80 		$958.86
$1,010.01
$1,064.21
$1,256.73 		$1,248.79
$1,299.94
$1,354.14
$1,546.66 		$289.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.00
$860.30
$968.70
$1,353.74
$2,057.14 		$1,047.93
$1,150.23
$1,258.63
$1,643.67 		$1,337.86
$1,440.16
$1,548.56
$1,933.60 		$1,627.79
$1,730.09
$1,838.49
$2,223.53 		$289.93
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 		$352.85
$400.48
$450.93
$630.18
$957.62 		$622.77
$670.40
$720.85
$900.10 		$892.69
$940.32
$990.77
$1,170.02 		$1,162.61
$1,210.24
$1,260.69
$1,439.94 		$269.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.70
$800.96
$901.86
$1,260.36
$1,915.24 		$975.62
$1,070.88
$1,171.78
$1,530.28 		$1,245.54
$1,340.80
$1,441.70
$1,800.20 		$1,515.46
$1,610.72
$1,711.62
$2,070.12 		$269.92
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 		$296.08
$336.04
$378.38
$528.78
$803.54 		$522.57
$562.53
$604.87
$755.27 		$749.06
$789.02
$831.36
$981.76 		$975.55
$1,015.51
$1,057.85
$1,208.25 		$226.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.16
$672.08
$756.76
$1,057.56
$1,607.08 		$818.65
$898.57
$983.25
$1,284.05 		$1,045.14
$1,125.06
$1,209.74
$1,510.54 		$1,271.63
$1,351.55
$1,436.23
$1,737.03 		$226.49
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 		$304.25
$345.31
$388.82
$543.37
$825.71 		$536.99
$578.05
$621.56
$776.11 		$769.73
$810.79
$854.30
$1,008.85 		$1,002.47
$1,043.53
$1,087.04
$1,241.59 		$232.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.50
$690.62
$777.64
$1,086.74
$1,651.42 		$841.24
$923.36
$1,010.38
$1,319.48 		$1,073.98
$1,156.10
$1,243.12
$1,552.22 		$1,306.72
$1,388.84
$1,475.86
$1,784.96 		$232.74
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 		$305.15
$346.34
$389.97
$544.99
$828.16 		$538.58
$579.77
$623.40
$778.42 		$772.01
$813.20
$856.83
$1,011.85 		$1,005.44
$1,046.63
$1,090.26
$1,245.28 		$233.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.30
$692.68
$779.94
$1,089.98
$1,656.32 		$843.73
$926.11
$1,013.37
$1,323.41 		$1,077.16
$1,159.54
$1,246.80
$1,556.84 		$1,310.59
$1,392.97
$1,480.23
$1,790.27 		$233.43
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 		$360.08
$408.68
$460.17
$643.09
$977.23 		$635.53
$684.13
$735.62
$918.54 		$910.98
$959.58
$1,011.07
$1,193.99 		$1,186.43
$1,235.03
$1,286.52
$1,469.44 		$275.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.16
$817.36
$920.34
$1,286.18
$1,954.46 		$995.61
$1,092.81
$1,195.79
$1,561.63 		$1,271.06
$1,368.26
$1,471.24
$1,837.08 		$1,546.51
$1,643.71
$1,746.69
$2,112.53 		$275.45
Toc - Plan #35 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple (Choice)

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 		$273.45
$310.36
$349.46
$488.37
$742.12 		$482.63
$519.54
$558.64
$697.55 		$691.81
$728.72
$767.82
$906.73 		$900.99
$937.90
$977.00
$1,115.91 		$209.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.90
$620.72
$698.92
$976.74
$1,484.24 		$756.08
$829.90
$908.10
$1,185.92 		$965.26
$1,039.08
$1,117.28
$1,395.10 		$1,174.44
$1,248.26
$1,326.46
$1,604.28 		$209.18
Toc - Plan #36 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- PCP Saver (Choice)

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 		$277.94
$315.45
$355.20
$496.38
$754.30 		$490.56
$528.07
$567.82
$709.00 		$703.18
$740.69
$780.44
$921.62 		$915.80
$953.31
$993.06
$1,134.24 		$212.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.88
$630.90
$710.40
$992.76
$1,508.60 		$768.50
$843.52
$923.02
$1,205.38 		$981.12
$1,056.14
$1,135.64
$1,418.00 		$1,193.74
$1,268.76
$1,348.26
$1,630.62 		$212.62
Toc - Plan #37 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic (Choice)

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 		$273.78
$310.73
$349.88
$488.95
$743.01 		$483.21
$520.16
$559.31
$698.38 		$692.64
$729.59
$768.74
$907.81 		$902.07
$939.02
$978.17
$1,117.24 		$209.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$547.56
$621.46
$699.76
$977.90
$1,486.02 		$756.99
$830.89
$909.19
$1,187.33 		$966.42
$1,040.32
$1,118.62
$1,396.76 		$1,175.85
$1,249.75
$1,328.05
$1,606.19 		$209.43
Toc - Plan #38 Oscar Insurance Company
Expanded Bronze

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

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 		$327.58
$371.80
$418.64
$585.05
$889.03 		$578.17
$622.39
$669.23
$835.64 		$828.76
$872.98
$919.82
$1,086.23 		$1,079.35
$1,123.57
$1,170.41
$1,336.82 		$250.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.16
$743.60
$837.28
$1,170.10
$1,778.06 		$905.75
$994.19
$1,087.87
$1,420.69 		$1,156.34
$1,244.78
$1,338.46
$1,671.28 		$1,406.93
$1,495.37
$1,589.05
$1,921.87 		$250.59
Toc - Plan #39 Oscar Insurance Company
Silver

(EPO) Silver Classic (Choice)

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 		$382.97
$434.66
$489.42
$683.96
$1,039.34 		$675.93
$727.62
$782.38
$976.92 		$968.89
$1,020.58
$1,075.34
$1,269.88 		$1,261.85
$1,313.54
$1,368.30
$1,562.84 		$292.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.94
$869.32
$978.84
$1,367.92
$2,078.68 		$1,058.90
$1,162.28
$1,271.80
$1,660.88 		$1,351.86
$1,455.24
$1,564.76
$1,953.84 		$1,644.82
$1,748.20
$1,857.72
$2,246.80 		$292.96
Toc - Plan #40 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver (Choice)

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 		$375.21
$425.86
$479.51
$670.11
$1,018.30 		$662.24
$712.89
$766.54
$957.14 		$949.27
$999.92
$1,053.57
$1,244.17 		$1,236.30
$1,286.95
$1,340.60
$1,531.20 		$287.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.42
$851.72
$959.02
$1,340.22
$2,036.60 		$1,037.45
$1,138.75
$1,246.05
$1,627.25 		$1,324.48
$1,425.78
$1,533.08
$1,914.28 		$1,611.51
$1,712.81
$1,820.11
$2,201.31 		$287.03
Toc - Plan #41 Oscar Insurance Company
Silver

(EPO) Silver Classic- PCP Saver (Choice)

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 		$383.32
$435.06
$489.87
$684.60
$1,040.31 		$676.55
$728.29
$783.10
$977.83 		$969.78
$1,021.52
$1,076.33
$1,271.06 		$1,263.01
$1,314.75
$1,369.56
$1,564.29 		$293.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.64
$870.12
$979.74
$1,369.20
$2,080.62 		$1,059.87
$1,163.35
$1,272.97
$1,662.43 		$1,353.10
$1,456.58
$1,566.20
$1,955.66 		$1,646.33
$1,749.81
$1,859.43
$2,248.89 		$293.23
Toc - Plan #42 Oscar Insurance Company
Catastrophic

(EPO) Secure (Choice)

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 		$226.19
$256.71
$289.06
$403.96
$613.85 		$399.22
$429.74
$462.09
$576.99 		$572.25
$602.77
$635.12
$750.02 		$745.28
$775.80
$808.15
$923.05 		$173.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452.38
$513.42
$578.12
$807.92
$1,227.70 		$625.41
$686.45
$751.15
$980.95 		$798.44
$859.48
$924.18
$1,153.98 		$971.47
$1,032.51
$1,097.21
$1,327.01 		$173.03
Toc - Plan #43 Oscar Insurance Company
Expanded Bronze

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

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 		$327.66
$371.88
$418.74
$585.18
$889.24 		$578.31
$622.53
$669.39
$835.83 		$828.96
$873.18
$920.04
$1,086.48 		$1,079.61
$1,123.83
$1,170.69
$1,337.13 		$250.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.32
$743.76
$837.48
$1,170.36
$1,778.48 		$905.97
$994.41
$1,088.13
$1,421.01 		$1,156.62
$1,245.06
$1,338.78
$1,671.66 		$1,407.27
$1,495.71
$1,589.43
$1,922.31 		$250.65
Toc - Plan #44 Oscar Insurance Company
Gold

(EPO) Gold Classic (Choice)

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 		$377.68
$428.66
$482.66
$674.52
$1,025.00 		$666.60
$717.58
$771.58
$963.44 		$955.52
$1,006.50
$1,060.50
$1,252.36 		$1,244.44
$1,295.42
$1,349.42
$1,541.28 		$288.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.36
$857.32
$965.32
$1,349.04
$2,050.00 		$1,044.28
$1,146.24
$1,254.24
$1,637.96 		$1,333.20
$1,435.16
$1,543.16
$1,926.88 		$1,622.12
$1,724.08
$1,832.08
$2,215.80 		$288.92
Toc - Plan #45 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA (Choice)

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 		$300.43
$340.98
$383.94
$536.55
$815.34 		$530.25
$570.80
$613.76
$766.37 		$760.07
$800.62
$843.58
$996.19 		$989.89
$1,030.44
$1,073.40
$1,226.01 		$229.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.86
$681.96
$767.88
$1,073.10
$1,630.68 		$830.68
$911.78
$997.70
$1,302.92 		$1,060.50
$1,141.60
$1,227.52
$1,532.74 		$1,290.32
$1,371.42
$1,457.34
$1,762.56 		$229.82
Toc - Plan #46 Oscar Insurance Company
Silver

(EPO) Silver Simple (Choice)

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 		$375.64
$426.34
$480.06
$670.88
$1,019.47 		$663.00
$713.70
$767.42
$958.24 		$950.36
$1,001.06
$1,054.78
$1,245.60 		$1,237.72
$1,288.42
$1,342.14
$1,532.96 		$287.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.28
$852.68
$960.12
$1,341.76
$2,038.94 		$1,038.64
$1,140.04
$1,247.48
$1,629.12 		$1,326.00
$1,427.40
$1,534.84
$1,916.48 		$1,613.36
$1,714.76
$1,822.20
$2,203.84 		$287.36
Toc - Plan #47 Oscar Insurance Company
Silver

(EPO) Silver Elite (Choice)

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 		$389.49
$442.06
$497.76
$695.61
$1,057.05 		$687.44
$740.01
$795.71
$993.56 		$985.39
$1,037.96
$1,093.66
$1,291.51 		$1,283.34
$1,335.91
$1,391.61
$1,589.46 		$297.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.98
$884.12
$995.52
$1,391.22
$2,114.10 		$1,076.93
$1,182.07
$1,293.47
$1,689.17 		$1,374.88
$1,480.02
$1,591.42
$1,987.12 		$1,672.83
$1,777.97
$1,889.37
$2,285.07 		$297.95
Toc - Plan #48 Oscar Insurance Company
Silver

(EPO) Silver Classic- $0 Ded (Choice)

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 		$405.37
$460.08
$518.05
$723.97
$1,100.15 		$715.47
$770.18
$828.15
$1,034.07 		$1,025.57
$1,080.28
$1,138.25
$1,344.17 		$1,335.67
$1,390.38
$1,448.35
$1,654.27 		$310.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.74
$920.16
$1,036.10
$1,447.94
$2,200.30 		$1,120.84
$1,230.26
$1,346.20
$1,758.04 		$1,430.94
$1,540.36
$1,656.30
$2,068.14 		$1,741.04
$1,850.46
$1,966.40
$2,378.24 		$310.10
Toc - Plan #49 Oscar Insurance Company
Gold

(EPO) Gold Classic- Low Ded (Choice)

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 		$385.62
$437.66
$492.80
$688.69
$1,046.53 		$680.61
$732.65
$787.79
$983.68 		$975.60
$1,027.64
$1,082.78
$1,278.67 		$1,270.59
$1,322.63
$1,377.77
$1,573.66 		$294.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.24
$875.32
$985.60
$1,377.38
$2,093.06 		$1,066.23
$1,170.31
$1,280.59
$1,672.37 		$1,361.22
$1,465.30
$1,575.58
$1,967.36 		$1,656.21
$1,760.29
$1,870.57
$2,262.35 		$294.99
Toc - Plan #50 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $0 PCP (Choice)

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 		$289.60
$328.69
$370.10
$517.21
$785.95 		$511.14
$550.23
$591.64
$738.75 		$732.68
$771.77
$813.18
$960.29 		$954.22
$993.31
$1,034.72
$1,181.83 		$221.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.20
$657.38
$740.20
$1,034.42
$1,571.90 		$800.74
$878.92
$961.74
$1,255.96 		$1,022.28
$1,100.46
$1,183.28
$1,477.50 		$1,243.82
$1,322.00
$1,404.82
$1,699.04 		$221.54
Toc - Plan #51 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Specialist Saver (Choice)

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 		$314.55
$357.01
$401.98
$561.77
$853.67 		$555.17
$597.63
$642.60
$802.39 		$795.79
$838.25
$883.22
$1,043.01 		$1,036.41
$1,078.87
$1,123.84
$1,283.63 		$240.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.10
$714.02
$803.96
$1,123.54
$1,707.34 		$869.72
$954.64
$1,044.58
$1,364.16 		$1,110.34
$1,195.26
$1,285.20
$1,604.78 		$1,350.96
$1,435.88
$1,525.82
$1,845.40 		$240.62
Toc - Plan #52 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $3250 Ded (Choice)

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 		$312.90
$355.14
$399.88
$558.83
$849.20 		$552.26
$594.50
$639.24
$798.19 		$791.62
$833.86
$878.60
$1,037.55 		$1,030.98
$1,073.22
$1,117.96
$1,276.91 		$239.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.80
$710.28
$799.76
$1,117.66
$1,698.40 		$865.16
$949.64
$1,039.12
$1,357.02 		$1,104.52
$1,189.00
$1,278.48
$1,596.38 		$1,343.88
$1,428.36
$1,517.84
$1,835.74 		$239.36
Toc - Plan #53 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded (Choice)

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 		$288.59
$327.54
$368.81
$515.41
$783.22 		$509.36
$548.31
$589.58
$736.18 		$730.13
$769.08
$810.35
$956.95 		$950.90
$989.85
$1,031.12
$1,177.72 		$220.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.18
$655.08
$737.62
$1,030.82
$1,566.44 		$797.95
$875.85
$958.39
$1,251.59 		$1,018.72
$1,096.62
$1,179.16
$1,472.36 		$1,239.49
$1,317.39
$1,399.93
$1,693.13 		$220.77
Toc - Plan #54 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver (Choice)

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 		$371.23
$421.34
$474.42
$663.00
$1,007.49 		$655.21
$705.32
$758.40
$946.98 		$939.19
$989.30
$1,042.38
$1,230.96 		$1,223.17
$1,273.28
$1,326.36
$1,514.94 		$283.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.46
$842.68
$948.84
$1,326.00
$2,014.98 		$1,026.44
$1,126.66
$1,232.82
$1,609.98 		$1,310.42
$1,410.64
$1,516.80
$1,893.96 		$1,594.40
$1,694.62
$1,800.78
$2,177.94 		$283.98
Toc - Plan #55 Oscar Insurance Company
Silver

(EPO) Silver Elite- Specialist Saver (Choice)

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 		$401.39
$455.56
$512.96
$716.86
$1,089.34 		$708.44
$762.61
$820.01
$1,023.91 		$1,015.49
$1,069.66
$1,127.06
$1,330.96 		$1,322.54
$1,376.71
$1,434.11
$1,638.01 		$307.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.78
$911.12
$1,025.92
$1,433.72
$2,178.68 		$1,109.83
$1,218.17
$1,332.97
$1,740.77 		$1,416.88
$1,525.22
$1,640.02
$2,047.82 		$1,723.93
$1,832.27
$1,947.07
$2,354.87 		$307.05
Toc - Plan #56 Oscar Insurance Company
Silver

(EPO) Silver Classic- Low Ded (Choice)

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 		$386.18
$438.31
$493.53
$689.70
$1,048.07 		$681.60
$733.73
$788.95
$985.12 		$977.02
$1,029.15
$1,084.37
$1,280.54 		$1,272.44
$1,324.57
$1,379.79
$1,575.96 		$295.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.36
$876.62
$987.06
$1,379.40
$2,096.14 		$1,067.78
$1,172.04
$1,282.48
$1,674.82 		$1,363.20
$1,467.46
$1,577.90
$1,970.24 		$1,658.62
$1,762.88
$1,873.32
$2,265.66 		$295.42
Toc - Plan #57 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 PCP (Choice)

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 		$398.73
$452.55
$509.57
$712.12
$1,082.14 		$703.75
$757.57
$814.59
$1,017.14 		$1,008.77
$1,062.59
$1,119.61
$1,322.16 		$1,313.79
$1,367.61
$1,424.63
$1,627.18 		$305.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.46
$905.10
$1,019.14
$1,424.24
$2,164.28 		$1,102.48
$1,210.12
$1,324.16
$1,729.26 		$1,407.50
$1,515.14
$1,629.18
$2,034.28 		$1,712.52
$1,820.16
$1,934.20
$2,339.30 		$305.02
Toc - Plan #58 Oscar Insurance Company
Silver

(EPO) Silver Simple- HSA (Choice)

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 		$397.88
$451.58
$508.48
$710.60
$1,079.83 		$702.25
$755.95
$812.85
$1,014.97 		$1,006.62
$1,060.32
$1,117.22
$1,319.34 		$1,310.99
$1,364.69
$1,421.59
$1,623.71 		$304.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.76
$903.16
$1,016.96
$1,421.20
$2,159.66 		$1,100.13
$1,207.53
$1,321.33
$1,725.57 		$1,404.50
$1,511.90
$1,625.70
$2,029.94 		$1,708.87
$1,816.27
$1,930.07
$2,334.31 		$304.37
Toc - Plan #59 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded (Choice)

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 		$394.03
$447.21
$503.56
$703.72
$1,069.37 		$695.46
$748.64
$804.99
$1,005.15 		$996.89
$1,050.07
$1,106.42
$1,306.58 		$1,298.32
$1,351.50
$1,407.85
$1,608.01 		$301.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.06
$894.42
$1,007.12
$1,407.44
$2,138.74 		$1,089.49
$1,195.85
$1,308.55
$1,708.87 		$1,390.92
$1,497.28
$1,609.98
$2,010.30 		$1,692.35
$1,798.71
$1,911.41
$2,311.73 		$301.43
Toc - Plan #60 Oscar Insurance Company
Gold

(EPO) Gold Simple (Choice)

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 		$362.07
$410.94
$462.71
$646.64
$982.63 		$639.05
$687.92
$739.69
$923.62 		$916.03
$964.90
$1,016.67
$1,200.60 		$1,193.01
$1,241.88
$1,293.65
$1,477.58 		$276.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.14
$821.88
$925.42
$1,293.28
$1,965.26 		$1,001.12
$1,098.86
$1,202.40
$1,570.26 		$1,278.10
$1,375.84
$1,479.38
$1,847.24 		$1,555.08
$1,652.82
$1,756.36
$2,124.22 		$276.98
Toc - Plan #61 Oscar Insurance Company
Gold

(EPO) Gold Classic- $0 PCP (Choice)

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 		$369.16
$418.98
$471.77
$659.30
$1,001.87 		$651.56
$701.38
$754.17
$941.70 		$933.96
$983.78
$1,036.57
$1,224.10 		$1,216.36
$1,266.18
$1,318.97
$1,506.50 		$282.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.32
$837.96
$943.54
$1,318.60
$2,003.74 		$1,020.72
$1,120.36
$1,225.94
$1,601.00 		$1,303.12
$1,402.76
$1,508.34
$1,883.40 		$1,585.52
$1,685.16
$1,790.74
$2,165.80 		$282.40
Toc - Plan #62 Oscar Insurance Company
Gold

(EPO) Gold Elite- $0 Ded (Choice)

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 		$422.56
$479.60
$540.02
$754.68
$1,146.81 		$745.81
$802.85
$863.27
$1,077.93 		$1,069.06
$1,126.10
$1,186.52
$1,401.18 		$1,392.31
$1,449.35
$1,509.77
$1,724.43 		$323.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.12
$959.20
$1,080.04
$1,509.36
$2,293.62 		$1,168.37
$1,282.45
$1,403.29
$1,832.61 		$1,491.62
$1,605.70
$1,726.54
$2,155.86 		$1,814.87
$1,928.95
$2,049.79
$2,479.11 		$323.25
Toc - Plan #63 Oscar Insurance Company
Gold

(EPO) Gold Elite (Choice)

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 		$399.35
$453.25
$510.36
$713.22
$1,083.81 		$704.84
$758.74
$815.85
$1,018.71 		$1,010.33
$1,064.23
$1,121.34
$1,324.20 		$1,315.82
$1,369.72
$1,426.83
$1,629.69 		$305.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.70
$906.50
$1,020.72
$1,426.44
$2,167.62 		$1,104.19
$1,211.99
$1,326.21
$1,731.93 		$1,409.68
$1,517.48
$1,631.70
$2,037.42 		$1,715.17
$1,822.97
$1,937.19
$2,342.91 		$305.49
Toc - Plan #64 Oscar Insurance Company
Gold

(EPO) Gold Classic- HSA (Choice)

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 		$371.77
$421.94
$475.10
$663.95
$1,008.94 		$656.16
$706.33
$759.49
$948.34 		$940.55
$990.72
$1,043.88
$1,232.73 		$1,224.94
$1,275.11
$1,328.27
$1,517.12 		$284.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.54
$843.88
$950.20
$1,327.90
$2,017.88 		$1,027.93
$1,128.27
$1,234.59
$1,612.29 		$1,312.32
$1,412.66
$1,518.98
$1,896.68 		$1,596.71
$1,697.05
$1,803.37
$2,181.07 		$284.39
Toc - Plan #65 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4000 Ded (Choice)

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 		$311.87
$353.96
$398.55
$556.98
$846.38 		$550.44
$592.53
$637.12
$795.55 		$789.01
$831.10
$875.69
$1,034.12 		$1,027.58
$1,069.67
$1,114.26
$1,272.69 		$238.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.74
$707.92
$797.10
$1,113.96
$1,692.76 		$862.31
$946.49
$1,035.67
$1,352.53 		$1,100.88
$1,185.06
$1,274.24
$1,591.10 		$1,339.45
$1,423.63
$1,512.81
$1,829.67 		$238.57
Toc - Plan #66 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite (Choice)

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 		$320.49
$363.74
$409.57
$572.37
$869.77 		$565.65
$608.90
$654.73
$817.53 		$810.81
$854.06
$899.89
$1,062.69 		$1,055.97
$1,099.22
$1,145.05
$1,307.85 		$245.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.98
$727.48
$819.14
$1,144.74
$1,739.54 		$886.14
$972.64
$1,064.30
$1,389.90 		$1,131.30
$1,217.80
$1,309.46
$1,635.06 		$1,376.46
$1,462.96
$1,554.62
$1,880.22 		$245.16
Toc - Plan #67 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $1000 Ded (Choice)

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 		$321.44
$364.82
$410.79
$574.07
$872.36 		$567.33
$610.71
$656.68
$819.96 		$813.22
$856.60
$902.57
$1,065.85 		$1,059.11
$1,102.49
$1,148.46
$1,311.74 		$245.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.88
$729.64
$821.58
$1,148.14
$1,744.72 		$888.77
$975.53
$1,067.47
$1,394.03 		$1,134.66
$1,221.42
$1,313.36
$1,639.92 		$1,380.55
$1,467.31
$1,559.25
$1,885.81 		$245.89
Toc - Plan #68 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes (Choice)

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 		$379.39
$430.60
$484.85
$677.57
$1,029.64 		$669.62
$720.83
$775.08
$967.80 		$959.85
$1,011.06
$1,065.31
$1,258.03 		$1,250.08
$1,301.29
$1,355.54
$1,548.26 		$290.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.78
$861.20
$969.70
$1,355.14
$2,059.28 		$1,049.01
$1,151.43
$1,259.93
$1,645.37 		$1,339.24
$1,441.66
$1,550.16
$1,935.60 		$1,629.47
$1,731.89
$1,840.39
$2,225.83 		$290.23

ADVERTISEMENT

Community Health Choice

Local: 1-713-295-6704 | Toll Free: 1-855-315-5386 | TTY: 1-855-315-5386
Toc - Plan #69 Community Health Choice
Expanded Bronze

(HMO) Community Vital Bronze 003 (No Deductible for PCP, Free Preventive Care, 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 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 		$277.57
$315.04
$354.74
$495.74
$753.33 		$489.91
$527.38
$567.08
$708.08 		$702.25
$739.72
$779.42
$920.42 		$914.59
$952.06
$991.76
$1,132.76 		$212.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.14
$630.08
$709.48
$991.48
$1,506.66 		$767.48
$842.42
$921.82
$1,203.82 		$979.82
$1,054.76
$1,134.16
$1,416.16 		$1,192.16
$1,267.10
$1,346.50
$1,628.50 		$212.34
Toc - Plan #70 Community Health Choice
Silver

(HMO) Community Advance Preferred Silver 004 (No deductible PCP, Specialists, Urgent Care and Generics, Free 24/7 Telehe

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

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 		$389.65
$442.25
$497.97
$695.92
$1,057.51 		$687.73
$740.33
$796.05
$994.00 		$985.81
$1,038.41
$1,094.13
$1,292.08 		$1,283.89
$1,336.49
$1,392.21
$1,590.16 		$298.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.30
$884.50
$995.94
$1,391.84
$2,115.02 		$1,077.38
$1,182.58
$1,294.02
$1,689.92 		$1,375.46
$1,480.66
$1,592.10
$1,988.00 		$1,673.54
$1,778.74
$1,890.18
$2,286.08 		$298.08
Toc - Plan #71 Community Health Choice
Gold

(HMO) Community Enhanced Gold 005 (No Deductible PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

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 		$362.35
$411.27
$463.09
$647.16
$983.43 		$639.55
$688.47
$740.29
$924.36 		$916.75
$965.67
$1,017.49
$1,201.56 		$1,193.95
$1,242.87
$1,294.69
$1,478.76 		$277.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.70
$822.54
$926.18
$1,294.32
$1,966.86 		$1,001.90
$1,099.74
$1,203.38
$1,571.52 		$1,279.10
$1,376.94
$1,480.58
$1,848.72 		$1,556.30
$1,654.14
$1,757.78
$2,125.92 		$277.20
Toc - Plan #72 Community Health Choice
Expanded Bronze

(HMO) Community Essential Bronze 008 HSA(No cost after deductible, No referrals for Specialists)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

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 		$283.70
$322.00
$362.57
$506.70
$769.97 		$500.73
$539.03
$579.60
$723.73 		$717.76
$756.06
$796.63
$940.76 		$934.79
$973.09
$1,013.66
$1,157.79 		$217.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.40
$644.00
$725.14
$1,013.40
$1,539.94 		$784.43
$861.03
$942.17
$1,230.43 		$1,001.46
$1,078.06
$1,159.20
$1,447.46 		$1,218.49
$1,295.09
$1,376.23
$1,664.49 		$217.03
Toc - Plan #73 Community Health Choice
Bronze

(HMO) Community Value Bronze 10 (Free Preventive Care, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

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 		$263.34
$298.89
$336.55
$470.33
$714.71 		$464.80
$500.35
$538.01
$671.79 		$666.26
$701.81
$739.47
$873.25 		$867.72
$903.27
$940.93
$1,074.71 		$201.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.68
$597.78
$673.10
$940.66
$1,429.42 		$728.14
$799.24
$874.56
$1,142.12 		$929.60
$1,000.70
$1,076.02
$1,343.58 		$1,131.06
$1,202.16
$1,277.48
$1,545.04 		$201.46
Toc - Plan #74 Community Health Choice
Expanded Bronze

(HMO) Community Virtual Now Bronze 11 (Unlimited Free 24/7 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

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 		$261.53
$296.83
$334.23
$467.09
$709.79 		$461.60
$496.90
$534.30
$667.16 		$661.67
$696.97
$734.37
$867.23 		$861.74
$897.04
$934.44
$1,067.30 		$200.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523.06
$593.66
$668.46
$934.18
$1,419.58 		$723.13
$793.73
$868.53
$1,134.25 		$923.20
$993.80
$1,068.60
$1,334.32 		$1,123.27
$1,193.87
$1,268.67
$1,534.39 		$200.07
Toc - Plan #75 Community Health Choice
Silver

(HMO) Community Standard Silver 12 (No deductible PCP, Urgent Care & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.90
$420.97
$474.01
$662.43
$1,006.62 		$654.64
$704.71
$757.75
$946.17 		$938.38
$988.45
$1,041.49
$1,229.91 		$1,222.12
$1,272.19
$1,325.23
$1,513.65 		$283.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.80
$841.94
$948.02
$1,324.86
$2,013.24 		$1,025.54
$1,125.68
$1,231.76
$1,608.60 		$1,309.28
$1,409.42
$1,515.50
$1,892.34 		$1,593.02
$1,693.16
$1,799.24
$2,176.08 		$283.74
Toc - Plan #76 Community Health Choice
Silver

(HMO) Community Advance Silver 13 (No Deductible PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

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 		$373.37
$423.77
$477.16
$666.83
$1,013.32 		$659.00
$709.40
$762.79
$952.46 		$944.63
$995.03
$1,048.42
$1,238.09 		$1,230.26
$1,280.66
$1,334.05
$1,523.72 		$285.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.74
$847.54
$954.32
$1,333.66
$2,026.64 		$1,032.37
$1,133.17
$1,239.95
$1,619.29 		$1,318.00
$1,418.80
$1,525.58
$1,904.92 		$1,603.63
$1,704.43
$1,811.21
$2,190.55 		$285.63

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #77 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 		$384.50
$436.39
$491.37
$686.69
$1,043.50 		$678.63
$730.52
$785.50
$980.82 		$972.76
$1,024.65
$1,079.63
$1,274.95 		$1,266.89
$1,318.78
$1,373.76
$1,569.08 		$294.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.00
$872.78
$982.74
$1,373.38
$2,087.00 		$1,063.13
$1,166.91
$1,276.87
$1,667.51 		$1,357.26
$1,461.04
$1,571.00
$1,961.64 		$1,651.39
$1,755.17
$1,865.13
$2,255.77 		$294.13
Toc - Plan #78 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 		$322.13
$365.61
$411.67
$575.31
$874.24 		$568.55
$612.03
$658.09
$821.73 		$814.97
$858.45
$904.51
$1,068.15 		$1,061.39
$1,104.87
$1,150.93
$1,314.57 		$246.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.26
$731.22
$823.34
$1,150.62
$1,748.48 		$890.68
$977.64
$1,069.76
$1,397.04 		$1,137.10
$1,224.06
$1,316.18
$1,643.46 		$1,383.52
$1,470.48
$1,562.60
$1,889.88 		$246.42
Toc - Plan #79 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 		$340.20
$386.12
$434.77
$607.59
$923.29 		$600.45
$646.37
$695.02
$867.84 		$860.70
$906.62
$955.27
$1,128.09 		$1,120.95
$1,166.87
$1,215.52
$1,388.34 		$260.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.40
$772.24
$869.54
$1,215.18
$1,846.58 		$940.65
$1,032.49
$1,129.79
$1,475.43 		$1,200.90
$1,292.74
$1,390.04
$1,735.68 		$1,461.15
$1,552.99
$1,650.29
$1,995.93 		$260.25
Toc - Plan #80 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 		$504.80
$572.94
$645.12
$901.56
$1,370.01 		$890.97
$959.11
$1,031.29
$1,287.73 		$1,277.14
$1,345.28
$1,417.46
$1,673.90 		$1,663.31
$1,731.45
$1,803.63
$2,060.07 		$386.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,009.60
$1,145.88
$1,290.24
$1,803.12
$2,740.02 		$1,395.77
$1,532.05
$1,676.41
$2,189.29 		$1,781.94
$1,918.22
$2,062.58
$2,575.46 		$2,168.11
$2,304.39
$2,448.75
$2,961.63 		$386.17
Toc - Plan #81 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 		$352.08
$399.60
$449.95
$628.80
$955.53 		$621.42
$668.94
$719.29
$898.14 		$890.76
$938.28
$988.63
$1,167.48 		$1,160.10
$1,207.62
$1,257.97
$1,436.82 		$269.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.16
$799.20
$899.90
$1,257.60
$1,911.06 		$973.50
$1,068.54
$1,169.24
$1,526.94 		$1,242.84
$1,337.88
$1,438.58
$1,796.28 		$1,512.18
$1,607.22
$1,707.92
$2,065.62 		$269.34
Toc - Plan #82 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 		$386.65
$438.84
$494.13
$690.54
$1,049.34 		$682.43
$734.62
$789.91
$986.32 		$978.21
$1,030.40
$1,085.69
$1,282.10 		$1,273.99
$1,326.18
$1,381.47
$1,577.88 		$295.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.30
$877.68
$988.26
$1,381.08
$2,098.68 		$1,069.08
$1,173.46
$1,284.04
$1,676.86 		$1,364.86
$1,469.24
$1,579.82
$1,972.64 		$1,660.64
$1,765.02
$1,875.60
$2,268.42 		$295.78
Toc - Plan #83 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 		$379.31
$430.50
$484.74
$677.42
$1,029.41 		$669.47
$720.66
$774.90
$967.58 		$959.63
$1,010.82
$1,065.06
$1,257.74 		$1,249.79
$1,300.98
$1,355.22
$1,547.90 		$290.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.62
$861.00
$969.48
$1,354.84
$2,058.82 		$1,048.78
$1,151.16
$1,259.64
$1,645.00 		$1,338.94
$1,441.32
$1,549.80
$1,935.16 		$1,629.10
$1,731.48
$1,839.96
$2,225.32 		$290.16
Toc - Plan #84 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 		$374.38
$424.92
$478.45
$668.63
$1,016.05 		$660.78
$711.32
$764.85
$955.03 		$947.18
$997.72
$1,051.25
$1,241.43 		$1,233.58
$1,284.12
$1,337.65
$1,527.83 		$286.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748.76
$849.84
$956.90
$1,337.26
$2,032.10 		$1,035.16
$1,136.24
$1,243.30
$1,623.66 		$1,321.56
$1,422.64
$1,529.70
$1,910.06 		$1,607.96
$1,709.04
$1,816.10
$2,196.46 		$286.40
Toc - Plan #85 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 		$374.00
$424.48
$477.96
$667.95
$1,015.01 		$660.10
$710.58
$764.06
$954.05 		$946.20
$996.68
$1,050.16
$1,240.15 		$1,232.30
$1,282.78
$1,336.26
$1,526.25 		$286.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748.00
$848.96
$955.92
$1,335.90
$2,030.02 		$1,034.10
$1,135.06
$1,242.02
$1,622.00 		$1,320.20
$1,421.16
$1,528.12
$1,908.10 		$1,606.30
$1,707.26
$1,814.22
$2,194.20 		$286.10
Toc - Plan #86 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 		$383.27
$435.00
$489.80
$684.50
$1,040.16 		$676.46
$728.19
$782.99
$977.69 		$969.65
$1,021.38
$1,076.18
$1,270.88 		$1,262.84
$1,314.57
$1,369.37
$1,564.07 		$293.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.54
$870.00
$979.60
$1,369.00
$2,080.32 		$1,059.73
$1,163.19
$1,272.79
$1,662.19 		$1,352.92
$1,456.38
$1,565.98
$1,955.38 		$1,646.11
$1,749.57
$1,859.17
$2,248.57 		$293.19
Toc - Plan #87 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 		$404.34
$458.91
$516.73
$722.13
$1,097.34 		$713.65
$768.22
$826.04
$1,031.44 		$1,022.96
$1,077.53
$1,135.35
$1,340.75 		$1,332.27
$1,386.84
$1,444.66
$1,650.06 		$309.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.68
$917.82
$1,033.46
$1,444.26
$2,194.68 		$1,117.99
$1,227.13
$1,342.77
$1,753.57 		$1,427.30
$1,536.44
$1,652.08
$2,062.88 		$1,736.61
$1,845.75
$1,961.39
$2,372.19 		$309.31
Toc - Plan #88 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 		$355.12
$403.05
$453.83
$634.23
$963.77 		$626.78
$674.71
$725.49
$905.89 		$898.44
$946.37
$997.15
$1,177.55 		$1,170.10
$1,218.03
$1,268.81
$1,449.21 		$271.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.24
$806.10
$907.66
$1,268.46
$1,927.54 		$981.90
$1,077.76
$1,179.32
$1,540.12 		$1,253.56
$1,349.42
$1,450.98
$1,811.78 		$1,525.22
$1,621.08
$1,722.64
$2,083.44 		$271.66
Toc - Plan #89 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 		$355.62
$403.62
$454.47
$635.12
$965.13 		$627.66
$675.66
$726.51
$907.16 		$899.70
$947.70
$998.55
$1,179.20 		$1,171.74
$1,219.74
$1,270.59
$1,451.24 		$272.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.24
$807.24
$908.94
$1,270.24
$1,930.26 		$983.28
$1,079.28
$1,180.98
$1,542.28 		$1,255.32
$1,351.32
$1,453.02
$1,814.32 		$1,527.36
$1,623.36
$1,725.06
$2,086.36 		$272.04
Toc - Plan #90 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 		$367.12
$416.67
$469.16
$655.65
$996.33 		$647.96
$697.51
$750.00
$936.49 		$928.80
$978.35
$1,030.84
$1,217.33 		$1,209.64
$1,259.19
$1,311.68
$1,498.17 		$280.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.24
$833.34
$938.32
$1,311.30
$1,992.66 		$1,015.08
$1,114.18
$1,219.16
$1,592.14 		$1,295.92
$1,395.02
$1,500.00
$1,872.98 		$1,576.76
$1,675.86
$1,780.84
$2,153.82 		$280.84
Toc - Plan #91 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 		$472.20
$535.93
$603.46
$843.33
$1,281.52 		$833.42
$897.15
$964.68
$1,204.55 		$1,194.64
$1,258.37
$1,325.90
$1,565.77 		$1,555.86
$1,619.59
$1,687.12
$1,926.99 		$361.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$944.40
$1,071.86
$1,206.92
$1,686.66
$2,563.04 		$1,305.62
$1,433.08
$1,568.14
$2,047.88 		$1,666.84
$1,794.30
$1,929.36
$2,409.10 		$2,028.06
$2,155.52
$2,290.58
$2,770.32 		$361.22
Toc - Plan #92 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 		$509.84
$578.65
$651.56
$910.55
$1,383.67 		$899.86
$968.67
$1,041.58
$1,300.57 		$1,289.88
$1,358.69
$1,431.60
$1,690.59 		$1,679.90
$1,748.71
$1,821.62
$2,080.61 		$390.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,019.68
$1,157.30
$1,303.12
$1,821.10
$2,767.34 		$1,409.70
$1,547.32
$1,693.14
$2,211.12 		$1,799.72
$1,937.34
$2,083.16
$2,601.14 		$2,189.74
$2,327.36
$2,473.18
$2,991.16 		$390.02
Toc - Plan #93 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 		$325.35
$369.26
$415.78
$581.05
$882.96 		$574.23
$618.14
$664.66
$829.93 		$823.11
$867.02
$913.54
$1,078.81 		$1,071.99
$1,115.90
$1,162.42
$1,327.69 		$248.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.70
$738.52
$831.56
$1,162.10
$1,765.92 		$899.58
$987.40
$1,080.44
$1,410.98 		$1,148.46
$1,236.28
$1,329.32
$1,659.86 		$1,397.34
$1,485.16
$1,578.20
$1,908.74 		$248.88
Toc - Plan #94 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 		$343.60
$389.97
$439.10
$613.65
$932.50 		$606.44
$652.81
$701.94
$876.49 		$869.28
$915.65
$964.78
$1,139.33 		$1,132.12
$1,178.49
$1,227.62
$1,402.17 		$262.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687.20
$779.94
$878.20
$1,227.30
$1,865.00 		$950.04
$1,042.78
$1,141.04
$1,490.14 		$1,212.88
$1,305.62
$1,403.88
$1,752.98 		$1,475.72
$1,568.46
$1,666.72
$2,015.82 		$262.84
Toc - Plan #95 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 		$388.33
$440.75
$496.28
$693.54
$1,053.91 		$685.40
$737.82
$793.35
$990.61 		$982.47
$1,034.89
$1,090.42
$1,287.68 		$1,279.54
$1,331.96
$1,387.49
$1,584.75 		$297.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.66
$881.50
$992.56
$1,387.08
$2,107.82 		$1,073.73
$1,178.57
$1,289.63
$1,684.15 		$1,370.80
$1,475.64
$1,586.70
$1,981.22 		$1,667.87
$1,772.71
$1,883.77
$2,278.29 		$297.07
Toc - Plan #96 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 		$355.60
$403.59
$454.44
$635.08
$965.06 		$627.62
$675.61
$726.46
$907.10 		$899.64
$947.63
$998.48
$1,179.12 		$1,171.66
$1,219.65
$1,270.50
$1,451.14 		$272.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.20
$807.18
$908.88
$1,270.16
$1,930.12 		$983.22
$1,079.20
$1,180.90
$1,542.18 		$1,255.24
$1,351.22
$1,452.92
$1,814.20 		$1,527.26
$1,623.24
$1,724.94
$2,086.22 		$272.02
Toc - Plan #97 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 		$390.51
$443.21
$499.05
$697.43
$1,059.81 		$689.24
$741.94
$797.78
$996.16 		$987.97
$1,040.67
$1,096.51
$1,294.89 		$1,286.70
$1,339.40
$1,395.24
$1,593.62 		$298.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.02
$886.42
$998.10
$1,394.86
$2,119.62 		$1,079.75
$1,185.15
$1,296.83
$1,693.59 		$1,378.48
$1,483.88
$1,595.56
$1,992.32 		$1,677.21
$1,782.61
$1,894.29
$2,291.05 		$298.73
Toc - Plan #98 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 		$383.09
$434.80
$489.58
$684.18
$1,039.68 		$676.15
$727.86
$782.64
$977.24 		$969.21
$1,020.92
$1,075.70
$1,270.30 		$1,262.27
$1,313.98
$1,368.76
$1,563.36 		$293.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.18
$869.60
$979.16
$1,368.36
$2,079.36 		$1,059.24
$1,162.66
$1,272.22
$1,661.42 		$1,352.30
$1,455.72
$1,565.28
$1,954.48 		$1,645.36
$1,748.78
$1,858.34
$2,247.54 		$293.06
Toc - Plan #99 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 		$377.73
$428.71
$482.73
$674.61
$1,025.13 		$666.69
$717.67
$771.69
$963.57 		$955.65
$1,006.63
$1,060.65
$1,252.53 		$1,244.61
$1,295.59
$1,349.61
$1,541.49 		$288.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.46
$857.42
$965.46
$1,349.22
$2,050.26 		$1,044.42
$1,146.38
$1,254.42
$1,638.18 		$1,333.38
$1,435.34
$1,543.38
$1,927.14 		$1,622.34
$1,724.30
$1,832.34
$2,216.10 		$288.96
Toc - Plan #100 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 		$387.09
$439.33
$494.69
$691.32
$1,050.53 		$683.21
$735.45
$790.81
$987.44 		$979.33
$1,031.57
$1,086.93
$1,283.56 		$1,275.45
$1,327.69
$1,383.05
$1,579.68 		$296.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.18
$878.66
$989.38
$1,382.64
$2,101.06 		$1,070.30
$1,174.78
$1,285.50
$1,678.76 		$1,366.42
$1,470.90
$1,581.62
$1,974.88 		$1,662.54
$1,767.02
$1,877.74
$2,271.00 		$296.12
Toc - Plan #101 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 		$408.37
$463.49
$521.88
$729.33
$1,108.29 		$720.76
$775.88
$834.27
$1,041.72 		$1,033.15
$1,088.27
$1,146.66
$1,354.11 		$1,345.54
$1,400.66
$1,459.05
$1,666.50 		$312.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.74
$926.98
$1,043.76
$1,458.66
$2,216.58 		$1,129.13
$1,239.37
$1,356.15
$1,771.05 		$1,441.52
$1,551.76
$1,668.54
$2,083.44 		$1,753.91
$1,864.15
$1,980.93
$2,395.83 		$312.39
Toc - Plan #102 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 		$359.17
$407.65
$459.01
$641.46
$974.76 		$633.93
$682.41
$733.77
$916.22 		$908.69
$957.17
$1,008.53
$1,190.98 		$1,183.45
$1,231.93
$1,283.29
$1,465.74 		$274.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.34
$815.30
$918.02
$1,282.92
$1,949.52 		$993.10
$1,090.06
$1,192.78
$1,557.68 		$1,267.86
$1,364.82
$1,467.54
$1,832.44 		$1,542.62
$1,639.58
$1,742.30
$2,107.20 		$274.76
Toc - Plan #103 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 		$370.78
$420.82
$473.84
$662.19
$1,006.27 		$654.42
$704.46
$757.48
$945.83 		$938.06
$988.10
$1,041.12
$1,229.47 		$1,221.70
$1,271.74
$1,324.76
$1,513.11 		$283.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.56
$841.64
$947.68
$1,324.38
$2,012.54 		$1,025.20
$1,125.28
$1,231.32
$1,608.02 		$1,308.84
$1,408.92
$1,514.96
$1,891.66 		$1,592.48
$1,692.56
$1,798.60
$2,175.30 		$283.64
Toc - Plan #104 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 		$476.91
$541.28
$609.48
$851.74
$1,294.30 		$841.74
$906.11
$974.31
$1,216.57 		$1,206.57
$1,270.94
$1,339.14
$1,581.40 		$1,571.40
$1,635.77
$1,703.97
$1,946.23 		$364.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$953.82
$1,082.56
$1,218.96
$1,703.48
$2,588.60 		$1,318.65
$1,447.39
$1,583.79
$2,068.31 		$1,683.48
$1,812.22
$1,948.62
$2,433.14 		$2,048.31
$2,177.05
$2,313.45
$2,797.97 		$364.83
Toc - Plan #105 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 		$378.12
$429.15
$483.22
$675.30
$1,026.19 		$667.37
$718.40
$772.47
$964.55 		$956.62
$1,007.65
$1,061.72
$1,253.80 		$1,245.87
$1,296.90
$1,350.97
$1,543.05 		$289.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.24
$858.30
$966.44
$1,350.60
$2,052.38 		$1,045.49
$1,147.55
$1,255.69
$1,639.85 		$1,334.74
$1,436.80
$1,544.94
$1,929.10 		$1,623.99
$1,726.05
$1,834.19
$2,218.35 		$289.25
Toc - Plan #106 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 		$525.72
$596.68
$671.86
$938.92
$1,426.78 		$927.89
$998.85
$1,074.03
$1,341.09 		$1,330.06
$1,401.02
$1,476.20
$1,743.26 		$1,732.23
$1,803.19
$1,878.37
$2,145.43 		$402.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,051.44
$1,193.36
$1,343.72
$1,877.84
$2,853.56 		$1,453.61
$1,595.53
$1,745.89
$2,280.01 		$1,855.78
$1,997.70
$2,148.06
$2,682.18 		$2,257.95
$2,399.87
$2,550.23
$3,084.35 		$402.17
Toc - Plan #107 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 		$335.48
$380.76
$428.73
$599.15
$910.47 		$592.12
$637.40
$685.37
$855.79 		$848.76
$894.04
$942.01
$1,112.43 		$1,105.40
$1,150.68
$1,198.65
$1,369.07 		$256.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.96
$761.52
$857.46
$1,198.30
$1,820.94 		$927.60
$1,018.16
$1,114.10
$1,454.94 		$1,184.24
$1,274.80
$1,370.74
$1,711.58 		$1,440.88
$1,531.44
$1,627.38
$1,968.22 		$256.64
Toc - Plan #108 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 		$354.30
$402.12
$452.79
$632.77
$961.55 		$625.33
$673.15
$723.82
$903.80 		$896.36
$944.18
$994.85
$1,174.83 		$1,167.39
$1,215.21
$1,265.88
$1,445.86 		$271.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.60
$804.24
$905.58
$1,265.54
$1,923.10 		$979.63
$1,075.27
$1,176.61
$1,536.57 		$1,250.66
$1,346.30
$1,447.64
$1,807.60 		$1,521.69
$1,617.33
$1,718.67
$2,078.63 		$271.03
Toc - Plan #109 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 		$400.43
$454.48
$511.74
$715.15
$1,086.74 		$706.75
$760.80
$818.06
$1,021.47 		$1,013.07
$1,067.12
$1,124.38
$1,327.79 		$1,319.39
$1,373.44
$1,430.70
$1,634.11 		$306.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800.86
$908.96
$1,023.48
$1,430.30
$2,173.48 		$1,107.18
$1,215.28
$1,329.80
$1,736.62 		$1,413.50
$1,521.60
$1,636.12
$2,042.94 		$1,719.82
$1,827.92
$1,942.44
$2,349.26 		$306.32
Toc - Plan #110 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 		$366.68
$416.17
$468.60
$654.86
$995.13 		$647.18
$696.67
$749.10
$935.36 		$927.68
$977.17
$1,029.60
$1,215.86 		$1,208.18
$1,257.67
$1,310.10
$1,496.36 		$280.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.36
$832.34
$937.20
$1,309.72
$1,990.26 		$1,013.86
$1,112.84
$1,217.70
$1,590.22 		$1,294.36
$1,393.34
$1,498.20
$1,870.72 		$1,574.86
$1,673.84
$1,778.70
$2,151.22 		$280.50
Toc - Plan #111 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 		$402.67
$457.02
$514.60
$719.16
$1,092.83 		$710.71
$765.06
$822.64
$1,027.20 		$1,018.75
$1,073.10
$1,130.68
$1,335.24 		$1,326.79
$1,381.14
$1,438.72
$1,643.28 		$308.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.34
$914.04
$1,029.20
$1,438.32
$2,185.66 		$1,113.38
$1,222.08
$1,337.24
$1,746.36 		$1,421.42
$1,530.12
$1,645.28
$2,054.40 		$1,729.46
$1,838.16
$1,953.32
$2,362.44 		$308.04
Toc - Plan #112 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 		$395.03
$448.34
$504.83
$705.50
$1,072.07 		$697.22
$750.53
$807.02
$1,007.69 		$999.41
$1,052.72
$1,109.21
$1,309.88 		$1,301.60
$1,354.91
$1,411.40
$1,612.07 		$302.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.06
$896.68
$1,009.66
$1,411.00
$2,144.14 		$1,092.25
$1,198.87
$1,311.85
$1,713.19 		$1,394.44
$1,501.06
$1,614.04
$2,015.38 		$1,696.63
$1,803.25
$1,916.23
$2,317.57 		$302.19
Toc - Plan #113 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 		$389.50
$442.07
$497.77
$695.63
$1,057.07 		$687.46
$740.03
$795.73
$993.59 		$985.42
$1,037.99
$1,093.69
$1,291.55 		$1,283.38
$1,335.95
$1,391.65
$1,589.51 		$297.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.00
$884.14
$995.54
$1,391.26
$2,114.14 		$1,076.96
$1,182.10
$1,293.50
$1,689.22 		$1,374.92
$1,480.06
$1,591.46
$1,987.18 		$1,672.88
$1,778.02
$1,889.42
$2,285.14 		$297.96
Toc - Plan #114 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 		$399.15
$453.02
$510.10
$712.86
$1,083.26 		$704.49
$758.36
$815.44
$1,018.20 		$1,009.83
$1,063.70
$1,120.78
$1,323.54 		$1,315.17
$1,369.04
$1,426.12
$1,628.88 		$305.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.30
$906.04
$1,020.20
$1,425.72
$2,166.52 		$1,103.64
$1,211.38
$1,325.54
$1,731.06 		$1,408.98
$1,516.72
$1,630.88
$2,036.40 		$1,714.32
$1,822.06
$1,936.22
$2,341.74 		$305.34
Toc - Plan #115 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 		$421.09
$477.93
$538.14
$752.05
$1,142.82 		$743.22
$800.06
$860.27
$1,074.18 		$1,065.35
$1,122.19
$1,182.40
$1,396.31 		$1,387.48
$1,444.32
$1,504.53
$1,718.44 		$322.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.18
$955.86
$1,076.28
$1,504.10
$2,285.64 		$1,164.31
$1,277.99
$1,398.41
$1,826.23 		$1,486.44
$1,600.12
$1,720.54
$2,148.36 		$1,808.57
$1,922.25
$2,042.67
$2,470.49 		$322.13
Toc - Plan #116 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 		$370.36
$420.35
$473.31
$661.44
$1,005.13 		$653.68
$703.67
$756.63
$944.76 		$937.00
$986.99
$1,039.95
$1,228.08 		$1,220.32
$1,270.31
$1,323.27
$1,511.40 		$283.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.72
$840.70
$946.62
$1,322.88
$2,010.26 		$1,024.04
$1,124.02
$1,229.94
$1,606.20 		$1,307.36
$1,407.34
$1,513.26
$1,889.52 		$1,590.68
$1,690.66
$1,796.58
$2,172.84 		$283.32
Toc - Plan #117 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 		$382.33
$433.94
$488.61
$682.83
$1,037.62 		$674.81
$726.42
$781.09
$975.31 		$967.29
$1,018.90
$1,073.57
$1,267.79 		$1,259.77
$1,311.38
$1,366.05
$1,560.27 		$292.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.66
$867.88
$977.22
$1,365.66
$2,075.24 		$1,057.14
$1,160.36
$1,269.70
$1,658.14 		$1,349.62
$1,452.84
$1,562.18
$1,950.62 		$1,642.10
$1,745.32
$1,854.66
$2,243.10 		$292.48
Toc - Plan #118 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 		$491.77
$558.14
$628.47
$878.28
$1,334.63 		$867.96
$934.33
$1,004.66
$1,254.47 		$1,244.15
$1,310.52
$1,380.85
$1,630.66 		$1,620.34
$1,686.71
$1,757.04
$2,006.85 		$376.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.54
$1,116.28
$1,256.94
$1,756.56
$2,669.26 		$1,359.73
$1,492.47
$1,633.13
$2,132.75 		$1,735.92
$1,868.66
$2,009.32
$2,508.94 		$2,112.11
$2,244.85
$2,385.51
$2,885.13 		$376.19
Toc - Plan #119 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 		$389.90
$442.53
$498.28
$696.34
$1,058.16 		$688.17
$740.80
$796.55
$994.61 		$986.44
$1,039.07
$1,094.82
$1,292.88 		$1,284.71
$1,337.34
$1,393.09
$1,591.15 		$298.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.80
$885.06
$996.56
$1,392.68
$2,116.32 		$1,078.07
$1,183.33
$1,294.83
$1,690.95 		$1,376.34
$1,481.60
$1,593.10
$1,989.22 		$1,674.61
$1,779.87
$1,891.37
$2,287.49 		$298.27

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 #120 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 		$379.03
$430.20
$484.40
$676.95
$1,028.69 		$668.99
$720.16
$774.36
$966.91 		$958.95
$1,010.12
$1,064.32
$1,256.87 		$1,248.91
$1,300.08
$1,354.28
$1,546.83 		$289.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.06
$860.40
$968.80
$1,353.90
$2,057.38 		$1,048.02
$1,150.36
$1,258.76
$1,643.86 		$1,337.98
$1,440.32
$1,548.72
$1,933.82 		$1,627.94
$1,730.28
$1,838.68
$2,223.78 		$289.96
Toc - Plan #121 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 		$279.49
$317.22
$357.18
$499.16
$758.52 		$493.30
$531.03
$570.99
$712.97 		$707.11
$744.84
$784.80
$926.78 		$920.92
$958.65
$998.61
$1,140.59 		$213.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558.98
$634.44
$714.36
$998.32
$1,517.04 		$772.79
$848.25
$928.17
$1,212.13 		$986.60
$1,062.06
$1,141.98
$1,425.94 		$1,200.41
$1,275.87
$1,355.79
$1,639.75 		$213.81
Toc - Plan #122 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 		$401.81
$456.06
$513.52
$717.64
$1,090.52 		$709.20
$763.45
$820.91
$1,025.03 		$1,016.59
$1,070.84
$1,128.30
$1,332.42 		$1,323.98
$1,378.23
$1,435.69
$1,639.81 		$307.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.62
$912.12
$1,027.04
$1,435.28
$2,181.04 		$1,111.01
$1,219.51
$1,334.43
$1,742.67 		$1,418.40
$1,526.90
$1,641.82
$2,050.06 		$1,725.79
$1,834.29
$1,949.21
$2,357.45 		$307.39
Toc - Plan #123 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 		$310.92
$352.90
$397.36
$555.31
$843.85 		$548.78
$590.76
$635.22
$793.17 		$786.64
$828.62
$873.08
$1,031.03 		$1,024.50
$1,066.48
$1,110.94
$1,268.89 		$237.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.84
$705.80
$794.72
$1,110.62
$1,687.70 		$859.70
$943.66
$1,032.58
$1,348.48 		$1,097.56
$1,181.52
$1,270.44
$1,586.34 		$1,335.42
$1,419.38
$1,508.30
$1,824.20 		$237.86
Toc - Plan #124 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 		$302.74
$343.61
$386.91
$540.70
$821.64 		$534.34
$575.21
$618.51
$772.30 		$765.94
$806.81
$850.11
$1,003.90 		$997.54
$1,038.41
$1,081.71
$1,235.50 		$231.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605.48
$687.22
$773.82
$1,081.40
$1,643.28 		$837.08
$918.82
$1,005.42
$1,313.00 		$1,068.68
$1,150.42
$1,237.02
$1,544.60 		$1,300.28
$1,382.02
$1,468.62
$1,776.20 		$231.60
Toc - Plan #125 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 		$400.19
$454.22
$511.45
$714.74
$1,086.12 		$706.34
$760.37
$817.60
$1,020.89 		$1,012.49
$1,066.52
$1,123.75
$1,327.04 		$1,318.64
$1,372.67
$1,429.90
$1,633.19 		$306.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800.38
$908.44
$1,022.90
$1,429.48
$2,172.24 		$1,106.53
$1,214.59
$1,329.05
$1,735.63 		$1,412.68
$1,520.74
$1,635.20
$2,041.78 		$1,718.83
$1,826.89
$1,941.35
$2,347.93 		$306.15
Toc - Plan #126 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 		$447.74
$508.18
$572.21
$799.66
$1,215.16 		$790.26
$850.70
$914.73
$1,142.18 		$1,132.78
$1,193.22
$1,257.25
$1,484.70 		$1,475.30
$1,535.74
$1,599.77
$1,827.22 		$342.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.48
$1,016.36
$1,144.42
$1,599.32
$2,430.32 		$1,238.00
$1,358.88
$1,486.94
$1,941.84 		$1,580.52
$1,701.40
$1,829.46
$2,284.36 		$1,923.04
$2,043.92
$2,171.98
$2,626.88 		$342.52
Toc - Plan #127 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 		$475.76
$539.99
$608.03
$849.72
$1,291.22 		$839.72
$903.95
$971.99
$1,213.68 		$1,203.68
$1,267.91
$1,335.95
$1,577.64 		$1,567.64
$1,631.87
$1,699.91
$1,941.60 		$363.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$951.52
$1,079.98
$1,216.06
$1,699.44
$2,582.44 		$1,315.48
$1,443.94
$1,580.02
$2,063.40 		$1,679.44
$1,807.90
$1,943.98
$2,427.36 		$2,043.40
$2,171.86
$2,307.94
$2,791.32 		$363.96
Toc - Plan #128 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 		$367.46
$417.07
$469.61
$656.28
$997.28 		$648.57
$698.18
$750.72
$937.39 		$929.68
$979.29
$1,031.83
$1,218.50 		$1,210.79
$1,260.40
$1,312.94
$1,499.61 		$281.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.92
$834.14
$939.22
$1,312.56
$1,994.56 		$1,016.03
$1,115.25
$1,220.33
$1,593.67 		$1,297.14
$1,396.36
$1,501.44
$1,874.78 		$1,578.25
$1,677.47
$1,782.55
$2,155.89 		$281.11
Toc - Plan #129 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 		$332.15
$377.00
$424.49
$593.23
$901.47 		$586.25
$631.10
$678.59
$847.33 		$840.35
$885.20
$932.69
$1,101.43 		$1,094.45
$1,139.30
$1,186.79
$1,355.53 		$254.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.30
$754.00
$848.98
$1,186.46
$1,802.94 		$918.40
$1,008.10
$1,103.08
$1,440.56 		$1,172.50
$1,262.20
$1,357.18
$1,694.66 		$1,426.60
$1,516.30
$1,611.28
$1,948.76 		$254.10
Toc - Plan #130 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 		$484.06
$549.41
$618.63
$864.54
$1,313.75 		$854.37
$919.72
$988.94
$1,234.85 		$1,224.68
$1,290.03
$1,359.25
$1,605.16 		$1,594.99
$1,660.34
$1,729.56
$1,975.47 		$370.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$968.12
$1,098.82
$1,237.26
$1,729.08
$2,627.50 		$1,338.43
$1,469.13
$1,607.57
$2,099.39 		$1,708.74
$1,839.44
$1,977.88
$2,469.70 		$2,079.05
$2,209.75
$2,348.19
$2,840.01 		$370.31

ADVERTISEMENT

UnitedHealthcare

Local: 1-866-811-2704 | Toll Free: 1-866-811-2704 | TTY: 1-866-811-2704
Toc - Plan #131 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 		$340.41
$386.37
$435.05
$607.98
$923.88 		$600.83
$646.79
$695.47
$868.40 		$861.25
$907.21
$955.89
$1,128.82 		$1,121.67
$1,167.63
$1,216.31
$1,389.24 		$260.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.82
$772.74
$870.10
$1,215.96
$1,847.76 		$941.24
$1,033.16
$1,130.52
$1,476.38 		$1,201.66
$1,293.58
$1,390.94
$1,736.80 		$1,462.08
$1,554.00
$1,651.36
$1,997.22 		$260.42
Toc - Plan #132 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 		$344.30
$390.78
$440.02
$614.93
$934.44 		$607.69
$654.17
$703.41
$878.32 		$871.08
$917.56
$966.80
$1,141.71 		$1,134.47
$1,180.95
$1,230.19
$1,405.10 		$263.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.60
$781.56
$880.04
$1,229.86
$1,868.88 		$951.99
$1,044.95
$1,143.43
$1,493.25 		$1,215.38
$1,308.34
$1,406.82
$1,756.64 		$1,478.77
$1,571.73
$1,670.21
$2,020.03 		$263.39
Toc - Plan #133 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 		$342.64
$388.90
$437.90
$611.96
$929.93 		$604.76
$651.02
$700.02
$874.08 		$866.88
$913.14
$962.14
$1,136.20 		$1,129.00
$1,175.26
$1,224.26
$1,398.32 		$262.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.28
$777.80
$875.80
$1,223.92
$1,859.86 		$947.40
$1,039.92
$1,137.92
$1,486.04 		$1,209.52
$1,302.04
$1,400.04
$1,748.16 		$1,471.64
$1,564.16
$1,662.16
$2,010.28 		$262.12
Toc - Plan #134 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 		$354.53
$402.39
$453.09
$633.19
$962.19 		$625.74
$673.60
$724.30
$904.40 		$896.95
$944.81
$995.51
$1,175.61 		$1,168.16
$1,216.02
$1,266.72
$1,446.82 		$271.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.06
$804.78
$906.18
$1,266.38
$1,924.38 		$980.27
$1,075.99
$1,177.39
$1,537.59 		$1,251.48
$1,347.20
$1,448.60
$1,808.80 		$1,522.69
$1,618.41
$1,719.81
$2,080.01 		$271.21
Toc - Plan #135 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 		$346.65
$393.45
$443.02
$619.11
$940.80 		$611.84
$658.64
$708.21
$884.30 		$877.03
$923.83
$973.40
$1,149.49 		$1,142.22
$1,189.02
$1,238.59
$1,414.68 		$265.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$693.30
$786.90
$886.04
$1,238.22
$1,881.60 		$958.49
$1,052.09
$1,151.23
$1,503.41 		$1,223.68
$1,317.28
$1,416.42
$1,768.60 		$1,488.87
$1,582.47
$1,681.61
$2,033.79 		$265.19
Toc - Plan #136 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 		$349.19
$396.33
$446.27
$623.65
$947.70 		$616.32
$663.46
$713.40
$890.78 		$883.45
$930.59
$980.53
$1,157.91 		$1,150.58
$1,197.72
$1,247.66
$1,425.04 		$267.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.38
$792.66
$892.54
$1,247.30
$1,895.40 		$965.51
$1,059.79
$1,159.67
$1,514.43 		$1,232.64
$1,326.92
$1,426.80
$1,781.56 		$1,499.77
$1,594.05
$1,693.93
$2,048.69 		$267.13
Toc - Plan #137 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 		$337.44
$383.00
$431.25
$602.67
$915.82 		$595.58
$641.14
$689.39
$860.81 		$853.72
$899.28
$947.53
$1,118.95 		$1,111.86
$1,157.42
$1,205.67
$1,377.09 		$258.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.88
$766.00
$862.50
$1,205.34
$1,831.64 		$933.02
$1,024.14
$1,120.64
$1,463.48 		$1,191.16
$1,282.28
$1,378.78
$1,721.62 		$1,449.30
$1,540.42
$1,636.92
$1,979.76 		$258.14
Toc - Plan #138 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 		$349.31
$396.47
$446.42
$623.87
$948.03 		$616.53
$663.69
$713.64
$891.09 		$883.75
$930.91
$980.86
$1,158.31 		$1,150.97
$1,198.13
$1,248.08
$1,425.53 		$267.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.62
$792.94
$892.84
$1,247.74
$1,896.06 		$965.84
$1,060.16
$1,160.06
$1,514.96 		$1,233.06
$1,327.38
$1,427.28
$1,782.18 		$1,500.28
$1,594.60
$1,694.50
$2,049.40 		$267.22
Toc - Plan #139 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 		$364.93
$414.20
$466.39
$651.77
$990.43 		$644.10
$693.37
$745.56
$930.94 		$923.27
$972.54
$1,024.73
$1,210.11 		$1,202.44
$1,251.71
$1,303.90
$1,489.28 		$279.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.86
$828.40
$932.78
$1,303.54
$1,980.86 		$1,009.03
$1,107.57
$1,211.95
$1,582.71 		$1,288.20
$1,386.74
$1,491.12
$1,861.88 		$1,567.37
$1,665.91
$1,770.29
$2,141.05 		$279.17
Toc - Plan #140 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 		$259.26
$294.26
$331.34
$463.04
$703.63 		$457.59
$492.59
$529.67
$661.37 		$655.92
$690.92
$728.00
$859.70 		$854.25
$889.25
$926.33
$1,058.03 		$198.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$518.52
$588.52
$662.68
$926.08
$1,407.26 		$716.85
$786.85
$861.01
$1,124.41 		$915.18
$985.18
$1,059.34
$1,322.74 		$1,113.51
$1,183.51
$1,257.67
$1,521.07 		$198.33
Toc - Plan #141 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 		$243.67
$276.56
$311.41
$435.19
$661.31 		$430.08
$462.97
$497.82
$621.60 		$616.49
$649.38
$684.23
$808.01 		$802.90
$835.79
$870.64
$994.42 		$186.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$487.34
$553.12
$622.82
$870.38
$1,322.62 		$673.75
$739.53
$809.23
$1,056.79 		$860.16
$925.94
$995.64
$1,243.20 		$1,046.57
$1,112.35
$1,182.05
$1,429.61 		$186.41
Toc - Plan #142 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 		$253.19
$287.38
$323.58
$452.21
$687.17 		$446.88
$481.07
$517.27
$645.90 		$640.57
$674.76
$710.96
$839.59 		$834.26
$868.45
$904.65
$1,033.28 		$193.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$506.38
$574.76
$647.16
$904.42
$1,374.34 		$700.07
$768.45
$840.85
$1,098.11 		$893.76
$962.14
$1,034.54
$1,291.80 		$1,087.45
$1,155.83
$1,228.23
$1,485.49 		$193.69
Toc - Plan #143 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 		$369.45
$419.33
$472.16
$659.84
$1,002.70 		$652.08
$701.96
$754.79
$942.47 		$934.71
$984.59
$1,037.42
$1,225.10 		$1,217.34
$1,267.22
$1,320.05
$1,507.73 		$282.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.90
$838.66
$944.32
$1,319.68
$2,005.40 		$1,021.53
$1,121.29
$1,226.95
$1,602.31 		$1,304.16
$1,403.92
$1,509.58
$1,884.94 		$1,586.79
$1,686.55
$1,792.21
$2,167.57 		$282.63

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #144 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 		$371.97
$422.19
$475.38
$664.34
$1,009.53 		$656.53
$706.75
$759.94
$948.90 		$941.09
$991.31
$1,044.50
$1,233.46 		$1,225.65
$1,275.87
$1,329.06
$1,518.02 		$284.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.94
$844.38
$950.76
$1,328.68
$2,019.06 		$1,028.50
$1,128.94
$1,235.32
$1,613.24 		$1,313.06
$1,413.50
$1,519.88
$1,897.80 		$1,597.62
$1,698.06
$1,804.44
$2,182.36 		$284.56
Toc - Plan #145 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 		$359.80
$408.38
$459.83
$642.61
$976.50 		$635.05
$683.63
$735.08
$917.86 		$910.30
$958.88
$1,010.33
$1,193.11 		$1,185.55
$1,234.13
$1,285.58
$1,468.36 		$275.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.60
$816.76
$919.66
$1,285.22
$1,953.00 		$994.85
$1,092.01
$1,194.91
$1,560.47 		$1,270.10
$1,367.26
$1,470.16
$1,835.72 		$1,545.35
$1,642.51
$1,745.41
$2,110.97 		$275.25
Toc - Plan #146 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 		$380.30
$431.64
$486.02
$679.21
$1,032.12 		$671.23
$722.57
$776.95
$970.14 		$962.16
$1,013.50
$1,067.88
$1,261.07 		$1,253.09
$1,304.43
$1,358.81
$1,552.00 		$290.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.60
$863.28
$972.04
$1,358.42
$2,064.24 		$1,051.53
$1,154.21
$1,262.97
$1,649.35 		$1,342.46
$1,445.14
$1,553.90
$1,940.28 		$1,633.39
$1,736.07
$1,844.83
$2,231.21 		$290.93
Toc - Plan #147 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 		$360.11
$408.72
$460.22
$643.15
$977.33 		$635.59
$684.20
$735.70
$918.63 		$911.07
$959.68
$1,011.18
$1,194.11 		$1,186.55
$1,235.16
$1,286.66
$1,469.59 		$275.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.22
$817.44
$920.44
$1,286.30
$1,954.66 		$995.70
$1,092.92
$1,195.92
$1,561.78 		$1,271.18
$1,368.40
$1,471.40
$1,837.26 		$1,546.66
$1,643.88
$1,746.88
$2,112.74 		$275.48
Toc - Plan #148 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 		$361.84
$410.69
$462.43
$646.24
$982.03 		$638.65
$687.50
$739.24
$923.05 		$915.46
$964.31
$1,016.05
$1,199.86 		$1,192.27
$1,241.12
$1,292.86
$1,476.67 		$276.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.68
$821.38
$924.86
$1,292.48
$1,964.06 		$1,000.49
$1,098.19
$1,201.67
$1,569.29 		$1,277.30
$1,375.00
$1,478.48
$1,846.10 		$1,554.11
$1,651.81
$1,755.29
$2,122.91 		$276.81
Toc - Plan #149 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 		$356.41
$404.53
$455.50
$636.55
$967.31 		$629.07
$677.19
$728.16
$909.21 		$901.73
$949.85
$1,000.82
$1,181.87 		$1,174.39
$1,222.51
$1,273.48
$1,454.53 		$272.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.82
$809.06
$911.00
$1,273.10
$1,934.62 		$985.48
$1,081.72
$1,183.66
$1,545.76 		$1,258.14
$1,354.38
$1,456.32
$1,818.42 		$1,530.80
$1,627.04
$1,728.98
$2,091.08 		$272.66
Toc - Plan #150 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 		$352.85
$400.48
$450.94
$630.19
$957.63 		$622.78
$670.41
$720.87
$900.12 		$892.71
$940.34
$990.80
$1,170.05 		$1,162.64
$1,210.27
$1,260.73
$1,439.98 		$269.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.70
$800.96
$901.88
$1,260.38
$1,915.26 		$975.63
$1,070.89
$1,171.81
$1,530.31 		$1,245.56
$1,340.82
$1,441.74
$1,800.24 		$1,515.49
$1,610.75
$1,711.67
$2,070.17 		$269.93
Toc - Plan #151 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 		$384.65
$436.58
$491.58
$686.98
$1,043.94 		$678.91
$730.84
$785.84
$981.24 		$973.17
$1,025.10
$1,080.10
$1,275.50 		$1,267.43
$1,319.36
$1,374.36
$1,569.76 		$294.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.30
$873.16
$983.16
$1,373.96
$2,087.88 		$1,063.56
$1,167.42
$1,277.42
$1,668.22 		$1,357.82
$1,461.68
$1,571.68
$1,962.48 		$1,652.08
$1,755.94
$1,865.94
$2,256.74 		$294.26
Toc - Plan #152 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 		$363.06
$412.08
$463.99
$648.43
$985.35 		$640.80
$689.82
$741.73
$926.17 		$918.54
$967.56
$1,019.47
$1,203.91 		$1,196.28
$1,245.30
$1,297.21
$1,481.65 		$277.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.12
$824.16
$927.98
$1,296.86
$1,970.70 		$1,003.86
$1,101.90
$1,205.72
$1,574.60 		$1,281.60
$1,379.64
$1,483.46
$1,852.34 		$1,559.34
$1,657.38
$1,761.20
$2,130.08 		$277.74

ADVERTISEMENT

Friday Health Plans

Local: 1-844-451-4444 | Toll Free: 1-844-451-4444 | TTY: 1-800-659-2656
Toc - Plan #153 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 		$194.10
$220.31
$248.06
$346.67
$526.79 		$342.59
$368.80
$396.55
$495.16 		$491.08
$517.29
$545.04
$643.65 		$639.57
$665.78
$693.53
$792.14 		$148.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$388.20
$440.62
$496.12
$693.34
$1,053.58 		$536.69
$589.11
$644.61
$841.83 		$685.18
$737.60
$793.10
$990.32 		$833.67
$886.09
$941.59
$1,138.81 		$148.49
Toc - Plan #154 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 		$213.49
$242.32
$272.85
$381.30
$579.42 		$376.81
$405.64
$436.17
$544.62 		$540.13
$568.96
$599.49
$707.94 		$703.45
$732.28
$762.81
$871.26 		$163.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$426.98
$484.64
$545.70
$762.60
$1,158.84 		$590.30
$647.96
$709.02
$925.92 		$753.62
$811.28
$872.34
$1,089.24 		$916.94
$974.60
$1,035.66
$1,252.56 		$163.32
Toc - Plan #155 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 		$218.30
$247.77
$278.99
$389.88
$592.46 		$385.30
$414.77
$445.99
$556.88 		$552.30
$581.77
$612.99
$723.88 		$719.30
$748.77
$779.99
$890.88 		$167.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$436.60
$495.54
$557.98
$779.76
$1,184.92 		$603.60
$662.54
$724.98
$946.76 		$770.60
$829.54
$891.98
$1,113.76 		$937.60
$996.54
$1,058.98
$1,280.76 		$167.00
Toc - Plan #156 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 		$224.73
$255.07
$287.21
$401.37
$609.92 		$396.65
$426.99
$459.13
$573.29 		$568.57
$598.91
$631.05
$745.21 		$740.49
$770.83
$802.97
$917.13 		$171.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$449.46
$510.14
$574.42
$802.74
$1,219.84 		$621.38
$682.06
$746.34
$974.66 		$793.30
$853.98
$918.26
$1,146.58 		$965.22
$1,025.90
$1,090.18
$1,318.50 		$171.92
Toc - Plan #157 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 		$299.26
$339.67
$382.46
$534.49
$812.20 		$528.20
$568.61
$611.40
$763.43 		$757.14
$797.55
$840.34
$992.37 		$986.08
$1,026.49
$1,069.28
$1,221.31 		$228.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.52
$679.34
$764.92
$1,068.98
$1,624.40 		$827.46
$908.28
$993.86
$1,297.92 		$1,056.40
$1,137.22
$1,222.80
$1,526.86 		$1,285.34
$1,366.16
$1,451.74
$1,755.80 		$228.94
Toc - Plan #158 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 		$282.62
$320.78
$361.19
$504.77
$767.04 		$498.83
$536.99
$577.40
$720.98 		$715.04
$753.20
$793.61
$937.19 		$931.25
$969.41
$1,009.82
$1,153.40 		$216.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.24
$641.56
$722.38
$1,009.54
$1,534.08 		$781.45
$857.77
$938.59
$1,225.75 		$997.66
$1,073.98
$1,154.80
$1,441.96 		$1,213.87
$1,290.19
$1,371.01
$1,658.17 		$216.21
Toc - Plan #159 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 		$220.28
$250.02
$281.52
$393.42
$597.85 		$388.80
$418.54
$450.04
$561.94 		$557.32
$587.06
$618.56
$730.46 		$725.84
$755.58
$787.08
$898.98 		$168.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$440.56
$500.04
$563.04
$786.84
$1,195.70 		$609.08
$668.56
$731.56
$955.36 		$777.60
$837.08
$900.08
$1,123.88 		$946.12
$1,005.60
$1,068.60
$1,292.40 		$168.52
Toc - Plan #160 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 		$303.09
$344.01
$387.35
$541.32
$822.59 		$534.95
$575.87
$619.21
$773.18 		$766.81
$807.73
$851.07
$1,005.04 		$998.67
$1,039.59
$1,082.93
$1,236.90 		$231.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.18
$688.02
$774.70
$1,082.64
$1,645.18 		$838.04
$919.88
$1,006.56
$1,314.50 		$1,069.90
$1,151.74
$1,238.42
$1,546.36 		$1,301.76
$1,383.60
$1,470.28
$1,778.22 		$231.86
Toc - Plan #161 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 		$295.51
$335.41
$377.67
$527.79
$802.03 		$521.58
$561.48
$603.74
$753.86 		$747.65
$787.55
$829.81
$979.93 		$973.72
$1,013.62
$1,055.88
$1,206.00 		$226.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591.02
$670.82
$755.34
$1,055.58
$1,604.06 		$817.09
$896.89
$981.41
$1,281.65 		$1,043.16
$1,122.96
$1,207.48
$1,507.72 		$1,269.23
$1,349.03
$1,433.55
$1,733.79 		$226.07

ADVERTISEMENT

Aetna Life Insurance Company

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #162 Aetna Life Insurance Company
Expanded Bronze

(HMO) Aetna CVS Bronze: Low-Cost Walk-In Clinic Visits, Telehealth, Store Discounts, Houston

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.03
$326.92
$368.10
$514.42
$781.72 		$508.37
$547.26
$588.44
$734.76 		$728.71
$767.60
$808.78
$955.10 		$949.05
$987.94
$1,029.12
$1,175.44 		$220.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.06
$653.84
$736.20
$1,028.84
$1,563.44 		$796.40
$874.18
$956.54
$1,249.18 		$1,016.74
$1,094.52
$1,176.88
$1,469.52 		$1,237.08
$1,314.86
$1,397.22
$1,689.86 		$220.34
Toc - Plan #163 Aetna Life Insurance Company
Bronze

(HMO) Aetna CVS Bronze: $0 Walk-In Clinic Visits, Telehealth, Store Discounts, Houston

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

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 		$258.83
$293.77
$330.79
$462.27
$702.47 		$456.84
$491.78
$528.80
$660.28 		$654.85
$689.79
$726.81
$858.29 		$852.86
$887.80
$924.82
$1,056.30 		$198.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$517.66
$587.54
$661.58
$924.54
$1,404.94 		$715.67
$785.55
$859.59
$1,122.55 		$913.68
$983.56
$1,057.60
$1,320.56 		$1,111.69
$1,181.57
$1,255.61
$1,518.57 		$198.01
Toc - Plan #164 Aetna Life Insurance Company
Gold

(HMO) Aetna CVS Gold: $0 Walk-In Clinic Visits, Telehealth, Store Discounts, Houston

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 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 		$399.04
$452.92
$509.98
$712.69
$1,083.01 		$704.31
$758.19
$815.25
$1,017.96 		$1,009.58
$1,063.46
$1,120.52
$1,323.23 		$1,314.85
$1,368.73
$1,425.79
$1,628.50 		$305.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.08
$905.84
$1,019.96
$1,425.38
$2,166.02 		$1,103.35
$1,211.11
$1,325.23
$1,730.65 		$1,408.62
$1,516.38
$1,630.50
$2,035.92 		$1,713.89
$1,821.65
$1,935.77
$2,341.19 		$305.27
Toc - Plan #165 Aetna Life Insurance Company
Silver

(HMO) Aetna CVS Silver 2: $0 Walk-In Clinic Visits, Telehealth, Store Discounts, Houston

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$346.35
$393.11
$442.63
$618.58
$939.99 		$611.31
$658.07
$707.59
$883.54 		$876.27
$923.03
$972.55
$1,148.50 		$1,141.23
$1,187.99
$1,237.51
$1,413.46 		$264.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.70
$786.22
$885.26
$1,237.16
$1,879.98 		$957.66
$1,051.18
$1,150.22
$1,502.12 		$1,222.62
$1,316.14
$1,415.18
$1,767.08 		$1,487.58
$1,581.10
$1,680.14
$2,032.04 		$264.96
Toc - Plan #166 Aetna Life Insurance Company
Silver

(HMO) Aetna CVS Silver 1: $0 Walk-In Clinic Visits, Telehealth, Store Discounts, Houston

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

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 		$399.96
$453.96
$511.15
$714.33
$1,085.49 		$705.93
$759.93
$817.12
$1,020.30 		$1,011.90
$1,065.90
$1,123.09
$1,326.27 		$1,317.87
$1,371.87
$1,429.06
$1,632.24 		$305.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.92
$907.92
$1,022.30
$1,428.66
$2,170.98 		$1,105.89
$1,213.89
$1,328.27
$1,734.63 		$1,411.86
$1,519.86
$1,634.24
$2,040.60 		$1,717.83
$1,825.83
$1,940.21
$2,346.57 		$305.97

ADVERTISEMENT

Ambetter from Superior Healthplan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-877-941-9237
Toc - Plan #167 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 		$344.79
$391.33
$440.63
$615.78
$935.74 		$608.55
$655.09
$704.39
$879.54 		$872.31
$918.85
$968.15
$1,143.30 		$1,136.07
$1,182.61
$1,231.91
$1,407.06 		$263.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689.58
$782.66
$881.26
$1,231.56
$1,871.48 		$953.34
$1,046.42
$1,145.02
$1,495.32 		$1,217.10
$1,310.18
$1,408.78
$1,759.08 		$1,480.86
$1,573.94
$1,672.54
$2,022.84 		$263.76
Toc - Plan #168 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 		$370.92
$420.98
$474.02
$662.45
$1,006.65 		$654.67
$704.73
$757.77
$946.20 		$938.42
$988.48
$1,041.52
$1,229.95 		$1,222.17
$1,272.23
$1,325.27
$1,513.70 		$283.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.84
$841.96
$948.04
$1,324.90
$2,013.30 		$1,025.59
$1,125.71
$1,231.79
$1,608.65 		$1,309.34
$1,409.46
$1,515.54
$1,892.40 		$1,593.09
$1,693.21
$1,799.29
$2,176.15 		$283.75
Toc - Plan #169 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 		$493.14
$559.71
$630.22
$880.74
$1,338.36 		$870.39
$936.96
$1,007.47
$1,257.99 		$1,247.64
$1,314.21
$1,384.72
$1,635.24 		$1,624.89
$1,691.46
$1,761.97
$2,012.49 		$377.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$986.28
$1,119.42
$1,260.44
$1,761.48
$2,676.72 		$1,363.53
$1,496.67
$1,637.69
$2,138.73 		$1,740.78
$1,873.92
$2,014.94
$2,515.98 		$2,118.03
$2,251.17
$2,392.19
$2,893.23 		$377.25
Toc - Plan #170 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 		$332.56
$377.44
$425.00
$593.93
$902.54 		$586.96
$631.84
$679.40
$848.33 		$841.36
$886.24
$933.80
$1,102.73 		$1,095.76
$1,140.64
$1,188.20
$1,357.13 		$254.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.12
$754.88
$850.00
$1,187.86
$1,805.08 		$919.52
$1,009.28
$1,104.40
$1,442.26 		$1,173.92
$1,263.68
$1,358.80
$1,696.66 		$1,428.32
$1,518.08
$1,613.20
$1,951.06 		$254.40
Toc - Plan #171 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 		$307.15
$348.60
$392.52
$548.55
$833.58 		$542.11
$583.56
$627.48
$783.51 		$777.07
$818.52
$862.44
$1,018.47 		$1,012.03
$1,053.48
$1,097.40
$1,253.43 		$234.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.30
$697.20
$785.04
$1,097.10
$1,667.16 		$849.26
$932.16
$1,020.00
$1,332.06 		$1,084.22
$1,167.12
$1,254.96
$1,567.02 		$1,319.18
$1,402.08
$1,489.92
$1,801.98 		$234.96
Toc - Plan #172 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 		$307.57
$349.09
$393.07
$549.31
$834.73 		$542.86
$584.38
$628.36
$784.60 		$778.15
$819.67
$863.65
$1,019.89 		$1,013.44
$1,054.96
$1,098.94
$1,255.18 		$235.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.14
$698.18
$786.14
$1,098.62
$1,669.46 		$850.43
$933.47
$1,021.43
$1,333.91 		$1,085.72
$1,168.76
$1,256.72
$1,569.20 		$1,321.01
$1,404.05
$1,492.01
$1,804.49 		$235.29
Toc - Plan #173 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 		$317.52
$360.38
$405.78
$567.08
$861.73 		$560.42
$603.28
$648.68
$809.98 		$803.32
$846.18
$891.58
$1,052.88 		$1,046.22
$1,089.08
$1,134.48
$1,295.78 		$242.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.04
$720.76
$811.56
$1,134.16
$1,723.46 		$877.94
$963.66
$1,054.46
$1,377.06 		$1,120.84
$1,206.56
$1,297.36
$1,619.96 		$1,363.74
$1,449.46
$1,540.26
$1,862.86 		$242.90
Toc - Plan #174 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 		$408.40
$463.52
$521.92
$729.38
$1,108.37 		$720.82
$775.94
$834.34
$1,041.80 		$1,033.24
$1,088.36
$1,146.76
$1,354.22 		$1,345.66
$1,400.78
$1,459.18
$1,666.64 		$312.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.80
$927.04
$1,043.84
$1,458.76
$2,216.74 		$1,129.22
$1,239.46
$1,356.26
$1,771.18 		$1,441.64
$1,551.88
$1,668.68
$2,083.60 		$1,754.06
$1,864.30
$1,981.10
$2,396.02 		$312.42

ADVERTISEMENT

Bright HealthCare

Local:  | Toll Free: 

Toc - Plan #175 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 		$323.02
$366.63
$412.82
$576.92
$876.68 		$570.13
$613.74
$659.93
$824.03 		$817.24
$860.85
$907.04
$1,071.14 		$1,064.35
$1,107.96
$1,154.15
$1,318.25 		$247.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.04
$733.26
$825.64
$1,153.84
$1,753.36 		$893.15
$980.37
$1,072.75
$1,400.95 		$1,140.26
$1,227.48
$1,319.86
$1,648.06 		$1,387.37
$1,474.59
$1,566.97
$1,895.17 		$247.11
Toc - Plan #176 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 		$362.70
$411.67
$463.53
$647.79
$984.37 		$640.17
$689.14
$741.00
$925.26 		$917.64
$966.61
$1,018.47
$1,202.73 		$1,195.11
$1,244.08
$1,295.94
$1,480.20 		$277.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.40
$823.34
$927.06
$1,295.58
$1,968.74 		$1,002.87
$1,100.81
$1,204.53
$1,573.05 		$1,280.34
$1,378.28
$1,482.00
$1,850.52 		$1,557.81
$1,655.75
$1,759.47
$2,127.99 		$277.47
Toc - Plan #177 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 		$333.37
$378.38
$426.05
$595.41
$904.78 		$588.40
$633.41
$681.08
$850.44 		$843.43
$888.44
$936.11
$1,105.47 		$1,098.46
$1,143.47
$1,191.14
$1,360.50 		$255.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.74
$756.76
$852.10
$1,190.82
$1,809.56 		$921.77
$1,011.79
$1,107.13
$1,445.85 		$1,176.80
$1,266.82
$1,362.16
$1,700.88 		$1,431.83
$1,521.85
$1,617.19
$1,955.91 		$255.03
Toc - Plan #178 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 		$335.89
$381.23
$429.27
$599.90
$911.60 		$592.85
$638.19
$686.23
$856.86 		$849.81
$895.15
$943.19
$1,113.82 		$1,106.77
$1,152.11
$1,200.15
$1,370.78 		$256.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.78
$762.46
$858.54
$1,199.80
$1,823.20 		$928.74
$1,019.42
$1,115.50
$1,456.76 		$1,185.70
$1,276.38
$1,372.46
$1,713.72 		$1,442.66
$1,533.34
$1,629.42
$1,970.68 		$256.96
Toc - Plan #179 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 		$346.76
$393.58
$443.16
$619.32
$941.12 		$612.03
$658.85
$708.43
$884.59 		$877.30
$924.12
$973.70
$1,149.86 		$1,142.57
$1,189.39
$1,238.97
$1,415.13 		$265.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$693.52
$787.16
$886.32
$1,238.64
$1,882.24 		$958.79
$1,052.43
$1,151.59
$1,503.91 		$1,224.06
$1,317.70
$1,416.86
$1,769.18 		$1,489.33
$1,582.97
$1,682.13
$2,034.45 		$265.27
Toc - Plan #180 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 		$339.35
$385.17
$433.69
$606.09
$921.01 		$598.96
$644.78
$693.30
$865.70 		$858.57
$904.39
$952.91
$1,125.31 		$1,118.18
$1,164.00
$1,212.52
$1,384.92 		$259.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.70
$770.34
$867.38
$1,212.18
$1,842.02 		$938.31
$1,029.95
$1,126.99
$1,471.79 		$1,197.92
$1,289.56
$1,386.60
$1,731.40 		$1,457.53
$1,549.17
$1,646.21
$1,991.01 		$259.61
Toc - Plan #181 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 		$345.94
$392.64
$442.11
$617.85
$938.88 		$610.58
$657.28
$706.75
$882.49 		$875.22
$921.92
$971.39
$1,147.13 		$1,139.86
$1,186.56
$1,236.03
$1,411.77 		$264.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.88
$785.28
$884.22
$1,235.70
$1,877.76 		$956.52
$1,049.92
$1,148.86
$1,500.34 		$1,221.16
$1,314.56
$1,413.50
$1,764.98 		$1,485.80
$1,579.20
$1,678.14
$2,029.62 		$264.64
Toc - Plan #182 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 		$243.46
$276.32
$311.14
$434.82
$660.74 		$429.71
$462.57
$497.39
$621.07 		$615.96
$648.82
$683.64
$807.32 		$802.21
$835.07
$869.89
$993.57 		$186.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.92
$552.64
$622.28
$869.64
$1,321.48 		$673.17
$738.89
$808.53
$1,055.89 		$859.42
$925.14
$994.78
$1,242.14 		$1,045.67
$1,111.39
$1,181.03
$1,428.39 		$186.25
Toc - Plan #183 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 		$263.22
$298.76
$336.40
$470.12
$714.39 		$464.59
$500.13
$537.77
$671.49 		$665.96
$701.50
$739.14
$872.86 		$867.33
$902.87
$940.51
$1,074.23 		$201.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.44
$597.52
$672.80
$940.24
$1,428.78 		$727.81
$798.89
$874.17
$1,141.61 		$929.18
$1,000.26
$1,075.54
$1,342.98 		$1,130.55
$1,201.63
$1,276.91
$1,544.35 		$201.37
Toc - Plan #184 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 		$251.36
$285.30
$321.24
$448.93
$682.20 		$443.65
$477.59
$513.53
$641.22 		$635.94
$669.88
$705.82
$833.51 		$828.23
$862.17
$898.11
$1,025.80 		$192.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$502.72
$570.60
$642.48
$897.86
$1,364.40 		$695.01
$762.89
$834.77
$1,090.15 		$887.30
$955.18
$1,027.06
$1,282.44 		$1,079.59
$1,147.47
$1,219.35
$1,474.73 		$192.29
Toc - Plan #185 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 		$281.17
$319.12
$359.33
$502.16
$763.08 		$496.26
$534.21
$574.42
$717.25 		$711.35
$749.30
$789.51
$932.34 		$926.44
$964.39
$1,004.60
$1,147.43 		$215.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.34
$638.24
$718.66
$1,004.32
$1,526.16 		$777.43
$853.33
$933.75
$1,219.41 		$992.52
$1,068.42
$1,148.84
$1,434.50 		$1,207.61
$1,283.51
$1,363.93
$1,649.59 		$215.09
Toc - Plan #186 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 		$257.95
$292.77
$329.66
$460.70
$700.07 		$455.28
$490.10
$526.99
$658.03 		$652.61
$687.43
$724.32
$855.36 		$849.94
$884.76
$921.65
$1,052.69 		$197.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$515.90
$585.54
$659.32
$921.40
$1,400.14 		$713.23
$782.87
$856.65
$1,118.73 		$910.56
$980.20
$1,053.98
$1,316.06 		$1,107.89
$1,177.53
$1,251.31
$1,513.39 		$197.33
Toc - Plan #187 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 		$208.45
$236.59
$266.40
$372.29
$565.74 		$367.92
$396.06
$425.87
$531.76 		$527.39
$555.53
$585.34
$691.23 		$686.86
$715.00
$744.81
$850.70 		$159.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$416.90
$473.18
$532.80
$744.58
$1,131.48 		$576.37
$632.65
$692.27
$904.05 		$735.84
$792.12
$851.74
$1,063.52 		$895.31
$951.59
$1,011.21
$1,222.99 		$159.47
Toc - Plan #188 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 		$240.18
$272.61
$306.96
$428.97
$651.86 		$423.92
$456.35
$490.70
$612.71 		$607.66
$640.09
$674.44
$796.45 		$791.40
$823.83
$858.18
$980.19 		$183.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$480.36
$545.22
$613.92
$857.94
$1,303.72 		$664.10
$728.96
$797.66
$1,041.68 		$847.84
$912.70
$981.40
$1,225.42 		$1,031.58
$1,096.44
$1,165.14
$1,409.16 		$183.74
Toc - Plan #189 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 		$329.17
$373.60
$420.67
$587.89
$893.35 		$580.98
$625.41
$672.48
$839.70 		$832.79
$877.22
$924.29
$1,091.51 		$1,084.60
$1,129.03
$1,176.10
$1,343.32 		$251.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658.34
$747.20
$841.34
$1,175.78
$1,786.70 		$910.15
$999.01
$1,093.15
$1,427.59 		$1,161.96
$1,250.82
$1,344.96
$1,679.40 		$1,413.77
$1,502.63
$1,596.77
$1,931.21 		$251.81

‡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 Montgomery County here.

Montgomery County is in “Rating Area 10” of Texas.

Currently, there are 189 plans offered in Rating Area 10.

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2022 Obamacare Plans for Montgomery County, TX

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