Obamacare 2023 Rates for Liberty County

Obamacare > Rates > Florida > Liberty 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 Liberty 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, 69 Plans and 2023 Rates for Liberty County, Florida

Below, you’ll find a summary of the 69 plans for Liberty 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 |

Liberty 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 		$615.91
$699.06
$787.13
$1,100.02
$1,671.58 		$1,087.08
$1,170.23
$1,258.30
$1,571.19 		$1,558.25
$1,641.40
$1,729.47
$2,042.36 		$2,029.42
$2,112.57
$2,200.64
$2,513.53 		$471.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,231.82
$1,398.12
$1,574.26
$2,200.04
$3,343.16 		$1,702.99
$1,869.29
$2,045.43
$2,671.21 		$2,174.16
$2,340.46
$2,516.60
$3,142.38 		$2,645.33
$2,811.63
$2,987.77
$3,613.55 		$471.17
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 		$398.47
$452.26
$509.24
$711.67
$1,081.45 		$703.30
$757.09
$814.07
$1,016.50 		$1,008.13
$1,061.92
$1,118.90
$1,321.33 		$1,312.96
$1,366.75
$1,423.73
$1,626.16 		$304.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.94
$904.52
$1,018.48
$1,423.34
$2,162.90 		$1,101.77
$1,209.35
$1,323.31
$1,728.17 		$1,406.60
$1,514.18
$1,628.14
$2,033.00 		$1,711.43
$1,819.01
$1,932.97
$2,337.83 		$304.83
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 		$619.29
$702.89
$791.45
$1,106.05
$1,680.75 		$1,093.05
$1,176.65
$1,265.21
$1,579.81 		$1,566.81
$1,650.41
$1,738.97
$2,053.57 		$2,040.57
$2,124.17
$2,212.73
$2,527.33 		$473.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,238.58
$1,405.78
$1,582.90
$2,212.10
$3,361.50 		$1,712.34
$1,879.54
$2,056.66
$2,685.86 		$2,186.10
$2,353.30
$2,530.42
$3,159.62 		$2,659.86
$2,827.06
$3,004.18
$3,633.38 		$473.76
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 		$779.34
$884.55
$996.00
$1,391.90
$2,115.13 		$1,375.54
$1,480.75
$1,592.20
$1,988.10 		$1,971.74
$2,076.95
$2,188.40
$2,584.30 		$2,567.94
$2,673.15
$2,784.60
$3,180.50 		$596.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,558.68
$1,769.10
$1,992.00
$2,783.80
$4,230.26 		$2,154.88
$2,365.30
$2,588.20
$3,380.00 		$2,751.08
$2,961.50
$3,184.40
$3,976.20 		$3,347.28
$3,557.70
$3,780.60
$4,572.40 		$596.20
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 		$415.06
$471.09
$530.45
$741.30
$1,126.47 		$732.58
$788.61
$847.97
$1,058.82 		$1,050.10
$1,106.13
$1,165.49
$1,376.34 		$1,367.62
$1,423.65
$1,483.01
$1,693.86 		$317.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.12
$942.18
$1,060.90
$1,482.60
$2,252.94 		$1,147.64
$1,259.70
$1,378.42
$1,800.12 		$1,465.16
$1,577.22
$1,695.94
$2,117.64 		$1,782.68
$1,894.74
$2,013.46
$2,435.16 		$317.52
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 		$816.60
$926.84
$1,043.61
$1,458.45
$2,216.25 		$1,441.30
$1,551.54
$1,668.31
$2,083.15 		$2,066.00
$2,176.24
$2,293.01
$2,707.85 		$2,690.70
$2,800.94
$2,917.71
$3,332.55 		$624.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,633.20
$1,853.68
$2,087.22
$2,916.90
$4,432.50 		$2,257.90
$2,478.38
$2,711.92
$3,541.60 		$2,882.60
$3,103.08
$3,336.62
$4,166.30 		$3,507.30
$3,727.78
$3,961.32
$4,791.00 		$624.70
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 		$578.13
$656.18
$738.85
$1,032.54
$1,569.04 		$1,020.40
$1,098.45
$1,181.12
$1,474.81 		$1,462.67
$1,540.72
$1,623.39
$1,917.08 		$1,904.94
$1,982.99
$2,065.66
$2,359.35 		$442.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,156.26
$1,312.36
$1,477.70
$2,065.08
$3,138.08 		$1,598.53
$1,754.63
$1,919.97
$2,507.35 		$2,040.80
$2,196.90
$2,362.24
$2,949.62 		$2,483.07
$2,639.17
$2,804.51
$3,391.89 		$442.27
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 		$669.31
$759.67
$855.38
$1,195.39
$1,816.51 		$1,181.33
$1,271.69
$1,367.40
$1,707.41 		$1,693.35
$1,783.71
$1,879.42
$2,219.43 		$2,205.37
$2,295.73
$2,391.44
$2,731.45 		$512.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,338.62
$1,519.34
$1,710.76
$2,390.78
$3,633.02 		$1,850.64
$2,031.36
$2,222.78
$2,902.80 		$2,362.66
$2,543.38
$2,734.80
$3,414.82 		$2,874.68
$3,055.40
$3,246.82
$3,926.84 		$512.02
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 		$403.49
$457.96
$515.66
$720.63
$1,095.07 		$712.16
$766.63
$824.33
$1,029.30 		$1,020.83
$1,075.30
$1,133.00
$1,337.97 		$1,329.50
$1,383.97
$1,441.67
$1,646.64 		$308.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.98
$915.92
$1,031.32
$1,441.26
$2,190.14 		$1,115.65
$1,224.59
$1,339.99
$1,749.93 		$1,424.32
$1,533.26
$1,648.66
$2,058.60 		$1,732.99
$1,841.93
$1,957.33
$2,367.27 		$308.67
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 		$647.55
$734.97
$827.57
$1,156.52
$1,757.45 		$1,142.93
$1,230.35
$1,322.95
$1,651.90 		$1,638.31
$1,725.73
$1,818.33
$2,147.28 		$2,133.69
$2,221.11
$2,313.71
$2,642.66 		$495.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,295.10
$1,469.94
$1,655.14
$2,313.04
$3,514.90 		$1,790.48
$1,965.32
$2,150.52
$2,808.42 		$2,285.86
$2,460.70
$2,645.90
$3,303.80 		$2,781.24
$2,956.08
$3,141.28
$3,799.18 		$495.38
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 		$439.58
$498.92
$561.78
$785.09
$1,193.02 		$775.86
$835.20
$898.06
$1,121.37 		$1,112.14
$1,171.48
$1,234.34
$1,457.65 		$1,448.42
$1,507.76
$1,570.62
$1,793.93 		$336.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.16
$997.84
$1,123.56
$1,570.18
$2,386.04 		$1,215.44
$1,334.12
$1,459.84
$1,906.46 		$1,551.72
$1,670.40
$1,796.12
$2,242.74 		$1,888.00
$2,006.68
$2,132.40
$2,579.02 		$336.28
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 		$380.86
$432.28
$486.74
$680.22
$1,033.65 		$672.22
$723.64
$778.10
$971.58 		$963.58
$1,015.00
$1,069.46
$1,262.94 		$1,254.94
$1,306.36
$1,360.82
$1,554.30 		$291.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.72
$864.56
$973.48
$1,360.44
$2,067.30 		$1,053.08
$1,155.92
$1,264.84
$1,651.80 		$1,344.44
$1,447.28
$1,556.20
$1,943.16 		$1,635.80
$1,738.64
$1,847.56
$2,234.52 		$291.36
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 		$409.43
$464.70
$523.25
$731.24
$1,111.19 		$722.64
$777.91
$836.46
$1,044.45 		$1,035.85
$1,091.12
$1,149.67
$1,357.66 		$1,349.06
$1,404.33
$1,462.88
$1,670.87 		$313.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.86
$929.40
$1,046.50
$1,462.48
$2,222.38 		$1,132.07
$1,242.61
$1,359.71
$1,775.69 		$1,445.28
$1,555.82
$1,672.92
$2,088.90 		$1,758.49
$1,869.03
$1,986.13
$2,402.11 		$313.21
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 		$609.62
$691.92
$779.09
$1,088.78
$1,654.51 		$1,075.98
$1,158.28
$1,245.45
$1,555.14 		$1,542.34
$1,624.64
$1,711.81
$2,021.50 		$2,008.70
$2,091.00
$2,178.17
$2,487.86 		$466.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,219.24
$1,383.84
$1,558.18
$2,177.56
$3,309.02 		$1,685.60
$1,850.20
$2,024.54
$2,643.92 		$2,151.96
$2,316.56
$2,490.90
$3,110.28 		$2,618.32
$2,782.92
$2,957.26
$3,576.64 		$466.36
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 		$622.21
$706.21
$795.18
$1,111.27
$1,688.68 		$1,098.20
$1,182.20
$1,271.17
$1,587.26 		$1,574.19
$1,658.19
$1,747.16
$2,063.25 		$2,050.18
$2,134.18
$2,223.15
$2,539.24 		$475.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,244.42
$1,412.42
$1,590.36
$2,222.54
$3,377.36 		$1,720.41
$1,888.41
$2,066.35
$2,698.53 		$2,196.40
$2,364.40
$2,542.34
$3,174.52 		$2,672.39
$2,840.39
$3,018.33
$3,650.51 		$475.99
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 		$814.56
$924.53
$1,041.01
$1,454.80
$2,210.72 		$1,437.70
$1,547.67
$1,664.15
$2,077.94 		$2,060.84
$2,170.81
$2,287.29
$2,701.08 		$2,683.98
$2,793.95
$2,910.43
$3,324.22 		$623.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,629.12
$1,849.06
$2,082.02
$2,909.60
$4,421.44 		$2,252.26
$2,472.20
$2,705.16
$3,532.74 		$2,875.40
$3,095.34
$3,328.30
$4,155.88 		$3,498.54
$3,718.48
$3,951.44
$4,779.02 		$623.14
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 		$430.93
$489.11
$550.73
$769.64
$1,169.54 		$760.59
$818.77
$880.39
$1,099.30 		$1,090.25
$1,148.43
$1,210.05
$1,428.96 		$1,419.91
$1,478.09
$1,539.71
$1,758.62 		$329.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.86
$978.22
$1,101.46
$1,539.28
$2,339.08 		$1,191.52
$1,307.88
$1,431.12
$1,868.94 		$1,521.18
$1,637.54
$1,760.78
$2,198.60 		$1,850.84
$1,967.20
$2,090.44
$2,528.26 		$329.66

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #18 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$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 		$409.90
$465.23
$523.84
$732.06
$1,112.44 		$723.47
$778.80
$837.41
$1,045.63 		$1,037.04
$1,092.37
$1,150.98
$1,359.20 		$1,350.61
$1,405.94
$1,464.55
$1,672.77 		$313.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.80
$930.46
$1,047.68
$1,464.12
$2,224.88 		$1,133.37
$1,244.03
$1,361.25
$1,777.69 		$1,446.94
$1,557.60
$1,674.82
$2,091.26 		$1,760.51
$1,871.17
$1,988.39
$2,404.83 		$313.57
Toc - Plan #19 Ambetter from Sunshine Health
Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.63
$346.88
$390.59
$545.84
$829.46 		$539.43
$580.68
$624.39
$779.64 		$773.23
$814.48
$858.19
$1,013.44 		$1,007.03
$1,048.28
$1,091.99
$1,247.24 		$233.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.26
$693.76
$781.18
$1,091.68
$1,658.92 		$845.06
$927.56
$1,014.98
$1,325.48 		$1,078.86
$1,161.36
$1,248.78
$1,559.28 		$1,312.66
$1,395.16
$1,482.58
$1,793.08 		$233.80
Toc - Plan #20 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336.59
$382.02
$430.15
$601.13
$913.48 		$594.07
$639.50
$687.63
$858.61 		$851.55
$896.98
$945.11
$1,116.09 		$1,109.03
$1,154.46
$1,202.59
$1,373.57 		$257.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$673.18
$764.04
$860.30
$1,202.26
$1,826.96 		$930.66
$1,021.52
$1,117.78
$1,459.74 		$1,188.14
$1,279.00
$1,375.26
$1,717.22 		$1,445.62
$1,536.48
$1,632.74
$1,974.70 		$257.48
Toc - Plan #21 Ambetter from Sunshine Health
Silver

(EPO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.28
$470.19
$529.43
$739.88
$1,124.32 		$731.19
$787.10
$846.34
$1,056.79 		$1,048.10
$1,104.01
$1,163.25
$1,373.70 		$1,365.01
$1,420.92
$1,480.16
$1,690.61 		$316.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.56
$940.38
$1,058.86
$1,479.76
$2,248.64 		$1,145.47
$1,257.29
$1,375.77
$1,796.67 		$1,462.38
$1,574.20
$1,692.68
$2,113.58 		$1,779.29
$1,891.11
$2,009.59
$2,430.49 		$316.91
Toc - Plan #22 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.62
$372.98
$419.97
$586.90
$891.86 		$580.01
$624.37
$671.36
$838.29 		$831.40
$875.76
$922.75
$1,089.68 		$1,082.79
$1,127.15
$1,174.14
$1,341.07 		$251.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.24
$745.96
$839.94
$1,173.80
$1,783.72 		$908.63
$997.35
$1,091.33
$1,425.19 		$1,160.02
$1,248.74
$1,342.72
$1,676.58 		$1,411.41
$1,500.13
$1,594.11
$1,927.97 		$251.39
Toc - Plan #23 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.63
$427.46
$481.32
$672.64
$1,022.15 		$664.74
$715.57
$769.43
$960.75 		$952.85
$1,003.68
$1,057.54
$1,248.86 		$1,240.96
$1,291.79
$1,345.65
$1,536.97 		$288.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.26
$854.92
$962.64
$1,345.28
$2,044.30 		$1,041.37
$1,143.03
$1,250.75
$1,633.39 		$1,329.48
$1,431.14
$1,538.86
$1,921.50 		$1,617.59
$1,719.25
$1,826.97
$2,209.61 		$288.11
Toc - Plan #24 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 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 		$409.32
$464.57
$523.10
$731.03
$1,110.87 		$722.44
$777.69
$836.22
$1,044.15 		$1,035.56
$1,090.81
$1,149.34
$1,357.27 		$1,348.68
$1,403.93
$1,462.46
$1,670.39 		$313.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.64
$929.14
$1,046.20
$1,462.06
$2,221.74 		$1,131.76
$1,242.26
$1,359.32
$1,775.18 		$1,444.88
$1,555.38
$1,672.44
$2,088.30 		$1,758.00
$1,868.50
$1,985.56
$2,401.42 		$313.12
Toc - Plan #25 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.79
$468.50
$527.53
$737.22
$1,120.28 		$728.57
$784.28
$843.31
$1,053.00 		$1,044.35
$1,100.06
$1,159.09
$1,368.78 		$1,360.13
$1,415.84
$1,474.87
$1,684.56 		$315.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.58
$937.00
$1,055.06
$1,474.44
$2,240.56 		$1,141.36
$1,252.78
$1,370.84
$1,790.22 		$1,457.14
$1,568.56
$1,686.62
$2,106.00 		$1,772.92
$1,884.34
$2,002.40
$2,421.78 		$315.78
Toc - Plan #26 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$391.16
$443.96
$499.89
$698.59
$1,061.58 		$690.39
$743.19
$799.12
$997.82 		$989.62
$1,042.42
$1,098.35
$1,297.05 		$1,288.85
$1,341.65
$1,397.58
$1,596.28 		$299.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.32
$887.92
$999.78
$1,397.18
$2,123.16 		$1,081.55
$1,187.15
$1,299.01
$1,696.41 		$1,380.78
$1,486.38
$1,598.24
$1,995.64 		$1,680.01
$1,785.61
$1,897.47
$2,294.87 		$299.23
Toc - Plan #27 Ambetter from Sunshine Health
Silver

(EPO) Enhanced Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$415.23
$471.27
$530.64
$741.57
$1,126.89 		$732.87
$788.91
$848.28
$1,059.21 		$1,050.51
$1,106.55
$1,165.92
$1,376.85 		$1,368.15
$1,424.19
$1,483.56
$1,694.49 		$317.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.46
$942.54
$1,061.28
$1,483.14
$2,253.78 		$1,148.10
$1,260.18
$1,378.92
$1,800.78 		$1,465.74
$1,577.82
$1,696.56
$2,118.42 		$1,783.38
$1,895.46
$2,014.20
$2,436.06 		$317.64
Toc - Plan #28 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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 		$455.14
$516.57
$581.66
$812.86
$1,235.23 		$803.32
$864.75
$929.84
$1,161.04 		$1,151.50
$1,212.93
$1,278.02
$1,509.22 		$1,499.68
$1,561.11
$1,626.20
$1,857.40 		$348.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.28
$1,033.14
$1,163.32
$1,625.72
$2,470.46 		$1,258.46
$1,381.32
$1,511.50
$1,973.90 		$1,606.64
$1,729.50
$1,859.68
$2,322.08 		$1,954.82
$2,077.68
$2,207.86
$2,670.26 		$348.18
Toc - Plan #29 Ambetter from Sunshine Health
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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 		$322.47
$366.00
$412.11
$575.92
$875.17 		$569.15
$612.68
$658.79
$822.60 		$815.83
$859.36
$905.47
$1,069.28 		$1,062.51
$1,106.04
$1,152.15
$1,315.96 		$246.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.94
$732.00
$824.22
$1,151.84
$1,750.34 		$891.62
$978.68
$1,070.90
$1,398.52 		$1,138.30
$1,225.36
$1,317.58
$1,645.20 		$1,384.98
$1,472.04
$1,564.26
$1,891.88 		$246.68
Toc - Plan #30 Ambetter from Sunshine Health
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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 		$409.07
$464.29
$522.78
$730.59
$1,110.20 		$722.00
$777.22
$835.71
$1,043.52 		$1,034.93
$1,090.15
$1,148.64
$1,356.45 		$1,347.86
$1,403.08
$1,461.57
$1,669.38 		$312.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.14
$928.58
$1,045.56
$1,461.18
$2,220.40 		$1,131.07
$1,241.51
$1,358.49
$1,774.11 		$1,444.00
$1,554.44
$1,671.42
$2,087.04 		$1,756.93
$1,867.37
$1,984.35
$2,399.97 		$312.93
Toc - Plan #31 Ambetter from Sunshine Health
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

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 		$383.07
$434.77
$489.55
$684.14
$1,039.62 		$676.11
$727.81
$782.59
$977.18 		$969.15
$1,020.85
$1,075.63
$1,270.22 		$1,262.19
$1,313.89
$1,368.67
$1,563.26 		$293.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.14
$869.54
$979.10
$1,368.28
$2,079.24 		$1,059.18
$1,162.58
$1,272.14
$1,661.32 		$1,352.22
$1,455.62
$1,565.18
$1,954.36 		$1,645.26
$1,748.66
$1,858.22
$2,247.40 		$293.04
Toc - Plan #32 Ambetter from Sunshine Health
Silver

(EPO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$429.64
$487.63
$549.07
$767.32
$1,166.02 		$758.31
$816.30
$877.74
$1,095.99 		$1,086.98
$1,144.97
$1,206.41
$1,424.66 		$1,415.65
$1,473.64
$1,535.08
$1,753.33 		$328.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.28
$975.26
$1,098.14
$1,534.64
$2,332.04 		$1,187.95
$1,303.93
$1,426.81
$1,863.31 		$1,516.62
$1,632.60
$1,755.48
$2,191.98 		$1,845.29
$1,961.27
$2,084.15
$2,520.65 		$328.67
Toc - Plan #33 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.08
$396.19
$446.11
$623.43
$947.36 		$616.12
$663.23
$713.15
$890.47 		$883.16
$930.27
$980.19
$1,157.51 		$1,150.20
$1,197.31
$1,247.23
$1,424.55 		$267.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.16
$792.38
$892.22
$1,246.86
$1,894.72 		$965.20
$1,059.42
$1,159.26
$1,513.90 		$1,232.24
$1,326.46
$1,426.30
$1,780.94 		$1,499.28
$1,593.50
$1,693.34
$2,047.98 		$267.04
Toc - Plan #34 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$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 		$425.11
$482.48
$543.27
$759.22
$1,153.71 		$750.31
$807.68
$868.47
$1,084.42 		$1,075.51
$1,132.88
$1,193.67
$1,409.62 		$1,400.71
$1,458.08
$1,518.87
$1,734.82 		$325.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.22
$964.96
$1,086.54
$1,518.44
$2,307.42 		$1,175.42
$1,290.16
$1,411.74
$1,843.64 		$1,500.62
$1,615.36
$1,736.94
$2,168.84 		$1,825.82
$1,940.56
$2,062.14
$2,494.04 		$325.20
Toc - Plan #35 Ambetter from Sunshine Health
Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.97
$359.75
$405.07
$566.09
$860.23 		$559.44
$602.22
$647.54
$808.56 		$801.91
$844.69
$890.01
$1,051.03 		$1,044.38
$1,087.16
$1,132.48
$1,293.50 		$242.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.94
$719.50
$810.14
$1,132.18
$1,720.46 		$876.41
$961.97
$1,052.61
$1,374.65 		$1,118.88
$1,204.44
$1,295.08
$1,617.12 		$1,361.35
$1,446.91
$1,537.55
$1,859.59 		$242.47
Toc - Plan #36 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 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 		$424.51
$481.80
$542.51
$758.15
$1,152.08 		$749.25
$806.54
$867.25
$1,082.89 		$1,073.99
$1,131.28
$1,191.99
$1,407.63 		$1,398.73
$1,456.02
$1,516.73
$1,732.37 		$324.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.02
$963.60
$1,085.02
$1,516.30
$2,304.16 		$1,173.76
$1,288.34
$1,409.76
$1,841.04 		$1,498.50
$1,613.08
$1,734.50
$2,165.78 		$1,823.24
$1,937.82
$2,059.24
$2,490.52 		$324.74
Toc - Plan #37 Ambetter from Sunshine Health
Silver

(EPO) Enhanced Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$430.63
$488.75
$550.33
$769.08
$1,168.70 		$760.05
$818.17
$879.75
$1,098.50 		$1,089.47
$1,147.59
$1,209.17
$1,427.92 		$1,418.89
$1,477.01
$1,538.59
$1,757.34 		$329.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.26
$977.50
$1,100.66
$1,538.16
$2,337.40 		$1,190.68
$1,306.92
$1,430.08
$1,867.58 		$1,520.10
$1,636.34
$1,759.50
$2,197.00 		$1,849.52
$1,965.76
$2,088.92
$2,526.42 		$329.42
Toc - Plan #38 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$472.02
$535.74
$603.23
$843.02
$1,281.05 		$833.11
$896.83
$964.32
$1,204.11 		$1,194.20
$1,257.92
$1,325.41
$1,565.20 		$1,555.29
$1,619.01
$1,686.50
$1,926.29 		$361.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$944.04
$1,071.48
$1,206.46
$1,686.04
$2,562.10 		$1,305.13
$1,432.57
$1,567.55
$2,047.13 		$1,666.22
$1,793.66
$1,928.64
$2,408.22 		$2,027.31
$2,154.75
$2,289.73
$2,769.31 		$361.09
Toc - Plan #39 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.81
$386.81
$435.55
$608.68
$924.94 		$601.52
$647.52
$696.26
$869.39 		$862.23
$908.23
$956.97
$1,130.10 		$1,122.94
$1,168.94
$1,217.68
$1,390.81 		$260.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.62
$773.62
$871.10
$1,217.36
$1,849.88 		$942.33
$1,034.33
$1,131.81
$1,478.07 		$1,203.04
$1,295.04
$1,392.52
$1,738.78 		$1,463.75
$1,555.75
$1,653.23
$1,999.49 		$260.71
Toc - Plan #40 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$390.60
$443.32
$499.18
$697.60
$1,060.06 		$689.40
$742.12
$797.98
$996.40 		$988.20
$1,040.92
$1,096.78
$1,295.20 		$1,287.00
$1,339.72
$1,395.58
$1,594.00 		$298.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.20
$886.64
$998.36
$1,395.20
$2,120.12 		$1,080.00
$1,185.44
$1,297.16
$1,694.00 		$1,378.80
$1,484.24
$1,595.96
$1,992.80 		$1,677.60
$1,783.04
$1,894.76
$2,291.60 		$298.80
Toc - Plan #41 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$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 		$428.10
$485.88
$547.10
$764.57
$1,161.84 		$755.59
$813.37
$874.59
$1,092.06 		$1,083.08
$1,140.86
$1,202.08
$1,419.55 		$1,410.57
$1,468.35
$1,529.57
$1,747.04 		$327.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.20
$971.76
$1,094.20
$1,529.14
$2,323.68 		$1,183.69
$1,299.25
$1,421.69
$1,856.63 		$1,511.18
$1,626.74
$1,749.18
$2,184.12 		$1,838.67
$1,954.23
$2,076.67
$2,511.61 		$327.49
Toc - Plan #42 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.67
$460.42
$518.43
$724.51
$1,100.96 		$716.00
$770.75
$828.76
$1,034.84 		$1,026.33
$1,081.08
$1,139.09
$1,345.17 		$1,336.66
$1,391.41
$1,449.42
$1,655.50 		$310.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.34
$920.84
$1,036.86
$1,449.02
$2,201.92 		$1,121.67
$1,231.17
$1,347.19
$1,759.35 		$1,432.00
$1,541.50
$1,657.52
$2,069.68 		$1,742.33
$1,851.83
$1,967.85
$2,380.01 		$310.33

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 #43 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $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 		$367.32
$416.91
$469.43
$656.03
$996.91 		$648.32
$697.91
$750.43
$937.03 		$929.32
$978.91
$1,031.43
$1,218.03 		$1,210.32
$1,259.91
$1,312.43
$1,499.03 		$281.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.64
$833.82
$938.86
$1,312.06
$1,993.82 		$1,015.64
$1,114.82
$1,219.86
$1,593.06 		$1,296.64
$1,395.82
$1,500.86
$1,874.06 		$1,577.64
$1,676.82
$1,781.86
$2,155.06 		$281.00
Toc - Plan #44 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1602 ($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
$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 		$345.78
$392.46
$441.91
$617.56
$938.45 		$610.30
$656.98
$706.43
$882.08 		$874.82
$921.50
$970.95
$1,146.60 		$1,139.34
$1,186.02
$1,235.47
$1,411.12 		$264.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.56
$784.92
$883.82
$1,235.12
$1,876.90 		$956.08
$1,049.44
$1,148.34
$1,499.64 		$1,220.60
$1,313.96
$1,412.86
$1,764.16 		$1,485.12
$1,578.48
$1,677.38
$2,028.68 		$264.52
Toc - Plan #45 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1603 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$452.37
$513.44
$578.13
$807.93
$1,227.73 		$798.43
$859.50
$924.19
$1,153.99 		$1,144.49
$1,205.56
$1,270.25
$1,500.05 		$1,490.55
$1,551.62
$1,616.31
$1,846.11 		$346.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.74
$1,026.88
$1,156.26
$1,615.86
$2,455.46 		$1,250.80
$1,372.94
$1,502.32
$1,961.92 		$1,596.86
$1,719.00
$1,848.38
$2,307.98 		$1,942.92
$2,065.06
$2,194.44
$2,654.04 		$346.06
Toc - Plan #46 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1604 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$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 		$431.21
$489.42
$551.09
$770.14
$1,170.30 		$761.09
$819.30
$880.97
$1,100.02 		$1,090.97
$1,149.18
$1,210.85
$1,429.90 		$1,420.85
$1,479.06
$1,540.73
$1,759.78 		$329.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.42
$978.84
$1,102.18
$1,540.28
$2,340.60 		$1,192.30
$1,308.72
$1,432.06
$1,870.16 		$1,522.18
$1,638.60
$1,761.94
$2,200.04 		$1,852.06
$1,968.48
$2,091.82
$2,529.92 		$329.88
Toc - Plan #47 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 1605 ($0 Virtual Visits / $0 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$940 $1,880 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$512.12
$581.26
$654.49
$914.65
$1,389.89 		$903.89
$973.03
$1,046.26
$1,306.42 		$1,295.66
$1,364.80
$1,438.03
$1,698.19 		$1,687.43
$1,756.57
$1,829.80
$2,089.96 		$391.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,024.24
$1,162.52
$1,308.98
$1,829.30
$2,779.78 		$1,416.01
$1,554.29
$1,700.75
$2,221.07 		$1,807.78
$1,946.06
$2,092.52
$2,612.84 		$2,199.55
$2,337.83
$2,484.29
$3,004.61 		$391.77
Toc - Plan #48 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1710 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 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 		$459.59
$521.63
$587.36
$820.83
$1,247.33 		$811.18
$873.22
$938.95
$1,172.42 		$1,162.77
$1,224.81
$1,290.54
$1,524.01 		$1,514.36
$1,576.40
$1,642.13
$1,875.60 		$351.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$919.18
$1,043.26
$1,174.72
$1,641.66
$2,494.66 		$1,270.77
$1,394.85
$1,526.31
$1,993.25 		$1,622.36
$1,746.44
$1,877.90
$2,344.84 		$1,973.95
$2,098.03
$2,229.49
$2,696.43 		$351.59
Toc - Plan #49 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2017 ($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
$6,000 $12,000 Annual Deductible
$7,400 $14,800 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 		$427.74
$485.48
$546.65
$763.94
$1,160.89 		$754.96
$812.70
$873.87
$1,091.16 		$1,082.18
$1,139.92
$1,201.09
$1,418.38 		$1,409.40
$1,467.14
$1,528.31
$1,745.60 		$327.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.48
$970.96
$1,093.30
$1,527.88
$2,321.78 		$1,182.70
$1,298.18
$1,420.52
$1,855.10 		$1,509.92
$1,625.40
$1,747.74
$2,182.32 		$1,837.14
$1,952.62
$2,074.96
$2,509.54 		$327.22
Toc - Plan #50 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2127 ($0 Virtual Visits / $25 Generic Meds / 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
$7,600 $15,200 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 		$426.12
$483.65
$544.58
$761.05
$1,156.49 		$752.10
$809.63
$870.56
$1,087.03 		$1,078.08
$1,135.61
$1,196.54
$1,413.01 		$1,404.06
$1,461.59
$1,522.52
$1,738.99 		$325.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.24
$967.30
$1,089.16
$1,522.10
$2,312.98 		$1,178.22
$1,293.28
$1,415.14
$1,848.08 		$1,504.20
$1,619.26
$1,741.12
$2,174.06 		$1,830.18
$1,945.24
$2,067.10
$2,500.04 		$325.98
Toc - Plan #51 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Deductible / $0 Virtual Visits / $35 PCP Visit / $80 Specialist Visits / $25 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 		$397.37
$451.01
$507.84
$709.70
$1,078.46 		$701.36
$755.00
$811.83
$1,013.69 		$1,005.35
$1,058.99
$1,115.82
$1,317.68 		$1,309.34
$1,362.98
$1,419.81
$1,621.67 		$303.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.74
$902.02
$1,015.68
$1,419.40
$2,156.92 		$1,098.73
$1,206.01
$1,319.67
$1,723.39 		$1,402.72
$1,510.00
$1,623.66
$2,027.38 		$1,706.71
$1,813.99
$1,927.65
$2,331.37 		$303.99
Toc - Plan #52 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2126 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 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 		$367.75
$417.40
$469.98
$656.80
$998.07 		$649.08
$698.73
$751.31
$938.13 		$930.41
$980.06
$1,032.64
$1,219.46 		$1,211.74
$1,261.39
$1,313.97
$1,500.79 		$281.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.50
$834.80
$939.96
$1,313.60
$1,996.14 		$1,016.83
$1,116.13
$1,221.29
$1,594.93 		$1,298.16
$1,397.46
$1,502.62
$1,876.26 		$1,579.49
$1,678.79
$1,783.95
$2,157.59 		$281.33
Toc - Plan #53 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237 ($0 Virtual Visits / $80 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 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 		$418.66
$475.18
$535.05
$747.73
$1,136.24 		$738.93
$795.45
$855.32
$1,068.00 		$1,059.20
$1,115.72
$1,175.59
$1,388.27 		$1,379.47
$1,435.99
$1,495.86
$1,708.54 		$320.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.32
$950.36
$1,070.10
$1,495.46
$2,272.48 		$1,157.59
$1,270.63
$1,390.37
$1,815.73 		$1,477.86
$1,590.90
$1,710.64
$2,136.00 		$1,798.13
$1,911.17
$2,030.91
$2,456.27 		$320.27
Toc - Plan #54 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2219 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 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 		$359.42
$407.94
$459.34
$641.92
$975.47 		$634.38
$682.90
$734.30
$916.88 		$909.34
$957.86
$1,009.26
$1,191.84 		$1,184.30
$1,232.82
$1,284.22
$1,466.80 		$274.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.84
$815.88
$918.68
$1,283.84
$1,950.94 		$993.80
$1,090.84
$1,193.64
$1,558.80 		$1,268.76
$1,365.80
$1,468.60
$1,833.76 		$1,543.72
$1,640.76
$1,743.56
$2,108.72 		$274.96
Toc - Plan #55 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2266 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 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 		$360.19
$408.82
$460.32
$643.30
$977.56 		$635.74
$684.37
$735.87
$918.85 		$911.29
$959.92
$1,011.42
$1,194.40 		$1,186.84
$1,235.47
$1,286.97
$1,469.95 		$275.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.38
$817.64
$920.64
$1,286.60
$1,955.12 		$995.93
$1,093.19
$1,196.19
$1,562.15 		$1,271.48
$1,368.74
$1,471.74
$1,837.70 		$1,547.03
$1,644.29
$1,747.29
$2,113.25 		$275.55
Toc - Plan #56 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) myBlue Bronze 2311S (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 		$327.25
$371.43
$418.23
$584.47
$888.16 		$577.60
$621.78
$668.58
$834.82 		$827.95
$872.13
$918.93
$1,085.17 		$1,078.30
$1,122.48
$1,169.28
$1,335.52 		$250.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.50
$742.86
$836.46
$1,168.94
$1,776.32 		$904.85
$993.21
$1,086.81
$1,419.29 		$1,155.20
$1,243.56
$1,337.16
$1,669.64 		$1,405.55
$1,493.91
$1,587.51
$1,919.99 		$250.35
Toc - Plan #57 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2312S (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 		$351.06
$398.45
$448.65
$626.99
$952.78 		$619.62
$667.01
$717.21
$895.55 		$888.18
$935.57
$985.77
$1,164.11 		$1,156.74
$1,204.13
$1,254.33
$1,432.67 		$268.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.12
$796.90
$897.30
$1,253.98
$1,905.56 		$970.68
$1,065.46
$1,165.86
$1,522.54 		$1,239.24
$1,334.02
$1,434.42
$1,791.10 		$1,507.80
$1,602.58
$1,702.98
$2,059.66 		$268.56
Toc - Plan #58 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2329 ($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 		$384.77
$436.71
$491.74
$687.20
$1,044.27 		$679.12
$731.06
$786.09
$981.55 		$973.47
$1,025.41
$1,080.44
$1,275.90 		$1,267.82
$1,319.76
$1,374.79
$1,570.25 		$294.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.54
$873.42
$983.48
$1,374.40
$2,088.54 		$1,063.89
$1,167.77
$1,277.83
$1,668.75 		$1,358.24
$1,462.12
$1,572.18
$1,963.10 		$1,652.59
$1,756.47
$1,866.53
$2,257.45 		$294.35
Toc - Plan #59 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2337 ($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
$4,500 $9,000 Annual Deductible
$8,300 $16,600 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 		$405.26
$459.97
$517.92
$723.79
$1,099.88 		$715.28
$769.99
$827.94
$1,033.81 		$1,025.30
$1,080.01
$1,137.96
$1,343.83 		$1,335.32
$1,390.03
$1,447.98
$1,653.85 		$310.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.52
$919.94
$1,035.84
$1,447.58
$2,199.76 		$1,120.54
$1,229.96
$1,345.86
$1,757.60 		$1,430.56
$1,539.98
$1,655.88
$2,067.62 		$1,740.58
$1,850.00
$1,965.90
$2,377.64 		$310.02
Toc - Plan #60 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2313S ($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 		$421.41
$478.30
$538.56
$752.64
$1,143.71 		$743.79
$800.68
$860.94
$1,075.02 		$1,066.17
$1,123.06
$1,183.32
$1,397.40 		$1,388.55
$1,445.44
$1,505.70
$1,719.78 		$322.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.82
$956.60
$1,077.12
$1,505.28
$2,287.42 		$1,165.20
$1,278.98
$1,399.50
$1,827.66 		$1,487.58
$1,601.36
$1,721.88
$2,150.04 		$1,809.96
$1,923.74
$2,044.26
$2,472.42 		$322.38
Toc - Plan #61 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 2314S ($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 		$484.74
$550.18
$619.50
$865.75
$1,315.58 		$855.57
$921.01
$990.33
$1,236.58 		$1,226.40
$1,291.84
$1,361.16
$1,607.41 		$1,597.23
$1,662.67
$1,731.99
$1,978.24 		$370.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969.48
$1,100.36
$1,239.00
$1,731.50
$2,631.16 		$1,340.31
$1,471.19
$1,609.83
$2,102.33 		$1,711.14
$1,842.02
$1,980.66
$2,473.16 		$2,081.97
$2,212.85
$2,351.49
$2,843.99 		$370.83
Toc - Plan #62 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237D ($0 Virtual Visits / $80 PCP Visits / Adult Dental / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 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 		$427.17
$484.84
$545.92
$762.93
$1,159.34 		$753.96
$811.63
$872.71
$1,089.72 		$1,080.75
$1,138.42
$1,199.50
$1,416.51 		$1,407.54
$1,465.21
$1,526.29
$1,743.30 		$326.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.34
$969.68
$1,091.84
$1,525.86
$2,318.68 		$1,181.13
$1,296.47
$1,418.63
$1,852.65 		$1,507.92
$1,623.26
$1,745.42
$2,179.44 		$1,834.71
$1,950.05
$2,072.21
$2,506.23 		$326.79
Toc - Plan #63 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2337D ($0 Virtual Visits / Adult Dental / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,300 $16,600 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 		$413.74
$469.59
$528.76
$738.94
$1,122.89 		$730.25
$786.10
$845.27
$1,055.45 		$1,046.76
$1,102.61
$1,161.78
$1,371.96 		$1,363.27
$1,419.12
$1,478.29
$1,688.47 		$316.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.48
$939.18
$1,057.52
$1,477.88
$2,245.78 		$1,143.99
$1,255.69
$1,374.03
$1,794.39 		$1,460.50
$1,572.20
$1,690.54
$2,110.90 		$1,777.01
$1,888.71
$2,007.05
$2,427.41 		$316.51

ADVERTISEMENT

Capital Health Plan

Local: 1-850-383-3311 | Toll Free: 1-877-247-6512 | TTY: 1-877-870-8943
Toc - Plan #64 Capital Health Plan
Silver

(HMO) Capital Health Plan HMO Silver 2100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-247-6512

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 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 		$417.03
$473.33
$532.97
$744.82
$1,131.82 		$736.06
$792.36
$852.00
$1,063.85 		$1,055.09
$1,111.39
$1,171.03
$1,382.88 		$1,374.12
$1,430.42
$1,490.06
$1,701.91 		$319.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.06
$946.66
$1,065.94
$1,489.64
$2,263.64 		$1,153.09
$1,265.69
$1,384.97
$1,808.67 		$1,472.12
$1,584.72
$1,704.00
$2,127.70 		$1,791.15
$1,903.75
$2,023.03
$2,446.73 		$319.03
Toc - Plan #65 Capital Health Plan
Gold

(HMO) Capital Health Plan HMO Gold 3000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-247-6512

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 		$458.69
$520.62
$586.21
$819.23
$1,244.89 		$809.59
$871.52
$937.11
$1,170.13 		$1,160.49
$1,222.42
$1,288.01
$1,521.03 		$1,511.39
$1,573.32
$1,638.91
$1,871.93 		$350.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.38
$1,041.24
$1,172.42
$1,638.46
$2,489.78 		$1,268.28
$1,392.14
$1,523.32
$1,989.36 		$1,619.18
$1,743.04
$1,874.22
$2,340.26 		$1,970.08
$2,093.94
$2,225.12
$2,691.16 		$350.90
Toc - Plan #66 Capital Health Plan
Expanded Bronze

(HMO) Capital Health Plan HMO Bronze 1000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-247-6512

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 		$315.95
$358.60
$403.79
$564.29
$857.49 		$557.65
$600.30
$645.49
$805.99 		$799.35
$842.00
$887.19
$1,047.69 		$1,041.05
$1,083.70
$1,128.89
$1,289.39 		$241.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.90
$717.20
$807.58
$1,128.58
$1,714.98 		$873.60
$958.90
$1,049.28
$1,370.28 		$1,115.30
$1,200.60
$1,290.98
$1,611.98 		$1,357.00
$1,442.30
$1,532.68
$1,853.68 		$241.70
Toc - Plan #67 Capital Health Plan
Silver

(HMO) Capital Health Plan HMO Silver 2300

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-247-6512

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 		$401.24
$455.40
$512.78
$716.61
$1,088.95 		$708.19
$762.35
$819.73
$1,023.56 		$1,015.14
$1,069.30
$1,126.68
$1,330.51 		$1,322.09
$1,376.25
$1,433.63
$1,637.46 		$306.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.48
$910.80
$1,025.56
$1,433.22
$2,177.90 		$1,109.43
$1,217.75
$1,332.51
$1,740.17 		$1,416.38
$1,524.70
$1,639.46
$2,047.12 		$1,723.33
$1,831.65
$1,946.41
$2,354.07 		$306.95
Toc - Plan #68 Capital Health Plan
Gold

(HMO) Capital Health Plan HMO Gold 3100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-247-6512

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 		$420.62
$477.40
$537.55
$751.23
$1,141.56 		$742.39
$799.17
$859.32
$1,073.00 		$1,064.16
$1,120.94
$1,181.09
$1,394.77 		$1,385.93
$1,442.71
$1,502.86
$1,716.54 		$321.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.24
$954.80
$1,075.10
$1,502.46
$2,283.12 		$1,163.01
$1,276.57
$1,396.87
$1,824.23 		$1,484.78
$1,598.34
$1,718.64
$2,146.00 		$1,806.55
$1,920.11
$2,040.41
$2,467.77 		$321.77
Toc - Plan #69 Capital Health Plan
Platinum

(HMO) Capital Health Plan HMO Platinum 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-247-6512

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 		$621.74
$705.67
$794.58
$1,110.42
$1,687.40 		$1,097.37
$1,181.30
$1,270.21
$1,586.05 		$1,573.00
$1,656.93
$1,745.84
$2,061.68 		$2,048.63
$2,132.56
$2,221.47
$2,537.31 		$475.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,243.48
$1,411.34
$1,589.16
$2,220.84
$3,374.80 		$1,719.11
$1,886.97
$2,064.79
$2,696.47 		$2,194.74
$2,362.60
$2,540.42
$3,172.10 		$2,670.37
$2,838.23
$3,016.05
$3,647.73 		$475.63

‡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 Liberty County here.

Liberty County is in “Rating Area 38” of Florida.

Currently, there are 69 plans offered in Rating Area 38.

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2023 Obamacare Plans for Liberty County, FL

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