Obamacare 2023 Rates for Flagler County

Obamacare > Rates > Florida > Flagler County

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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 Flagler County, FL.

The health insurance rates listed below are for calendar year 2023.

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, 148 Plans and 2023 Rates for Flagler County, Florida

Below, you’ll find a summary of the 148 plans for Flagler County, Florida and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

Flagler County Resources

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Florida Blue (BlueCross BlueShield FL)

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

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$826.06
$937.58
$1,055.70
$1,475.34
$2,241.93 		$1,458.00
$1,569.52
$1,687.64
$2,107.28 		$2,089.94
$2,201.46
$2,319.58
$2,739.22 		$2,721.88
$2,833.40
$2,951.52
$3,371.16 		$631.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,652.12
$1,875.16
$2,111.40
$2,950.68
$4,483.86 		$2,284.06
$2,507.10
$2,743.34
$3,582.62 		$2,916.00
$3,139.04
$3,375.28
$4,214.56 		$3,547.94
$3,770.98
$4,007.22
$4,846.50 		$631.94
Toc - Plan #2 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,100 $18,200 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 		$534.43
$606.58
$683.00
$954.49
$1,450.44 		$943.27
$1,015.42
$1,091.84
$1,363.33 		$1,352.11
$1,424.26
$1,500.68
$1,772.17 		$1,760.95
$1,833.10
$1,909.52
$2,181.01 		$408.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,068.86
$1,213.16
$1,366.00
$1,908.98
$2,900.88 		$1,477.70
$1,622.00
$1,774.84
$2,317.82 		$1,886.54
$2,030.84
$2,183.68
$2,726.66 		$2,295.38
$2,439.68
$2,592.52
$3,135.50 		$408.84
Toc - Plan #3 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 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 		$830.60
$942.73
$1,061.51
$1,483.45
$2,254.25 		$1,466.01
$1,578.14
$1,696.92
$2,118.86 		$2,101.42
$2,213.55
$2,332.33
$2,754.27 		$2,736.83
$2,848.96
$2,967.74
$3,389.68 		$635.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,661.20
$1,885.46
$2,123.02
$2,966.90
$4,508.50 		$2,296.61
$2,520.87
$2,758.43
$3,602.31 		$2,932.02
$3,156.28
$3,393.84
$4,237.72 		$3,567.43
$3,791.69
$4,029.25
$4,873.13 		$635.41
Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,000 $8,000 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 		$1,045.25
$1,186.36
$1,335.83
$1,866.82
$2,836.81 		$1,844.87
$1,985.98
$2,135.45
$2,666.44 		$2,644.49
$2,785.60
$2,935.07
$3,466.06 		$3,444.11
$3,585.22
$3,734.69
$4,265.68 		$799.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,090.50
$2,372.72
$2,671.66
$3,733.64
$5,673.62 		$2,890.12
$3,172.34
$3,471.28
$4,533.26 		$3,689.74
$3,971.96
$4,270.90
$5,332.88 		$4,489.36
$4,771.58
$5,070.52
$6,132.50 		$799.62
Toc - Plan #5 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,100 $18,200 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 		$556.68
$631.83
$711.44
$994.23
$1,510.83 		$982.54
$1,057.69
$1,137.30
$1,420.09 		$1,408.40
$1,483.55
$1,563.16
$1,845.95 		$1,834.26
$1,909.41
$1,989.02
$2,271.81 		$425.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,113.36
$1,263.66
$1,422.88
$1,988.46
$3,021.66 		$1,539.22
$1,689.52
$1,848.74
$2,414.32 		$1,965.08
$2,115.38
$2,274.60
$2,840.18 		$2,390.94
$2,541.24
$2,700.46
$3,266.04 		$425.86
Toc - Plan #6 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$1,095.24
$1,243.10
$1,399.72
$1,956.10
$2,972.48 		$1,933.10
$2,080.96
$2,237.58
$2,793.96 		$2,770.96
$2,918.82
$3,075.44
$3,631.82 		$3,608.82
$3,756.68
$3,913.30
$4,469.68 		$837.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,190.48
$2,486.20
$2,799.44
$3,912.20
$5,944.96 		$3,028.34
$3,324.06
$3,637.30
$4,750.06 		$3,866.20
$4,161.92
$4,475.16
$5,587.92 		$4,704.06
$4,999.78
$5,313.02
$6,425.78 		$837.86
Toc - Plan #7 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$775.39
$880.07
$990.95
$1,384.85
$2,104.41 		$1,368.56
$1,473.24
$1,584.12
$1,978.02 		$1,961.73
$2,066.41
$2,177.29
$2,571.19 		$2,554.90
$2,659.58
$2,770.46
$3,164.36 		$593.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,550.78
$1,760.14
$1,981.90
$2,769.70
$4,208.82 		$2,143.95
$2,353.31
$2,575.07
$3,362.87 		$2,737.12
$2,946.48
$3,168.24
$3,956.04 		$3,330.29
$3,539.65
$3,761.41
$4,549.21 		$593.17
Toc - Plan #8 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $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 		$897.68
$1,018.87
$1,147.24
$1,603.26
$2,436.30 		$1,584.41
$1,705.60
$1,833.97
$2,289.99 		$2,271.14
$2,392.33
$2,520.70
$2,976.72 		$2,957.87
$3,079.06
$3,207.43
$3,663.45 		$686.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,795.36
$2,037.74
$2,294.48
$3,206.52
$4,872.60 		$2,482.09
$2,724.47
$2,981.21
$3,893.25 		$3,168.82
$3,411.20
$3,667.94
$4,579.98 		$3,855.55
$4,097.93
$4,354.67
$5,266.71 		$686.73
Toc - Plan #9 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$541.17
$614.23
$691.62
$966.53
$1,468.74 		$955.17
$1,028.23
$1,105.62
$1,380.53 		$1,369.17
$1,442.23
$1,519.62
$1,794.53 		$1,783.17
$1,856.23
$1,933.62
$2,208.53 		$414.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,082.34
$1,228.46
$1,383.24
$1,933.06
$2,937.48 		$1,496.34
$1,642.46
$1,797.24
$2,347.06 		$1,910.34
$2,056.46
$2,211.24
$2,761.06 		$2,324.34
$2,470.46
$2,625.24
$3,175.06 		$414.00
Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1805 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$868.50
$985.75
$1,109.94
$1,551.14
$2,357.11 		$1,532.90
$1,650.15
$1,774.34
$2,215.54 		$2,197.30
$2,314.55
$2,438.74
$2,879.94 		$2,861.70
$2,978.95
$3,103.14
$3,544.34 		$664.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,737.00
$1,971.50
$2,219.88
$3,102.28
$4,714.22 		$2,401.40
$2,635.90
$2,884.28
$3,766.68 		$3,065.80
$3,300.30
$3,548.68
$4,431.08 		$3,730.20
$3,964.70
$4,213.08
$5,095.48 		$664.40
Toc - Plan #11 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 2119 ($0 Deductible / $0 Virtual Visits / $50 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$589.57
$669.16
$753.47
$1,052.97
$1,600.09 		$1,040.59
$1,120.18
$1,204.49
$1,503.99 		$1,491.61
$1,571.20
$1,655.51
$1,955.01 		$1,942.63
$2,022.22
$2,106.53
$2,406.03 		$451.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,179.14
$1,338.32
$1,506.94
$2,105.94
$3,200.18 		$1,630.16
$1,789.34
$1,957.96
$2,556.96 		$2,081.18
$2,240.36
$2,408.98
$3,007.98 		$2,532.20
$2,691.38
$2,860.00
$3,459.00 		$451.02
Toc - Plan #12 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueOptions Bronze 2301S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$510.82
$579.78
$652.83
$912.32
$1,386.37 		$901.60
$970.56
$1,043.61
$1,303.10 		$1,292.38
$1,361.34
$1,434.39
$1,693.88 		$1,683.16
$1,752.12
$1,825.17
$2,084.66 		$390.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,021.64
$1,159.56
$1,305.66
$1,824.64
$2,772.74 		$1,412.42
$1,550.34
$1,696.44
$2,215.42 		$1,803.20
$1,941.12
$2,087.22
$2,606.20 		$2,193.98
$2,331.90
$2,478.00
$2,996.98 		$390.78
Toc - Plan #13 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 2302S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$549.13
$623.26
$701.79
$980.75
$1,490.34 		$969.21
$1,043.34
$1,121.87
$1,400.83 		$1,389.29
$1,463.42
$1,541.95
$1,820.91 		$1,809.37
$1,883.50
$1,962.03
$2,240.99 		$420.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,098.26
$1,246.52
$1,403.58
$1,961.50
$2,980.68 		$1,518.34
$1,666.60
$1,823.66
$2,381.58 		$1,938.42
$2,086.68
$2,243.74
$2,801.66 		$2,358.50
$2,506.76
$2,663.82
$3,221.74 		$420.08
Toc - Plan #14 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 2303S ($40 PCP Visits / Multilingual Available/ Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$817.62
$928.00
$1,044.92
$1,460.27
$2,219.02 		$1,443.10
$1,553.48
$1,670.40
$2,085.75 		$2,068.58
$2,178.96
$2,295.88
$2,711.23 		$2,694.06
$2,804.44
$2,921.36
$3,336.71 		$625.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,635.24
$1,856.00
$2,089.84
$2,920.54
$4,438.04 		$2,260.72
$2,481.48
$2,715.32
$3,546.02 		$2,886.20
$3,106.96
$3,340.80
$4,171.50 		$3,511.68
$3,732.44
$3,966.28
$4,796.98 		$625.48
Toc - Plan #15 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 2304S ($30 PCP Visits / Multilingual Available / Rewards $$$)

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

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 		$834.51
$947.17
$1,066.50
$1,490.43
$2,264.86 		$1,472.91
$1,585.57
$1,704.90
$2,128.83 		$2,111.31
$2,223.97
$2,343.30
$2,767.23 		$2,749.71
$2,862.37
$2,981.70
$3,405.63 		$638.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,669.02
$1,894.34
$2,133.00
$2,980.86
$4,529.72 		$2,307.42
$2,532.74
$2,771.40
$3,619.26 		$2,945.82
$3,171.14
$3,409.80
$4,257.66 		$3,584.22
$3,809.54
$4,048.20
$4,896.06 		$638.40
Toc - Plan #16 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueOptions Platinum 2305S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 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 		$1,092.49
$1,239.98
$1,396.20
$1,951.19
$2,965.02 		$1,928.24
$2,075.73
$2,231.95
$2,786.94 		$2,763.99
$2,911.48
$3,067.70
$3,622.69 		$3,599.74
$3,747.23
$3,903.45
$4,458.44 		$835.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,184.98
$2,479.96
$2,792.40
$3,902.38
$5,930.04 		$3,020.73
$3,315.71
$3,628.15
$4,738.13 		$3,856.48
$4,151.46
$4,463.90
$5,573.88 		$4,692.23
$4,987.21
$5,299.65
$6,409.63 		$835.75
Toc - Plan #17 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 2319 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$577.97
$656.00
$738.65
$1,032.25
$1,568.61 		$1,020.12
$1,098.15
$1,180.80
$1,474.40 		$1,462.27
$1,540.30
$1,622.95
$1,916.55 		$1,904.42
$1,982.45
$2,065.10
$2,358.70 		$442.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,155.94
$1,312.00
$1,477.30
$2,064.50
$3,137.22 		$1,598.09
$1,754.15
$1,919.45
$2,506.65 		$2,040.24
$2,196.30
$2,361.60
$2,948.80 		$2,482.39
$2,638.45
$2,803.75
$3,390.95 		$442.15

ADVERTISEMENT

Florida Blue HMO (a BlueCross BlueShield FL company)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771
Toc - Plan #18 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 Annual Deductible
$7,250 $14,500 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 		$616.69
$699.94
$788.13
$1,101.41
$1,673.70 		$1,088.46
$1,171.71
$1,259.90
$1,573.18 		$1,560.23
$1,643.48
$1,731.67
$2,044.95 		$2,032.00
$2,115.25
$2,203.44
$2,516.72 		$471.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,233.38
$1,399.88
$1,576.26
$2,202.82
$3,347.40 		$1,705.15
$1,871.65
$2,048.03
$2,674.59 		$2,176.92
$2,343.42
$2,519.80
$3,146.36 		$2,648.69
$2,815.19
$2,991.57
$3,618.13 		$471.77
Toc - Plan #19 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,100 $18,200 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 		$436.19
$495.08
$557.45
$779.04
$1,183.82 		$769.88
$828.77
$891.14
$1,112.73 		$1,103.57
$1,162.46
$1,224.83
$1,446.42 		$1,437.26
$1,496.15
$1,558.52
$1,780.11 		$333.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$872.38
$990.16
$1,114.90
$1,558.08
$2,367.64 		$1,206.07
$1,323.85
$1,448.59
$1,891.77 		$1,539.76
$1,657.54
$1,782.28
$2,225.46 		$1,873.45
$1,991.23
$2,115.97
$2,559.15 		$333.69
Toc - Plan #20 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 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 		$631.21
$716.42
$806.69
$1,127.34
$1,713.10 		$1,114.09
$1,199.30
$1,289.57
$1,610.22 		$1,596.97
$1,682.18
$1,772.45
$2,093.10 		$2,079.85
$2,165.06
$2,255.33
$2,575.98 		$482.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,262.42
$1,432.84
$1,613.38
$2,254.68
$3,426.20 		$1,745.30
$1,915.72
$2,096.26
$2,737.56 		$2,228.18
$2,398.60
$2,579.14
$3,220.44 		$2,711.06
$2,881.48
$3,062.02
$3,703.32 		$482.88
Toc - Plan #21 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,000 $8,000 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 		$739.76
$839.63
$945.41
$1,321.21
$2,007.71 		$1,305.68
$1,405.55
$1,511.33
$1,887.13 		$1,871.60
$1,971.47
$2,077.25
$2,453.05 		$2,437.52
$2,537.39
$2,643.17
$3,018.97 		$565.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,479.52
$1,679.26
$1,890.82
$2,642.42
$4,015.42 		$2,045.44
$2,245.18
$2,456.74
$3,208.34 		$2,611.36
$2,811.10
$3,022.66
$3,774.26 		$3,177.28
$3,377.02
$3,588.58
$4,340.18 		$565.92
Toc - Plan #22 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,100 $18,200 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 		$462.33
$524.74
$590.86
$825.72
$1,254.76 		$816.01
$878.42
$944.54
$1,179.40 		$1,169.69
$1,232.10
$1,298.22
$1,533.08 		$1,523.37
$1,585.78
$1,651.90
$1,886.76 		$353.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$924.66
$1,049.48
$1,181.72
$1,651.44
$2,509.52 		$1,278.34
$1,403.16
$1,535.40
$2,005.12 		$1,632.02
$1,756.84
$1,889.08
$2,358.80 		$1,985.70
$2,110.52
$2,242.76
$2,712.48 		$353.68
Toc - Plan #23 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$786.42
$892.59
$1,005.04
$1,404.55
$2,134.34 		$1,388.03
$1,494.20
$1,606.65
$2,006.16 		$1,989.64
$2,095.81
$2,208.26
$2,607.77 		$2,591.25
$2,697.42
$2,809.87
$3,209.38 		$601.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,572.84
$1,785.18
$2,010.08
$2,809.10
$4,268.68 		$2,174.45
$2,386.79
$2,611.69
$3,410.71 		$2,776.06
$2,988.40
$3,213.30
$4,012.32 		$3,377.67
$3,590.01
$3,814.91
$4,613.93 		$601.61
Toc - Plan #24 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$568.79
$645.58
$726.91
$1,015.86
$1,543.70 		$1,003.91
$1,080.70
$1,162.03
$1,450.98 		$1,439.03
$1,515.82
$1,597.15
$1,886.10 		$1,874.15
$1,950.94
$2,032.27
$2,321.22 		$435.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,137.58
$1,291.16
$1,453.82
$2,031.72
$3,087.40 		$1,572.70
$1,726.28
$1,888.94
$2,466.84 		$2,007.82
$2,161.40
$2,324.06
$2,901.96 		$2,442.94
$2,596.52
$2,759.18
$3,337.08 		$435.12
Toc - Plan #25 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 1565 ($0 Virtual Visits / $20 PCP Visit / $15 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $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 		$693.88
$787.55
$886.78
$1,239.27
$1,883.19 		$1,224.70
$1,318.37
$1,417.60
$1,770.09 		$1,755.52
$1,849.19
$1,948.42
$2,300.91 		$2,286.34
$2,380.01
$2,479.24
$2,831.73 		$530.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,387.76
$1,575.10
$1,773.56
$2,478.54
$3,766.38 		$1,918.58
$2,105.92
$2,304.38
$3,009.36 		$2,449.40
$2,636.74
$2,835.20
$3,540.18 		$2,980.22
$3,167.56
$3,366.02
$4,071.00 		$530.82
Toc - Plan #26 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$441.35
$500.93
$564.05
$788.25
$1,197.82 		$778.98
$838.56
$901.68
$1,125.88 		$1,116.61
$1,176.19
$1,239.31
$1,463.51 		$1,454.24
$1,513.82
$1,576.94
$1,801.14 		$337.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$882.70
$1,001.86
$1,128.10
$1,576.50
$2,395.64 		$1,220.33
$1,339.49
$1,465.73
$1,914.13 		$1,557.96
$1,677.12
$1,803.36
$2,251.76 		$1,895.59
$2,014.75
$2,140.99
$2,589.39 		$337.63
Toc - Plan #27 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 1865 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$664.07
$753.72
$848.68
$1,186.03
$1,802.29 		$1,172.08
$1,261.73
$1,356.69
$1,694.04 		$1,680.09
$1,769.74
$1,864.70
$2,202.05 		$2,188.10
$2,277.75
$2,372.71
$2,710.06 		$508.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,328.14
$1,507.44
$1,697.36
$2,372.06
$3,604.58 		$1,836.15
$2,015.45
$2,205.37
$2,880.07 		$2,344.16
$2,523.46
$2,713.38
$3,388.08 		$2,852.17
$3,031.47
$3,221.39
$3,896.09 		$508.01
Toc - Plan #28 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2179 ($0 Deductible / $0 Virtual Visits / $50 PCP Visit / $30 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$501.74
$569.47
$641.22
$896.11
$1,361.72 		$885.57
$953.30
$1,025.05
$1,279.94 		$1,269.40
$1,337.13
$1,408.88
$1,663.77 		$1,653.23
$1,720.96
$1,792.71
$2,047.60 		$383.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,003.48
$1,138.94
$1,282.44
$1,792.22
$2,723.44 		$1,387.31
$1,522.77
$1,666.27
$2,176.05 		$1,771.14
$1,906.60
$2,050.10
$2,559.88 		$2,154.97
$2,290.43
$2,433.93
$2,943.71 		$383.83
Toc - Plan #29 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) BlueCare Bronze 2361S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.87
$467.47
$526.37
$735.60
$1,117.82 		$726.95
$782.55
$841.45
$1,050.68 		$1,042.03
$1,097.63
$1,156.53
$1,365.76 		$1,357.11
$1,412.71
$1,471.61
$1,680.84 		$315.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.74
$934.94
$1,052.74
$1,471.20
$2,235.64 		$1,138.82
$1,250.02
$1,367.82
$1,786.28 		$1,453.90
$1,565.10
$1,682.90
$2,101.36 		$1,768.98
$1,880.18
$1,997.98
$2,416.44 		$315.08
Toc - Plan #30 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2362S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$453.76
$515.02
$579.91
$810.42
$1,231.50 		$800.89
$862.15
$927.04
$1,157.55 		$1,148.02
$1,209.28
$1,274.17
$1,504.68 		$1,495.15
$1,556.41
$1,621.30
$1,851.81 		$347.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$907.52
$1,030.04
$1,159.82
$1,620.84
$2,463.00 		$1,254.65
$1,377.17
$1,506.95
$1,967.97 		$1,601.78
$1,724.30
$1,854.08
$2,315.10 		$1,948.91
$2,071.43
$2,201.21
$2,662.23 		$347.13
Toc - Plan #31 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 2363S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$610.03
$692.38
$779.62
$1,089.51
$1,655.62 		$1,076.70
$1,159.05
$1,246.29
$1,556.18 		$1,543.37
$1,625.72
$1,712.96
$2,022.85 		$2,010.04
$2,092.39
$2,179.63
$2,489.52 		$466.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,220.06
$1,384.76
$1,559.24
$2,179.02
$3,311.24 		$1,686.73
$1,851.43
$2,025.91
$2,645.69 		$2,153.40
$2,318.10
$2,492.58
$3,112.36 		$2,620.07
$2,784.77
$2,959.25
$3,579.03 		$466.67
Toc - Plan #32 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 2364S ($30 PCP Visit / Multilingual Available / Rewards $$$)

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

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 		$628.92
$713.82
$803.76
$1,123.25
$1,706.89 		$1,110.04
$1,194.94
$1,284.88
$1,604.37 		$1,591.16
$1,676.06
$1,766.00
$2,085.49 		$2,072.28
$2,157.18
$2,247.12
$2,566.61 		$481.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,257.84
$1,427.64
$1,607.52
$2,246.50
$3,413.78 		$1,738.96
$1,908.76
$2,088.64
$2,727.62 		$2,220.08
$2,389.88
$2,569.76
$3,208.74 		$2,701.20
$2,871.00
$3,050.88
$3,689.86 		$481.12
Toc - Plan #33 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 2365S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 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 		$784.26
$890.14
$1,002.28
$1,400.69
$2,128.48 		$1,384.22
$1,490.10
$1,602.24
$2,000.65 		$1,984.18
$2,090.06
$2,202.20
$2,600.61 		$2,584.14
$2,690.02
$2,802.16
$3,200.57 		$599.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,568.52
$1,780.28
$2,004.56
$2,801.38
$4,256.96 		$2,168.48
$2,380.24
$2,604.52
$3,401.34 		$2,768.44
$2,980.20
$3,204.48
$4,001.30 		$3,368.40
$3,580.16
$3,804.44
$4,601.26 		$599.96
Toc - Plan #34 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2379 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 Not Applicable Annual Deductible
$9,100 $18,200 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 		$485.21
$550.71
$620.10
$866.59
$1,316.86 		$856.40
$921.90
$991.29
$1,237.78 		$1,227.59
$1,293.09
$1,362.48
$1,608.97 		$1,598.78
$1,664.28
$1,733.67
$1,980.16 		$371.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$970.42
$1,101.42
$1,240.20
$1,733.18
$2,633.72 		$1,341.61
$1,472.61
$1,611.39
$2,104.37 		$1,712.80
$1,843.80
$1,982.58
$2,475.56 		$2,083.99
$2,214.99
$2,353.77
$2,846.75 		$371.19

ADVERTISEMENT

Health First Commercial Plans, Inc.

Local: 1-855-443-4735 | Toll Free: 1-855-443-4735 | TTY: 1-800-955-8771
Toc - Plan #35 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze Gym Access HSA 1658 (HSA Qualified, $0 Preventive Care, Open Access, Fitness Center Included)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

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 		$338.39
$384.07
$432.46
$604.37
$918.39 		$597.26
$642.94
$691.33
$863.24 		$856.13
$901.81
$950.20
$1,122.11 		$1,115.00
$1,160.68
$1,209.07
$1,380.98 		$258.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$676.78
$768.14
$864.92
$1,208.74
$1,836.78 		$935.65
$1,027.01
$1,123.79
$1,467.61 		$1,194.52
$1,285.88
$1,382.66
$1,726.48 		$1,453.39
$1,544.75
$1,641.53
$1,985.35 		$258.87
Toc - Plan #36 Health First Commercial Plans, Inc.
Silver

(HMO) Silver Gym Access 1664 (Primary Care & Specialist Copays, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access, Fitness Center Included)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 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 		$415.61
$471.72
$531.15
$742.28
$1,127.96 		$733.55
$789.66
$849.09
$1,060.22 		$1,051.49
$1,107.60
$1,167.03
$1,378.16 		$1,369.43
$1,425.54
$1,484.97
$1,696.10 		$317.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.22
$943.44
$1,062.30
$1,484.56
$2,255.92 		$1,149.16
$1,261.38
$1,380.24
$1,802.50 		$1,467.10
$1,579.32
$1,698.18
$2,120.44 		$1,785.04
$1,897.26
$2,016.12
$2,438.38 		$317.94
Toc - Plan #37 Health First Commercial Plans, Inc.
Silver

(HMO) Silver Gym Access 1688 ($0 Preventive Care, $2 Tier 1 Perscriptions, Open Access, Fitness Center Included)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.51
$467.06
$525.91
$734.95
$1,116.83 		$726.31
$781.86
$840.71
$1,049.75 		$1,041.11
$1,096.66
$1,155.51
$1,364.55 		$1,355.91
$1,411.46
$1,470.31
$1,679.35 		$314.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.02
$934.12
$1,051.82
$1,469.90
$2,233.66 		$1,137.82
$1,248.92
$1,366.62
$1,784.70 		$1,452.62
$1,563.72
$1,681.42
$2,099.50 		$1,767.42
$1,878.52
$1,996.22
$2,414.30 		$314.80
Toc - Plan #38 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$2,650 $5,300 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 		$452.02
$513.04
$577.68
$807.30
$1,226.77 		$797.81
$858.83
$923.47
$1,153.09 		$1,143.60
$1,204.62
$1,269.26
$1,498.88 		$1,489.39
$1,550.41
$1,615.05
$1,844.67 		$345.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.04
$1,026.08
$1,155.36
$1,614.60
$2,453.54 		$1,249.83
$1,371.87
$1,501.15
$1,960.39 		$1,595.62
$1,717.66
$1,846.94
$2,306.18 		$1,941.41
$2,063.45
$2,192.73
$2,651.97 		$345.79
Toc - Plan #39 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Gym Access 1740 (Low Copays, $0 Outpatient Labs, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$437.78
$496.88
$559.49
$781.88
$1,188.14 		$772.68
$831.78
$894.39
$1,116.78 		$1,107.58
$1,166.68
$1,229.29
$1,451.68 		$1,442.48
$1,501.58
$1,564.19
$1,786.58 		$334.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$875.56
$993.76
$1,118.98
$1,563.76
$2,376.28 		$1,210.46
$1,328.66
$1,453.88
$1,898.66 		$1,545.36
$1,663.56
$1,788.78
$2,233.56 		$1,880.26
$1,998.46
$2,123.68
$2,568.46 		$334.90
Toc - Plan #40 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Gym Access 1742 (Emergency Room & Inpatient Hospitalization Copay, $0 Outpatient Labs, $0 MRI, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,750 $15,500 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 		$461.36
$523.65
$589.62
$824.00
$1,252.14 		$814.30
$876.59
$942.56
$1,176.94 		$1,167.24
$1,229.53
$1,295.50
$1,529.88 		$1,520.18
$1,582.47
$1,648.44
$1,882.82 		$352.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.72
$1,047.30
$1,179.24
$1,648.00
$2,504.28 		$1,275.66
$1,400.24
$1,532.18
$2,000.94 		$1,628.60
$1,753.18
$1,885.12
$2,353.88 		$1,981.54
$2,106.12
$2,238.06
$2,706.82 		$352.94
Toc - Plan #41 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Gym Access HSA 1744 (Low Deductible, Low Out of Pocket Maximum, HSA Qualified, $0 Preventive Care, Open Access, Fitness Center Included)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$1,700 $3,400 Annual Deductible
$4,350 $8,700 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 		$448.82
$509.41
$573.59
$801.59
$1,218.10 		$792.17
$852.76
$916.94
$1,144.94 		$1,135.52
$1,196.11
$1,260.29
$1,488.29 		$1,478.87
$1,539.46
$1,603.64
$1,831.64 		$343.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$897.64
$1,018.82
$1,147.18
$1,603.18
$2,436.20 		$1,240.99
$1,362.17
$1,490.53
$1,946.53 		$1,584.34
$1,705.52
$1,833.88
$2,289.88 		$1,927.69
$2,048.87
$2,177.23
$2,633.23 		$343.35
Toc - Plan #42 Health First Commercial Plans, Inc.
Catastrophic

(HMO) Catastrophic Gym Access 1746 (Primary Care Copay, $0 Preventive Care, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$182.58
$207.23
$233.34
$326.09
$495.53 		$322.26
$346.91
$373.02
$465.77 		$461.94
$486.59
$512.70
$605.45 		$601.62
$626.27
$652.38
$745.13 		$139.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$365.16
$414.46
$466.68
$652.18
$991.06 		$504.84
$554.14
$606.36
$791.86 		$644.52
$693.82
$746.04
$931.54 		$784.20
$833.50
$885.72
$1,071.22 		$139.68
Toc - Plan #43 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze Gym Access 1796 (Primary Care & Specialist Copays, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access, Fitness Center Included)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 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 		$326.58
$370.67
$417.37
$583.27
$886.34 		$576.41
$620.50
$667.20
$833.10 		$826.24
$870.33
$917.03
$1,082.93 		$1,076.07
$1,120.16
$1,166.86
$1,332.76 		$249.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.16
$741.34
$834.74
$1,166.54
$1,772.68 		$902.99
$991.17
$1,084.57
$1,416.37 		$1,152.82
$1,241.00
$1,334.40
$1,666.20 		$1,402.65
$1,490.83
$1,584.23
$1,916.03 		$249.83
Toc - Plan #44 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze Gym Access 1656 (Primary Care & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access, Fitness Center Included)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$342.39
$388.61
$437.57
$611.51
$929.24 		$604.32
$650.54
$699.50
$873.44 		$866.25
$912.47
$961.43
$1,135.37 		$1,128.18
$1,174.40
$1,223.36
$1,397.30 		$261.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.78
$777.22
$875.14
$1,223.02
$1,858.48 		$946.71
$1,039.15
$1,137.07
$1,484.95 		$1,208.64
$1,301.08
$1,399.00
$1,746.88 		$1,470.57
$1,563.01
$1,660.93
$2,008.81 		$261.93
Toc - Plan #45 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze 1750 (Unlimited Primary Care, Specialist & Urgent Care Copay Visits, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$330.38
$374.98
$422.23
$590.06
$896.66 		$583.12
$627.72
$674.97
$842.80 		$835.86
$880.46
$927.71
$1,095.54 		$1,088.60
$1,133.20
$1,180.45
$1,348.28 		$252.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$660.76
$749.96
$844.46
$1,180.12
$1,793.32 		$913.50
$1,002.70
$1,097.20
$1,432.86 		$1,166.24
$1,255.44
$1,349.94
$1,685.60 		$1,418.98
$1,508.18
$1,602.68
$1,938.34 		$252.74
Toc - Plan #46 Health First Commercial Plans, Inc.
Gold

(HMO) Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 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 		$438.22
$497.38
$560.05
$782.66
$1,189.33 		$773.46
$832.62
$895.29
$1,117.90 		$1,108.70
$1,167.86
$1,230.53
$1,453.14 		$1,443.94
$1,503.10
$1,565.77
$1,788.38 		$335.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$876.44
$994.76
$1,120.10
$1,565.32
$2,378.66 		$1,211.68
$1,330.00
$1,455.34
$1,900.56 		$1,546.92
$1,665.24
$1,790.58
$2,235.80 		$1,882.16
$2,000.48
$2,125.82
$2,571.04 		$335.24
Toc - Plan #47 Health First Commercial Plans, Inc.
Bronze

(HMO) Bronze 1774 ($0 Preventive Care, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317.92
$360.84
$406.30
$567.80
$862.83 		$561.13
$604.05
$649.51
$811.01 		$804.34
$847.26
$892.72
$1,054.22 		$1,047.55
$1,090.47
$1,135.93
$1,297.43 		$243.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.84
$721.68
$812.60
$1,135.60
$1,725.66 		$879.05
$964.89
$1,055.81
$1,378.81 		$1,122.26
$1,208.10
$1,299.02
$1,622.02 		$1,365.47
$1,451.31
$1,542.23
$1,865.23 		$243.21
Toc - Plan #48 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze HSA 1794 (HSA Qualified, $0 Preventive Care, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

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 		$334.84
$380.04
$427.93
$598.02
$908.76 		$590.99
$636.19
$684.08
$854.17 		$847.14
$892.34
$940.23
$1,110.32 		$1,103.29
$1,148.49
$1,196.38
$1,366.47 		$256.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.68
$760.08
$855.86
$1,196.04
$1,817.52 		$925.83
$1,016.23
$1,112.01
$1,452.19 		$1,181.98
$1,272.38
$1,368.16
$1,708.34 		$1,438.13
$1,528.53
$1,624.31
$1,964.49 		$256.15
Toc - Plan #49 Health First Commercial Plans, Inc.
Silver

(HMO) Silver 1806 ($2,100 Deductible, $0 Preventive Care, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$398.59
$452.40
$509.40
$711.89
$1,081.78 		$703.51
$757.32
$814.32
$1,016.81 		$1,008.43
$1,062.24
$1,119.24
$1,321.73 		$1,313.35
$1,367.16
$1,424.16
$1,626.65 		$304.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.18
$904.80
$1,018.80
$1,423.78
$2,163.56 		$1,102.10
$1,209.72
$1,323.72
$1,728.70 		$1,407.02
$1,514.64
$1,628.64
$2,033.62 		$1,711.94
$1,819.56
$1,933.56
$2,338.54 		$304.92
Toc - Plan #50 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze 1826 ($0 Deductible, $0 Primary Care Copay- Visits 1 & 2, Specialist, Urgent Care, Emergency Room & Hospitalization Copay, $0 Tier 1 Prescriptions, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,050 $18,100 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 		$348.83
$395.93
$445.81
$623.02
$946.74 		$615.69
$662.79
$712.67
$889.88 		$882.55
$929.65
$979.53
$1,156.74 		$1,149.41
$1,196.51
$1,246.39
$1,423.60 		$266.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.66
$791.86
$891.62
$1,246.04
$1,893.48 		$964.52
$1,058.72
$1,158.48
$1,512.90 		$1,231.38
$1,325.58
$1,425.34
$1,779.76 		$1,498.24
$1,592.44
$1,692.20
$2,046.62 		$266.86
Toc - Plan #51 Health First Commercial Plans, Inc.
Bronze

(HMO) Bronze Standard 1827

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.56
$353.62
$398.18
$556.45
$845.58 		$549.91
$591.97
$636.53
$794.80 		$788.26
$830.32
$874.88
$1,033.15 		$1,026.61
$1,068.67
$1,113.23
$1,271.50 		$238.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.12
$707.24
$796.36
$1,112.90
$1,691.16 		$861.47
$945.59
$1,034.71
$1,351.25 		$1,099.82
$1,183.94
$1,273.06
$1,589.60 		$1,338.17
$1,422.29
$1,511.41
$1,827.95 		$238.35
Toc - Plan #52 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze Standard 1828

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$324.05
$367.79
$414.13
$578.75
$879.46 		$571.95
$615.69
$662.03
$826.65 		$819.85
$863.59
$909.93
$1,074.55 		$1,067.75
$1,111.49
$1,157.83
$1,322.45 		$247.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.10
$735.58
$828.26
$1,157.50
$1,758.92 		$896.00
$983.48
$1,076.16
$1,405.40 		$1,143.90
$1,231.38
$1,324.06
$1,653.30 		$1,391.80
$1,479.28
$1,571.96
$1,901.20 		$247.90
Toc - Plan #53 Health First Commercial Plans, Inc.
Silver

(HMO) Silver Standard 1829

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$395.17
$448.51
$505.02
$705.77
$1,072.48 		$697.47
$750.81
$807.32
$1,008.07 		$999.77
$1,053.11
$1,109.62
$1,310.37 		$1,302.07
$1,355.41
$1,411.92
$1,612.67 		$302.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.34
$897.02
$1,010.04
$1,411.54
$2,144.96 		$1,092.64
$1,199.32
$1,312.34
$1,713.84 		$1,394.94
$1,501.62
$1,614.64
$2,016.14 		$1,697.24
$1,803.92
$1,916.94
$2,318.44 		$302.30
Toc - Plan #54 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Standard 1833

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

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 		$429.17
$487.10
$548.47
$766.49
$1,164.76 		$757.48
$815.41
$876.78
$1,094.80 		$1,085.79
$1,143.72
$1,205.09
$1,423.11 		$1,414.10
$1,472.03
$1,533.40
$1,751.42 		$328.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.34
$974.20
$1,096.94
$1,532.98
$2,329.52 		$1,186.65
$1,302.51
$1,425.25
$1,861.29 		$1,514.96
$1,630.82
$1,753.56
$2,189.60 		$1,843.27
$1,959.13
$2,081.87
$2,517.91 		$328.31
Toc - Plan #55 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze Savings 1820 (Primary Care Copay, $0 Preventive Care, $3 Tier 1 Prescriptions, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.69
$346.96
$390.67
$545.96
$829.64 		$539.54
$580.81
$624.52
$779.81 		$773.39
$814.66
$858.37
$1,013.66 		$1,007.24
$1,048.51
$1,092.22
$1,247.51 		$233.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.38
$693.92
$781.34
$1,091.92
$1,659.28 		$845.23
$927.77
$1,015.19
$1,325.77 		$1,079.08
$1,161.62
$1,249.04
$1,559.62 		$1,312.93
$1,395.47
$1,482.89
$1,793.47 		$233.85
Toc - Plan #56 Health First Commercial Plans, Inc.
Silver

(HMO) Silver Savings 1821 (Primary Care Copay, $0 Preventive Care, $3 Tier 1 Prescriptions, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 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 		$383.26
$435.00
$489.81
$684.51
$1,040.17 		$676.46
$728.20
$783.01
$977.71 		$969.66
$1,021.40
$1,076.21
$1,270.91 		$1,262.86
$1,314.60
$1,369.41
$1,564.11 		$293.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.52
$870.00
$979.62
$1,369.02
$2,080.34 		$1,059.72
$1,163.20
$1,272.82
$1,662.22 		$1,352.92
$1,456.40
$1,566.02
$1,955.42 		$1,646.12
$1,749.60
$1,859.22
$2,248.62 		$293.20
Toc - Plan #57 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, $0 Preventive Care, $3 Tier 1 Prescriptions, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$2,900 $5,800 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 		$420.95
$477.77
$537.97
$751.81
$1,142.45 		$742.97
$799.79
$859.99
$1,073.83 		$1,064.99
$1,121.81
$1,182.01
$1,395.85 		$1,387.01
$1,443.83
$1,504.03
$1,717.87 		$322.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.90
$955.54
$1,075.94
$1,503.62
$2,284.90 		$1,163.92
$1,277.56
$1,397.96
$1,825.64 		$1,485.94
$1,599.58
$1,719.98
$2,147.66 		$1,807.96
$1,921.60
$2,042.00
$2,469.68 		$322.02

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #58 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 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 		$306.37
$347.72
$391.53
$547.16
$831.46 		$540.73
$582.08
$625.89
$781.52 		$775.09
$816.44
$860.25
$1,015.88 		$1,009.45
$1,050.80
$1,094.61
$1,250.24 		$234.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.74
$695.44
$783.06
$1,094.32
$1,662.92 		$847.10
$929.80
$1,017.42
$1,328.68 		$1,081.46
$1,164.16
$1,251.78
$1,563.04 		$1,315.82
$1,398.52
$1,486.14
$1,797.40 		$234.36
Toc - Plan #59 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 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 		$297.16
$337.27
$379.76
$530.72
$806.48 		$524.48
$564.59
$607.08
$758.04 		$751.80
$791.91
$834.40
$985.36 		$979.12
$1,019.23
$1,061.72
$1,212.68 		$227.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$594.32
$674.54
$759.52
$1,061.44
$1,612.96 		$821.64
$901.86
$986.84
$1,288.76 		$1,048.96
$1,129.18
$1,214.16
$1,516.08 		$1,276.28
$1,356.50
$1,441.48
$1,743.40 		$227.32
Toc - Plan #60 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- Deductible+PCP Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$361.85
$410.68
$462.43
$646.24
$982.02 		$638.65
$687.48
$739.23
$923.04 		$915.45
$964.28
$1,016.03
$1,199.84 		$1,192.25
$1,241.08
$1,292.83
$1,476.64 		$276.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.70
$821.36
$924.86
$1,292.48
$1,964.04 		$1,000.50
$1,098.16
$1,201.66
$1,569.28 		$1,277.30
$1,374.96
$1,478.46
$1,846.08 		$1,554.10
$1,651.76
$1,755.26
$2,122.88 		$276.80
Toc - Plan #61 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 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 		$402.27
$456.56
$514.09
$718.44
$1,091.73 		$710.00
$764.29
$821.82
$1,026.17 		$1,017.73
$1,072.02
$1,129.55
$1,333.90 		$1,325.46
$1,379.75
$1,437.28
$1,641.63 		$307.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.54
$913.12
$1,028.18
$1,436.88
$2,183.46 		$1,112.27
$1,220.85
$1,335.91
$1,744.61 		$1,420.00
$1,528.58
$1,643.64
$2,052.34 		$1,727.73
$1,836.31
$1,951.37
$2,360.07 		$307.73
Toc - Plan #62 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,000 $18,000 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 		$399.93
$453.91
$511.10
$714.26
$1,085.39 		$705.87
$759.85
$817.04
$1,020.20 		$1,011.81
$1,065.79
$1,122.98
$1,326.14 		$1,317.75
$1,371.73
$1,428.92
$1,632.08 		$305.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.86
$907.82
$1,022.20
$1,428.52
$2,170.78 		$1,105.80
$1,213.76
$1,328.14
$1,734.46 		$1,411.74
$1,519.70
$1,634.08
$2,040.40 		$1,717.68
$1,825.64
$1,940.02
$2,346.34 		$305.94
Toc - Plan #63 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,650 $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 		$402.85
$457.23
$514.83
$719.48
$1,093.32 		$711.03
$765.41
$823.01
$1,027.66 		$1,019.21
$1,073.59
$1,131.19
$1,335.84 		$1,327.39
$1,381.77
$1,439.37
$1,644.02 		$308.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.70
$914.46
$1,029.66
$1,438.96
$2,186.64 		$1,113.88
$1,222.64
$1,337.84
$1,747.14 		$1,422.06
$1,530.82
$1,646.02
$2,055.32 		$1,730.24
$1,839.00
$1,954.20
$2,363.50 		$308.18
Toc - Plan #64 Oscar Insurance Company of Florida
Catastrophic

(EPO) Secure

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$229.42
$260.38
$293.18
$409.72
$622.61 		$404.92
$435.88
$468.68
$585.22 		$580.42
$611.38
$644.18
$760.72 		$755.92
$786.88
$819.68
$936.22 		$175.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$458.84
$520.76
$586.36
$819.44
$1,245.22 		$634.34
$696.26
$761.86
$994.94 		$809.84
$871.76
$937.36
$1,170.44 		$985.34
$1,047.26
$1,112.86
$1,345.94 		$175.50
Toc - Plan #65 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- Deductible+Specialist Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.90
$409.61
$461.22
$644.56
$979.47 		$636.98
$685.69
$737.30
$920.64 		$913.06
$961.77
$1,013.38
$1,196.72 		$1,189.14
$1,237.85
$1,289.46
$1,472.80 		$276.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.80
$819.22
$922.44
$1,289.12
$1,958.94 		$997.88
$1,095.30
$1,198.52
$1,565.20 		$1,273.96
$1,371.38
$1,474.60
$1,841.28 		$1,550.04
$1,647.46
$1,750.68
$2,117.36 		$276.08
Toc - Plan #66 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.90
$483.38
$544.29
$760.64
$1,155.87 		$751.71
$809.19
$870.10
$1,086.45 		$1,077.52
$1,135.00
$1,195.91
$1,412.26 		$1,403.33
$1,460.81
$1,521.72
$1,738.07 		$325.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.80
$966.76
$1,088.58
$1,521.28
$2,311.74 		$1,177.61
$1,292.57
$1,414.39
$1,847.09 		$1,503.42
$1,618.38
$1,740.20
$2,172.90 		$1,829.23
$1,944.19
$2,066.01
$2,498.71 		$325.81
Toc - Plan #67 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$7,450 $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 		$317.78
$360.67
$406.12
$567.54
$862.44 		$560.88
$603.77
$649.22
$810.64 		$803.98
$846.87
$892.32
$1,053.74 		$1,047.08
$1,089.97
$1,135.42
$1,296.84 		$243.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.56
$721.34
$812.24
$1,135.08
$1,724.88 		$878.66
$964.44
$1,055.34
$1,378.18 		$1,121.76
$1,207.54
$1,298.44
$1,621.28 		$1,364.86
$1,450.64
$1,541.54
$1,864.38 		$243.10
Toc - Plan #68 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$9,000 $18,000 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 #69 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$407.53
$462.54
$520.81
$727.84
$1,106.02 		$719.29
$774.30
$832.57
$1,039.60 		$1,031.05
$1,086.06
$1,144.33
$1,351.36 		$1,342.81
$1,397.82
$1,456.09
$1,663.12 		$311.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.06
$925.08
$1,041.62
$1,455.68
$2,212.04 		$1,126.82
$1,236.84
$1,353.38
$1,767.44 		$1,438.58
$1,548.60
$1,665.14
$2,079.20 		$1,750.34
$1,860.36
$1,976.90
$2,390.96 		$311.76
Toc - Plan #70 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- Deductible 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
$9,000 $18,000 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 		$410.46
$465.86
$524.56
$733.07
$1,113.96 		$724.46
$779.86
$838.56
$1,047.07 		$1,038.46
$1,093.86
$1,152.56
$1,361.07 		$1,352.46
$1,407.86
$1,466.56
$1,675.07 		$314.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.92
$931.72
$1,049.12
$1,466.14
$2,227.92 		$1,134.92
$1,245.72
$1,363.12
$1,780.14 		$1,448.92
$1,559.72
$1,677.12
$2,094.14 		$1,762.92
$1,873.72
$1,991.12
$2,408.14 		$314.00
Toc - Plan #71 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- PCP Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,100 $18,200 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 		$316.07
$358.73
$403.92
$564.48
$857.79 		$557.86
$600.52
$645.71
$806.27 		$799.65
$842.31
$887.50
$1,048.06 		$1,041.44
$1,084.10
$1,129.29
$1,289.85 		$241.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.14
$717.46
$807.84
$1,128.96
$1,715.58 		$873.93
$959.25
$1,049.63
$1,370.75 		$1,115.72
$1,201.04
$1,291.42
$1,612.54 		$1,357.51
$1,442.83
$1,533.21
$1,854.33 		$241.79
Toc - Plan #72 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- Deductible Saver

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
$9,100 $18,200 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 		$325.34
$369.25
$415.78
$581.05
$882.96 		$574.22
$618.13
$664.66
$829.93 		$823.10
$867.01
$913.54
$1,078.81 		$1,071.98
$1,115.89
$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 		$650.68
$738.50
$831.56
$1,162.10
$1,765.92 		$899.56
$987.38
$1,080.44
$1,410.98 		$1,148.44
$1,236.26
$1,329.32
$1,659.86 		$1,397.32
$1,485.14
$1,578.20
$1,908.74 		$248.88
Toc - Plan #73 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,900 $17,800 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 		$396.43
$449.94
$506.63
$708.01
$1,075.89 		$699.69
$753.20
$809.89
$1,011.27 		$1,002.95
$1,056.46
$1,113.15
$1,314.53 		$1,306.21
$1,359.72
$1,416.41
$1,617.79 		$303.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792.86
$899.88
$1,013.26
$1,416.02
$2,151.78 		$1,096.12
$1,203.14
$1,316.52
$1,719.28 		$1,399.38
$1,506.40
$1,619.78
$2,022.54 		$1,702.64
$1,809.66
$1,923.04
$2,325.80 		$303.26
Toc - Plan #74 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- PCP Saver Plus

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 		$412.22
$467.86
$526.80
$736.21
$1,118.74 		$727.56
$783.20
$842.14
$1,051.55 		$1,042.90
$1,098.54
$1,157.48
$1,366.89 		$1,358.24
$1,413.88
$1,472.82
$1,682.23 		$315.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.44
$935.72
$1,053.60
$1,472.42
$2,237.48 		$1,139.78
$1,251.06
$1,368.94
$1,787.76 		$1,455.12
$1,566.40
$1,684.28
$2,103.10 		$1,770.46
$1,881.74
$1,999.62
$2,418.44 		$315.34
Toc - Plan #75 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$402.27
$456.56
$514.09
$718.44
$1,091.73 		$710.00
$764.29
$821.82
$1,026.17 		$1,017.73
$1,072.02
$1,129.55
$1,333.90 		$1,325.46
$1,379.75
$1,437.28
$1,641.63 		$307.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.54
$913.12
$1,028.18
$1,436.88
$2,183.46 		$1,112.27
$1,220.85
$1,335.91
$1,744.61 		$1,420.00
$1,528.58
$1,643.64
$2,052.34 		$1,727.73
$1,836.31
$1,951.37
$2,360.07 		$307.73
Toc - Plan #76 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite- Deductible Saver Plus

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 		$466.91
$529.93
$596.70
$833.89
$1,267.17 		$824.09
$887.11
$953.88
$1,191.07 		$1,181.27
$1,244.29
$1,311.06
$1,548.25 		$1,538.45
$1,601.47
$1,668.24
$1,905.43 		$357.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$933.82
$1,059.86
$1,193.40
$1,667.78
$2,534.34 		$1,291.00
$1,417.04
$1,550.58
$2,024.96 		$1,648.18
$1,774.22
$1,907.76
$2,382.14 		$2,005.36
$2,131.40
$2,264.94
$2,739.32 		$357.18
Toc - Plan #77 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite

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

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,500 $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 		$437.18
$496.18
$558.70
$780.78
$1,186.47 		$771.61
$830.61
$893.13
$1,115.21 		$1,106.04
$1,165.04
$1,227.56
$1,449.64 		$1,440.47
$1,499.47
$1,561.99
$1,784.07 		$334.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.36
$992.36
$1,117.40
$1,561.56
$2,372.94 		$1,208.79
$1,326.79
$1,451.83
$1,895.99 		$1,543.22
$1,661.22
$1,786.26
$2,230.42 		$1,877.65
$1,995.65
$2,120.69
$2,564.85 		$334.43
Toc - Plan #78 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$352.44
$400.00
$450.40
$629.43
$956.49 		$622.05
$669.61
$720.01
$899.04 		$891.66
$939.22
$989.62
$1,168.65 		$1,161.27
$1,208.83
$1,259.23
$1,438.26 		$269.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.88
$800.00
$900.80
$1,258.86
$1,912.98 		$974.49
$1,069.61
$1,170.41
$1,528.47 		$1,244.10
$1,339.22
$1,440.02
$1,798.08 		$1,513.71
$1,608.83
$1,709.63
$2,067.69 		$269.61
Toc - Plan #79 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,550 $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 		$401.10
$455.24
$512.59
$716.35
$1,088.56 		$707.93
$762.07
$819.42
$1,023.18 		$1,014.76
$1,068.90
$1,126.25
$1,330.01 		$1,321.59
$1,375.73
$1,433.08
$1,636.84 		$306.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.20
$910.48
$1,025.18
$1,432.70
$2,177.12 		$1,109.03
$1,217.31
$1,332.01
$1,739.53 		$1,415.86
$1,524.14
$1,638.84
$2,046.36 		$1,722.69
$1,830.97
$1,945.67
$2,353.19 		$306.83
Toc - Plan #80 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- Standard

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
$9,000 $18,000 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 		$322.09
$365.57
$411.62
$575.24
$874.14 		$568.48
$611.96
$658.01
$821.63 		$814.87
$858.35
$904.40
$1,068.02 		$1,061.26
$1,104.74
$1,150.79
$1,314.41 		$246.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.18
$731.14
$823.24
$1,150.48
$1,748.28 		$890.57
$977.53
$1,069.63
$1,396.87 		$1,136.96
$1,223.92
$1,316.02
$1,643.26 		$1,383.35
$1,470.31
$1,562.41
$1,889.65 		$246.39
Toc - Plan #81 Oscar Insurance Company of Florida
Bronze

(EPO) Bronze Simple- Standard

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

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$283.42
$321.67
$362.20
$506.18
$769.18 		$500.23
$538.48
$579.01
$722.99 		$717.04
$755.29
$795.82
$939.80 		$933.85
$972.10
$1,012.63
$1,156.61 		$216.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$566.84
$643.34
$724.40
$1,012.36
$1,538.36 		$783.65
$860.15
$941.21
$1,229.17 		$1,000.46
$1,076.96
$1,158.02
$1,445.98 		$1,217.27
$1,293.77
$1,374.83
$1,662.79 		$216.81
Toc - Plan #82 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- Standard

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$397.01
$450.60
$507.37
$709.05
$1,077.47 		$700.72
$754.31
$811.08
$1,012.76 		$1,004.43
$1,058.02
$1,114.79
$1,316.47 		$1,308.14
$1,361.73
$1,418.50
$1,620.18 		$303.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.02
$901.20
$1,014.74
$1,418.10
$2,154.94 		$1,097.73
$1,204.91
$1,318.45
$1,721.81 		$1,401.44
$1,508.62
$1,622.16
$2,025.52 		$1,705.15
$1,812.33
$1,925.87
$2,329.23 		$303.71
Toc - Plan #83 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- Standard

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 		$406.14
$460.95
$519.03
$725.34
$1,102.23 		$716.83
$771.64
$829.72
$1,036.03 		$1,027.52
$1,082.33
$1,140.41
$1,346.72 		$1,338.21
$1,393.02
$1,451.10
$1,657.41 		$310.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.28
$921.90
$1,038.06
$1,450.68
$2,204.46 		$1,122.97
$1,232.59
$1,348.75
$1,761.37 		$1,433.66
$1,543.28
$1,659.44
$2,072.06 		$1,744.35
$1,853.97
$1,970.13
$2,382.75 		$310.69

ADVERTISEMENT

Florida Health Care Plans

Local: 1-386-676-7110 | Toll Free: 1-800-232-0578 | TTY: 1-800-955-8771
Toc - Plan #84 Florida Health Care Plans
Catastrophic

(HMO) Gym Access IND Essential Plus Catastrophic HMO 36

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$230.62
$261.75
$294.73
$411.89
$625.90 		$407.04
$438.17
$471.15
$588.31 		$583.46
$614.59
$647.57
$764.73 		$759.88
$791.01
$823.99
$941.15 		$176.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$461.24
$523.50
$589.46
$823.78
$1,251.80 		$637.66
$699.92
$765.88
$1,000.20 		$814.08
$876.34
$942.30
$1,176.62 		$990.50
$1,052.76
$1,118.72
$1,353.04 		$176.42
Toc - Plan #85 Florida Health Care Plans
Catastrophic

(POS) Gym Access IND Essential Plus Catastrophic POS 37

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$249.07
$282.69
$318.31
$444.84
$675.98 		$439.61
$473.23
$508.85
$635.38 		$630.15
$663.77
$699.39
$825.92 		$820.69
$854.31
$889.93
$1,016.46 		$190.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$498.14
$565.38
$636.62
$889.68
$1,351.96 		$688.68
$755.92
$827.16
$1,080.22 		$879.22
$946.46
$1,017.70
$1,270.76 		$1,069.76
$1,137.00
$1,208.24
$1,461.30 		$190.54
Toc - Plan #86 Florida Health Care Plans
Silver

(HMO) Gym Access IND Essential Plus Silver HMO 53

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,900 $17,800 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 		$407.51
$462.52
$520.80
$727.81
$1,105.98 		$719.26
$774.27
$832.55
$1,039.56 		$1,031.01
$1,086.02
$1,144.30
$1,351.31 		$1,342.76
$1,397.77
$1,456.05
$1,663.06 		$311.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.02
$925.04
$1,041.60
$1,455.62
$2,211.96 		$1,126.77
$1,236.79
$1,353.35
$1,767.37 		$1,438.52
$1,548.54
$1,665.10
$2,079.12 		$1,750.27
$1,860.29
$1,976.85
$2,390.87 		$311.75
Toc - Plan #87 Florida Health Care Plans
Gold

(HMO) Gym Access IND Essential Plus Gold HMO 63

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$5,200 $10,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$446.43
$506.70
$570.54
$797.32
$1,211.61 		$787.95
$848.22
$912.06
$1,138.84 		$1,129.47
$1,189.74
$1,253.58
$1,480.36 		$1,470.99
$1,531.26
$1,595.10
$1,821.88 		$341.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.86
$1,013.40
$1,141.08
$1,594.64
$2,423.22 		$1,234.38
$1,354.92
$1,482.60
$1,936.16 		$1,575.90
$1,696.44
$1,824.12
$2,277.68 		$1,917.42
$2,037.96
$2,165.64
$2,619.20 		$341.52
Toc - Plan #88 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Essential Plus Platinum HMO 65

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$611.06
$693.55
$780.93
$1,091.35
$1,658.42 		$1,078.52
$1,161.01
$1,248.39
$1,558.81 		$1,545.98
$1,628.47
$1,715.85
$2,026.27 		$2,013.44
$2,095.93
$2,183.31
$2,493.73 		$467.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,222.12
$1,387.10
$1,561.86
$2,182.70
$3,316.84 		$1,689.58
$1,854.56
$2,029.32
$2,650.16 		$2,157.04
$2,322.02
$2,496.78
$3,117.62 		$2,624.50
$2,789.48
$2,964.24
$3,585.08 		$467.46
Toc - Plan #89 Florida Health Care Plans
Silver

(POS) Gym Access IND Essential Plus Silver POS 54

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,900 $17,800 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 		$419.94
$476.63
$536.68
$750.01
$1,139.72 		$741.19
$797.88
$857.93
$1,071.26 		$1,062.44
$1,119.13
$1,179.18
$1,392.51 		$1,383.69
$1,440.38
$1,500.43
$1,713.76 		$321.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.88
$953.26
$1,073.36
$1,500.02
$2,279.44 		$1,161.13
$1,274.51
$1,394.61
$1,821.27 		$1,482.38
$1,595.76
$1,715.86
$2,142.52 		$1,803.63
$1,917.01
$2,037.11
$2,463.77 		$321.25
Toc - Plan #90 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$4,000 $8,000 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 		$606.07
$687.89
$774.56
$1,082.44
$1,644.87 		$1,069.71
$1,151.53
$1,238.20
$1,546.08 		$1,533.35
$1,615.17
$1,701.84
$2,009.72 		$1,996.99
$2,078.81
$2,165.48
$2,473.36 		$463.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,212.14
$1,375.78
$1,549.12
$2,164.88
$3,289.74 		$1,675.78
$1,839.42
$2,012.76
$2,628.52 		$2,139.42
$2,303.06
$2,476.40
$3,092.16 		$2,603.06
$2,766.70
$2,940.04
$3,555.80 		$463.64
Toc - Plan #91 Florida Health Care Plans
Platinum

(POS) Gym Access IND Platinum POS 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$4,000 $8,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$654.56
$742.93
$836.53
$1,169.04
$1,776.48 		$1,155.30
$1,243.67
$1,337.27
$1,669.78 		$1,656.04
$1,744.41
$1,838.01
$2,170.52 		$2,156.78
$2,245.15
$2,338.75
$2,671.26 		$500.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,309.12
$1,485.86
$1,673.06
$2,338.08
$3,552.96 		$1,809.86
$1,986.60
$2,173.80
$2,838.82 		$2,310.60
$2,487.34
$2,674.54
$3,339.56 		$2,811.34
$2,988.08
$3,175.28
$3,840.30 		$500.74
Toc - Plan #92 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO 55001

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$451.07
$511.96
$576.47
$805.61
$1,224.20 		$796.14
$857.03
$921.54
$1,150.68 		$1,141.21
$1,202.10
$1,266.61
$1,495.75 		$1,486.28
$1,547.17
$1,611.68
$1,840.82 		$345.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902.14
$1,023.92
$1,152.94
$1,611.22
$2,448.40 		$1,247.21
$1,368.99
$1,498.01
$1,956.29 		$1,592.28
$1,714.06
$1,843.08
$2,301.36 		$1,937.35
$2,059.13
$2,188.15
$2,646.43 		$345.07
Toc - Plan #93 Florida Health Care Plans
Gold

(POS) Gym Access IND Gold POS 55001

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$487.16
$552.93
$622.59
$870.07
$1,322.15 		$859.84
$925.61
$995.27
$1,242.75 		$1,232.52
$1,298.29
$1,367.95
$1,615.43 		$1,605.20
$1,670.97
$1,740.63
$1,988.11 		$372.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$974.32
$1,105.86
$1,245.18
$1,740.14
$2,644.30 		$1,347.00
$1,478.54
$1,617.86
$2,112.82 		$1,719.68
$1,851.22
$1,990.54
$2,485.50 		$2,092.36
$2,223.90
$2,363.22
$2,858.18 		$372.68
Toc - Plan #94 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,550 $5,100 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 		$449.19
$509.83
$574.06
$802.25
$1,219.10 		$792.82
$853.46
$917.69
$1,145.88 		$1,136.45
$1,197.09
$1,261.32
$1,489.51 		$1,480.08
$1,540.72
$1,604.95
$1,833.14 		$343.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.38
$1,019.66
$1,148.12
$1,604.50
$2,438.20 		$1,242.01
$1,363.29
$1,491.75
$1,948.13 		$1,585.64
$1,706.92
$1,835.38
$2,291.76 		$1,929.27
$2,050.55
$2,179.01
$2,635.39 		$343.63
Toc - Plan #95 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO HSA 5065

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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 		$314.23
$356.65
$401.59
$561.21
$852.82 		$554.62
$597.04
$641.98
$801.60 		$795.01
$837.43
$882.37
$1,041.99 		$1,035.40
$1,077.82
$1,122.76
$1,282.38 		$240.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.46
$713.30
$803.18
$1,122.42
$1,705.64 		$868.85
$953.69
$1,043.57
$1,362.81 		$1,109.24
$1,194.08
$1,283.96
$1,603.20 		$1,349.63
$1,434.47
$1,524.35
$1,843.59 		$240.39
Toc - Plan #96 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO HSA 6060

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$312.04
$354.17
$398.79
$557.30
$846.88 		$550.75
$592.88
$637.50
$796.01 		$789.46
$831.59
$876.21
$1,034.72 		$1,028.17
$1,070.30
$1,114.92
$1,273.43 		$238.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.08
$708.34
$797.58
$1,114.60
$1,693.76 		$862.79
$947.05
$1,036.29
$1,353.31 		$1,101.50
$1,185.76
$1,275.00
$1,592.02 		$1,340.21
$1,424.47
$1,513.71
$1,830.73 		$238.71
Toc - Plan #97 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO BC 3841

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 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 		$325.33
$369.25
$415.77
$581.04
$882.95 		$574.21
$618.13
$664.65
$829.92 		$823.09
$867.01
$913.53
$1,078.80 		$1,071.97
$1,115.89
$1,162.41
$1,327.68 		$248.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.66
$738.50
$831.54
$1,162.08
$1,765.90 		$899.54
$987.38
$1,080.42
$1,410.96 		$1,148.42
$1,236.26
$1,329.30
$1,659.84 		$1,397.30
$1,485.14
$1,578.18
$1,908.72 		$248.88
Toc - Plan #98 Florida Health Care Plans
Expanded Bronze

(POS) Gym Access IND Bronze POS BC 3841

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 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 		$351.35
$398.78
$449.03
$627.51
$953.56 		$620.13
$667.56
$717.81
$896.29 		$888.91
$936.34
$986.59
$1,165.07 		$1,157.69
$1,205.12
$1,255.37
$1,433.85 		$268.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.70
$797.56
$898.06
$1,255.02
$1,907.12 		$971.48
$1,066.34
$1,166.84
$1,523.80 		$1,240.26
$1,335.12
$1,435.62
$1,792.58 		$1,509.04
$1,603.90
$1,704.40
$2,061.36 		$268.78
Toc - Plan #99 Florida Health Care Plans
Silver

(HMO) Gym Access IND Silver HMO BC 0941

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$394.99
$448.31
$504.80
$705.45
$1,072.00 		$697.16
$750.48
$806.97
$1,007.62 		$999.33
$1,052.65
$1,109.14
$1,309.79 		$1,301.50
$1,354.82
$1,411.31
$1,611.96 		$302.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.98
$896.62
$1,009.60
$1,410.90
$2,144.00 		$1,092.15
$1,198.79
$1,311.77
$1,713.07 		$1,394.32
$1,500.96
$1,613.94
$2,015.24 		$1,696.49
$1,803.13
$1,916.11
$2,317.41 		$302.17
Toc - Plan #100 Florida Health Care Plans
Silver

(POS) Gym Access IND Silver POS BC 0941

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$426.59
$484.18
$545.18
$761.89
$1,157.77 		$752.93
$810.52
$871.52
$1,088.23 		$1,079.27
$1,136.86
$1,197.86
$1,414.57 		$1,405.61
$1,463.20
$1,524.20
$1,740.91 		$326.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.18
$968.36
$1,090.36
$1,523.78
$2,315.54 		$1,179.52
$1,294.70
$1,416.70
$1,850.12 		$1,505.86
$1,621.04
$1,743.04
$2,176.46 		$1,832.20
$1,947.38
$2,069.38
$2,502.80 		$326.34
Toc - Plan #101 Florida Health Care Plans
Silver

(HMO) Gym Access IND Silver HMO BC 7741

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$391.29
$444.11
$500.07
$698.84
$1,061.96 		$690.63
$743.45
$799.41
$998.18 		$989.97
$1,042.79
$1,098.75
$1,297.52 		$1,289.31
$1,342.13
$1,398.09
$1,596.86 		$299.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.58
$888.22
$1,000.14
$1,397.68
$2,123.92 		$1,081.92
$1,187.56
$1,299.48
$1,697.02 		$1,381.26
$1,486.90
$1,598.82
$1,996.36 		$1,680.60
$1,786.24
$1,898.16
$2,295.70 		$299.34
Toc - Plan #102 Florida Health Care Plans
Silver

(POS) Gym Access IND Silver POS BC 7741

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$422.59
$479.64
$540.07
$754.75
$1,146.91 		$745.87
$802.92
$863.35
$1,078.03 		$1,069.15
$1,126.20
$1,186.63
$1,401.31 		$1,392.43
$1,449.48
$1,509.91
$1,724.59 		$323.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.18
$959.28
$1,080.14
$1,509.50
$2,293.82 		$1,168.46
$1,282.56
$1,403.42
$1,832.78 		$1,491.74
$1,605.84
$1,726.70
$2,156.06 		$1,815.02
$1,929.12
$2,049.98
$2,479.34 		$323.28
Toc - Plan #103 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO BC 5651

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,900 $11,800 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 		$468.65
$531.92
$598.93
$837.01
$1,271.92 		$827.17
$890.44
$957.45
$1,195.53 		$1,185.69
$1,248.96
$1,315.97
$1,554.05 		$1,544.21
$1,607.48
$1,674.49
$1,912.57 		$358.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$937.30
$1,063.84
$1,197.86
$1,674.02
$2,543.84 		$1,295.82
$1,422.36
$1,556.38
$2,032.54 		$1,654.34
$1,780.88
$1,914.90
$2,391.06 		$2,012.86
$2,139.40
$2,273.42
$2,749.58 		$358.52
Toc - Plan #104 Florida Health Care Plans
Gold

(POS) Gym Access IND Gold POS BC 5651

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,900 $11,800 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 		$506.30
$574.65
$647.05
$904.25
$1,374.10 		$893.62
$961.97
$1,034.37
$1,291.57 		$1,280.94
$1,349.29
$1,421.69
$1,678.89 		$1,668.26
$1,736.61
$1,809.01
$2,066.21 		$387.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,012.60
$1,149.30
$1,294.10
$1,808.50
$2,748.20 		$1,399.92
$1,536.62
$1,681.42
$2,195.82 		$1,787.24
$1,923.94
$2,068.74
$2,583.14 		$2,174.56
$2,311.26
$2,456.06
$2,970.46 		$387.32
Toc - Plan #105 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO BC 5841

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$800 $1,600 Annual Deductible
$2,500 $5,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$602.24
$683.54
$769.66
$1,075.60
$1,634.48 		$1,062.95
$1,144.25
$1,230.37
$1,536.31 		$1,523.66
$1,604.96
$1,691.08
$1,997.02 		$1,984.37
$2,065.67
$2,151.79
$2,457.73 		$460.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,204.48
$1,367.08
$1,539.32
$2,151.20
$3,268.96 		$1,665.19
$1,827.79
$2,000.03
$2,611.91 		$2,125.90
$2,288.50
$2,460.74
$3,072.62 		$2,586.61
$2,749.21
$2,921.45
$3,533.33 		$460.71
Toc - Plan #106 Florida Health Care Plans
Platinum

(POS) Gym Access IND Platinum POS BC 5841

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$800 $1,600 Annual Deductible
$2,500 $5,000 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 		$650.42
$738.23
$831.24
$1,161.65
$1,765.24 		$1,147.99
$1,235.80
$1,328.81
$1,659.22 		$1,645.56
$1,733.37
$1,826.38
$2,156.79 		$2,143.13
$2,230.94
$2,323.95
$2,654.36 		$497.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,300.84
$1,476.46
$1,662.48
$2,323.30
$3,530.48 		$1,798.41
$1,974.03
$2,160.05
$2,820.87 		$2,295.98
$2,471.60
$2,657.62
$3,318.44 		$2,793.55
$2,969.17
$3,155.19
$3,816.01 		$497.57
Toc - Plan #107 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO BC 1941

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$621.96
$705.92
$794.86
$1,110.82
$1,688.00 		$1,097.76
$1,181.72
$1,270.66
$1,586.62 		$1,573.56
$1,657.52
$1,746.46
$2,062.42 		$2,049.36
$2,133.32
$2,222.26
$2,538.22 		$475.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,243.92
$1,411.84
$1,589.72
$2,221.64
$3,376.00 		$1,719.72
$1,887.64
$2,065.52
$2,697.44 		$2,195.52
$2,363.44
$2,541.32
$3,173.24 		$2,671.32
$2,839.24
$3,017.12
$3,649.04 		$475.80
Toc - Plan #108 Florida Health Care Plans
Platinum

(POS) Gym Access IND Platinum POS BC 1941

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$671.71
$762.39
$858.45
$1,199.67
$1,823.02 		$1,185.57
$1,276.25
$1,372.31
$1,713.53 		$1,699.43
$1,790.11
$1,886.17
$2,227.39 		$2,213.29
$2,303.97
$2,400.03
$2,741.25 		$513.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,343.42
$1,524.78
$1,716.90
$2,399.34
$3,646.04 		$1,857.28
$2,038.64
$2,230.76
$2,913.20 		$2,371.14
$2,552.50
$2,744.62
$3,427.06 		$2,885.00
$3,066.36
$3,258.48
$3,940.92 		$513.86
Toc - Plan #109 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO 91

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$250 $500 Annual Deductible
$2,500 $5,000 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 		$617.35
$700.69
$788.97
$1,102.59
$1,675.49 		$1,089.62
$1,172.96
$1,261.24
$1,574.86 		$1,561.89
$1,645.23
$1,733.51
$2,047.13 		$2,034.16
$2,117.50
$2,205.78
$2,519.40 		$472.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,234.70
$1,401.38
$1,577.94
$2,205.18
$3,350.98 		$1,706.97
$1,873.65
$2,050.21
$2,677.45 		$2,179.24
$2,345.92
$2,522.48
$3,149.72 		$2,651.51
$2,818.19
$2,994.75
$3,621.99 		$472.27
Toc - Plan #110 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze Standardized HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$7,150 $14,300 Annual Deductible
$9,000 $18,000 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 		$325.14
$369.03
$415.53
$580.70
$882.43 		$573.87
$617.76
$664.26
$829.43 		$822.60
$866.49
$912.99
$1,078.16 		$1,071.33
$1,115.22
$1,161.72
$1,326.89 		$248.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.28
$738.06
$831.06
$1,161.40
$1,764.86 		$899.01
$986.79
$1,079.79
$1,410.13 		$1,147.74
$1,235.52
$1,328.52
$1,658.86 		$1,396.47
$1,484.25
$1,577.25
$1,907.59 		$248.73
Toc - Plan #111 Florida Health Care Plans
Silver

(HMO) Gym Access IND Silver Standardized HMO 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$8,800 $17,600 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 		$433.37
$491.87
$553.85
$774.00
$1,176.17 		$764.90
$823.40
$885.38
$1,105.53 		$1,096.43
$1,154.93
$1,216.91
$1,437.06 		$1,427.96
$1,486.46
$1,548.44
$1,768.59 		$331.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.74
$983.74
$1,107.70
$1,548.00
$2,352.34 		$1,198.27
$1,315.27
$1,439.23
$1,879.53 		$1,529.80
$1,646.80
$1,770.76
$2,211.06 		$1,861.33
$1,978.33
$2,102.29
$2,542.59 		$331.53
Toc - Plan #112 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO 1340

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$309.29
$351.04
$395.27
$552.39
$839.41 		$545.90
$587.65
$631.88
$789.00 		$782.51
$824.26
$868.49
$1,025.61 		$1,019.12
$1,060.87
$1,105.10
$1,262.22 		$236.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.58
$702.08
$790.54
$1,104.78
$1,678.82 		$855.19
$938.69
$1,027.15
$1,341.39 		$1,091.80
$1,175.30
$1,263.76
$1,578.00 		$1,328.41
$1,411.91
$1,500.37
$1,814.61 		$236.61
Toc - Plan #113 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO 1041

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$9,100 $18,200 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 		$320.36
$363.61
$409.42
$572.16
$869.46 		$565.44
$608.69
$654.50
$817.24 		$810.52
$853.77
$899.58
$1,062.32 		$1,055.60
$1,098.85
$1,144.66
$1,307.40 		$245.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.72
$727.22
$818.84
$1,144.32
$1,738.92 		$885.80
$972.30
$1,063.92
$1,389.40 		$1,130.88
$1,217.38
$1,309.00
$1,634.48 		$1,375.96
$1,462.46
$1,554.08
$1,879.56 		$245.08
Toc - Plan #114 Florida Health Care Plans
Expanded Bronze

(POS) Gym Access IND Bronze POS 1042

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$9,100 $18,200 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 		$345.98
$392.69
$442.16
$617.92
$938.99 		$610.65
$657.36
$706.83
$882.59 		$875.32
$922.03
$971.50
$1,147.26 		$1,139.99
$1,186.70
$1,236.17
$1,411.93 		$264.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.96
$785.38
$884.32
$1,235.84
$1,877.98 		$956.63
$1,050.05
$1,148.99
$1,500.51 		$1,221.30
$1,314.72
$1,413.66
$1,765.18 		$1,485.97
$1,579.39
$1,678.33
$2,029.85 		$264.67
Toc - Plan #115 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO H.S.A 9010

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 Annual Deductible
$4,000 $8,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.94
$470.96
$530.29
$741.08
$1,126.15 		$732.37
$788.39
$847.72
$1,058.51 		$1,049.80
$1,105.82
$1,165.15
$1,375.94 		$1,367.23
$1,423.25
$1,482.58
$1,693.37 		$317.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.88
$941.92
$1,060.58
$1,482.16
$2,252.30 		$1,147.31
$1,259.35
$1,378.01
$1,799.59 		$1,464.74
$1,576.78
$1,695.44
$2,117.02 		$1,782.17
$1,894.21
$2,012.87
$2,434.45 		$317.43
Toc - Plan #116 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO OA 1211

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$353.95
$401.73
$452.35
$632.15
$960.62 		$624.72
$672.50
$723.12
$902.92 		$895.49
$943.27
$993.89
$1,173.69 		$1,166.26
$1,214.04
$1,264.66
$1,444.46 		$270.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.90
$803.46
$904.70
$1,264.30
$1,921.24 		$978.67
$1,074.23
$1,175.47
$1,535.07 		$1,249.44
$1,345.00
$1,446.24
$1,805.84 		$1,520.21
$1,615.77
$1,717.01
$2,076.61 		$270.77
Toc - Plan #117 Florida Health Care Plans
Silver

(HMO) Gym Access IND Silver HMO OA 1009

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.63
$477.42
$537.57
$751.25
$1,141.59 		$742.41
$799.20
$859.35
$1,073.03 		$1,064.19
$1,120.98
$1,181.13
$1,394.81 		$1,385.97
$1,442.76
$1,502.91
$1,716.59 		$321.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.26
$954.84
$1,075.14
$1,502.50
$2,283.18 		$1,163.04
$1,276.62
$1,396.92
$1,824.28 		$1,484.82
$1,598.40
$1,718.70
$2,146.06 		$1,806.60
$1,920.18
$2,040.48
$2,467.84 		$321.78
Toc - Plan #118 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO OA 0928

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$2,900 $5,800 Annual Deductible
$9,100 $18,200 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 		$328.97
$373.38
$420.42
$587.54
$892.82 		$580.63
$625.04
$672.08
$839.20 		$832.29
$876.70
$923.74
$1,090.86 		$1,083.95
$1,128.36
$1,175.40
$1,342.52 		$251.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.94
$746.76
$840.84
$1,175.08
$1,785.64 		$909.60
$998.42
$1,092.50
$1,426.74 		$1,161.26
$1,250.08
$1,344.16
$1,678.40 		$1,412.92
$1,501.74
$1,595.82
$1,930.06 		$251.66
Toc - Plan #119 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO OA 28

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,800 $17,600 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 		$474.45
$538.50
$606.35
$847.37
$1,287.66 		$837.40
$901.45
$969.30
$1,210.32 		$1,200.35
$1,264.40
$1,332.25
$1,573.27 		$1,563.30
$1,627.35
$1,695.20
$1,936.22 		$362.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$948.90
$1,077.00
$1,212.70
$1,694.74
$2,575.32 		$1,311.85
$1,439.95
$1,575.65
$2,057.69 		$1,674.80
$1,802.90
$1,938.60
$2,420.64 		$2,037.75
$2,165.85
$2,301.55
$2,783.59 		$362.95
Toc - Plan #120 Florida Health Care Plans
Bronze

(HMO) Gym Access IND Bronze HMO OA Standard 2440

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$305.18
$346.38
$390.02
$545.05
$828.26 		$538.64
$579.84
$623.48
$778.51 		$772.10
$813.30
$856.94
$1,011.97 		$1,005.56
$1,046.76
$1,090.40
$1,245.43 		$233.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.36
$692.76
$780.04
$1,090.10
$1,656.52 		$843.82
$926.22
$1,013.50
$1,323.56 		$1,077.28
$1,159.68
$1,246.96
$1,557.02 		$1,310.74
$1,393.14
$1,480.42
$1,790.48 		$233.46
Toc - Plan #121 Florida Health Care Plans
Expanded Bronze

(HMO) Gym Access IND Bronze HMO OA Standard 2450

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$324.46
$368.26
$414.66
$579.49
$880.58 		$572.67
$616.47
$662.87
$827.70 		$820.88
$864.68
$911.08
$1,075.91 		$1,069.09
$1,112.89
$1,159.29
$1,324.12 		$248.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.92
$736.52
$829.32
$1,158.98
$1,761.16 		$897.13
$984.73
$1,077.53
$1,407.19 		$1,145.34
$1,232.94
$1,325.74
$1,655.40 		$1,393.55
$1,481.15
$1,573.95
$1,903.61 		$248.21
Toc - Plan #122 Florida Health Care Plans
Silver

(HMO) Gym Access IND Silver HMO OA Standard 1440

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$389.68
$442.29
$498.01
$695.97
$1,057.59 		$687.79
$740.40
$796.12
$994.08 		$985.90
$1,038.51
$1,094.23
$1,292.19 		$1,284.01
$1,336.62
$1,392.34
$1,590.30 		$298.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.36
$884.58
$996.02
$1,391.94
$2,115.18 		$1,077.47
$1,182.69
$1,294.13
$1,690.05 		$1,375.58
$1,480.80
$1,592.24
$1,988.16 		$1,673.69
$1,778.91
$1,890.35
$2,286.27 		$298.11
Toc - Plan #123 Florida Health Care Plans
Gold

(HMO) Gym Access IND Gold HMO OA Standard 3450

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

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 		$418.62
$475.13
$535.00
$747.66
$1,136.13 		$738.86
$795.37
$855.24
$1,067.90 		$1,059.10
$1,115.61
$1,175.48
$1,388.14 		$1,379.34
$1,435.85
$1,495.72
$1,708.38 		$320.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.24
$950.26
$1,070.00
$1,495.32
$2,272.26 		$1,157.48
$1,270.50
$1,390.24
$1,815.56 		$1,477.72
$1,590.74
$1,710.48
$2,135.80 		$1,797.96
$1,910.98
$2,030.72
$2,456.04 		$320.24
Toc - Plan #124 Florida Health Care Plans
Platinum

(HMO) Gym Access IND Platinum HMO OA Standard 4450

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 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 		$607.23
$689.21
$776.04
$1,084.51
$1,648.02 		$1,071.76
$1,153.74
$1,240.57
$1,549.04 		$1,536.29
$1,618.27
$1,705.10
$2,013.57 		$2,000.82
$2,082.80
$2,169.63
$2,478.10 		$464.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,214.46
$1,378.42
$1,552.08
$2,169.02
$3,296.04 		$1,678.99
$1,842.95
$2,016.61
$2,633.55 		$2,143.52
$2,307.48
$2,481.14
$3,098.08 		$2,608.05
$2,772.01
$2,945.67
$3,562.61 		$464.53
Toc - Plan #125 Florida Health Care Plans
Expanded Bronze

(POS) Gym Access IND Bronze POS OA Standard 2450

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$350.41
$397.72
$447.82
$625.83
$951.01 		$618.47
$665.78
$715.88
$893.89 		$886.53
$933.84
$983.94
$1,161.95 		$1,154.59
$1,201.90
$1,252.00
$1,430.01 		$268.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.82
$795.44
$895.64
$1,251.66
$1,902.02 		$968.88
$1,063.50
$1,163.70
$1,519.72 		$1,236.94
$1,331.56
$1,431.76
$1,787.78 		$1,505.00
$1,599.62
$1,699.82
$2,055.84 		$268.06
Toc - Plan #126 Florida Health Care Plans
Silver

(POS) Gym Access IND Silver POS OA Standard 1440

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.86
$477.68
$537.86
$751.66
$1,142.21 		$742.82
$799.64
$859.82
$1,073.62 		$1,064.78
$1,121.60
$1,181.78
$1,395.58 		$1,386.74
$1,443.56
$1,503.74
$1,717.54 		$321.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.72
$955.36
$1,075.72
$1,503.32
$2,284.42 		$1,163.68
$1,277.32
$1,397.68
$1,825.28 		$1,485.64
$1,599.28
$1,719.64
$2,147.24 		$1,807.60
$1,921.24
$2,041.60
$2,469.20 		$321.96
Toc - Plan #127 Florida Health Care Plans
Gold

(POS) Gym Access IND Gold POS OA Standard 3450

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

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 		$452.10
$513.13
$577.78
$807.45
$1,227.00 		$797.96
$858.99
$923.64
$1,153.31 		$1,143.82
$1,204.85
$1,269.50
$1,499.17 		$1,489.68
$1,550.71
$1,615.36
$1,845.03 		$345.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.20
$1,026.26
$1,155.56
$1,614.90
$2,454.00 		$1,250.06
$1,372.12
$1,501.42
$1,960.76 		$1,595.92
$1,717.98
$1,847.28
$2,306.62 		$1,941.78
$2,063.84
$2,193.14
$2,652.48 		$345.86
Toc - Plan #128 Florida Health Care Plans
Platinum

(POS) Gym Access IND Platinum POS OA Standard 4450

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-232-0578

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 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 		$655.80
$744.33
$838.11
$1,171.26
$1,779.84 		$1,157.49
$1,246.02
$1,339.80
$1,672.95 		$1,659.18
$1,747.71
$1,841.49
$2,174.64 		$2,160.87
$2,249.40
$2,343.18
$2,676.33 		$501.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,311.60
$1,488.66
$1,676.22
$2,342.52
$3,559.68 		$1,813.29
$1,990.35
$2,177.91
$2,844.21 		$2,314.98
$2,492.04
$2,679.60
$3,345.90 		$2,816.67
$2,993.73
$3,181.29
$3,847.59 		$501.69

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0405 | Toll Free: 1-888-200-0405 | TTY: 1-888-200-0405
Toc - Plan #129 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,150 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,150 $4,300 Annual Deductible
$9,100 $18,200 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 		$483.32
$548.57
$617.68
$863.21
$1,311.73 		$853.06
$918.31
$987.42
$1,232.95 		$1,222.80
$1,288.05
$1,357.16
$1,602.69 		$1,592.54
$1,657.79
$1,726.90
$1,972.43 		$369.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$966.64
$1,097.14
$1,235.36
$1,726.42
$2,623.46 		$1,336.38
$1,466.88
$1,605.10
$2,096.16 		$1,706.12
$1,836.62
$1,974.84
$2,465.90 		$2,075.86
$2,206.36
$2,344.58
$2,835.64 		$369.74
Toc - Plan #130 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,200 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 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 		$482.16
$547.25
$616.20
$861.14
$1,308.58 		$851.01
$916.10
$985.05
$1,229.99 		$1,219.86
$1,284.95
$1,353.90
$1,598.84 		$1,588.71
$1,653.80
$1,722.75
$1,967.69 		$368.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$964.32
$1,094.50
$1,232.40
$1,722.28
$2,617.16 		$1,333.17
$1,463.35
$1,601.25
$2,091.13 		$1,702.02
$1,832.20
$1,970.10
$2,459.98 		$2,070.87
$2,201.05
$2,338.95
$2,828.83 		$368.85
Toc - Plan #131 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 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 		$431.49
$489.75
$551.45
$770.65
$1,171.07 		$761.58
$819.84
$881.54
$1,100.74 		$1,091.67
$1,149.93
$1,211.63
$1,430.83 		$1,421.76
$1,480.02
$1,541.72
$1,760.92 		$330.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.98
$979.50
$1,102.90
$1,541.30
$2,342.14 		$1,193.07
$1,309.59
$1,432.99
$1,871.39 		$1,523.16
$1,639.68
$1,763.08
$2,201.48 		$1,853.25
$1,969.77
$2,093.17
$2,531.57 		$330.09
Toc - Plan #132 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First $3,800 Indiv Ded ($0 App-based Care, $3 Generic Rx Pref Pharm) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$9,100 $18,200 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 		$418.77
$475.31
$535.19
$747.93
$1,136.55 		$739.13
$795.67
$855.55
$1,068.29 		$1,059.49
$1,116.03
$1,175.91
$1,388.65 		$1,379.85
$1,436.39
$1,496.27
$1,709.01 		$320.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.54
$950.62
$1,070.38
$1,495.86
$2,273.10 		$1,157.90
$1,270.98
$1,390.74
$1,816.22 		$1,478.26
$1,591.34
$1,711.10
$2,136.58 		$1,798.62
$1,911.70
$2,031.46
$2,456.94 		$320.36
Toc - Plan #133 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,400 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 Annual Deductible
$9,100 $18,200 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 		$430.29
$488.38
$549.91
$768.50
$1,167.81 		$759.46
$817.55
$879.08
$1,097.67 		$1,088.63
$1,146.72
$1,208.25
$1,426.84 		$1,417.80
$1,475.89
$1,537.42
$1,756.01 		$329.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.58
$976.76
$1,099.82
$1,537.00
$2,335.62 		$1,189.75
$1,305.93
$1,428.99
$1,866.17 		$1,518.92
$1,635.10
$1,758.16
$2,195.34 		$1,848.09
$1,964.27
$2,087.33
$2,524.51 		$329.17
Toc - Plan #134 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 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 		$430.10
$488.16
$549.66
$768.15
$1,167.28 		$759.12
$817.18
$878.68
$1,097.17 		$1,088.14
$1,146.20
$1,207.70
$1,426.19 		$1,417.16
$1,475.22
$1,536.72
$1,755.21 		$329.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.20
$976.32
$1,099.32
$1,536.30
$2,334.56 		$1,189.22
$1,305.34
$1,428.34
$1,865.32 		$1,518.24
$1,634.36
$1,757.36
$2,194.34 		$1,847.26
$1,963.38
$2,086.38
$2,523.36 		$329.02
Toc - Plan #135 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First $3,400 Indiv Ded ($0 App-based Care, $3 Generic Rx Pref Pharm) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 Annual Deductible
$9,100 $18,200 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 		$419.34
$475.95
$535.92
$748.95
$1,138.10 		$740.14
$796.75
$856.72
$1,069.75 		$1,060.94
$1,117.55
$1,177.52
$1,390.55 		$1,381.74
$1,438.35
$1,498.32
$1,711.35 		$320.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.68
$951.90
$1,071.84
$1,497.90
$2,276.20 		$1,159.48
$1,272.70
$1,392.64
$1,818.70 		$1,480.28
$1,593.50
$1,713.44
$2,139.50 		$1,801.08
$1,914.30
$2,034.24
$2,460.30 		$320.80
Toc - Plan #136 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $9,100 Indiv Ded ($3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$335.85
$381.19
$429.22
$599.83
$911.49 		$592.77
$638.11
$686.14
$856.75 		$849.69
$895.03
$943.06
$1,113.67 		$1,106.61
$1,151.95
$1,199.98
$1,370.59 		$256.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.70
$762.38
$858.44
$1,199.66
$1,822.98 		$928.62
$1,019.30
$1,115.36
$1,456.58 		$1,185.54
$1,276.22
$1,372.28
$1,713.50 		$1,442.46
$1,533.14
$1,629.20
$1,970.42 		$256.92
Toc - Plan #137 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 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 		$344.43
$390.92
$440.18
$615.15
$934.77 		$607.92
$654.41
$703.67
$878.64 		$871.41
$917.90
$967.16
$1,142.13 		$1,134.90
$1,181.39
$1,230.65
$1,405.62 		$263.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.86
$781.84
$880.36
$1,230.30
$1,869.54 		$952.35
$1,045.33
$1,143.85
$1,493.79 		$1,215.84
$1,308.82
$1,407.34
$1,757.28 		$1,479.33
$1,572.31
$1,670.83
$2,020.77 		$263.49
Toc - Plan #138 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First ($0 App-based Care, $3 Generic Rx Pref Pharm) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,100 $18,200 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 		$335.16
$380.40
$428.33
$598.59
$909.61 		$591.55
$636.79
$684.72
$854.98 		$847.94
$893.18
$941.11
$1,111.37 		$1,104.33
$1,149.57
$1,197.50
$1,367.76 		$256.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.32
$760.80
$856.66
$1,197.18
$1,819.22 		$926.71
$1,017.19
$1,113.05
$1,453.57 		$1,183.10
$1,273.58
$1,369.44
$1,709.96 		$1,439.49
$1,529.97
$1,625.83
$1,966.35 		$256.39
Toc - Plan #139 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$513.81
$583.17
$656.64
$917.66
$1,394.47 		$906.87
$976.23
$1,049.70
$1,310.72 		$1,299.93
$1,369.29
$1,442.76
$1,703.78 		$1,692.99
$1,762.35
$1,835.82
$2,096.84 		$393.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,027.62
$1,166.34
$1,313.28
$1,835.32
$2,788.94 		$1,420.68
$1,559.40
$1,706.34
$2,228.38 		$1,813.74
$1,952.46
$2,099.40
$2,621.44 		$2,206.80
$2,345.52
$2,492.46
$3,014.50 		$393.06
Toc - Plan #140 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$514.13
$583.53
$657.05
$918.23
$1,395.34 		$907.44
$976.84
$1,050.36
$1,311.54 		$1,300.75
$1,370.15
$1,443.67
$1,704.85 		$1,694.06
$1,763.46
$1,836.98
$2,098.16 		$393.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,028.26
$1,167.06
$1,314.10
$1,836.46
$2,790.68 		$1,421.57
$1,560.37
$1,707.41
$2,229.77 		$1,814.88
$1,953.68
$2,100.72
$2,623.08 		$2,208.19
$2,346.99
$2,494.03
$3,016.39 		$393.31
Toc - Plan #141 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

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 		$491.30
$557.62
$627.88
$877.46
$1,333.38 		$867.14
$933.46
$1,003.72
$1,253.30 		$1,242.98
$1,309.30
$1,379.56
$1,629.14 		$1,618.82
$1,685.14
$1,755.40
$2,004.98 		$375.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$982.60
$1,115.24
$1,255.76
$1,754.92
$2,666.76 		$1,358.44
$1,491.08
$1,631.60
$2,130.76 		$1,734.28
$1,866.92
$2,007.44
$2,506.60 		$2,110.12
$2,242.76
$2,383.28
$2,882.44 		$375.84
Toc - Plan #142 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 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 		$431.89
$490.19
$551.95
$771.35
$1,172.14 		$762.28
$820.58
$882.34
$1,101.74 		$1,092.67
$1,150.97
$1,212.73
$1,432.13 		$1,423.06
$1,481.36
$1,543.12
$1,762.52 		$330.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.78
$980.38
$1,103.90
$1,542.70
$2,344.28 		$1,194.17
$1,310.77
$1,434.29
$1,873.09 		$1,524.56
$1,641.16
$1,764.68
$2,203.48 		$1,854.95
$1,971.55
$2,095.07
$2,533.87 		$330.39
Toc - Plan #143 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$451.04
$511.93
$576.43
$805.56
$1,224.13 		$796.09
$856.98
$921.48
$1,150.61 		$1,141.14
$1,202.03
$1,266.53
$1,495.66 		$1,486.19
$1,547.08
$1,611.58
$1,840.71 		$345.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902.08
$1,023.86
$1,152.86
$1,611.12
$2,448.26 		$1,247.13
$1,368.91
$1,497.91
$1,956.17 		$1,592.18
$1,713.96
$1,842.96
$2,301.22 		$1,937.23
$2,059.01
$2,188.01
$2,646.27 		$345.05
Toc - Plan #144 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 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 		$453.18
$514.35
$579.16
$809.37
$1,229.92 		$799.86
$861.03
$925.84
$1,156.05 		$1,146.54
$1,207.71
$1,272.52
$1,502.73 		$1,493.22
$1,554.39
$1,619.20
$1,849.41 		$346.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$906.36
$1,028.70
$1,158.32
$1,618.74
$2,459.84 		$1,253.04
$1,375.38
$1,505.00
$1,965.42 		$1,599.72
$1,722.06
$1,851.68
$2,312.10 		$1,946.40
$2,068.74
$2,198.36
$2,658.78 		$346.68
Toc - Plan #145 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$432.25
$490.60
$552.42
$772.00
$1,173.13 		$762.92
$821.27
$883.09
$1,102.67 		$1,093.59
$1,151.94
$1,213.76
$1,433.34 		$1,424.26
$1,482.61
$1,544.43
$1,764.01 		$330.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$864.50
$981.20
$1,104.84
$1,544.00
$2,346.26 		$1,195.17
$1,311.87
$1,435.51
$1,874.67 		$1,525.84
$1,642.54
$1,766.18
$2,205.34 		$1,856.51
$1,973.21
$2,096.85
$2,536.01 		$330.67
Toc - Plan #146 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $6,350 Indiv Ded ($3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,100 $18,200 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 		$334.33
$379.46
$427.27
$597.11
$907.36 		$590.09
$635.22
$683.03
$852.87 		$845.85
$890.98
$938.79
$1,108.63 		$1,101.61
$1,146.74
$1,194.55
$1,364.39 		$255.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.66
$758.92
$854.54
$1,194.22
$1,814.72 		$924.42
$1,014.68
$1,110.30
$1,449.98 		$1,180.18
$1,270.44
$1,366.06
$1,705.74 		$1,435.94
$1,526.20
$1,621.82
$1,961.50 		$255.76
Toc - Plan #147 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$346.47
$393.24
$442.78
$618.79
$940.31 		$611.52
$658.29
$707.83
$883.84 		$876.57
$923.34
$972.88
$1,148.89 		$1,141.62
$1,188.39
$1,237.93
$1,413.94 		$265.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.94
$786.48
$885.56
$1,237.58
$1,880.62 		$957.99
$1,051.53
$1,150.61
$1,502.63 		$1,223.04
$1,316.58
$1,415.66
$1,767.68 		$1,488.09
$1,581.63
$1,680.71
$2,032.73 		$265.05
Toc - Plan #148 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$327.49
$371.70
$418.53
$584.90
$888.81 		$578.02
$622.23
$669.06
$835.43 		$828.55
$872.76
$919.59
$1,085.96 		$1,079.08
$1,123.29
$1,170.12
$1,336.49 		$250.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.98
$743.40
$837.06
$1,169.80
$1,777.62 		$905.51
$993.93
$1,087.59
$1,420.33 		$1,156.04
$1,244.46
$1,338.12
$1,670.86 		$1,406.57
$1,494.99
$1,588.65
$1,921.39 		$250.53

‡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 Flagler County here.

Flagler County is in “Rating Area 17” of Florida.

Currently, there are 148 plans offered in Rating Area 17.

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2023 Obamacare Plans for Flagler County, FL

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