Obamacare 2023 Rates for Martin County

Obamacare > Rates > Florida > Martin 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 Martin 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, 129 Plans and 2023 Rates for Martin County, Florida

Below, you’ll find a summary of the 129 plans for Martin 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 |

Martin 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 		$731.49
$830.24
$934.84
$1,306.44
$1,985.26 		$1,291.08
$1,389.83
$1,494.43
$1,866.03 		$1,850.67
$1,949.42
$2,054.02
$2,425.62 		$2,410.26
$2,509.01
$2,613.61
$2,985.21 		$559.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,462.98
$1,660.48
$1,869.68
$2,612.88
$3,970.52 		$2,022.57
$2,220.07
$2,429.27
$3,172.47 		$2,582.16
$2,779.66
$2,988.86
$3,732.06 		$3,141.75
$3,339.25
$3,548.45
$4,291.65 		$559.59
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 		$473.25
$537.14
$604.81
$845.22
$1,284.40 		$835.29
$899.18
$966.85
$1,207.26 		$1,197.33
$1,261.22
$1,328.89
$1,569.30 		$1,559.37
$1,623.26
$1,690.93
$1,931.34 		$362.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$946.50
$1,074.28
$1,209.62
$1,690.44
$2,568.80 		$1,308.54
$1,436.32
$1,571.66
$2,052.48 		$1,670.58
$1,798.36
$1,933.70
$2,414.52 		$2,032.62
$2,160.40
$2,295.74
$2,776.56 		$362.04
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 		$735.51
$834.80
$939.98
$1,313.62
$1,996.17 		$1,298.18
$1,397.47
$1,502.65
$1,876.29 		$1,860.85
$1,960.14
$2,065.32
$2,438.96 		$2,423.52
$2,522.81
$2,627.99
$3,001.63 		$562.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,471.02
$1,669.60
$1,879.96
$2,627.24
$3,992.34 		$2,033.69
$2,232.27
$2,442.63
$3,189.91 		$2,596.36
$2,794.94
$3,005.30
$3,752.58 		$3,159.03
$3,357.61
$3,567.97
$4,315.25 		$562.67
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 		$925.59
$1,050.54
$1,182.90
$1,653.10
$2,512.05 		$1,633.67
$1,758.62
$1,890.98
$2,361.18 		$2,341.75
$2,466.70
$2,599.06
$3,069.26 		$3,049.83
$3,174.78
$3,307.14
$3,777.34 		$708.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,851.18
$2,101.08
$2,365.80
$3,306.20
$5,024.10 		$2,559.26
$2,809.16
$3,073.88
$4,014.28 		$3,267.34
$3,517.24
$3,781.96
$4,722.36 		$3,975.42
$4,225.32
$4,490.04
$5,430.44 		$708.08
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 		$492.95
$559.50
$629.99
$880.41
$1,337.87 		$870.06
$936.61
$1,007.10
$1,257.52 		$1,247.17
$1,313.72
$1,384.21
$1,634.63 		$1,624.28
$1,690.83
$1,761.32
$2,011.74 		$377.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.90
$1,119.00
$1,259.98
$1,760.82
$2,675.74 		$1,363.01
$1,496.11
$1,637.09
$2,137.93 		$1,740.12
$1,873.22
$2,014.20
$2,515.04 		$2,117.23
$2,250.33
$2,391.31
$2,892.15 		$377.11
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 		$969.85
$1,100.78
$1,239.47
$1,732.15
$2,632.17 		$1,711.79
$1,842.72
$1,981.41
$2,474.09 		$2,453.73
$2,584.66
$2,723.35
$3,216.03 		$3,195.67
$3,326.60
$3,465.29
$3,957.97 		$741.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,939.70
$2,201.56
$2,478.94
$3,464.30
$5,264.34 		$2,681.64
$2,943.50
$3,220.88
$4,206.24 		$3,423.58
$3,685.44
$3,962.82
$4,948.18 		$4,165.52
$4,427.38
$4,704.76
$5,690.12 		$741.94
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 		$686.62
$779.31
$877.50
$1,226.30
$1,863.49 		$1,211.88
$1,304.57
$1,402.76
$1,751.56 		$1,737.14
$1,829.83
$1,928.02
$2,276.82 		$2,262.40
$2,355.09
$2,453.28
$2,802.08 		$525.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,373.24
$1,558.62
$1,755.00
$2,452.60
$3,726.98 		$1,898.50
$2,083.88
$2,280.26
$2,977.86 		$2,423.76
$2,609.14
$2,805.52
$3,503.12 		$2,949.02
$3,134.40
$3,330.78
$4,028.38 		$525.26
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 		$794.92
$902.23
$1,015.91
$1,419.73
$2,157.41 		$1,403.03
$1,510.34
$1,624.02
$2,027.84 		$2,011.14
$2,118.45
$2,232.13
$2,635.95 		$2,619.25
$2,726.56
$2,840.24
$3,244.06 		$608.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,589.84
$1,804.46
$2,031.82
$2,839.46
$4,314.82 		$2,197.95
$2,412.57
$2,639.93
$3,447.57 		$2,806.06
$3,020.68
$3,248.04
$4,055.68 		$3,414.17
$3,628.79
$3,856.15
$4,663.79 		$608.11
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 		$479.22
$543.91
$612.44
$855.89
$1,300.60 		$845.82
$910.51
$979.04
$1,222.49 		$1,212.42
$1,277.11
$1,345.64
$1,589.09 		$1,579.02
$1,643.71
$1,712.24
$1,955.69 		$366.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.44
$1,087.82
$1,224.88
$1,711.78
$2,601.20 		$1,325.04
$1,454.42
$1,591.48
$2,078.38 		$1,691.64
$1,821.02
$1,958.08
$2,444.98 		$2,058.24
$2,187.62
$2,324.68
$2,811.58 		$366.60
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 		$769.07
$872.89
$982.87
$1,373.56
$2,087.26 		$1,357.41
$1,461.23
$1,571.21
$1,961.90 		$1,945.75
$2,049.57
$2,159.55
$2,550.24 		$2,534.09
$2,637.91
$2,747.89
$3,138.58 		$588.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,538.14
$1,745.78
$1,965.74
$2,747.12
$4,174.52 		$2,126.48
$2,334.12
$2,554.08
$3,335.46 		$2,714.82
$2,922.46
$3,142.42
$3,923.80 		$3,303.16
$3,510.80
$3,730.76
$4,512.14 		$588.34
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 		$522.08
$592.56
$667.22
$932.43
$1,416.93 		$921.47
$991.95
$1,066.61
$1,331.82 		$1,320.86
$1,391.34
$1,466.00
$1,731.21 		$1,720.25
$1,790.73
$1,865.39
$2,130.60 		$399.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,044.16
$1,185.12
$1,334.44
$1,864.86
$2,833.86 		$1,443.55
$1,584.51
$1,733.83
$2,264.25 		$1,842.94
$1,983.90
$2,133.22
$2,663.64 		$2,242.33
$2,383.29
$2,532.61
$3,063.03 		$399.39
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 		$452.34
$513.41
$578.09
$807.88
$1,227.65 		$798.38
$859.45
$924.13
$1,153.92 		$1,144.42
$1,205.49
$1,270.17
$1,499.96 		$1,490.46
$1,551.53
$1,616.21
$1,846.00 		$346.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.68
$1,026.82
$1,156.18
$1,615.76
$2,455.30 		$1,250.72
$1,372.86
$1,502.22
$1,961.80 		$1,596.76
$1,718.90
$1,848.26
$2,307.84 		$1,942.80
$2,064.94
$2,194.30
$2,653.88 		$346.04
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 		$486.27
$551.92
$621.45
$868.48
$1,319.74 		$858.27
$923.92
$993.45
$1,240.48 		$1,230.27
$1,295.92
$1,365.45
$1,612.48 		$1,602.27
$1,667.92
$1,737.45
$1,984.48 		$372.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$972.54
$1,103.84
$1,242.90
$1,736.96
$2,639.48 		$1,344.54
$1,475.84
$1,614.90
$2,108.96 		$1,716.54
$1,847.84
$1,986.90
$2,480.96 		$2,088.54
$2,219.84
$2,358.90
$2,852.96 		$372.00
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 		$724.02
$821.76
$925.30
$1,293.10
$1,964.99 		$1,277.90
$1,375.64
$1,479.18
$1,846.98 		$1,831.78
$1,929.52
$2,033.06
$2,400.86 		$2,385.66
$2,483.40
$2,586.94
$2,954.74 		$553.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,448.04
$1,643.52
$1,850.60
$2,586.20
$3,929.98 		$2,001.92
$2,197.40
$2,404.48
$3,140.08 		$2,555.80
$2,751.28
$2,958.36
$3,693.96 		$3,109.68
$3,305.16
$3,512.24
$4,247.84 		$553.88
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 		$738.98
$838.74
$944.42
$1,319.82
$2,005.59 		$1,304.30
$1,404.06
$1,509.74
$1,885.14 		$1,869.62
$1,969.38
$2,075.06
$2,450.46 		$2,434.94
$2,534.70
$2,640.38
$3,015.78 		$565.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,477.96
$1,677.48
$1,888.84
$2,639.64
$4,011.18 		$2,043.28
$2,242.80
$2,454.16
$3,204.96 		$2,608.60
$2,808.12
$3,019.48
$3,770.28 		$3,173.92
$3,373.44
$3,584.80
$4,335.60 		$565.32
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 		$967.42
$1,098.02
$1,236.36
$1,727.81
$2,625.58 		$1,707.50
$1,838.10
$1,976.44
$2,467.89 		$2,447.58
$2,578.18
$2,716.52
$3,207.97 		$3,187.66
$3,318.26
$3,456.60
$3,948.05 		$740.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,934.84
$2,196.04
$2,472.72
$3,455.62
$5,251.16 		$2,674.92
$2,936.12
$3,212.80
$4,195.70 		$3,415.00
$3,676.20
$3,952.88
$4,935.78 		$4,155.08
$4,416.28
$4,692.96
$5,675.86 		$740.08
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 		$511.80
$580.89
$654.08
$914.07
$1,389.03 		$903.33
$972.42
$1,045.61
$1,305.60 		$1,294.86
$1,363.95
$1,437.14
$1,697.13 		$1,686.39
$1,755.48
$1,828.67
$2,088.66 		$391.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,023.60
$1,161.78
$1,308.16
$1,828.14
$2,778.06 		$1,415.13
$1,553.31
$1,699.69
$2,219.67 		$1,806.66
$1,944.84
$2,091.22
$2,611.20 		$2,198.19
$2,336.37
$2,482.75
$3,002.73 		$391.53
Toc - Plan #18 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1456 ($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 		$478.33
$542.90
$611.31
$854.30
$1,298.19 		$844.25
$908.82
$977.23
$1,220.22 		$1,210.17
$1,274.74
$1,343.15
$1,586.14 		$1,576.09
$1,640.66
$1,709.07
$1,952.06 		$365.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$956.66
$1,085.80
$1,222.62
$1,708.60
$2,596.38 		$1,322.58
$1,451.72
$1,588.54
$2,074.52 		$1,688.50
$1,817.64
$1,954.46
$2,440.44 		$2,054.42
$2,183.56
$2,320.38
$2,806.36 		$365.92
Toc - Plan #19 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1452 ($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 		$360.15
$408.77
$460.27
$643.23
$977.45 		$635.66
$684.28
$735.78
$918.74 		$911.17
$959.79
$1,011.29
$1,194.25 		$1,186.68
$1,235.30
$1,286.80
$1,469.76 		$275.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.30
$817.54
$920.54
$1,286.46
$1,954.90 		$995.81
$1,093.05
$1,196.05
$1,561.97 		$1,271.32
$1,368.56
$1,471.56
$1,837.48 		$1,546.83
$1,644.07
$1,747.07
$2,112.99 		$275.51
Toc - Plan #20 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1464 ($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 		$476.84
$541.21
$609.40
$851.64
$1,294.14 		$841.62
$905.99
$974.18
$1,216.42 		$1,206.40
$1,270.77
$1,338.96
$1,581.20 		$1,571.18
$1,635.55
$1,703.74
$1,945.98 		$364.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$953.68
$1,082.42
$1,218.80
$1,703.28
$2,588.28 		$1,318.46
$1,447.20
$1,583.58
$2,068.06 		$1,683.24
$1,811.98
$1,948.36
$2,432.84 		$2,048.02
$2,176.76
$2,313.14
$2,797.62 		$364.78
Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1451 ($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 		$605.06
$686.74
$773.27
$1,080.64
$1,642.13 		$1,067.93
$1,149.61
$1,236.14
$1,543.51 		$1,530.80
$1,612.48
$1,699.01
$2,006.38 		$1,993.67
$2,075.35
$2,161.88
$2,469.25 		$462.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,210.12
$1,373.48
$1,546.54
$2,161.28
$3,284.26 		$1,672.99
$1,836.35
$2,009.41
$2,624.15 		$2,135.86
$2,299.22
$2,472.28
$3,087.02 		$2,598.73
$2,762.09
$2,935.15
$3,549.89 		$462.87
Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($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 		$372.03
$422.25
$475.45
$664.45
$1,009.69 		$656.63
$706.85
$760.05
$949.05 		$941.23
$991.45
$1,044.65
$1,233.65 		$1,225.83
$1,276.05
$1,329.25
$1,518.25 		$284.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.06
$844.50
$950.90
$1,328.90
$2,019.38 		$1,028.66
$1,129.10
$1,235.50
$1,613.50 		$1,313.26
$1,413.70
$1,520.10
$1,898.10 		$1,597.86
$1,698.30
$1,804.70
$2,182.70 		$284.60
Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1457 ($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 		$633.18
$718.66
$809.20
$1,130.86
$1,718.45 		$1,117.56
$1,203.04
$1,293.58
$1,615.24 		$1,601.94
$1,687.42
$1,777.96
$2,099.62 		$2,086.32
$2,171.80
$2,262.34
$2,584.00 		$484.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,266.36
$1,437.32
$1,618.40
$2,261.72
$3,436.90 		$1,750.74
$1,921.70
$2,102.78
$2,746.10 		$2,235.12
$2,406.08
$2,587.16
$3,230.48 		$2,719.50
$2,890.46
$3,071.54
$3,714.86 		$484.38
Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1443 ($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
$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 		$447.62
$508.05
$572.06
$799.45
$1,214.84 		$790.05
$850.48
$914.49
$1,141.88 		$1,132.48
$1,192.91
$1,256.92
$1,484.31 		$1,474.91
$1,535.34
$1,599.35
$1,826.74 		$342.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.24
$1,016.10
$1,144.12
$1,598.90
$2,429.68 		$1,237.67
$1,358.53
$1,486.55
$1,941.33 		$1,580.10
$1,700.96
$1,828.98
$2,283.76 		$1,922.53
$2,043.39
$2,171.41
$2,626.19 		$342.43
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1535 ($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 		$528.16
$599.46
$674.99
$943.29
$1,433.43 		$932.20
$1,003.50
$1,079.03
$1,347.33 		$1,336.24
$1,407.54
$1,483.07
$1,751.37 		$1,740.28
$1,811.58
$1,887.11
$2,155.41 		$404.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,056.32
$1,198.92
$1,349.98
$1,886.58
$2,866.86 		$1,460.36
$1,602.96
$1,754.02
$2,290.62 		$1,864.40
$2,007.00
$2,158.06
$2,694.66 		$2,268.44
$2,411.04
$2,562.10
$3,098.70 		$404.04
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze (HSA) 1735 (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 		$364.04
$413.19
$465.24
$650.18
$988.00 		$642.53
$691.68
$743.73
$928.67 		$921.02
$970.17
$1,022.22
$1,207.16 		$1,199.51
$1,248.66
$1,300.71
$1,485.65 		$278.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.08
$826.38
$930.48
$1,300.36
$1,976.00 		$1,006.57
$1,104.87
$1,208.97
$1,578.85 		$1,285.06
$1,383.36
$1,487.46
$1,857.34 		$1,563.55
$1,661.85
$1,765.95
$2,135.83 		$278.49
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1835 ($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 		$510.94
$579.92
$652.98
$912.54
$1,386.69 		$901.81
$970.79
$1,043.85
$1,303.41 		$1,292.68
$1,361.66
$1,434.72
$1,694.28 		$1,683.55
$1,752.53
$1,825.59
$2,085.15 		$390.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,021.88
$1,159.84
$1,305.96
$1,825.08
$2,773.38 		$1,412.75
$1,550.71
$1,696.83
$2,215.95 		$1,803.62
$1,941.58
$2,087.70
$2,606.82 		$2,194.49
$2,332.45
$2,478.57
$2,997.69 		$390.87
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2139 ($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 		$394.17
$447.38
$503.75
$703.99
$1,069.78 		$695.71
$748.92
$805.29
$1,005.53 		$997.25
$1,050.46
$1,106.83
$1,307.07 		$1,298.79
$1,352.00
$1,408.37
$1,608.61 		$301.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.34
$894.76
$1,007.50
$1,407.98
$2,139.56 		$1,089.88
$1,196.30
$1,309.04
$1,709.52 		$1,391.42
$1,497.84
$1,610.58
$2,011.06 		$1,692.96
$1,799.38
$1,912.12
$2,312.60 		$301.54
Toc - Plan #29 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueSelect Bronze 2341S (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 		$341.64
$387.76
$436.62
$610.17
$927.21 		$602.99
$649.11
$697.97
$871.52 		$864.34
$910.46
$959.32
$1,132.87 		$1,125.69
$1,171.81
$1,220.67
$1,394.22 		$261.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.28
$775.52
$873.24
$1,220.34
$1,854.42 		$944.63
$1,036.87
$1,134.59
$1,481.69 		$1,205.98
$1,298.22
$1,395.94
$1,743.04 		$1,467.33
$1,559.57
$1,657.29
$2,004.39 		$261.35
Toc - Plan #30 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2342S (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 		$367.31
$416.90
$469.42
$656.02
$996.88 		$648.30
$697.89
$750.41
$937.01 		$929.29
$978.88
$1,031.40
$1,218.00 		$1,210.28
$1,259.87
$1,312.39
$1,498.99 		$280.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.62
$833.80
$938.84
$1,312.04
$1,993.76 		$1,015.61
$1,114.79
$1,219.83
$1,593.03 		$1,296.60
$1,395.78
$1,500.82
$1,874.02 		$1,577.59
$1,676.77
$1,781.81
$2,155.01 		$280.99
Toc - Plan #31 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 2343S ($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 		$472.04
$535.77
$603.27
$843.06
$1,281.12 		$833.15
$896.88
$964.38
$1,204.17 		$1,194.26
$1,257.99
$1,325.49
$1,565.28 		$1,555.37
$1,619.10
$1,686.60
$1,926.39 		$361.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$944.08
$1,071.54
$1,206.54
$1,686.12
$2,562.24 		$1,305.19
$1,432.65
$1,567.65
$2,047.23 		$1,666.30
$1,793.76
$1,928.76
$2,408.34 		$2,027.41
$2,154.87
$2,289.87
$2,769.45 		$361.11
Toc - Plan #32 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 2344S ($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 		$491.03
$557.32
$627.54
$876.98
$1,332.66 		$866.67
$932.96
$1,003.18
$1,252.62 		$1,242.31
$1,308.60
$1,378.82
$1,628.26 		$1,617.95
$1,684.24
$1,754.46
$2,003.90 		$375.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$982.06
$1,114.64
$1,255.08
$1,753.96
$2,665.32 		$1,357.70
$1,490.28
$1,630.72
$2,129.60 		$1,733.34
$1,865.92
$2,006.36
$2,505.24 		$2,108.98
$2,241.56
$2,382.00
$2,880.88 		$375.64
Toc - Plan #33 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 2345S ($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 		$631.56
$716.82
$807.13
$1,127.97
$1,714.05 		$1,114.70
$1,199.96
$1,290.27
$1,611.11 		$1,597.84
$1,683.10
$1,773.41
$2,094.25 		$2,080.98
$2,166.24
$2,256.55
$2,577.39 		$483.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,263.12
$1,433.64
$1,614.26
$2,255.94
$3,428.10 		$1,746.26
$1,916.78
$2,097.40
$2,739.08 		$2,229.40
$2,399.92
$2,580.54
$3,222.22 		$2,712.54
$2,883.06
$3,063.68
$3,705.36 		$483.14
Toc - Plan #34 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2339 ($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 		$386.57
$438.76
$494.04
$690.41
$1,049.15 		$682.30
$734.49
$789.77
$986.14 		$978.03
$1,030.22
$1,085.50
$1,281.87 		$1,273.76
$1,325.95
$1,381.23
$1,577.60 		$295.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.14
$877.52
$988.08
$1,380.82
$2,098.30 		$1,068.87
$1,173.25
$1,283.81
$1,676.55 		$1,364.60
$1,468.98
$1,579.54
$1,972.28 		$1,660.33
$1,764.71
$1,875.27
$2,268.01 		$295.73

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915 | TTY: 1-877-336-3915
Toc - Plan #35 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.76
$483.23
$544.12
$760.40
$1,155.50 		$751.46
$808.93
$869.82
$1,086.10 		$1,077.16
$1,134.63
$1,195.52
$1,411.80 		$1,402.86
$1,460.33
$1,521.22
$1,737.50 		$325.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.52
$966.46
$1,088.24
$1,520.80
$2,311.00 		$1,177.22
$1,292.16
$1,413.94
$1,846.50 		$1,502.92
$1,617.86
$1,739.64
$2,172.20 		$1,828.62
$1,943.56
$2,065.34
$2,497.90 		$325.70
Toc - Plan #36 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

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 		$394.33
$447.56
$503.95
$704.27
$1,070.21 		$695.99
$749.22
$805.61
$1,005.93 		$997.65
$1,050.88
$1,107.27
$1,307.59 		$1,299.31
$1,352.54
$1,408.93
$1,609.25 		$301.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.66
$895.12
$1,007.90
$1,408.54
$2,140.42 		$1,090.32
$1,196.78
$1,309.56
$1,710.20 		$1,391.98
$1,498.44
$1,611.22
$2,011.86 		$1,693.64
$1,800.10
$1,912.88
$2,313.52 		$301.66
Toc - Plan #37 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

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 		$323.60
$367.29
$413.57
$577.96
$878.26 		$571.16
$614.85
$661.13
$825.52 		$818.72
$862.41
$908.69
$1,073.08 		$1,066.28
$1,109.97
$1,156.25
$1,320.64 		$247.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.20
$734.58
$827.14
$1,155.92
$1,756.52 		$894.76
$982.14
$1,074.70
$1,403.48 		$1,142.32
$1,229.70
$1,322.26
$1,651.04 		$1,389.88
$1,477.26
$1,569.82
$1,898.60 		$247.56
Toc - Plan #38 Aetna CVS Health
Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

Individual Family
$4,425 $8,850 Annual Deductible
$8,850 $17,700 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 		$422.77
$479.84
$540.30
$755.06
$1,147.39 		$746.19
$803.26
$863.72
$1,078.48 		$1,069.61
$1,126.68
$1,187.14
$1,401.90 		$1,393.03
$1,450.10
$1,510.56
$1,725.32 		$323.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.54
$959.68
$1,080.60
$1,510.12
$2,294.78 		$1,168.96
$1,283.10
$1,404.02
$1,833.54 		$1,492.38
$1,606.52
$1,727.44
$2,156.96 		$1,815.80
$1,929.94
$2,050.86
$2,480.38 		$323.42
Toc - Plan #39 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

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 		$451.89
$512.90
$577.52
$807.08
$1,226.44 		$797.59
$858.60
$923.22
$1,152.78 		$1,143.29
$1,204.30
$1,268.92
$1,498.48 		$1,488.99
$1,550.00
$1,614.62
$1,844.18 		$345.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.78
$1,025.80
$1,155.04
$1,614.16
$2,452.88 		$1,249.48
$1,371.50
$1,500.74
$1,959.86 		$1,595.18
$1,717.20
$1,846.44
$2,305.56 		$1,940.88
$2,062.90
$2,192.14
$2,651.26 		$345.70
Toc - Plan #40 Aetna CVS Health
Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,850 $17,700 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 		$410.24
$465.62
$524.28
$732.69
$1,113.39 		$724.07
$779.45
$838.11
$1,046.52 		$1,037.90
$1,093.28
$1,151.94
$1,360.35 		$1,351.73
$1,407.11
$1,465.77
$1,674.18 		$313.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.48
$931.24
$1,048.56
$1,465.38
$2,226.78 		$1,134.31
$1,245.07
$1,362.39
$1,779.21 		$1,448.14
$1,558.90
$1,676.22
$2,093.04 		$1,761.97
$1,872.73
$1,990.05
$2,406.87 		$313.83
Toc - Plan #41 Aetna CVS Health
Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$480.64
$545.52
$614.25
$858.42
$1,304.45 		$848.33
$913.21
$981.94
$1,226.11 		$1,216.02
$1,280.90
$1,349.63
$1,593.80 		$1,583.71
$1,648.59
$1,717.32
$1,961.49 		$367.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$961.28
$1,091.04
$1,228.50
$1,716.84
$2,608.90 		$1,328.97
$1,458.73
$1,596.19
$2,084.53 		$1,696.66
$1,826.42
$1,963.88
$2,452.22 		$2,064.35
$2,194.11
$2,331.57
$2,819.91 		$367.69

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 #42 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 		$501.35
$569.03
$640.73
$895.41
$1,360.66 		$884.88
$952.56
$1,024.26
$1,278.94 		$1,268.41
$1,336.09
$1,407.79
$1,662.47 		$1,651.94
$1,719.62
$1,791.32
$2,046.00 		$383.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,002.70
$1,138.06
$1,281.46
$1,790.82
$2,721.32 		$1,386.23
$1,521.59
$1,664.99
$2,174.35 		$1,769.76
$1,905.12
$2,048.52
$2,557.88 		$2,153.29
$2,288.65
$2,432.05
$2,941.41 		$383.53
Toc - Plan #43 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 		$354.61
$402.48
$453.19
$633.33
$962.41 		$625.89
$673.76
$724.47
$904.61 		$897.17
$945.04
$995.75
$1,175.89 		$1,168.45
$1,216.32
$1,267.03
$1,447.17 		$271.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.22
$804.96
$906.38
$1,266.66
$1,924.82 		$980.50
$1,076.24
$1,177.66
$1,537.94 		$1,251.78
$1,347.52
$1,448.94
$1,809.22 		$1,523.06
$1,618.80
$1,720.22
$2,080.50 		$271.28
Toc - Plan #44 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 		$513.15
$582.43
$655.81
$916.49
$1,392.69 		$905.71
$974.99
$1,048.37
$1,309.05 		$1,298.27
$1,367.55
$1,440.93
$1,701.61 		$1,690.83
$1,760.11
$1,833.49
$2,094.17 		$392.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,026.30
$1,164.86
$1,311.62
$1,832.98
$2,785.38 		$1,418.86
$1,557.42
$1,704.18
$2,225.54 		$1,811.42
$1,949.98
$2,096.74
$2,618.10 		$2,203.98
$2,342.54
$2,489.30
$3,010.66 		$392.56
Toc - Plan #45 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 		$601.40
$682.59
$768.59
$1,074.10
$1,632.20 		$1,061.47
$1,142.66
$1,228.66
$1,534.17 		$1,521.54
$1,602.73
$1,688.73
$1,994.24 		$1,981.61
$2,062.80
$2,148.80
$2,454.31 		$460.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,202.80
$1,365.18
$1,537.18
$2,148.20
$3,264.40 		$1,662.87
$1,825.25
$1,997.25
$2,608.27 		$2,122.94
$2,285.32
$2,457.32
$3,068.34 		$2,583.01
$2,745.39
$2,917.39
$3,528.41 		$460.07
Toc - Plan #46 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 		$375.86
$426.60
$480.35
$671.29
$1,020.08 		$663.39
$714.13
$767.88
$958.82 		$950.92
$1,001.66
$1,055.41
$1,246.35 		$1,238.45
$1,289.19
$1,342.94
$1,533.88 		$287.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.72
$853.20
$960.70
$1,342.58
$2,040.16 		$1,039.25
$1,140.73
$1,248.23
$1,630.11 		$1,326.78
$1,428.26
$1,535.76
$1,917.64 		$1,614.31
$1,715.79
$1,823.29
$2,205.17 		$287.53
Toc - Plan #47 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 		$639.34
$725.65
$817.08
$1,141.86
$1,735.17 		$1,128.44
$1,214.75
$1,306.18
$1,630.96 		$1,617.54
$1,703.85
$1,795.28
$2,120.06 		$2,106.64
$2,192.95
$2,284.38
$2,609.16 		$489.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,278.68
$1,451.30
$1,634.16
$2,283.72
$3,470.34 		$1,767.78
$1,940.40
$2,123.26
$2,772.82 		$2,256.88
$2,429.50
$2,612.36
$3,261.92 		$2,745.98
$2,918.60
$3,101.46
$3,751.02 		$489.10
Toc - Plan #48 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 		$462.41
$524.84
$590.96
$825.86
$1,254.98 		$816.15
$878.58
$944.70
$1,179.60 		$1,169.89
$1,232.32
$1,298.44
$1,533.34 		$1,523.63
$1,586.06
$1,652.18
$1,887.08 		$353.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$924.82
$1,049.68
$1,181.92
$1,651.72
$2,509.96 		$1,278.56
$1,403.42
$1,535.66
$2,005.46 		$1,632.30
$1,757.16
$1,889.40
$2,359.20 		$1,986.04
$2,110.90
$2,243.14
$2,712.94 		$353.74
Toc - Plan #49 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 		$564.10
$640.25
$720.92
$1,007.48
$1,530.97 		$995.64
$1,071.79
$1,152.46
$1,439.02 		$1,427.18
$1,503.33
$1,584.00
$1,870.56 		$1,858.72
$1,934.87
$2,015.54
$2,302.10 		$431.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,128.20
$1,280.50
$1,441.84
$2,014.96
$3,061.94 		$1,559.74
$1,712.04
$1,873.38
$2,446.50 		$1,991.28
$2,143.58
$2,304.92
$2,878.04 		$2,422.82
$2,575.12
$2,736.46
$3,309.58 		$431.54
Toc - Plan #50 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 		$358.80
$407.24
$458.55
$640.82
$973.78 		$633.28
$681.72
$733.03
$915.30 		$907.76
$956.20
$1,007.51
$1,189.78 		$1,182.24
$1,230.68
$1,281.99
$1,464.26 		$274.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.60
$814.48
$917.10
$1,281.64
$1,947.56 		$992.08
$1,088.96
$1,191.58
$1,556.12 		$1,266.56
$1,363.44
$1,466.06
$1,830.60 		$1,541.04
$1,637.92
$1,740.54
$2,105.08 		$274.48
Toc - Plan #51 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 		$539.87
$612.75
$689.95
$964.21
$1,465.21 		$952.87
$1,025.75
$1,102.95
$1,377.21 		$1,365.87
$1,438.75
$1,515.95
$1,790.21 		$1,778.87
$1,851.75
$1,928.95
$2,203.21 		$413.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,079.74
$1,225.50
$1,379.90
$1,928.42
$2,930.42 		$1,492.74
$1,638.50
$1,792.90
$2,341.42 		$1,905.74
$2,051.50
$2,205.90
$2,754.42 		$2,318.74
$2,464.50
$2,618.90
$3,167.42 		$413.00
Toc - Plan #52 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 		$407.90
$462.97
$521.30
$728.51
$1,107.04 		$719.94
$775.01
$833.34
$1,040.55 		$1,031.98
$1,087.05
$1,145.38
$1,352.59 		$1,344.02
$1,399.09
$1,457.42
$1,664.63 		$312.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.80
$925.94
$1,042.60
$1,457.02
$2,214.08 		$1,127.84
$1,237.98
$1,354.64
$1,769.06 		$1,439.88
$1,550.02
$1,666.68
$2,081.10 		$1,751.92
$1,862.06
$1,978.72
$2,393.14 		$312.04
Toc - Plan #53 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 		$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 #54 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 		$368.90
$418.70
$471.45
$658.86
$1,001.19 		$651.11
$700.91
$753.66
$941.07 		$933.32
$983.12
$1,035.87
$1,223.28 		$1,215.53
$1,265.33
$1,318.08
$1,505.49 		$282.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.80
$837.40
$942.90
$1,317.72
$2,002.38 		$1,020.01
$1,119.61
$1,225.11
$1,599.93 		$1,302.22
$1,401.82
$1,507.32
$1,882.14 		$1,584.43
$1,684.03
$1,789.53
$2,164.35 		$282.21
Toc - Plan #55 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 		$495.94
$562.89
$633.81
$885.75
$1,345.98 		$875.33
$942.28
$1,013.20
$1,265.14 		$1,254.72
$1,321.67
$1,392.59
$1,644.53 		$1,634.11
$1,701.06
$1,771.98
$2,023.92 		$379.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.88
$1,125.78
$1,267.62
$1,771.50
$2,691.96 		$1,371.27
$1,505.17
$1,647.01
$2,150.89 		$1,750.66
$1,884.56
$2,026.40
$2,530.28 		$2,130.05
$2,263.95
$2,405.79
$2,909.67 		$379.39
Toc - Plan #56 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 		$511.29
$580.31
$653.43
$913.16
$1,387.64 		$902.43
$971.45
$1,044.57
$1,304.30 		$1,293.57
$1,362.59
$1,435.71
$1,695.44 		$1,684.71
$1,753.73
$1,826.85
$2,086.58 		$391.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,022.58
$1,160.62
$1,306.86
$1,826.32
$2,775.28 		$1,413.72
$1,551.76
$1,698.00
$2,217.46 		$1,804.86
$1,942.90
$2,089.14
$2,608.60 		$2,196.00
$2,334.04
$2,480.28
$2,999.74 		$391.14
Toc - Plan #57 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 		$637.58
$723.65
$814.83
$1,138.72
$1,730.39 		$1,125.33
$1,211.40
$1,302.58
$1,626.47 		$1,613.08
$1,699.15
$1,790.33
$2,114.22 		$2,100.83
$2,186.90
$2,278.08
$2,601.97 		$487.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,275.16
$1,447.30
$1,629.66
$2,277.44
$3,460.78 		$1,762.91
$1,935.05
$2,117.41
$2,765.19 		$2,250.66
$2,422.80
$2,605.16
$3,252.94 		$2,738.41
$2,910.55
$3,092.91
$3,740.69 		$487.75
Toc - Plan #58 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 		$394.46
$447.71
$504.12
$704.51
$1,070.56 		$696.22
$749.47
$805.88
$1,006.27 		$997.98
$1,051.23
$1,107.64
$1,308.03 		$1,299.74
$1,352.99
$1,409.40
$1,609.79 		$301.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.92
$895.42
$1,008.24
$1,409.02
$2,141.12 		$1,090.68
$1,197.18
$1,310.00
$1,710.78 		$1,392.44
$1,498.94
$1,611.76
$2,012.54 		$1,694.20
$1,800.70
$1,913.52
$2,314.30 		$301.76
Toc - Plan #59 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 		$353.82
$401.59
$452.18
$631.92
$960.27 		$624.49
$672.26
$722.85
$902.59 		$895.16
$942.93
$993.52
$1,173.26 		$1,165.83
$1,213.60
$1,264.19
$1,443.93 		$270.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.64
$803.18
$904.36
$1,263.84
$1,920.54 		$978.31
$1,073.85
$1,175.03
$1,534.51 		$1,248.98
$1,344.52
$1,445.70
$1,805.18 		$1,519.65
$1,615.19
$1,716.37
$2,075.85 		$270.67
Toc - Plan #60 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 		$333.08
$378.05
$425.68
$594.88
$903.98 		$587.89
$632.86
$680.49
$849.69 		$842.70
$887.67
$935.30
$1,104.50 		$1,097.51
$1,142.48
$1,190.11
$1,359.31 		$254.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.16
$756.10
$851.36
$1,189.76
$1,807.96 		$920.97
$1,010.91
$1,106.17
$1,444.57 		$1,175.78
$1,265.72
$1,360.98
$1,699.38 		$1,430.59
$1,520.53
$1,615.79
$1,954.19 		$254.81
Toc - Plan #61 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 		$435.74
$494.56
$556.88
$778.23
$1,182.60 		$769.08
$827.90
$890.22
$1,111.57 		$1,102.42
$1,161.24
$1,223.56
$1,444.91 		$1,435.76
$1,494.58
$1,556.90
$1,778.25 		$333.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.48
$989.12
$1,113.76
$1,556.46
$2,365.20 		$1,204.82
$1,322.46
$1,447.10
$1,889.80 		$1,538.16
$1,655.80
$1,780.44
$2,223.14 		$1,871.50
$1,989.14
$2,113.78
$2,556.48 		$333.34
Toc - Plan #62 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 		$415.36
$471.43
$530.83
$741.83
$1,127.29 		$733.11
$789.18
$848.58
$1,059.58 		$1,050.86
$1,106.93
$1,166.33
$1,377.33 		$1,368.61
$1,424.68
$1,484.08
$1,695.08 		$317.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.72
$942.86
$1,061.66
$1,483.66
$2,254.58 		$1,148.47
$1,260.61
$1,379.41
$1,801.41 		$1,466.22
$1,578.36
$1,697.16
$2,119.16 		$1,783.97
$1,896.11
$2,014.91
$2,436.91 		$317.75
Toc - Plan #63 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 		$493.30
$559.90
$630.44
$881.03
$1,338.82 		$870.67
$937.27
$1,007.81
$1,258.40 		$1,248.04
$1,314.64
$1,385.18
$1,635.77 		$1,625.41
$1,692.01
$1,762.55
$2,013.14 		$377.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$986.60
$1,119.80
$1,260.88
$1,762.06
$2,677.64 		$1,363.97
$1,497.17
$1,638.25
$2,139.43 		$1,741.34
$1,874.54
$2,015.62
$2,516.80 		$2,118.71
$2,251.91
$2,392.99
$2,894.17 		$377.37
Toc - Plan #64 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 		$442.70
$502.46
$565.77
$790.66
$1,201.49 		$781.37
$841.13
$904.44
$1,129.33 		$1,120.04
$1,179.80
$1,243.11
$1,468.00 		$1,458.71
$1,518.47
$1,581.78
$1,806.67 		$338.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$885.40
$1,004.92
$1,131.54
$1,581.32
$2,402.98 		$1,224.07
$1,343.59
$1,470.21
$1,919.99 		$1,562.74
$1,682.26
$1,808.88
$2,258.66 		$1,901.41
$2,020.93
$2,147.55
$2,597.33 		$338.67
Toc - Plan #65 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 		$412.02
$467.64
$526.56
$735.87
$1,118.22 		$727.22
$782.84
$841.76
$1,051.07 		$1,042.42
$1,098.04
$1,156.96
$1,366.27 		$1,357.62
$1,413.24
$1,472.16
$1,681.47 		$315.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.04
$935.28
$1,053.12
$1,471.74
$2,236.44 		$1,139.24
$1,250.48
$1,368.32
$1,786.94 		$1,454.44
$1,565.68
$1,683.52
$2,102.14 		$1,769.64
$1,880.88
$1,998.72
$2,417.34 		$315.20
Toc - Plan #66 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 		$410.46
$465.87
$524.57
$733.08
$1,113.99 		$724.46
$779.87
$838.57
$1,047.08 		$1,038.46
$1,093.87
$1,152.57
$1,361.08 		$1,352.46
$1,407.87
$1,466.57
$1,675.08 		$314.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.92
$931.74
$1,049.14
$1,466.16
$2,227.98 		$1,134.92
$1,245.74
$1,363.14
$1,780.16 		$1,448.92
$1,559.74
$1,677.14
$2,094.16 		$1,762.92
$1,873.74
$1,991.14
$2,408.16 		$314.00
Toc - Plan #67 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 		$382.76
$434.43
$489.17
$683.61
$1,038.81 		$675.57
$727.24
$781.98
$976.42 		$968.38
$1,020.05
$1,074.79
$1,269.23 		$1,261.19
$1,312.86
$1,367.60
$1,562.04 		$292.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.52
$868.86
$978.34
$1,367.22
$2,077.62 		$1,058.33
$1,161.67
$1,271.15
$1,660.03 		$1,351.14
$1,454.48
$1,563.96
$1,952.84 		$1,643.95
$1,747.29
$1,856.77
$2,245.65 		$292.81
Toc - Plan #68 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 		$354.23
$402.05
$452.71
$632.65
$961.38 		$625.22
$673.04
$723.70
$903.64 		$896.21
$944.03
$994.69
$1,174.63 		$1,167.20
$1,215.02
$1,265.68
$1,445.62 		$270.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.46
$804.10
$905.42
$1,265.30
$1,922.76 		$979.45
$1,075.09
$1,176.41
$1,536.29 		$1,250.44
$1,346.08
$1,447.40
$1,807.28 		$1,521.43
$1,617.07
$1,718.39
$2,078.27 		$270.99
Toc - Plan #69 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 		$403.27
$457.71
$515.38
$720.24
$1,094.47 		$711.77
$766.21
$823.88
$1,028.74 		$1,020.27
$1,074.71
$1,132.38
$1,337.24 		$1,328.77
$1,383.21
$1,440.88
$1,645.74 		$308.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.54
$915.42
$1,030.76
$1,440.48
$2,188.94 		$1,115.04
$1,223.92
$1,339.26
$1,748.98 		$1,423.54
$1,532.42
$1,647.76
$2,057.48 		$1,732.04
$1,840.92
$1,956.26
$2,365.98 		$308.50
Toc - Plan #70 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 		$346.22
$392.96
$442.47
$618.35
$939.64 		$611.08
$657.82
$707.33
$883.21 		$875.94
$922.68
$972.19
$1,148.07 		$1,140.80
$1,187.54
$1,237.05
$1,412.93 		$264.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.44
$785.92
$884.94
$1,236.70
$1,879.28 		$957.30
$1,050.78
$1,149.80
$1,501.56 		$1,222.16
$1,315.64
$1,414.66
$1,766.42 		$1,487.02
$1,580.50
$1,679.52
$2,031.28 		$264.86
Toc - Plan #71 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 		$346.95
$393.79
$443.40
$619.65
$941.62 		$612.37
$659.21
$708.82
$885.07 		$877.79
$924.63
$974.24
$1,150.49 		$1,143.21
$1,190.05
$1,239.66
$1,415.91 		$265.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$693.90
$787.58
$886.80
$1,239.30
$1,883.24 		$959.32
$1,053.00
$1,152.22
$1,504.72 		$1,224.74
$1,318.42
$1,417.64
$1,770.14 		$1,490.16
$1,583.84
$1,683.06
$2,035.56 		$265.42
Toc - Plan #72 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 		$315.22
$357.77
$402.85
$562.98
$855.51 		$556.36
$598.91
$643.99
$804.12 		$797.50
$840.05
$885.13
$1,045.26 		$1,038.64
$1,081.19
$1,126.27
$1,286.40 		$241.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.44
$715.54
$805.70
$1,125.96
$1,711.02 		$871.58
$956.68
$1,046.84
$1,367.10 		$1,112.72
$1,197.82
$1,287.98
$1,608.24 		$1,353.86
$1,438.96
$1,529.12
$1,849.38 		$241.14
Toc - Plan #73 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 		$338.16
$383.81
$432.17
$603.95
$917.77 		$596.85
$642.50
$690.86
$862.64 		$855.54
$901.19
$949.55
$1,121.33 		$1,114.23
$1,159.88
$1,208.24
$1,380.02 		$258.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$676.32
$767.62
$864.34
$1,207.90
$1,835.54 		$935.01
$1,026.31
$1,123.03
$1,466.59 		$1,193.70
$1,285.00
$1,381.72
$1,725.28 		$1,452.39
$1,543.69
$1,640.41
$1,983.97 		$258.69
Toc - Plan #74 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 		$370.63
$420.67
$473.67
$661.95
$1,005.89 		$654.16
$704.20
$757.20
$945.48 		$937.69
$987.73
$1,040.73
$1,229.01 		$1,221.22
$1,271.26
$1,324.26
$1,512.54 		$283.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.26
$841.34
$947.34
$1,323.90
$2,011.78 		$1,024.79
$1,124.87
$1,230.87
$1,607.43 		$1,308.32
$1,408.40
$1,514.40
$1,890.96 		$1,591.85
$1,691.93
$1,797.93
$2,174.49 		$283.53
Toc - Plan #75 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 		$390.37
$443.07
$498.89
$697.20
$1,059.46 		$689.00
$741.70
$797.52
$995.83 		$987.63
$1,040.33
$1,096.15
$1,294.46 		$1,286.26
$1,338.96
$1,394.78
$1,593.09 		$298.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.74
$886.14
$997.78
$1,394.40
$2,118.92 		$1,079.37
$1,184.77
$1,296.41
$1,693.03 		$1,378.00
$1,483.40
$1,595.04
$1,991.66 		$1,676.63
$1,782.03
$1,893.67
$2,290.29 		$298.63
Toc - Plan #76 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 		$405.93
$460.73
$518.78
$724.99
$1,101.69 		$716.47
$771.27
$829.32
$1,035.53 		$1,027.01
$1,081.81
$1,139.86
$1,346.07 		$1,337.55
$1,392.35
$1,450.40
$1,656.61 		$310.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.86
$921.46
$1,037.56
$1,449.98
$2,203.38 		$1,122.40
$1,232.00
$1,348.10
$1,760.52 		$1,432.94
$1,542.54
$1,658.64
$2,071.06 		$1,743.48
$1,853.08
$1,969.18
$2,381.60 		$310.54
Toc - Plan #77 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 		$466.93
$529.97
$596.74
$833.94
$1,267.25 		$824.13
$887.17
$953.94
$1,191.14 		$1,181.33
$1,244.37
$1,311.14
$1,548.34 		$1,538.53
$1,601.57
$1,668.34
$1,905.54 		$357.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$933.86
$1,059.94
$1,193.48
$1,667.88
$2,534.50 		$1,291.06
$1,417.14
$1,550.68
$2,025.08 		$1,648.26
$1,774.34
$1,907.88
$2,382.28 		$2,005.46
$2,131.54
$2,265.08
$2,739.48 		$357.20
Toc - Plan #78 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 		$411.47
$467.02
$525.86
$734.89
$1,116.73 		$726.24
$781.79
$840.63
$1,049.66 		$1,041.01
$1,096.56
$1,155.40
$1,364.43 		$1,355.78
$1,411.33
$1,470.17
$1,679.20 		$314.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.94
$934.04
$1,051.72
$1,469.78
$2,233.46 		$1,137.71
$1,248.81
$1,366.49
$1,784.55 		$1,452.48
$1,563.58
$1,681.26
$2,099.32 		$1,767.25
$1,878.35
$1,996.03
$2,414.09 		$314.77
Toc - Plan #79 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 		$398.53
$452.33
$509.32
$711.77
$1,081.61 		$703.41
$757.21
$814.20
$1,016.65 		$1,008.29
$1,062.09
$1,119.08
$1,321.53 		$1,313.17
$1,366.97
$1,423.96
$1,626.41 		$304.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.06
$904.66
$1,018.64
$1,423.54
$2,163.22 		$1,101.94
$1,209.54
$1,323.52
$1,728.42 		$1,406.82
$1,514.42
$1,628.40
$2,033.30 		$1,711.70
$1,819.30
$1,933.28
$2,338.18 		$304.88

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #80 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 		$301.33
$342.00
$385.09
$538.16
$817.78 		$531.84
$572.51
$615.60
$768.67 		$762.35
$803.02
$846.11
$999.18 		$992.86
$1,033.53
$1,076.62
$1,229.69 		$230.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.66
$684.00
$770.18
$1,076.32
$1,635.56 		$833.17
$914.51
$1,000.69
$1,306.83 		$1,063.68
$1,145.02
$1,231.20
$1,537.34 		$1,294.19
$1,375.53
$1,461.71
$1,767.85 		$230.51
Toc - Plan #81 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 		$292.28
$331.72
$373.52
$521.99
$793.22 		$515.86
$555.30
$597.10
$745.57 		$739.44
$778.88
$820.68
$969.15 		$963.02
$1,002.46
$1,044.26
$1,192.73 		$223.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.56
$663.44
$747.04
$1,043.98
$1,586.44 		$808.14
$887.02
$970.62
$1,267.56 		$1,031.72
$1,110.60
$1,194.20
$1,491.14 		$1,255.30
$1,334.18
$1,417.78
$1,714.72 		$223.58
Toc - Plan #82 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 		$355.90
$403.93
$454.82
$635.61
$965.87 		$628.15
$676.18
$727.07
$907.86 		$900.40
$948.43
$999.32
$1,180.11 		$1,172.65
$1,220.68
$1,271.57
$1,452.36 		$272.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.80
$807.86
$909.64
$1,271.22
$1,931.74 		$984.05
$1,080.11
$1,181.89
$1,543.47 		$1,256.30
$1,352.36
$1,454.14
$1,815.72 		$1,528.55
$1,624.61
$1,726.39
$2,087.97 		$272.25
Toc - Plan #83 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 		$395.65
$449.06
$505.63
$706.62
$1,073.78 		$698.32
$751.73
$808.30
$1,009.29 		$1,000.99
$1,054.40
$1,110.97
$1,311.96 		$1,303.66
$1,357.07
$1,413.64
$1,614.63 		$302.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.30
$898.12
$1,011.26
$1,413.24
$2,147.56 		$1,093.97
$1,200.79
$1,313.93
$1,715.91 		$1,396.64
$1,503.46
$1,616.60
$2,018.58 		$1,699.31
$1,806.13
$1,919.27
$2,321.25 		$302.67
Toc - Plan #84 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 		$393.36
$446.45
$502.70
$702.52
$1,067.54 		$694.27
$747.36
$803.61
$1,003.43 		$995.18
$1,048.27
$1,104.52
$1,304.34 		$1,296.09
$1,349.18
$1,405.43
$1,605.25 		$300.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.72
$892.90
$1,005.40
$1,405.04
$2,135.08 		$1,087.63
$1,193.81
$1,306.31
$1,705.95 		$1,388.54
$1,494.72
$1,607.22
$2,006.86 		$1,689.45
$1,795.63
$1,908.13
$2,307.77 		$300.91
Toc - Plan #85 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 		$396.23
$449.71
$506.37
$707.65
$1,075.34 		$699.34
$752.82
$809.48
$1,010.76 		$1,002.45
$1,055.93
$1,112.59
$1,313.87 		$1,305.56
$1,359.04
$1,415.70
$1,616.98 		$303.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792.46
$899.42
$1,012.74
$1,415.30
$2,150.68 		$1,095.57
$1,202.53
$1,315.85
$1,718.41 		$1,398.68
$1,505.64
$1,618.96
$2,021.52 		$1,701.79
$1,808.75
$1,922.07
$2,324.63 		$303.11
Toc - Plan #86 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 		$225.65
$256.10
$288.36
$402.98
$612.37 		$398.26
$428.71
$460.97
$575.59 		$570.87
$601.32
$633.58
$748.20 		$743.48
$773.93
$806.19
$920.81 		$172.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$451.30
$512.20
$576.72
$805.96
$1,224.74 		$623.91
$684.81
$749.33
$978.57 		$796.52
$857.42
$921.94
$1,151.18 		$969.13
$1,030.03
$1,094.55
$1,323.79 		$172.61
Toc - Plan #87 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 		$354.97
$402.88
$453.64
$633.96
$963.36 		$626.51
$674.42
$725.18
$905.50 		$898.05
$945.96
$996.72
$1,177.04 		$1,169.59
$1,217.50
$1,268.26
$1,448.58 		$271.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.94
$805.76
$907.28
$1,267.92
$1,926.72 		$981.48
$1,077.30
$1,178.82
$1,539.46 		$1,253.02
$1,348.84
$1,450.36
$1,811.00 		$1,524.56
$1,620.38
$1,721.90
$2,082.54 		$271.54
Toc - Plan #88 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 		$418.90
$475.44
$535.34
$748.13
$1,136.86 		$739.35
$795.89
$855.79
$1,068.58 		$1,059.80
$1,116.34
$1,176.24
$1,389.03 		$1,380.25
$1,436.79
$1,496.69
$1,709.48 		$320.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.80
$950.88
$1,070.68
$1,496.26
$2,273.72 		$1,158.25
$1,271.33
$1,391.13
$1,816.71 		$1,478.70
$1,591.78
$1,711.58
$2,137.16 		$1,799.15
$1,912.23
$2,032.03
$2,457.61 		$320.45
Toc - Plan #89 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 		$312.56
$354.74
$399.44
$558.21
$848.26 		$551.66
$593.84
$638.54
$797.31 		$790.76
$832.94
$877.64
$1,036.41 		$1,029.86
$1,072.04
$1,116.74
$1,275.51 		$239.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.12
$709.48
$798.88
$1,116.42
$1,696.52 		$864.22
$948.58
$1,037.98
$1,355.52 		$1,103.32
$1,187.68
$1,277.08
$1,594.62 		$1,342.42
$1,426.78
$1,516.18
$1,833.72 		$239.10
Toc - Plan #90 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 		$392.78
$445.80
$501.96
$701.49
$1,065.98 		$693.25
$746.27
$802.43
$1,001.96 		$993.72
$1,046.74
$1,102.90
$1,302.43 		$1,294.19
$1,347.21
$1,403.37
$1,602.90 		$300.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.56
$891.60
$1,003.92
$1,402.98
$2,131.96 		$1,086.03
$1,192.07
$1,304.39
$1,703.45 		$1,386.50
$1,492.54
$1,604.86
$2,003.92 		$1,686.97
$1,793.01
$1,905.33
$2,304.39 		$300.47
Toc - Plan #91 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 		$400.83
$454.93
$512.25
$715.87
$1,087.83 		$707.46
$761.56
$818.88
$1,022.50 		$1,014.09
$1,068.19
$1,125.51
$1,329.13 		$1,320.72
$1,374.82
$1,432.14
$1,635.76 		$306.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.66
$909.86
$1,024.50
$1,431.74
$2,175.66 		$1,108.29
$1,216.49
$1,331.13
$1,738.37 		$1,414.92
$1,523.12
$1,637.76
$2,045.00 		$1,721.55
$1,829.75
$1,944.39
$2,351.63 		$306.63
Toc - Plan #92 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 		$403.71
$458.20
$515.93
$721.01
$1,095.65 		$712.54
$767.03
$824.76
$1,029.84 		$1,021.37
$1,075.86
$1,133.59
$1,338.67 		$1,330.20
$1,384.69
$1,442.42
$1,647.50 		$308.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.42
$916.40
$1,031.86
$1,442.02
$2,191.30 		$1,116.25
$1,225.23
$1,340.69
$1,750.85 		$1,425.08
$1,534.06
$1,649.52
$2,059.68 		$1,733.91
$1,842.89
$1,958.35
$2,368.51 		$308.83
Toc - Plan #93 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 		$310.87
$352.83
$397.28
$555.20
$843.68 		$548.68
$590.64
$635.09
$793.01 		$786.49
$828.45
$872.90
$1,030.82 		$1,024.30
$1,066.26
$1,110.71
$1,268.63 		$237.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.74
$705.66
$794.56
$1,110.40
$1,687.36 		$859.55
$943.47
$1,032.37
$1,348.21 		$1,097.36
$1,181.28
$1,270.18
$1,586.02 		$1,335.17
$1,419.09
$1,507.99
$1,823.83 		$237.81
Toc - Plan #94 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 		$319.99
$363.18
$408.94
$571.49
$868.44 		$564.78
$607.97
$653.73
$816.28 		$809.57
$852.76
$898.52
$1,061.07 		$1,054.36
$1,097.55
$1,143.31
$1,305.86 		$244.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.98
$726.36
$817.88
$1,142.98
$1,736.88 		$884.77
$971.15
$1,062.67
$1,387.77 		$1,129.56
$1,215.94
$1,307.46
$1,632.56 		$1,374.35
$1,460.73
$1,552.25
$1,877.35 		$244.79
Toc - Plan #95 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 		$389.91
$442.54
$498.30
$696.37
$1,058.19 		$688.19
$740.82
$796.58
$994.65 		$986.47
$1,039.10
$1,094.86
$1,292.93 		$1,284.75
$1,337.38
$1,393.14
$1,591.21 		$298.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.82
$885.08
$996.60
$1,392.74
$2,116.38 		$1,078.10
$1,183.36
$1,294.88
$1,691.02 		$1,376.38
$1,481.64
$1,593.16
$1,989.30 		$1,674.66
$1,779.92
$1,891.44
$2,287.58 		$298.28
Toc - Plan #96 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 		$405.44
$460.16
$518.14
$724.10
$1,100.34 		$715.59
$770.31
$828.29
$1,034.25 		$1,025.74
$1,080.46
$1,138.44
$1,344.40 		$1,335.89
$1,390.61
$1,448.59
$1,654.55 		$310.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.88
$920.32
$1,036.28
$1,448.20
$2,200.68 		$1,121.03
$1,230.47
$1,346.43
$1,758.35 		$1,431.18
$1,540.62
$1,656.58
$2,068.50 		$1,741.33
$1,850.77
$1,966.73
$2,378.65 		$310.15
Toc - Plan #97 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 		$395.65
$449.06
$505.63
$706.62
$1,073.78 		$698.32
$751.73
$808.30
$1,009.29 		$1,000.99
$1,054.40
$1,110.97
$1,311.96 		$1,303.66
$1,357.07
$1,413.64
$1,614.63 		$302.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.30
$898.12
$1,011.26
$1,413.24
$2,147.56 		$1,093.97
$1,200.79
$1,313.93
$1,715.91 		$1,396.64
$1,503.46
$1,616.60
$2,018.58 		$1,699.31
$1,806.13
$1,919.27
$2,321.25 		$302.67
Toc - Plan #98 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 		$459.23
$521.22
$586.89
$820.18
$1,246.34 		$810.54
$872.53
$938.20
$1,171.49 		$1,161.85
$1,223.84
$1,289.51
$1,522.80 		$1,513.16
$1,575.15
$1,640.82
$1,874.11 		$351.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.46
$1,042.44
$1,173.78
$1,640.36
$2,492.68 		$1,269.77
$1,393.75
$1,525.09
$1,991.67 		$1,621.08
$1,745.06
$1,876.40
$2,342.98 		$1,972.39
$2,096.37
$2,227.71
$2,694.29 		$351.31
Toc - Plan #99 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 		$429.99
$488.02
$549.51
$767.94
$1,166.96 		$758.92
$816.95
$878.44
$1,096.87 		$1,087.85
$1,145.88
$1,207.37
$1,425.80 		$1,416.78
$1,474.81
$1,536.30
$1,754.73 		$328.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.98
$976.04
$1,099.02
$1,535.88
$2,333.92 		$1,188.91
$1,304.97
$1,427.95
$1,864.81 		$1,517.84
$1,633.90
$1,756.88
$2,193.74 		$1,846.77
$1,962.83
$2,085.81
$2,522.67 		$328.93
Toc - Plan #100 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 		$346.64
$393.43
$442.99
$619.08
$940.76 		$611.81
$658.60
$708.16
$884.25 		$876.98
$923.77
$973.33
$1,149.42 		$1,142.15
$1,188.94
$1,238.50
$1,414.59 		$265.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$693.28
$786.86
$885.98
$1,238.16
$1,881.52 		$958.45
$1,052.03
$1,151.15
$1,503.33 		$1,223.62
$1,317.20
$1,416.32
$1,768.50 		$1,488.79
$1,582.37
$1,681.49
$2,033.67 		$265.17
Toc - Plan #101 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 		$394.51
$447.75
$504.16
$704.57
$1,070.66 		$696.30
$749.54
$805.95
$1,006.36 		$998.09
$1,051.33
$1,107.74
$1,308.15 		$1,299.88
$1,353.12
$1,409.53
$1,609.94 		$301.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.02
$895.50
$1,008.32
$1,409.14
$2,141.32 		$1,090.81
$1,197.29
$1,310.11
$1,710.93 		$1,392.60
$1,499.08
$1,611.90
$2,012.72 		$1,694.39
$1,800.87
$1,913.69
$2,314.51 		$301.79
Toc - Plan #102 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 		$316.80
$359.55
$404.85
$565.78
$859.76 		$559.14
$601.89
$647.19
$808.12 		$801.48
$844.23
$889.53
$1,050.46 		$1,043.82
$1,086.57
$1,131.87
$1,292.80 		$242.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.60
$719.10
$809.70
$1,131.56
$1,719.52 		$875.94
$961.44
$1,052.04
$1,373.90 		$1,118.28
$1,203.78
$1,294.38
$1,616.24 		$1,360.62
$1,446.12
$1,536.72
$1,858.58 		$242.34
Toc - Plan #103 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 		$278.76
$316.38
$356.25
$497.85
$756.53 		$492.01
$529.63
$569.50
$711.10 		$705.26
$742.88
$782.75
$924.35 		$918.51
$956.13
$996.00
$1,137.60 		$213.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.52
$632.76
$712.50
$995.70
$1,513.06 		$770.77
$846.01
$925.75
$1,208.95 		$984.02
$1,059.26
$1,139.00
$1,422.20 		$1,197.27
$1,272.51
$1,352.25
$1,635.45 		$213.25
Toc - Plan #104 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 		$390.49
$443.19
$499.03
$697.39
$1,059.75 		$689.20
$741.90
$797.74
$996.10 		$987.91
$1,040.61
$1,096.45
$1,294.81 		$1,286.62
$1,339.32
$1,395.16
$1,593.52 		$298.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.98
$886.38
$998.06
$1,394.78
$2,119.50 		$1,079.69
$1,185.09
$1,296.77
$1,693.49 		$1,378.40
$1,483.80
$1,595.48
$1,992.20 		$1,677.11
$1,782.51
$1,894.19
$2,290.91 		$298.71
Toc - Plan #105 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 		$399.46
$453.37
$510.49
$713.41
$1,084.10 		$705.04
$758.95
$816.07
$1,018.99 		$1,010.62
$1,064.53
$1,121.65
$1,324.57 		$1,316.20
$1,370.11
$1,427.23
$1,630.15 		$305.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.92
$906.74
$1,020.98
$1,426.82
$2,168.20 		$1,104.50
$1,212.32
$1,326.56
$1,732.40 		$1,410.08
$1,517.90
$1,632.14
$2,037.98 		$1,715.66
$1,823.48
$1,937.72
$2,343.56 		$305.58

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #106 Cigna Healthcare
Bronze

(EPO) Cigna Connect 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$311.43
$353.47
$398.01
$556.22
$845.23 		$549.68
$591.72
$636.26
$794.47 		$787.93
$829.97
$874.51
$1,032.72 		$1,026.18
$1,068.22
$1,112.76
$1,270.97 		$238.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.86
$706.94
$796.02
$1,112.44
$1,690.46 		$861.11
$945.19
$1,034.27
$1,350.69 		$1,099.36
$1,183.44
$1,272.52
$1,588.94 		$1,337.61
$1,421.69
$1,510.77
$1,827.19 		$238.25
Toc - Plan #107 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7300

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$7,300 $14,600 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 		$323.46
$367.13
$413.38
$577.70
$877.87 		$570.91
$614.58
$660.83
$825.15 		$818.36
$862.03
$908.28
$1,072.60 		$1,065.81
$1,109.48
$1,155.73
$1,320.05 		$247.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.92
$734.26
$826.76
$1,155.40
$1,755.74 		$894.37
$981.71
$1,074.21
$1,402.85 		$1,141.82
$1,229.16
$1,321.66
$1,650.30 		$1,389.27
$1,476.61
$1,569.11
$1,897.75 		$247.45
Toc - Plan #108 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 8200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$323.59
$367.27
$413.55
$577.93
$878.22 		$571.14
$614.82
$661.10
$825.48 		$818.69
$862.37
$908.65
$1,073.03 		$1,066.24
$1,109.92
$1,156.20
$1,320.58 		$247.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.18
$734.54
$827.10
$1,155.86
$1,756.44 		$894.73
$982.09
$1,074.65
$1,403.41 		$1,142.28
$1,229.64
$1,322.20
$1,650.96 		$1,389.83
$1,477.19
$1,569.75
$1,898.51 		$247.55
Toc - Plan #109 Cigna Healthcare
Silver

(EPO) Cigna Connect 4400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 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 		$371.79
$421.98
$475.15
$664.02
$1,009.04 		$656.21
$706.40
$759.57
$948.44 		$940.63
$990.82
$1,043.99
$1,232.86 		$1,225.05
$1,275.24
$1,328.41
$1,517.28 		$284.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.58
$843.96
$950.30
$1,328.04
$2,018.08 		$1,028.00
$1,128.38
$1,234.72
$1,612.46 		$1,312.42
$1,412.80
$1,519.14
$1,896.88 		$1,596.84
$1,697.22
$1,803.56
$2,181.30 		$284.42
Toc - Plan #110 Cigna Healthcare
Silver

(EPO) Cigna Connect 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$375.64
$426.36
$480.07
$670.90
$1,019.50 		$663.01
$713.73
$767.44
$958.27 		$950.38
$1,001.10
$1,054.81
$1,245.64 		$1,237.75
$1,288.47
$1,342.18
$1,533.01 		$287.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.28
$852.72
$960.14
$1,341.80
$2,039.00 		$1,038.65
$1,140.09
$1,247.51
$1,629.17 		$1,326.02
$1,427.46
$1,534.88
$1,916.54 		$1,613.39
$1,714.83
$1,822.25
$2,203.91 		$287.37
Toc - Plan #111 Cigna Healthcare
Silver

(EPO) Cigna Connect 8900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$8,900 $17,800 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 		$378.60
$429.71
$483.85
$676.18
$1,027.52 		$668.23
$719.34
$773.48
$965.81 		$957.86
$1,008.97
$1,063.11
$1,255.44 		$1,247.49
$1,298.60
$1,352.74
$1,545.07 		$289.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.20
$859.42
$967.70
$1,352.36
$2,055.04 		$1,046.83
$1,149.05
$1,257.33
$1,641.99 		$1,336.46
$1,438.68
$1,546.96
$1,931.62 		$1,626.09
$1,728.31
$1,836.59
$2,221.25 		$289.63
Toc - Plan #112 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$379.20
$430.39
$484.61
$677.25
$1,029.14 		$669.29
$720.48
$774.70
$967.34 		$959.38
$1,010.57
$1,064.79
$1,257.43 		$1,249.47
$1,300.66
$1,354.88
$1,547.52 		$290.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.40
$860.78
$969.22
$1,354.50
$2,058.28 		$1,048.49
$1,150.87
$1,259.31
$1,644.59 		$1,338.58
$1,440.96
$1,549.40
$1,934.68 		$1,628.67
$1,731.05
$1,839.49
$2,224.77 		$290.09
Toc - Plan #113 Cigna Healthcare
Gold

(EPO) Cigna Connect 1950

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$1,950 $3,900 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$451.33
$512.26
$576.80
$806.07
$1,224.91 		$796.60
$857.53
$922.07
$1,151.34 		$1,141.87
$1,202.80
$1,267.34
$1,496.61 		$1,487.14
$1,548.07
$1,612.61
$1,841.88 		$345.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902.66
$1,024.52
$1,153.60
$1,612.14
$2,449.82 		$1,247.93
$1,369.79
$1,498.87
$1,957.41 		$1,593.20
$1,715.06
$1,844.14
$2,302.68 		$1,938.47
$2,060.33
$2,189.41
$2,647.95 		$345.27
Toc - Plan #114 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 8000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$322.73
$366.30
$412.45
$576.40
$875.90 		$569.62
$613.19
$659.34
$823.29 		$816.51
$860.08
$906.23
$1,070.18 		$1,063.40
$1,106.97
$1,153.12
$1,317.07 		$246.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.46
$732.60
$824.90
$1,152.80
$1,751.80 		$892.35
$979.49
$1,071.79
$1,399.69 		$1,139.24
$1,226.38
$1,318.68
$1,646.58 		$1,386.13
$1,473.27
$1,565.57
$1,893.47 		$246.89
Toc - Plan #115 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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 		$322.52
$366.06
$412.18
$576.02
$875.32 		$569.25
$612.79
$658.91
$822.75 		$815.98
$859.52
$905.64
$1,069.48 		$1,062.71
$1,106.25
$1,152.37
$1,316.21 		$246.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.04
$732.12
$824.36
$1,152.04
$1,750.64 		$891.77
$978.85
$1,071.09
$1,398.77 		$1,138.50
$1,225.58
$1,317.82
$1,645.50 		$1,385.23
$1,472.31
$1,564.55
$1,892.23 		$246.73
Toc - Plan #116 Cigna Healthcare
Silver

(EPO) Cigna Connect 3000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$372.99
$423.34
$476.68
$666.16
$1,012.30 		$658.33
$708.68
$762.02
$951.50 		$943.67
$994.02
$1,047.36
$1,236.84 		$1,229.01
$1,279.36
$1,332.70
$1,522.18 		$285.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.98
$846.68
$953.36
$1,332.32
$2,024.60 		$1,031.32
$1,132.02
$1,238.70
$1,617.66 		$1,316.66
$1,417.36
$1,524.04
$1,903.00 		$1,602.00
$1,702.70
$1,809.38
$2,188.34 		$285.34
Toc - Plan #117 Cigna Healthcare
Silver

(EPO) Cigna Connect 0B

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$389.26
$441.81
$497.47
$695.21
$1,056.44 		$687.04
$739.59
$795.25
$992.99 		$984.82
$1,037.37
$1,093.03
$1,290.77 		$1,282.60
$1,335.15
$1,390.81
$1,588.55 		$297.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.52
$883.62
$994.94
$1,390.42
$2,112.88 		$1,076.30
$1,181.40
$1,292.72
$1,688.20 		$1,374.08
$1,479.18
$1,590.50
$1,985.98 		$1,671.86
$1,776.96
$1,888.28
$2,283.76 		$297.78
Toc - Plan #118 Cigna Healthcare
Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 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 		$376.29
$427.09
$480.89
$672.05
$1,021.24 		$664.15
$714.95
$768.75
$959.91 		$952.01
$1,002.81
$1,056.61
$1,247.77 		$1,239.87
$1,290.67
$1,344.47
$1,535.63 		$287.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.58
$854.18
$961.78
$1,344.10
$2,042.48 		$1,040.44
$1,142.04
$1,249.64
$1,631.96 		$1,328.30
$1,429.90
$1,537.50
$1,919.82 		$1,616.16
$1,717.76
$1,825.36
$2,207.68 		$287.86
Toc - Plan #119 Cigna Healthcare
Gold

(EPO) Cigna Connect 900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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 		$469.14
$532.47
$599.56
$837.88
$1,273.24 		$828.03
$891.36
$958.45
$1,196.77 		$1,186.92
$1,250.25
$1,317.34
$1,555.66 		$1,545.81
$1,609.14
$1,676.23
$1,914.55 		$358.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$938.28
$1,064.94
$1,199.12
$1,675.76
$2,546.48 		$1,297.17
$1,423.83
$1,558.01
$2,034.65 		$1,656.06
$1,782.72
$1,916.90
$2,393.54 		$2,014.95
$2,141.61
$2,275.79
$2,752.43 		$358.89
Toc - Plan #120 Cigna Healthcare
Gold

(EPO) Cigna Connect 1900 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 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 		$454.03
$515.32
$580.25
$810.89
$1,232.23 		$801.36
$862.65
$927.58
$1,158.22 		$1,148.69
$1,209.98
$1,274.91
$1,505.55 		$1,496.02
$1,557.31
$1,622.24
$1,852.88 		$347.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.06
$1,030.64
$1,160.50
$1,621.78
$2,464.46 		$1,255.39
$1,377.97
$1,507.83
$1,969.11 		$1,602.72
$1,725.30
$1,855.16
$2,316.44 		$1,950.05
$2,072.63
$2,202.49
$2,663.77 		$347.33
Toc - Plan #121 Cigna Healthcare
Gold

(EPO) Cigna Simple Choice 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$451.93
$512.94
$577.57
$807.15
$1,226.54 		$797.66
$858.67
$923.30
$1,152.88 		$1,143.39
$1,204.40
$1,269.03
$1,498.61 		$1,489.12
$1,550.13
$1,614.76
$1,844.34 		$345.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.86
$1,025.88
$1,155.14
$1,614.30
$2,453.08 		$1,249.59
$1,371.61
$1,500.87
$1,960.03 		$1,595.32
$1,717.34
$1,846.60
$2,305.76 		$1,941.05
$2,063.07
$2,192.33
$2,651.49 		$345.73
Toc - Plan #122 Cigna Healthcare
Silver

(EPO) Cigna Simple Choice 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$372.18
$422.42
$475.64
$664.71
$1,010.09 		$656.90
$707.14
$760.36
$949.43 		$941.62
$991.86
$1,045.08
$1,234.15 		$1,226.34
$1,276.58
$1,329.80
$1,518.87 		$284.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.36
$844.84
$951.28
$1,329.42
$2,020.18 		$1,029.08
$1,129.56
$1,236.00
$1,614.14 		$1,313.80
$1,414.28
$1,520.72
$1,898.86 		$1,598.52
$1,699.00
$1,805.44
$2,183.58 		$284.72
Toc - Plan #123 Cigna Healthcare
Bronze

(EPO) Cigna Simple Choice 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$308.43
$350.07
$394.18
$550.86
$837.09 		$544.38
$586.02
$630.13
$786.81 		$780.33
$821.97
$866.08
$1,022.76 		$1,016.28
$1,057.92
$1,102.03
$1,258.71 		$235.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.86
$700.14
$788.36
$1,101.72
$1,674.18 		$852.81
$936.09
$1,024.31
$1,337.67 		$1,088.76
$1,172.04
$1,260.26
$1,573.62 		$1,324.71
$1,407.99
$1,496.21
$1,809.57 		$235.95
Toc - Plan #124 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Simple Choice 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$321.41
$364.80
$410.76
$574.03
$872.30 		$567.29
$610.68
$656.64
$819.91 		$813.17
$856.56
$902.52
$1,065.79 		$1,059.05
$1,102.44
$1,148.40
$1,311.67 		$245.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.82
$729.60
$821.52
$1,148.06
$1,744.60 		$888.70
$975.48
$1,067.40
$1,393.94 		$1,134.58
$1,221.36
$1,313.28
$1,639.82 		$1,380.46
$1,467.24
$1,559.16
$1,885.70 		$245.88
Toc - Plan #125 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 0A

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$346.32
$393.07
$442.60
$618.53
$939.91 		$611.26
$658.01
$707.54
$883.47 		$876.20
$922.95
$972.48
$1,148.41 		$1,141.14
$1,187.89
$1,237.42
$1,413.35 		$264.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.64
$786.14
$885.20
$1,237.06
$1,879.82 		$957.58
$1,051.08
$1,150.14
$1,502.00 		$1,222.52
$1,316.02
$1,415.08
$1,766.94 		$1,487.46
$1,580.96
$1,680.02
$2,031.88 		$264.94
Toc - Plan #126 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7600 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 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 		$322.43
$365.96
$412.07
$575.87
$875.08 		$569.09
$612.62
$658.73
$822.53 		$815.75
$859.28
$905.39
$1,069.19 		$1,062.41
$1,105.94
$1,152.05
$1,315.85 		$246.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.86
$731.92
$824.14
$1,151.74
$1,750.16 		$891.52
$978.58
$1,070.80
$1,398.40 		$1,138.18
$1,225.24
$1,317.46
$1,645.06 		$1,384.84
$1,471.90
$1,564.12
$1,891.72 		$246.66
Toc - Plan #127 Cigna Healthcare
Gold

(EPO) Cigna Connect 2100 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$451.37
$512.31
$576.85
$806.15
$1,225.02 		$796.67
$857.61
$922.15
$1,151.45 		$1,141.97
$1,202.91
$1,267.45
$1,496.75 		$1,487.27
$1,548.21
$1,612.75
$1,842.05 		$345.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902.74
$1,024.62
$1,153.70
$1,612.30
$2,450.04 		$1,248.04
$1,369.92
$1,499.00
$1,957.60 		$1,593.34
$1,715.22
$1,844.30
$2,302.90 		$1,938.64
$2,060.52
$2,189.60
$2,648.20 		$345.30
Toc - Plan #128 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 5400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 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 		$328.55
$372.91
$419.89
$586.80
$891.70 		$579.89
$624.25
$671.23
$838.14 		$831.23
$875.59
$922.57
$1,089.48 		$1,082.57
$1,126.93
$1,173.91
$1,340.82 		$251.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.10
$745.82
$839.78
$1,173.60
$1,783.40 		$908.44
$997.16
$1,091.12
$1,424.94 		$1,159.78
$1,248.50
$1,342.46
$1,676.28 		$1,411.12
$1,499.84
$1,593.80
$1,927.62 		$251.34
Toc - Plan #129 Cigna Healthcare
Silver

(EPO) Cigna Connect 3800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$375.82
$426.55
$480.29
$671.21
$1,019.96 		$663.32
$714.05
$767.79
$958.71 		$950.82
$1,001.55
$1,055.29
$1,246.21 		$1,238.32
$1,289.05
$1,342.79
$1,533.71 		$287.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.64
$853.10
$960.58
$1,342.42
$2,039.92 		$1,039.14
$1,140.60
$1,248.08
$1,629.92 		$1,326.64
$1,428.10
$1,535.58
$1,917.42 		$1,614.14
$1,715.60
$1,823.08
$2,204.92 		$287.50

‡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 Martin County here.

Martin County is in “Rating Area 42” of Florida.

Currently, there are 129 plans offered in Rating Area 42.

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2023 Obamacare Plans for Martin County, FL

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