Obamacare 2023 Rates for Polk County

Obamacare > Rates > Florida > Polk 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 Polk 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, 125 Plans and 2023 Rates for Polk County, Florida

Below, you’ll find a summary of the 125 plans for Polk 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 |

Polk 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 		$763.02
$866.03
$975.14
$1,362.75
$2,070.84 		$1,346.73
$1,449.74
$1,558.85
$1,946.46 		$1,930.44
$2,033.45
$2,142.56
$2,530.17 		$2,514.15
$2,617.16
$2,726.27
$3,113.88 		$583.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,526.04
$1,732.06
$1,950.28
$2,725.50
$4,141.68 		$2,109.75
$2,315.77
$2,533.99
$3,309.21 		$2,693.46
$2,899.48
$3,117.70
$3,892.92 		$3,277.17
$3,483.19
$3,701.41
$4,476.63 		$583.71
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 		$493.65
$560.29
$630.88
$881.66
$1,339.77 		$871.29
$937.93
$1,008.52
$1,259.30 		$1,248.93
$1,315.57
$1,386.16
$1,636.94 		$1,626.57
$1,693.21
$1,763.80
$2,014.58 		$377.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$987.30
$1,120.58
$1,261.76
$1,763.32
$2,679.54 		$1,364.94
$1,498.22
$1,639.40
$2,140.96 		$1,742.58
$1,875.86
$2,017.04
$2,518.60 		$2,120.22
$2,253.50
$2,394.68
$2,896.24 		$377.64
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 		$767.21
$870.78
$980.49
$1,370.24
$2,082.21 		$1,354.13
$1,457.70
$1,567.41
$1,957.16 		$1,941.05
$2,044.62
$2,154.33
$2,544.08 		$2,527.97
$2,631.54
$2,741.25
$3,131.00 		$586.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,534.42
$1,741.56
$1,960.98
$2,740.48
$4,164.42 		$2,121.34
$2,328.48
$2,547.90
$3,327.40 		$2,708.26
$2,915.40
$3,134.82
$3,914.32 		$3,295.18
$3,502.32
$3,721.74
$4,501.24 		$586.92
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 		$965.48
$1,095.82
$1,233.88
$1,724.35
$2,620.31 		$1,704.07
$1,834.41
$1,972.47
$2,462.94 		$2,442.66
$2,573.00
$2,711.06
$3,201.53 		$3,181.25
$3,311.59
$3,449.65
$3,940.12 		$738.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,930.96
$2,191.64
$2,467.76
$3,448.70
$5,240.62 		$2,669.55
$2,930.23
$3,206.35
$4,187.29 		$3,408.14
$3,668.82
$3,944.94
$4,925.88 		$4,146.73
$4,407.41
$4,683.53
$5,664.47 		$738.59
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 		$514.20
$583.62
$657.15
$918.36
$1,395.54 		$907.56
$976.98
$1,050.51
$1,311.72 		$1,300.92
$1,370.34
$1,443.87
$1,705.08 		$1,694.28
$1,763.70
$1,837.23
$2,098.44 		$393.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,028.40
$1,167.24
$1,314.30
$1,836.72
$2,791.08 		$1,421.76
$1,560.60
$1,707.66
$2,230.08 		$1,815.12
$1,953.96
$2,101.02
$2,623.44 		$2,208.48
$2,347.32
$2,494.38
$3,016.80 		$393.36
Toc - Plan #6 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$1,011.65
$1,148.22
$1,292.89
$1,806.81
$2,745.62 		$1,785.56
$1,922.13
$2,066.80
$2,580.72 		$2,559.47
$2,696.04
$2,840.71
$3,354.63 		$3,333.38
$3,469.95
$3,614.62
$4,128.54 		$773.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,023.30
$2,296.44
$2,585.78
$3,613.62
$5,491.24 		$2,797.21
$3,070.35
$3,359.69
$4,387.53 		$3,571.12
$3,844.26
$4,133.60
$5,161.44 		$4,345.03
$4,618.17
$4,907.51
$5,935.35 		$773.91
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 		$716.21
$812.90
$915.32
$1,279.15
$1,943.79 		$1,264.11
$1,360.80
$1,463.22
$1,827.05 		$1,812.01
$1,908.70
$2,011.12
$2,374.95 		$2,359.91
$2,456.60
$2,559.02
$2,922.85 		$547.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,432.42
$1,625.80
$1,830.64
$2,558.30
$3,887.58 		$1,980.32
$2,173.70
$2,378.54
$3,106.20 		$2,528.22
$2,721.60
$2,926.44
$3,654.10 		$3,076.12
$3,269.50
$3,474.34
$4,202.00 		$547.90
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 		$829.17
$941.11
$1,059.68
$1,480.90
$2,250.37 		$1,463.49
$1,575.43
$1,694.00
$2,115.22 		$2,097.81
$2,209.75
$2,328.32
$2,749.54 		$2,732.13
$2,844.07
$2,962.64
$3,383.86 		$634.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,658.34
$1,882.22
$2,119.36
$2,961.80
$4,500.74 		$2,292.66
$2,516.54
$2,753.68
$3,596.12 		$2,926.98
$3,150.86
$3,388.00
$4,230.44 		$3,561.30
$3,785.18
$4,022.32
$4,864.76 		$634.32
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 		$499.87
$567.35
$638.83
$892.77
$1,356.65 		$882.27
$949.75
$1,021.23
$1,275.17 		$1,264.67
$1,332.15
$1,403.63
$1,657.57 		$1,647.07
$1,714.55
$1,786.03
$2,039.97 		$382.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$999.74
$1,134.70
$1,277.66
$1,785.54
$2,713.30 		$1,382.14
$1,517.10
$1,660.06
$2,167.94 		$1,764.54
$1,899.50
$2,042.46
$2,550.34 		$2,146.94
$2,281.90
$2,424.86
$2,932.74 		$382.40
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 		$802.21
$910.51
$1,025.22
$1,432.75
$2,177.20 		$1,415.90
$1,524.20
$1,638.91
$2,046.44 		$2,029.59
$2,137.89
$2,252.60
$2,660.13 		$2,643.28
$2,751.58
$2,866.29
$3,273.82 		$613.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,604.42
$1,821.02
$2,050.44
$2,865.50
$4,354.40 		$2,218.11
$2,434.71
$2,664.13
$3,479.19 		$2,831.80
$3,048.40
$3,277.82
$4,092.88 		$3,445.49
$3,662.09
$3,891.51
$4,706.57 		$613.69
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 		$544.57
$618.09
$695.96
$972.60
$1,477.96 		$961.17
$1,034.69
$1,112.56
$1,389.20 		$1,377.77
$1,451.29
$1,529.16
$1,805.80 		$1,794.37
$1,867.89
$1,945.76
$2,222.40 		$416.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,089.14
$1,236.18
$1,391.92
$1,945.20
$2,955.92 		$1,505.74
$1,652.78
$1,808.52
$2,361.80 		$1,922.34
$2,069.38
$2,225.12
$2,778.40 		$2,338.94
$2,485.98
$2,641.72
$3,195.00 		$416.60
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 		$471.83
$535.53
$603.00
$842.69
$1,280.55 		$832.78
$896.48
$963.95
$1,203.64 		$1,193.73
$1,257.43
$1,324.90
$1,564.59 		$1,554.68
$1,618.38
$1,685.85
$1,925.54 		$360.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$943.66
$1,071.06
$1,206.00
$1,685.38
$2,561.10 		$1,304.61
$1,432.01
$1,566.95
$2,046.33 		$1,665.56
$1,792.96
$1,927.90
$2,407.28 		$2,026.51
$2,153.91
$2,288.85
$2,768.23 		$360.95
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 		$507.22
$575.69
$648.23
$905.89
$1,376.60 		$895.24
$963.71
$1,036.25
$1,293.91 		$1,283.26
$1,351.73
$1,424.27
$1,681.93 		$1,671.28
$1,739.75
$1,812.29
$2,069.95 		$388.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,014.44
$1,151.38
$1,296.46
$1,811.78
$2,753.20 		$1,402.46
$1,539.40
$1,684.48
$2,199.80 		$1,790.48
$1,927.42
$2,072.50
$2,587.82 		$2,178.50
$2,315.44
$2,460.52
$2,975.84 		$388.02
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 		$755.22
$857.17
$965.17
$1,348.82
$2,049.67 		$1,332.96
$1,434.91
$1,542.91
$1,926.56 		$1,910.70
$2,012.65
$2,120.65
$2,504.30 		$2,488.44
$2,590.39
$2,698.39
$3,082.04 		$577.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,510.44
$1,714.34
$1,930.34
$2,697.64
$4,099.34 		$2,088.18
$2,292.08
$2,508.08
$3,275.38 		$2,665.92
$2,869.82
$3,085.82
$3,853.12 		$3,243.66
$3,447.56
$3,663.56
$4,430.86 		$577.74
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 		$770.82
$874.88
$985.11
$1,376.68
$2,092.01 		$1,360.50
$1,464.56
$1,574.79
$1,966.36 		$1,950.18
$2,054.24
$2,164.47
$2,556.04 		$2,539.86
$2,643.92
$2,754.15
$3,145.72 		$589.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,541.64
$1,749.76
$1,970.22
$2,753.36
$4,184.02 		$2,131.32
$2,339.44
$2,559.90
$3,343.04 		$2,721.00
$2,929.12
$3,149.58
$3,932.72 		$3,310.68
$3,518.80
$3,739.26
$4,522.40 		$589.68
Toc - Plan #16 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$1,009.11
$1,145.34
$1,289.64
$1,802.27
$2,738.72 		$1,781.08
$1,917.31
$2,061.61
$2,574.24 		$2,553.05
$2,689.28
$2,833.58
$3,346.21 		$3,325.02
$3,461.25
$3,605.55
$4,118.18 		$771.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,018.22
$2,290.68
$2,579.28
$3,604.54
$5,477.44 		$2,790.19
$3,062.65
$3,351.25
$4,376.51 		$3,562.16
$3,834.62
$4,123.22
$5,148.48 		$4,334.13
$4,606.59
$4,895.19
$5,920.45 		$771.97
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 		$533.86
$605.93
$682.27
$953.47
$1,448.90 		$942.26
$1,014.33
$1,090.67
$1,361.87 		$1,350.66
$1,422.73
$1,499.07
$1,770.27 		$1,759.06
$1,831.13
$1,907.47
$2,178.67 		$408.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,067.72
$1,211.86
$1,364.54
$1,906.94
$2,897.80 		$1,476.12
$1,620.26
$1,772.94
$2,315.34 		$1,884.52
$2,028.66
$2,181.34
$2,723.74 		$2,292.92
$2,437.06
$2,589.74
$3,132.14 		$408.40
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 		$498.94
$566.30
$637.65
$891.11
$1,354.12 		$880.63
$947.99
$1,019.34
$1,272.80 		$1,262.32
$1,329.68
$1,401.03
$1,654.49 		$1,644.01
$1,711.37
$1,782.72
$2,036.18 		$381.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$997.88
$1,132.60
$1,275.30
$1,782.22
$2,708.24 		$1,379.57
$1,514.29
$1,656.99
$2,163.91 		$1,761.26
$1,895.98
$2,038.68
$2,545.60 		$2,142.95
$2,277.67
$2,420.37
$2,927.29 		$381.69
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 		$375.67
$426.39
$480.11
$670.95
$1,019.57 		$663.06
$713.78
$767.50
$958.34 		$950.45
$1,001.17
$1,054.89
$1,245.73 		$1,237.84
$1,288.56
$1,342.28
$1,533.12 		$287.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.34
$852.78
$960.22
$1,341.90
$2,039.14 		$1,038.73
$1,140.17
$1,247.61
$1,629.29 		$1,326.12
$1,427.56
$1,535.00
$1,916.68 		$1,613.51
$1,714.95
$1,822.39
$2,204.07 		$287.39
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 		$497.39
$564.54
$635.66
$888.34
$1,349.92 		$877.89
$945.04
$1,016.16
$1,268.84 		$1,258.39
$1,325.54
$1,396.66
$1,649.34 		$1,638.89
$1,706.04
$1,777.16
$2,029.84 		$380.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$994.78
$1,129.08
$1,271.32
$1,776.68
$2,699.84 		$1,375.28
$1,509.58
$1,651.82
$2,157.18 		$1,755.78
$1,890.08
$2,032.32
$2,537.68 		$2,136.28
$2,270.58
$2,412.82
$2,918.18 		$380.50
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 		$631.13
$716.33
$806.58
$1,127.20
$1,712.89 		$1,113.94
$1,199.14
$1,289.39
$1,610.01 		$1,596.75
$1,681.95
$1,772.20
$2,092.82 		$2,079.56
$2,164.76
$2,255.01
$2,575.63 		$482.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,262.26
$1,432.66
$1,613.16
$2,254.40
$3,425.78 		$1,745.07
$1,915.47
$2,095.97
$2,737.21 		$2,227.88
$2,398.28
$2,578.78
$3,220.02 		$2,710.69
$2,881.09
$3,061.59
$3,702.83 		$482.81
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 		$388.06
$440.45
$495.94
$693.08
$1,053.19 		$684.93
$737.32
$792.81
$989.95 		$981.80
$1,034.19
$1,089.68
$1,286.82 		$1,278.67
$1,331.06
$1,386.55
$1,583.69 		$296.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.12
$880.90
$991.88
$1,386.16
$2,106.38 		$1,072.99
$1,177.77
$1,288.75
$1,683.03 		$1,369.86
$1,474.64
$1,585.62
$1,979.90 		$1,666.73
$1,771.51
$1,882.49
$2,276.77 		$296.87
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 		$660.47
$749.63
$844.08
$1,179.60
$1,792.52 		$1,165.73
$1,254.89
$1,349.34
$1,684.86 		$1,670.99
$1,760.15
$1,854.60
$2,190.12 		$2,176.25
$2,265.41
$2,359.86
$2,695.38 		$505.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,320.94
$1,499.26
$1,688.16
$2,359.20
$3,585.04 		$1,826.20
$2,004.52
$2,193.42
$2,864.46 		$2,331.46
$2,509.78
$2,698.68
$3,369.72 		$2,836.72
$3,015.04
$3,203.94
$3,874.98 		$505.26
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 		$466.91
$529.94
$596.71
$833.90
$1,267.19 		$824.10
$887.13
$953.90
$1,191.09 		$1,181.29
$1,244.32
$1,311.09
$1,548.28 		$1,538.48
$1,601.51
$1,668.28
$1,905.47 		$357.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$933.82
$1,059.88
$1,193.42
$1,667.80
$2,534.38 		$1,291.01
$1,417.07
$1,550.61
$2,024.99 		$1,648.20
$1,774.26
$1,907.80
$2,382.18 		$2,005.39
$2,131.45
$2,264.99
$2,739.37 		$357.19
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 		$550.92
$625.29
$704.08
$983.94
$1,495.20 		$972.37
$1,046.74
$1,125.53
$1,405.39 		$1,393.82
$1,468.19
$1,546.98
$1,826.84 		$1,815.27
$1,889.64
$1,968.43
$2,248.29 		$421.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,101.84
$1,250.58
$1,408.16
$1,967.88
$2,990.40 		$1,523.29
$1,672.03
$1,829.61
$2,389.33 		$1,944.74
$2,093.48
$2,251.06
$2,810.78 		$2,366.19
$2,514.93
$2,672.51
$3,232.23 		$421.45
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 		$379.72
$430.98
$485.28
$678.18
$1,030.56 		$670.21
$721.47
$775.77
$968.67 		$960.70
$1,011.96
$1,066.26
$1,259.16 		$1,251.19
$1,302.45
$1,356.75
$1,549.65 		$290.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$759.44
$861.96
$970.56
$1,356.36
$2,061.12 		$1,049.93
$1,152.45
$1,261.05
$1,646.85 		$1,340.42
$1,442.94
$1,551.54
$1,937.34 		$1,630.91
$1,733.43
$1,842.03
$2,227.83 		$290.49
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 		$532.96
$604.91
$681.12
$951.87
$1,446.45 		$940.67
$1,012.62
$1,088.83
$1,359.58 		$1,348.38
$1,420.33
$1,496.54
$1,767.29 		$1,756.09
$1,828.04
$1,904.25
$2,175.00 		$407.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,065.92
$1,209.82
$1,362.24
$1,903.74
$2,892.90 		$1,473.63
$1,617.53
$1,769.95
$2,311.45 		$1,881.34
$2,025.24
$2,177.66
$2,719.16 		$2,289.05
$2,432.95
$2,585.37
$3,126.87 		$407.71
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 		$411.16
$466.67
$525.46
$734.33
$1,115.89 		$725.70
$781.21
$840.00
$1,048.87 		$1,040.24
$1,095.75
$1,154.54
$1,363.41 		$1,354.78
$1,410.29
$1,469.08
$1,677.95 		$314.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.32
$933.34
$1,050.92
$1,468.66
$2,231.78 		$1,136.86
$1,247.88
$1,365.46
$1,783.20 		$1,451.40
$1,562.42
$1,680.00
$2,097.74 		$1,765.94
$1,876.96
$1,994.54
$2,412.28 		$314.54
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 		$356.36
$404.47
$455.43
$636.46
$967.16 		$628.98
$677.09
$728.05
$909.08 		$901.60
$949.71
$1,000.67
$1,181.70 		$1,174.22
$1,222.33
$1,273.29
$1,454.32 		$272.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.72
$808.94
$910.86
$1,272.92
$1,934.32 		$985.34
$1,081.56
$1,183.48
$1,545.54 		$1,257.96
$1,354.18
$1,456.10
$1,818.16 		$1,530.58
$1,626.80
$1,728.72
$2,090.78 		$272.62
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 		$383.14
$434.86
$489.65
$684.29
$1,039.84 		$676.24
$727.96
$782.75
$977.39 		$969.34
$1,021.06
$1,075.85
$1,270.49 		$1,262.44
$1,314.16
$1,368.95
$1,563.59 		$293.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.28
$869.72
$979.30
$1,368.58
$2,079.68 		$1,059.38
$1,162.82
$1,272.40
$1,661.68 		$1,352.48
$1,455.92
$1,565.50
$1,954.78 		$1,645.58
$1,749.02
$1,858.60
$2,247.88 		$293.10
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 		$492.38
$558.85
$629.26
$879.39
$1,336.32 		$869.05
$935.52
$1,005.93
$1,256.06 		$1,245.72
$1,312.19
$1,382.60
$1,632.73 		$1,622.39
$1,688.86
$1,759.27
$2,009.40 		$376.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$984.76
$1,117.70
$1,258.52
$1,758.78
$2,672.64 		$1,361.43
$1,494.37
$1,635.19
$2,135.45 		$1,738.10
$1,871.04
$2,011.86
$2,512.12 		$2,114.77
$2,247.71
$2,388.53
$2,888.79 		$376.67
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 		$512.20
$581.35
$654.59
$914.79
$1,390.11 		$904.03
$973.18
$1,046.42
$1,306.62 		$1,295.86
$1,365.01
$1,438.25
$1,698.45 		$1,687.69
$1,756.84
$1,830.08
$2,090.28 		$391.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,024.40
$1,162.70
$1,309.18
$1,829.58
$2,780.22 		$1,416.23
$1,554.53
$1,701.01
$2,221.41 		$1,808.06
$1,946.36
$2,092.84
$2,613.24 		$2,199.89
$2,338.19
$2,484.67
$3,005.07 		$391.83
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 		$658.78
$747.72
$841.92
$1,176.58
$1,787.93 		$1,162.75
$1,251.69
$1,345.89
$1,680.55 		$1,666.72
$1,755.66
$1,849.86
$2,184.52 		$2,170.69
$2,259.63
$2,353.83
$2,688.49 		$503.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,317.56
$1,495.44
$1,683.84
$2,353.16
$3,575.86 		$1,821.53
$1,999.41
$2,187.81
$2,857.13 		$2,325.50
$2,503.38
$2,691.78
$3,361.10 		$2,829.47
$3,007.35
$3,195.75
$3,865.07 		$503.97
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 		$403.23
$457.67
$515.33
$720.17
$1,094.37 		$711.70
$766.14
$823.80
$1,028.64 		$1,020.17
$1,074.61
$1,132.27
$1,337.11 		$1,328.64
$1,383.08
$1,440.74
$1,645.58 		$308.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.46
$915.34
$1,030.66
$1,440.34
$2,188.74 		$1,114.93
$1,223.81
$1,339.13
$1,748.81 		$1,423.40
$1,532.28
$1,647.60
$2,057.28 		$1,731.87
$1,840.75
$1,956.07
$2,365.75 		$308.47

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #35 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382.62
$434.26
$488.97
$683.33
$1,038.39 		$675.31
$726.95
$781.66
$976.02 		$968.00
$1,019.64
$1,074.35
$1,268.71 		$1,260.69
$1,312.33
$1,367.04
$1,561.40 		$292.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.24
$868.52
$977.94
$1,366.66
$2,076.78 		$1,057.93
$1,161.21
$1,270.63
$1,659.35 		$1,350.62
$1,453.90
$1,563.32
$1,952.04 		$1,643.31
$1,746.59
$1,856.01
$2,244.73 		$292.69
Toc - Plan #36 Ambetter from Sunshine Health
Bronze

(EPO) Clear Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$285.29
$323.79
$364.59
$509.51
$774.25 		$503.53
$542.03
$582.83
$727.75 		$721.77
$760.27
$801.07
$945.99 		$940.01
$978.51
$1,019.31
$1,164.23 		$218.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.58
$647.58
$729.18
$1,019.02
$1,548.50 		$788.82
$865.82
$947.42
$1,237.26 		$1,007.06
$1,084.06
$1,165.66
$1,455.50 		$1,225.30
$1,302.30
$1,383.90
$1,673.74 		$218.24
Toc - Plan #37 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$314.19
$356.59
$401.52
$561.12
$852.67 		$554.53
$596.93
$641.86
$801.46 		$794.87
$837.27
$882.20
$1,041.80 		$1,035.21
$1,077.61
$1,122.54
$1,282.14 		$240.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.38
$713.18
$803.04
$1,122.24
$1,705.34 		$868.72
$953.52
$1,043.38
$1,362.58 		$1,109.06
$1,193.86
$1,283.72
$1,602.92 		$1,349.40
$1,434.20
$1,524.06
$1,843.26 		$240.34
Toc - Plan #38 Ambetter from Sunshine Health
Silver

(EPO) Everyday Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$386.70
$438.89
$494.19
$690.63
$1,049.48 		$682.52
$734.71
$790.01
$986.45 		$978.34
$1,030.53
$1,085.83
$1,282.27 		$1,274.16
$1,326.35
$1,381.65
$1,578.09 		$295.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.40
$877.78
$988.38
$1,381.26
$2,098.96 		$1,069.22
$1,173.60
$1,284.20
$1,677.08 		$1,365.04
$1,469.42
$1,580.02
$1,972.90 		$1,660.86
$1,765.24
$1,875.84
$2,268.72 		$295.82
Toc - Plan #39 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$306.75
$348.15
$392.01
$547.84
$832.49 		$541.41
$582.81
$626.67
$782.50 		$776.07
$817.47
$861.33
$1,017.16 		$1,010.73
$1,052.13
$1,095.99
$1,251.82 		$234.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.50
$696.30
$784.02
$1,095.68
$1,664.98 		$848.16
$930.96
$1,018.68
$1,330.34 		$1,082.82
$1,165.62
$1,253.34
$1,565.00 		$1,317.48
$1,400.28
$1,488.00
$1,799.66 		$234.66
Toc - Plan #40 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$351.56
$399.01
$449.28
$627.87
$954.11 		$620.50
$667.95
$718.22
$896.81 		$889.44
$936.89
$987.16
$1,165.75 		$1,158.38
$1,205.83
$1,256.10
$1,434.69 		$268.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$703.12
$798.02
$898.56
$1,255.74
$1,908.22 		$972.06
$1,066.96
$1,167.50
$1,524.68 		$1,241.00
$1,335.90
$1,436.44
$1,793.62 		$1,509.94
$1,604.84
$1,705.38
$2,062.56 		$268.94
Toc - Plan #41 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382.08
$433.65
$488.28
$682.37
$1,036.93 		$674.36
$725.93
$780.56
$974.65 		$966.64
$1,018.21
$1,072.84
$1,266.93 		$1,258.92
$1,310.49
$1,365.12
$1,559.21 		$292.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.16
$867.30
$976.56
$1,364.74
$2,073.86 		$1,056.44
$1,159.58
$1,268.84
$1,657.02 		$1,348.72
$1,451.86
$1,561.12
$1,949.30 		$1,641.00
$1,744.14
$1,853.40
$2,241.58 		$292.28
Toc - Plan #42 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$385.31
$437.32
$492.42
$688.15
$1,045.71 		$680.07
$732.08
$787.18
$982.91 		$974.83
$1,026.84
$1,081.94
$1,277.67 		$1,269.59
$1,321.60
$1,376.70
$1,572.43 		$294.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.62
$874.64
$984.84
$1,376.30
$2,091.42 		$1,065.38
$1,169.40
$1,279.60
$1,671.06 		$1,360.14
$1,464.16
$1,574.36
$1,965.82 		$1,654.90
$1,758.92
$1,869.12
$2,260.58 		$294.76
Toc - Plan #43 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$365.12
$414.40
$466.62
$652.09
$990.92 		$644.43
$693.71
$745.93
$931.40 		$923.74
$973.02
$1,025.24
$1,210.71 		$1,203.05
$1,252.33
$1,304.55
$1,490.02 		$279.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.24
$828.80
$933.24
$1,304.18
$1,981.84 		$1,009.55
$1,108.11
$1,212.55
$1,583.49 		$1,288.86
$1,387.42
$1,491.86
$1,862.80 		$1,568.17
$1,666.73
$1,771.17
$2,142.11 		$279.31
Toc - Plan #44 Ambetter from Sunshine Health
Silver

(EPO) Enhanced Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$387.59
$439.90
$495.32
$692.21
$1,051.88 		$684.09
$736.40
$791.82
$988.71 		$980.59
$1,032.90
$1,088.32
$1,285.21 		$1,277.09
$1,329.40
$1,384.82
$1,581.71 		$296.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.18
$879.80
$990.64
$1,384.42
$2,103.76 		$1,071.68
$1,176.30
$1,287.14
$1,680.92 		$1,368.18
$1,472.80
$1,583.64
$1,977.42 		$1,664.68
$1,769.30
$1,880.14
$2,273.92 		$296.50
Toc - Plan #45 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$424.85
$482.19
$542.94
$758.76
$1,153.00 		$749.85
$807.19
$867.94
$1,083.76 		$1,074.85
$1,132.19
$1,192.94
$1,408.76 		$1,399.85
$1,457.19
$1,517.94
$1,733.76 		$325.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.70
$964.38
$1,085.88
$1,517.52
$2,306.00 		$1,174.70
$1,289.38
$1,410.88
$1,842.52 		$1,499.70
$1,614.38
$1,735.88
$2,167.52 		$1,824.70
$1,939.38
$2,060.88
$2,492.52 		$325.00
Toc - Plan #46 Ambetter from Sunshine Health
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301.01
$341.63
$384.68
$537.58
$816.91 		$531.27
$571.89
$614.94
$767.84 		$761.53
$802.15
$845.20
$998.10 		$991.79
$1,032.41
$1,075.46
$1,228.36 		$230.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.02
$683.26
$769.36
$1,075.16
$1,633.82 		$832.28
$913.52
$999.62
$1,305.42 		$1,062.54
$1,143.78
$1,229.88
$1,535.68 		$1,292.80
$1,374.04
$1,460.14
$1,765.94 		$230.26
Toc - Plan #47 Ambetter from Sunshine Health
Silver

(EPO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$381.85
$433.38
$487.99
$681.96
$1,036.30 		$673.95
$725.48
$780.09
$974.06 		$966.05
$1,017.58
$1,072.19
$1,266.16 		$1,258.15
$1,309.68
$1,364.29
$1,558.26 		$292.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.70
$866.76
$975.98
$1,363.92
$2,072.60 		$1,055.80
$1,158.86
$1,268.08
$1,656.02 		$1,347.90
$1,450.96
$1,560.18
$1,948.12 		$1,640.00
$1,743.06
$1,852.28
$2,240.22 		$292.10
Toc - Plan #48 Ambetter from Sunshine Health
Gold

(EPO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$357.57
$405.83
$456.96
$638.61
$970.42 		$631.10
$679.36
$730.49
$912.14 		$904.63
$952.89
$1,004.02
$1,185.67 		$1,178.16
$1,226.42
$1,277.55
$1,459.20 		$273.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.14
$811.66
$913.92
$1,277.22
$1,940.84 		$988.67
$1,085.19
$1,187.45
$1,550.75 		$1,262.20
$1,358.72
$1,460.98
$1,824.28 		$1,535.73
$1,632.25
$1,734.51
$2,097.81 		$273.53
Toc - Plan #49 Ambetter from Sunshine Health
Silver

(EPO) Everyday Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.04
$455.17
$512.52
$716.25
$1,088.41 		$707.83
$761.96
$819.31
$1,023.04 		$1,014.62
$1,068.75
$1,126.10
$1,329.83 		$1,321.41
$1,375.54
$1,432.89
$1,636.62 		$306.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.08
$910.34
$1,025.04
$1,432.50
$2,176.82 		$1,108.87
$1,217.13
$1,331.83
$1,739.29 		$1,415.66
$1,523.92
$1,638.62
$2,046.08 		$1,722.45
$1,830.71
$1,945.41
$2,352.87 		$306.79
Toc - Plan #50 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.84
$369.82
$416.41
$581.93
$884.30 		$575.10
$619.08
$665.67
$831.19 		$824.36
$868.34
$914.93
$1,080.45 		$1,073.62
$1,117.60
$1,164.19
$1,329.71 		$249.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.68
$739.64
$832.82
$1,163.86
$1,768.60 		$900.94
$988.90
$1,082.08
$1,413.12 		$1,150.20
$1,238.16
$1,331.34
$1,662.38 		$1,399.46
$1,487.42
$1,580.60
$1,911.64 		$249.26
Toc - Plan #51 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$396.81
$450.37
$507.11
$708.68
$1,076.91 		$700.36
$753.92
$810.66
$1,012.23 		$1,003.91
$1,057.47
$1,114.21
$1,315.78 		$1,307.46
$1,361.02
$1,417.76
$1,619.33 		$303.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.62
$900.74
$1,014.22
$1,417.36
$2,153.82 		$1,097.17
$1,204.29
$1,317.77
$1,720.91 		$1,400.72
$1,507.84
$1,621.32
$2,024.46 		$1,704.27
$1,811.39
$1,924.87
$2,328.01 		$303.55
Toc - Plan #52 Ambetter from Sunshine Health
Bronze

(EPO) Clear Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$295.87
$335.80
$378.11
$528.41
$802.97 		$522.20
$562.13
$604.44
$754.74 		$748.53
$788.46
$830.77
$981.07 		$974.86
$1,014.79
$1,057.10
$1,207.40 		$226.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591.74
$671.60
$756.22
$1,056.82
$1,605.94 		$818.07
$897.93
$982.55
$1,283.15 		$1,044.40
$1,124.26
$1,208.88
$1,509.48 		$1,270.73
$1,350.59
$1,435.21
$1,735.81 		$226.33
Toc - Plan #53 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$396.25
$449.73
$506.39
$707.68
$1,075.39 		$699.37
$752.85
$809.51
$1,010.80 		$1,002.49
$1,055.97
$1,112.63
$1,313.92 		$1,305.61
$1,359.09
$1,415.75
$1,617.04 		$303.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792.50
$899.46
$1,012.78
$1,415.36
$2,150.78 		$1,095.62
$1,202.58
$1,315.90
$1,718.48 		$1,398.74
$1,505.70
$1,619.02
$2,021.60 		$1,701.86
$1,808.82
$1,922.14
$2,324.72 		$303.12
Toc - Plan #54 Ambetter from Sunshine Health
Silver

(EPO) Enhanced Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.96
$456.22
$513.70
$717.89
$1,090.90 		$709.45
$763.71
$821.19
$1,025.38 		$1,016.94
$1,071.20
$1,128.68
$1,332.87 		$1,324.43
$1,378.69
$1,436.17
$1,640.36 		$307.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.92
$912.44
$1,027.40
$1,435.78
$2,181.80 		$1,111.41
$1,219.93
$1,334.89
$1,743.27 		$1,418.90
$1,527.42
$1,642.38
$2,050.76 		$1,726.39
$1,834.91
$1,949.87
$2,358.25 		$307.49
Toc - Plan #55 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$440.60
$500.08
$563.08
$786.90
$1,195.77 		$777.66
$837.14
$900.14
$1,123.96 		$1,114.72
$1,174.20
$1,237.20
$1,461.02 		$1,451.78
$1,511.26
$1,574.26
$1,798.08 		$337.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.20
$1,000.16
$1,126.16
$1,573.80
$2,391.54 		$1,218.26
$1,337.22
$1,463.22
$1,910.86 		$1,555.32
$1,674.28
$1,800.28
$2,247.92 		$1,892.38
$2,011.34
$2,137.34
$2,584.98 		$337.06
Toc - Plan #56 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$318.13
$361.06
$406.56
$568.16
$863.37 		$561.49
$604.42
$649.92
$811.52 		$804.85
$847.78
$893.28
$1,054.88 		$1,048.21
$1,091.14
$1,136.64
$1,298.24 		$243.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.26
$722.12
$813.12
$1,136.32
$1,726.74 		$879.62
$965.48
$1,056.48
$1,379.68 		$1,122.98
$1,208.84
$1,299.84
$1,623.04 		$1,366.34
$1,452.20
$1,543.20
$1,866.40 		$243.36
Toc - Plan #57 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.60
$413.81
$465.95
$651.16
$989.50 		$643.51
$692.72
$744.86
$930.07 		$922.42
$971.63
$1,023.77
$1,208.98 		$1,201.33
$1,250.54
$1,302.68
$1,487.89 		$278.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.20
$827.62
$931.90
$1,302.32
$1,979.00 		$1,008.11
$1,106.53
$1,210.81
$1,581.23 		$1,287.02
$1,385.44
$1,489.72
$1,860.14 		$1,565.93
$1,664.35
$1,768.63
$2,139.05 		$278.91
Toc - Plan #58 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.61
$453.54
$510.68
$713.68
$1,084.50 		$705.30
$759.23
$816.37
$1,019.37 		$1,010.99
$1,064.92
$1,122.06
$1,325.06 		$1,316.68
$1,370.61
$1,427.75
$1,630.75 		$305.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.22
$907.08
$1,021.36
$1,427.36
$2,169.00 		$1,104.91
$1,212.77
$1,327.05
$1,733.05 		$1,410.60
$1,518.46
$1,632.74
$2,038.74 		$1,716.29
$1,824.15
$1,938.43
$2,344.43 		$305.69
Toc - Plan #59 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$378.67
$429.78
$483.92
$676.28
$1,027.68 		$668.34
$719.45
$773.59
$965.95 		$958.01
$1,009.12
$1,063.26
$1,255.62 		$1,247.68
$1,298.79
$1,352.93
$1,545.29 		$289.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.34
$859.56
$967.84
$1,352.56
$2,055.36 		$1,047.01
$1,149.23
$1,257.51
$1,642.23 		$1,336.68
$1,438.90
$1,547.18
$1,931.90 		$1,626.35
$1,728.57
$1,836.85
$2,221.57 		$289.67

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 #60 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 		$543.66
$617.05
$694.80
$970.98
$1,475.49 		$959.56
$1,032.95
$1,110.70
$1,386.88 		$1,375.46
$1,448.85
$1,526.60
$1,802.78 		$1,791.36
$1,864.75
$1,942.50
$2,218.68 		$415.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,087.32
$1,234.10
$1,389.60
$1,941.96
$2,950.98 		$1,503.22
$1,650.00
$1,805.50
$2,357.86 		$1,919.12
$2,065.90
$2,221.40
$2,773.76 		$2,335.02
$2,481.80
$2,637.30
$3,189.66 		$415.90
Toc - Plan #61 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 		$384.53
$436.44
$491.43
$686.77
$1,043.61 		$678.70
$730.61
$785.60
$980.94 		$972.87
$1,024.78
$1,079.77
$1,275.11 		$1,267.04
$1,318.95
$1,373.94
$1,569.28 		$294.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.06
$872.88
$982.86
$1,373.54
$2,087.22 		$1,063.23
$1,167.05
$1,277.03
$1,667.71 		$1,357.40
$1,461.22
$1,571.20
$1,961.88 		$1,651.57
$1,755.39
$1,865.37
$2,256.05 		$294.17
Toc - Plan #62 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 		$556.46
$631.58
$711.16
$993.84
$1,510.23 		$982.15
$1,057.27
$1,136.85
$1,419.53 		$1,407.84
$1,482.96
$1,562.54
$1,845.22 		$1,833.53
$1,908.65
$1,988.23
$2,270.91 		$425.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,112.92
$1,263.16
$1,422.32
$1,987.68
$3,020.46 		$1,538.61
$1,688.85
$1,848.01
$2,413.37 		$1,964.30
$2,114.54
$2,273.70
$2,839.06 		$2,389.99
$2,540.23
$2,699.39
$3,264.75 		$425.69
Toc - Plan #63 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 		$652.15
$740.19
$833.45
$1,164.74
$1,769.94 		$1,151.04
$1,239.08
$1,332.34
$1,663.63 		$1,649.93
$1,737.97
$1,831.23
$2,162.52 		$2,148.82
$2,236.86
$2,330.12
$2,661.41 		$498.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,304.30
$1,480.38
$1,666.90
$2,329.48
$3,539.88 		$1,803.19
$1,979.27
$2,165.79
$2,828.37 		$2,302.08
$2,478.16
$2,664.68
$3,327.26 		$2,800.97
$2,977.05
$3,163.57
$3,826.15 		$498.89
Toc - Plan #64 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 		$407.58
$462.60
$520.89
$727.94
$1,106.17 		$719.38
$774.40
$832.69
$1,039.74 		$1,031.18
$1,086.20
$1,144.49
$1,351.54 		$1,342.98
$1,398.00
$1,456.29
$1,663.34 		$311.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.16
$925.20
$1,041.78
$1,455.88
$2,212.34 		$1,126.96
$1,237.00
$1,353.58
$1,767.68 		$1,438.76
$1,548.80
$1,665.38
$2,079.48 		$1,750.56
$1,860.60
$1,977.18
$2,391.28 		$311.80
Toc - Plan #65 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 		$693.29
$786.88
$886.02
$1,238.22
$1,881.59 		$1,223.66
$1,317.25
$1,416.39
$1,768.59 		$1,754.03
$1,847.62
$1,946.76
$2,298.96 		$2,284.40
$2,377.99
$2,477.13
$2,829.33 		$530.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,386.58
$1,573.76
$1,772.04
$2,476.44
$3,763.18 		$1,916.95
$2,104.13
$2,302.41
$3,006.81 		$2,447.32
$2,634.50
$2,832.78
$3,537.18 		$2,977.69
$3,164.87
$3,363.15
$4,067.55 		$530.37
Toc - Plan #66 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 		$501.44
$569.13
$640.84
$895.57
$1,360.91 		$885.04
$952.73
$1,024.44
$1,279.17 		$1,268.64
$1,336.33
$1,408.04
$1,662.77 		$1,652.24
$1,719.93
$1,791.64
$2,046.37 		$383.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,002.88
$1,138.26
$1,281.68
$1,791.14
$2,721.82 		$1,386.48
$1,521.86
$1,665.28
$2,174.74 		$1,770.08
$1,905.46
$2,048.88
$2,558.34 		$2,153.68
$2,289.06
$2,432.48
$2,941.94 		$383.60
Toc - Plan #67 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 		$611.71
$694.29
$781.77
$1,092.51
$1,660.18 		$1,079.67
$1,162.25
$1,249.73
$1,560.47 		$1,547.63
$1,630.21
$1,717.69
$2,028.43 		$2,015.59
$2,098.17
$2,185.65
$2,496.39 		$467.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,223.42
$1,388.58
$1,563.54
$2,185.02
$3,320.36 		$1,691.38
$1,856.54
$2,031.50
$2,652.98 		$2,159.34
$2,324.50
$2,499.46
$3,120.94 		$2,627.30
$2,792.46
$2,967.42
$3,588.90 		$467.96
Toc - Plan #68 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 		$389.08
$441.61
$497.24
$694.90
$1,055.96 		$686.73
$739.26
$794.89
$992.55 		$984.38
$1,036.91
$1,092.54
$1,290.20 		$1,282.03
$1,334.56
$1,390.19
$1,587.85 		$297.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.16
$883.22
$994.48
$1,389.80
$2,111.92 		$1,075.81
$1,180.87
$1,292.13
$1,687.45 		$1,373.46
$1,478.52
$1,589.78
$1,985.10 		$1,671.11
$1,776.17
$1,887.43
$2,282.75 		$297.65
Toc - Plan #69 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 		$585.43
$664.46
$748.18
$1,045.58
$1,588.86 		$1,033.28
$1,112.31
$1,196.03
$1,493.43 		$1,481.13
$1,560.16
$1,643.88
$1,941.28 		$1,928.98
$2,008.01
$2,091.73
$2,389.13 		$447.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,170.86
$1,328.92
$1,496.36
$2,091.16
$3,177.72 		$1,618.71
$1,776.77
$1,944.21
$2,539.01 		$2,066.56
$2,224.62
$2,392.06
$2,986.86 		$2,514.41
$2,672.47
$2,839.91
$3,434.71 		$447.85
Toc - Plan #70 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 		$442.32
$502.03
$565.28
$789.98
$1,200.46 		$780.69
$840.40
$903.65
$1,128.35 		$1,119.06
$1,178.77
$1,242.02
$1,466.72 		$1,457.43
$1,517.14
$1,580.39
$1,805.09 		$338.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.64
$1,004.06
$1,130.56
$1,579.96
$2,400.92 		$1,223.01
$1,342.43
$1,468.93
$1,918.33 		$1,561.38
$1,680.80
$1,807.30
$2,256.70 		$1,899.75
$2,019.17
$2,145.67
$2,595.07 		$338.37
Toc - Plan #71 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 		$363.10
$412.12
$464.04
$648.50
$985.45 		$640.87
$689.89
$741.81
$926.27 		$918.64
$967.66
$1,019.58
$1,204.04 		$1,196.41
$1,245.43
$1,297.35
$1,481.81 		$277.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.20
$824.24
$928.08
$1,297.00
$1,970.90 		$1,003.97
$1,102.01
$1,205.85
$1,574.77 		$1,281.74
$1,379.78
$1,483.62
$1,852.54 		$1,559.51
$1,657.55
$1,761.39
$2,130.31 		$277.77
Toc - Plan #72 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 		$400.03
$454.03
$511.24
$714.45
$1,085.68 		$706.05
$760.05
$817.26
$1,020.47 		$1,012.07
$1,066.07
$1,123.28
$1,326.49 		$1,318.09
$1,372.09
$1,429.30
$1,632.51 		$306.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800.06
$908.06
$1,022.48
$1,428.90
$2,171.36 		$1,106.08
$1,214.08
$1,328.50
$1,734.92 		$1,412.10
$1,520.10
$1,634.52
$2,040.94 		$1,718.12
$1,826.12
$1,940.54
$2,346.96 		$306.02
Toc - Plan #73 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 		$537.79
$610.39
$687.30
$960.49
$1,459.56 		$949.20
$1,021.80
$1,098.71
$1,371.90 		$1,360.61
$1,433.21
$1,510.12
$1,783.31 		$1,772.02
$1,844.62
$1,921.53
$2,194.72 		$411.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,075.58
$1,220.78
$1,374.60
$1,920.98
$2,919.12 		$1,486.99
$1,632.19
$1,786.01
$2,332.39 		$1,898.40
$2,043.60
$2,197.42
$2,743.80 		$2,309.81
$2,455.01
$2,608.83
$3,155.21 		$411.41
Toc - Plan #74 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 		$554.44
$629.29
$708.57
$990.23
$1,504.75 		$978.59
$1,053.44
$1,132.72
$1,414.38 		$1,402.74
$1,477.59
$1,556.87
$1,838.53 		$1,826.89
$1,901.74
$1,981.02
$2,262.68 		$424.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,108.88
$1,258.58
$1,417.14
$1,980.46
$3,009.50 		$1,533.03
$1,682.73
$1,841.29
$2,404.61 		$1,957.18
$2,106.88
$2,265.44
$2,828.76 		$2,381.33
$2,531.03
$2,689.59
$3,252.91 		$424.15
Toc - Plan #75 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 		$691.39
$784.73
$883.60
$1,234.82
$1,876.43 		$1,220.30
$1,313.64
$1,412.51
$1,763.73 		$1,749.21
$1,842.55
$1,941.42
$2,292.64 		$2,278.12
$2,371.46
$2,470.33
$2,821.55 		$528.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,382.78
$1,569.46
$1,767.20
$2,469.64
$3,752.86 		$1,911.69
$2,098.37
$2,296.11
$2,998.55 		$2,440.60
$2,627.28
$2,825.02
$3,527.46 		$2,969.51
$3,156.19
$3,353.93
$4,056.37 		$528.91
Toc - Plan #76 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 		$427.75
$485.50
$546.66
$763.96
$1,160.91 		$754.98
$812.73
$873.89
$1,091.19 		$1,082.21
$1,139.96
$1,201.12
$1,418.42 		$1,409.44
$1,467.19
$1,528.35
$1,745.65 		$327.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.50
$971.00
$1,093.32
$1,527.92
$2,321.82 		$1,182.73
$1,298.23
$1,420.55
$1,855.15 		$1,509.96
$1,625.46
$1,747.78
$2,182.38 		$1,837.19
$1,952.69
$2,075.01
$2,509.61 		$327.23
Toc - Plan #77 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 		$383.68
$435.48
$490.34
$685.25
$1,041.31 		$677.20
$729.00
$783.86
$978.77 		$970.72
$1,022.52
$1,077.38
$1,272.29 		$1,264.24
$1,316.04
$1,370.90
$1,565.81 		$293.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.36
$870.96
$980.68
$1,370.50
$2,082.62 		$1,060.88
$1,164.48
$1,274.20
$1,664.02 		$1,354.40
$1,458.00
$1,567.72
$1,957.54 		$1,647.92
$1,751.52
$1,861.24
$2,251.06 		$293.52
Toc - Plan #78 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 		$361.19
$409.95
$461.60
$645.09
$980.27 		$637.50
$686.26
$737.91
$921.40 		$913.81
$962.57
$1,014.22
$1,197.71 		$1,190.12
$1,238.88
$1,290.53
$1,474.02 		$276.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.38
$819.90
$923.20
$1,290.18
$1,960.54 		$998.69
$1,096.21
$1,199.51
$1,566.49 		$1,275.00
$1,372.52
$1,475.82
$1,842.80 		$1,551.31
$1,648.83
$1,752.13
$2,119.11 		$276.31
Toc - Plan #79 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 		$472.52
$536.31
$603.88
$843.92
$1,282.42 		$834.00
$897.79
$965.36
$1,205.40 		$1,195.48
$1,259.27
$1,326.84
$1,566.88 		$1,556.96
$1,620.75
$1,688.32
$1,928.36 		$361.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945.04
$1,072.62
$1,207.76
$1,687.84
$2,564.84 		$1,306.52
$1,434.10
$1,569.24
$2,049.32 		$1,668.00
$1,795.58
$1,930.72
$2,410.80 		$2,029.48
$2,157.06
$2,292.20
$2,772.28 		$361.48
Toc - Plan #80 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 		$450.42
$511.23
$575.64
$804.45
$1,222.44 		$794.99
$855.80
$920.21
$1,149.02 		$1,139.56
$1,200.37
$1,264.78
$1,493.59 		$1,484.13
$1,544.94
$1,609.35
$1,838.16 		$344.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.84
$1,022.46
$1,151.28
$1,608.90
$2,444.88 		$1,245.41
$1,367.03
$1,495.85
$1,953.47 		$1,589.98
$1,711.60
$1,840.42
$2,298.04 		$1,934.55
$2,056.17
$2,184.99
$2,642.61 		$344.57
Toc - Plan #81 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 		$534.93
$607.15
$683.64
$955.38
$1,451.80 		$944.15
$1,016.37
$1,092.86
$1,364.60 		$1,353.37
$1,425.59
$1,502.08
$1,773.82 		$1,762.59
$1,834.81
$1,911.30
$2,183.04 		$409.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,069.86
$1,214.30
$1,367.28
$1,910.76
$2,903.60 		$1,479.08
$1,623.52
$1,776.50
$2,319.98 		$1,888.30
$2,032.74
$2,185.72
$2,729.20 		$2,297.52
$2,441.96
$2,594.94
$3,138.42 		$409.22
Toc - Plan #82 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 		$480.06
$544.87
$613.52
$857.39
$1,302.88 		$847.31
$912.12
$980.77
$1,224.64 		$1,214.56
$1,279.37
$1,348.02
$1,591.89 		$1,581.81
$1,646.62
$1,715.27
$1,959.14 		$367.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$960.12
$1,089.74
$1,227.04
$1,714.78
$2,605.76 		$1,327.37
$1,456.99
$1,594.29
$2,082.03 		$1,694.62
$1,824.24
$1,961.54
$2,449.28 		$2,061.87
$2,191.49
$2,328.79
$2,816.53 		$367.25
Toc - Plan #83 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 		$446.79
$507.11
$571.00
$797.97
$1,212.59 		$788.58
$848.90
$912.79
$1,139.76 		$1,130.37
$1,190.69
$1,254.58
$1,481.55 		$1,472.16
$1,532.48
$1,596.37
$1,823.34 		$341.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$893.58
$1,014.22
$1,142.00
$1,595.94
$2,425.18 		$1,235.37
$1,356.01
$1,483.79
$1,937.73 		$1,577.16
$1,697.80
$1,825.58
$2,279.52 		$1,918.95
$2,039.59
$2,167.37
$2,621.31 		$341.79
Toc - Plan #84 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 		$445.10
$505.19
$568.84
$794.95
$1,208.00 		$785.60
$845.69
$909.34
$1,135.45 		$1,126.10
$1,186.19
$1,249.84
$1,475.95 		$1,466.60
$1,526.69
$1,590.34
$1,816.45 		$340.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.20
$1,010.38
$1,137.68
$1,589.90
$2,416.00 		$1,230.70
$1,350.88
$1,478.18
$1,930.40 		$1,571.20
$1,691.38
$1,818.68
$2,270.90 		$1,911.70
$2,031.88
$2,159.18
$2,611.40 		$340.50
Toc - Plan #85 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 		$415.07
$471.10
$530.46
$741.32
$1,126.50 		$732.60
$788.63
$847.99
$1,058.85 		$1,050.13
$1,106.16
$1,165.52
$1,376.38 		$1,367.66
$1,423.69
$1,483.05
$1,693.91 		$317.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.14
$942.20
$1,060.92
$1,482.64
$2,253.00 		$1,147.67
$1,259.73
$1,378.45
$1,800.17 		$1,465.20
$1,577.26
$1,695.98
$2,117.70 		$1,782.73
$1,894.79
$2,013.51
$2,435.23 		$317.53
Toc - Plan #86 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 		$384.13
$435.99
$490.92
$686.06
$1,042.53 		$677.99
$729.85
$784.78
$979.92 		$971.85
$1,023.71
$1,078.64
$1,273.78 		$1,265.71
$1,317.57
$1,372.50
$1,567.64 		$293.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$768.26
$871.98
$981.84
$1,372.12
$2,085.06 		$1,062.12
$1,165.84
$1,275.70
$1,665.98 		$1,355.98
$1,459.70
$1,569.56
$1,959.84 		$1,649.84
$1,753.56
$1,863.42
$2,253.70 		$293.86
Toc - Plan #87 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 		$437.30
$496.34
$558.87
$781.02
$1,186.83 		$771.83
$830.87
$893.40
$1,115.55 		$1,106.36
$1,165.40
$1,227.93
$1,450.08 		$1,440.89
$1,499.93
$1,562.46
$1,784.61 		$334.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.60
$992.68
$1,117.74
$1,562.04
$2,373.66 		$1,209.13
$1,327.21
$1,452.27
$1,896.57 		$1,543.66
$1,661.74
$1,786.80
$2,231.10 		$1,878.19
$1,996.27
$2,121.33
$2,565.63 		$334.53
Toc - Plan #88 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 		$375.43
$426.11
$479.80
$670.52
$1,018.92 		$662.63
$713.31
$767.00
$957.72 		$949.83
$1,000.51
$1,054.20
$1,244.92 		$1,237.03
$1,287.71
$1,341.40
$1,532.12 		$287.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.86
$852.22
$959.60
$1,341.04
$2,037.84 		$1,038.06
$1,139.42
$1,246.80
$1,628.24 		$1,325.26
$1,426.62
$1,534.00
$1,915.44 		$1,612.46
$1,713.82
$1,821.20
$2,202.64 		$287.20
Toc - Plan #89 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 		$376.23
$427.02
$480.82
$671.95
$1,021.09 		$664.05
$714.84
$768.64
$959.77 		$951.87
$1,002.66
$1,056.46
$1,247.59 		$1,239.69
$1,290.48
$1,344.28
$1,535.41 		$287.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.46
$854.04
$961.64
$1,343.90
$2,042.18 		$1,040.28
$1,141.86
$1,249.46
$1,631.72 		$1,328.10
$1,429.68
$1,537.28
$1,919.54 		$1,615.92
$1,717.50
$1,825.10
$2,207.36 		$287.82
Toc - Plan #90 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 		$341.83
$387.98
$436.86
$610.51
$927.73 		$603.33
$649.48
$698.36
$872.01 		$864.83
$910.98
$959.86
$1,133.51 		$1,126.33
$1,172.48
$1,221.36
$1,395.01 		$261.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.66
$775.96
$873.72
$1,221.02
$1,855.46 		$945.16
$1,037.46
$1,135.22
$1,482.52 		$1,206.66
$1,298.96
$1,396.72
$1,744.02 		$1,468.16
$1,560.46
$1,658.22
$2,005.52 		$261.50
Toc - Plan #91 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 		$366.70
$416.20
$468.64
$654.93
$995.22 		$647.23
$696.73
$749.17
$935.46 		$927.76
$977.26
$1,029.70
$1,215.99 		$1,208.29
$1,257.79
$1,310.23
$1,496.52 		$280.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.40
$832.40
$937.28
$1,309.86
$1,990.44 		$1,013.93
$1,112.93
$1,217.81
$1,590.39 		$1,294.46
$1,393.46
$1,498.34
$1,870.92 		$1,574.99
$1,673.99
$1,778.87
$2,151.45 		$280.53
Toc - Plan #92 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 		$401.90
$456.16
$513.63
$717.79
$1,090.76 		$709.35
$763.61
$821.08
$1,025.24 		$1,016.80
$1,071.06
$1,128.53
$1,332.69 		$1,324.25
$1,378.51
$1,435.98
$1,640.14 		$307.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.80
$912.32
$1,027.26
$1,435.58
$2,181.52 		$1,111.25
$1,219.77
$1,334.71
$1,743.03 		$1,418.70
$1,527.22
$1,642.16
$2,050.48 		$1,726.15
$1,834.67
$1,949.61
$2,357.93 		$307.45
Toc - Plan #93 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 		$423.31
$480.46
$540.99
$756.03
$1,148.86 		$747.14
$804.29
$864.82
$1,079.86 		$1,070.97
$1,128.12
$1,188.65
$1,403.69 		$1,394.80
$1,451.95
$1,512.48
$1,727.52 		$323.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.62
$960.92
$1,081.98
$1,512.06
$2,297.72 		$1,170.45
$1,284.75
$1,405.81
$1,835.89 		$1,494.28
$1,608.58
$1,729.64
$2,159.72 		$1,818.11
$1,932.41
$2,053.47
$2,483.55 		$323.83
Toc - Plan #94 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 		$440.18
$499.60
$562.55
$786.16
$1,194.65 		$776.92
$836.34
$899.29
$1,122.90 		$1,113.66
$1,173.08
$1,236.03
$1,459.64 		$1,450.40
$1,509.82
$1,572.77
$1,796.38 		$336.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.36
$999.20
$1,125.10
$1,572.32
$2,389.30 		$1,217.10
$1,335.94
$1,461.84
$1,909.06 		$1,553.84
$1,672.68
$1,798.58
$2,245.80 		$1,890.58
$2,009.42
$2,135.32
$2,582.54 		$336.74
Toc - Plan #95 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 		$506.33
$574.68
$647.09
$904.31
$1,374.18 		$893.67
$962.02
$1,034.43
$1,291.65 		$1,281.01
$1,349.36
$1,421.77
$1,678.99 		$1,668.35
$1,736.70
$1,809.11
$2,066.33 		$387.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,012.66
$1,149.36
$1,294.18
$1,808.62
$2,748.36 		$1,400.00
$1,536.70
$1,681.52
$2,195.96 		$1,787.34
$1,924.04
$2,068.86
$2,583.30 		$2,174.68
$2,311.38
$2,456.20
$2,970.64 		$387.34
Toc - Plan #96 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 		$446.20
$506.44
$570.24
$796.91
$1,210.99 		$787.54
$847.78
$911.58
$1,138.25 		$1,128.88
$1,189.12
$1,252.92
$1,479.59 		$1,470.22
$1,530.46
$1,594.26
$1,820.93 		$341.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.40
$1,012.88
$1,140.48
$1,593.82
$2,421.98 		$1,233.74
$1,354.22
$1,481.82
$1,935.16 		$1,575.08
$1,695.56
$1,823.16
$2,276.50 		$1,916.42
$2,036.90
$2,164.50
$2,617.84 		$341.34
Toc - Plan #97 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 		$432.16
$490.50
$552.30
$771.84
$1,172.88 		$762.76
$821.10
$882.90
$1,102.44 		$1,093.36
$1,151.70
$1,213.50
$1,433.04 		$1,423.96
$1,482.30
$1,544.10
$1,763.64 		$330.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$864.32
$981.00
$1,104.60
$1,543.68
$2,345.76 		$1,194.92
$1,311.60
$1,435.20
$1,874.28 		$1,525.52
$1,642.20
$1,765.80
$2,204.88 		$1,856.12
$1,972.80
$2,096.40
$2,535.48 		$330.60

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-5716 | Toll Free: 1-888-560-5716 | TTY: 1-800-955-8771
Toc - Plan #98 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

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 		$486.20
$551.84
$621.36
$868.35
$1,319.55 		$858.14
$923.78
$993.30
$1,240.29 		$1,230.08
$1,295.72
$1,365.24
$1,612.23 		$1,602.02
$1,667.66
$1,737.18
$1,984.17 		$371.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$972.40
$1,103.68
$1,242.72
$1,736.70
$2,639.10 		$1,344.34
$1,475.62
$1,614.66
$2,108.64 		$1,716.28
$1,847.56
$1,986.60
$2,480.58 		$2,088.22
$2,219.50
$2,358.54
$2,852.52 		$371.94
Toc - Plan #99 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$422.74
$479.81
$540.26
$755.01
$1,147.32 		$746.14
$803.21
$863.66
$1,078.41 		$1,069.54
$1,126.61
$1,187.06
$1,401.81 		$1,392.94
$1,450.01
$1,510.46
$1,725.21 		$323.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.48
$959.62
$1,080.52
$1,510.02
$2,294.64 		$1,168.88
$1,283.02
$1,403.92
$1,833.42 		$1,492.28
$1,606.42
$1,727.32
$2,156.82 		$1,815.68
$1,929.82
$2,050.72
$2,480.22 		$323.40
Toc - Plan #100 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$388.06
$440.45
$495.94
$693.08
$1,053.20 		$684.93
$737.32
$792.81
$989.95 		$981.80
$1,034.19
$1,089.68
$1,286.82 		$1,278.67
$1,331.06
$1,386.55
$1,583.69 		$296.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.12
$880.90
$991.88
$1,386.16
$2,106.40 		$1,072.99
$1,177.77
$1,288.75
$1,683.03 		$1,369.86
$1,474.64
$1,585.62
$1,979.90 		$1,666.73
$1,771.51
$1,882.49
$2,276.77 		$296.87
Toc - Plan #101 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

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 		$496.32
$563.33
$634.30
$886.43
$1,347.02 		$876.01
$943.02
$1,013.99
$1,266.12 		$1,255.70
$1,322.71
$1,393.68
$1,645.81 		$1,635.39
$1,702.40
$1,773.37
$2,025.50 		$379.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$992.64
$1,126.66
$1,268.60
$1,772.86
$2,694.04 		$1,372.33
$1,506.35
$1,648.29
$2,152.55 		$1,752.02
$1,886.04
$2,027.98
$2,532.24 		$2,131.71
$2,265.73
$2,407.67
$2,911.93 		$379.69
Toc - Plan #102 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

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 		$430.74
$488.89
$550.49
$769.30
$1,169.03 		$760.26
$818.41
$880.01
$1,098.82 		$1,089.78
$1,147.93
$1,209.53
$1,428.34 		$1,419.30
$1,477.45
$1,539.05
$1,757.86 		$329.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.48
$977.78
$1,100.98
$1,538.60
$2,338.06 		$1,191.00
$1,307.30
$1,430.50
$1,868.12 		$1,520.52
$1,636.82
$1,760.02
$2,197.64 		$1,850.04
$1,966.34
$2,089.54
$2,527.16 		$329.52
Toc - Plan #103 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

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 		$335.71
$381.03
$429.03
$599.57
$911.11 		$592.53
$637.85
$685.85
$856.39 		$849.35
$894.67
$942.67
$1,113.21 		$1,106.17
$1,151.49
$1,199.49
$1,370.03 		$256.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.42
$762.06
$858.06
$1,199.14
$1,822.22 		$928.24
$1,018.88
$1,114.88
$1,455.96 		$1,185.06
$1,275.70
$1,371.70
$1,712.78 		$1,441.88
$1,532.52
$1,628.52
$1,969.60 		$256.82
Toc - Plan #104 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

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 		$490.77
$557.02
$627.20
$876.51
$1,331.94 		$866.21
$932.46
$1,002.64
$1,251.95 		$1,241.65
$1,307.90
$1,378.08
$1,627.39 		$1,617.09
$1,683.34
$1,753.52
$2,002.83 		$375.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$981.54
$1,114.04
$1,254.40
$1,753.02
$2,663.88 		$1,356.98
$1,489.48
$1,629.84
$2,128.46 		$1,732.42
$1,864.92
$2,005.28
$2,503.90 		$2,107.86
$2,240.36
$2,380.72
$2,879.34 		$375.44
Toc - Plan #105 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$427.31
$485.00
$546.10
$763.18
$1,159.72 		$754.20
$811.89
$872.99
$1,090.07 		$1,081.09
$1,138.78
$1,199.88
$1,416.96 		$1,407.98
$1,465.67
$1,526.77
$1,743.85 		$326.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.62
$970.00
$1,092.20
$1,526.36
$2,319.44 		$1,181.51
$1,296.89
$1,419.09
$1,853.25 		$1,508.40
$1,623.78
$1,745.98
$2,180.14 		$1,835.29
$1,950.67
$2,072.87
$2,507.03 		$326.89

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0405 | Toll Free: 1-888-200-0405 | TTY: 1-888-200-0405
Toc - Plan #106 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,150 $4,300 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$553.63
$628.37
$707.54
$988.79
$1,502.56 		$977.16
$1,051.90
$1,131.07
$1,412.32 		$1,400.69
$1,475.43
$1,554.60
$1,835.85 		$1,824.22
$1,898.96
$1,978.13
$2,259.38 		$423.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,107.26
$1,256.74
$1,415.08
$1,977.58
$3,005.12 		$1,530.79
$1,680.27
$1,838.61
$2,401.11 		$1,954.32
$2,103.80
$2,262.14
$2,824.64 		$2,377.85
$2,527.33
$2,685.67
$3,248.17 		$423.53
Toc - Plan #107 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$552.30
$626.86
$705.84
$986.41
$1,498.95 		$974.81
$1,049.37
$1,128.35
$1,408.92 		$1,397.32
$1,471.88
$1,550.86
$1,831.43 		$1,819.83
$1,894.39
$1,973.37
$2,253.94 		$422.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,104.60
$1,253.72
$1,411.68
$1,972.82
$2,997.90 		$1,527.11
$1,676.23
$1,834.19
$2,395.33 		$1,949.62
$2,098.74
$2,256.70
$2,817.84 		$2,372.13
$2,521.25
$2,679.21
$3,240.35 		$422.51
Toc - Plan #108 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$494.27
$560.99
$631.67
$882.76
$1,341.44 		$872.38
$939.10
$1,009.78
$1,260.87 		$1,250.49
$1,317.21
$1,387.89
$1,638.98 		$1,628.60
$1,695.32
$1,766.00
$2,017.09 		$378.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$988.54
$1,121.98
$1,263.34
$1,765.52
$2,682.88 		$1,366.65
$1,500.09
$1,641.45
$2,143.63 		$1,744.76
$1,878.20
$2,019.56
$2,521.74 		$2,122.87
$2,256.31
$2,397.67
$2,899.85 		$378.11
Toc - Plan #109 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$479.69
$544.45
$613.05
$856.74
$1,301.89 		$846.66
$911.42
$980.02
$1,223.71 		$1,213.63
$1,278.39
$1,346.99
$1,590.68 		$1,580.60
$1,645.36
$1,713.96
$1,957.65 		$366.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$959.38
$1,088.90
$1,226.10
$1,713.48
$2,603.78 		$1,326.35
$1,455.87
$1,593.07
$2,080.45 		$1,693.32
$1,822.84
$1,960.04
$2,447.42 		$2,060.29
$2,189.81
$2,327.01
$2,814.39 		$366.97
Toc - Plan #110 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$492.89
$559.43
$629.91
$880.30
$1,337.70 		$869.95
$936.49
$1,006.97
$1,257.36 		$1,247.01
$1,313.55
$1,384.03
$1,634.42 		$1,624.07
$1,690.61
$1,761.09
$2,011.48 		$377.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.78
$1,118.86
$1,259.82
$1,760.60
$2,675.40 		$1,362.84
$1,495.92
$1,636.88
$2,137.66 		$1,739.90
$1,872.98
$2,013.94
$2,514.72 		$2,116.96
$2,250.04
$2,391.00
$2,891.78 		$377.06
Toc - Plan #111 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$492.66
$559.17
$629.63
$879.90
$1,337.09 		$869.55
$936.06
$1,006.52
$1,256.79 		$1,246.44
$1,312.95
$1,383.41
$1,633.68 		$1,623.33
$1,689.84
$1,760.30
$2,010.57 		$376.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.32
$1,118.34
$1,259.26
$1,759.80
$2,674.18 		$1,362.21
$1,495.23
$1,636.15
$2,136.69 		$1,739.10
$1,872.12
$2,013.04
$2,513.58 		$2,115.99
$2,249.01
$2,389.93
$2,890.47 		$376.89
Toc - Plan #112 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$480.35
$545.19
$613.88
$857.90
$1,303.66 		$847.82
$912.66
$981.35
$1,225.37 		$1,215.29
$1,280.13
$1,348.82
$1,592.84 		$1,582.76
$1,647.60
$1,716.29
$1,960.31 		$367.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$960.70
$1,090.38
$1,227.76
$1,715.80
$2,607.32 		$1,328.17
$1,457.85
$1,595.23
$2,083.27 		$1,695.64
$1,825.32
$1,962.70
$2,450.74 		$2,063.11
$2,192.79
$2,330.17
$2,818.21 		$367.47
Toc - Plan #113 UnitedHealthcare
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$384.71
$436.64
$491.66
$687.09
$1,044.10 		$679.01
$730.94
$785.96
$981.39 		$973.31
$1,025.24
$1,080.26
$1,275.69 		$1,267.61
$1,319.54
$1,374.56
$1,569.99 		$294.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.42
$873.28
$983.32
$1,374.18
$2,088.20 		$1,063.72
$1,167.58
$1,277.62
$1,668.48 		$1,358.02
$1,461.88
$1,571.92
$1,962.78 		$1,652.32
$1,756.18
$1,866.22
$2,257.08 		$294.30
Toc - Plan #114 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.53
$447.79
$504.21
$704.64
$1,070.76 		$696.35
$749.61
$806.03
$1,006.46 		$998.17
$1,051.43
$1,107.85
$1,308.28 		$1,299.99
$1,353.25
$1,409.67
$1,610.10 		$301.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.06
$895.58
$1,008.42
$1,409.28
$2,141.52 		$1,090.88
$1,197.40
$1,310.24
$1,711.10 		$1,392.70
$1,499.22
$1,612.06
$2,012.92 		$1,694.52
$1,801.04
$1,913.88
$2,314.74 		$301.82
Toc - Plan #115 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.91
$435.74
$490.64
$685.67
$1,041.94 		$677.60
$729.43
$784.33
$979.36 		$971.29
$1,023.12
$1,078.02
$1,273.05 		$1,264.98
$1,316.81
$1,371.71
$1,566.74 		$293.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.82
$871.48
$981.28
$1,371.34
$2,083.88 		$1,061.51
$1,165.17
$1,274.97
$1,665.03 		$1,355.20
$1,458.86
$1,568.66
$1,958.72 		$1,648.89
$1,752.55
$1,862.35
$2,252.41 		$293.69
Toc - Plan #116 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$588.55
$668.01
$752.17
$1,051.16
$1,597.33 		$1,038.79
$1,118.25
$1,202.41
$1,501.40 		$1,489.03
$1,568.49
$1,652.65
$1,951.64 		$1,939.27
$2,018.73
$2,102.89
$2,401.88 		$450.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,177.10
$1,336.02
$1,504.34
$2,102.32
$3,194.66 		$1,627.34
$1,786.26
$1,954.58
$2,552.56 		$2,077.58
$2,236.50
$2,404.82
$3,002.80 		$2,527.82
$2,686.74
$2,855.06
$3,453.04 		$450.24
Toc - Plan #117 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$588.92
$668.43
$752.64
$1,051.81
$1,598.33 		$1,039.44
$1,118.95
$1,203.16
$1,502.33 		$1,489.96
$1,569.47
$1,653.68
$1,952.85 		$1,940.48
$2,019.99
$2,104.20
$2,403.37 		$450.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,177.84
$1,336.86
$1,505.28
$2,103.62
$3,196.66 		$1,628.36
$1,787.38
$1,955.80
$2,554.14 		$2,078.88
$2,237.90
$2,406.32
$3,004.66 		$2,529.40
$2,688.42
$2,856.84
$3,455.18 		$450.52
Toc - Plan #118 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$562.77
$638.74
$719.22
$1,005.11
$1,527.35 		$993.29
$1,069.26
$1,149.74
$1,435.63 		$1,423.81
$1,499.78
$1,580.26
$1,866.15 		$1,854.33
$1,930.30
$2,010.78
$2,296.67 		$430.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,125.54
$1,277.48
$1,438.44
$2,010.22
$3,054.70 		$1,556.06
$1,708.00
$1,868.96
$2,440.74 		$1,986.58
$2,138.52
$2,299.48
$2,871.26 		$2,417.10
$2,569.04
$2,730.00
$3,301.78 		$430.52
Toc - Plan #119 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$494.72
$561.50
$632.25
$883.57
$1,342.66 		$873.18
$939.96
$1,010.71
$1,262.03 		$1,251.64
$1,318.42
$1,389.17
$1,640.49 		$1,630.10
$1,696.88
$1,767.63
$2,018.95 		$378.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$989.44
$1,123.00
$1,264.50
$1,767.14
$2,685.32 		$1,367.90
$1,501.46
$1,642.96
$2,145.60 		$1,746.36
$1,879.92
$2,021.42
$2,524.06 		$2,124.82
$2,258.38
$2,399.88
$2,902.52 		$378.46
Toc - Plan #120 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$516.66
$586.41
$660.29
$922.75
$1,402.21 		$911.90
$981.65
$1,055.53
$1,317.99 		$1,307.14
$1,376.89
$1,450.77
$1,713.23 		$1,702.38
$1,772.13
$1,846.01
$2,108.47 		$395.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,033.32
$1,172.82
$1,320.58
$1,845.50
$2,804.42 		$1,428.56
$1,568.06
$1,715.82
$2,240.74 		$1,823.80
$1,963.30
$2,111.06
$2,635.98 		$2,219.04
$2,358.54
$2,506.30
$3,031.22 		$395.24
Toc - Plan #121 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$519.10
$589.18
$663.41
$927.12
$1,408.84 		$916.21
$986.29
$1,060.52
$1,324.23 		$1,313.32
$1,383.40
$1,457.63
$1,721.34 		$1,710.43
$1,780.51
$1,854.74
$2,118.45 		$397.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,038.20
$1,178.36
$1,326.82
$1,854.24
$2,817.68 		$1,435.31
$1,575.47
$1,723.93
$2,251.35 		$1,832.42
$1,972.58
$2,121.04
$2,648.46 		$2,229.53
$2,369.69
$2,518.15
$3,045.57 		$397.11
Toc - Plan #122 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$495.13
$561.98
$632.78
$884.31
$1,343.79 		$873.91
$940.76
$1,011.56
$1,263.09 		$1,252.69
$1,319.54
$1,390.34
$1,641.87 		$1,631.47
$1,698.32
$1,769.12
$2,020.65 		$378.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$990.26
$1,123.96
$1,265.56
$1,768.62
$2,687.58 		$1,369.04
$1,502.74
$1,644.34
$2,147.40 		$1,747.82
$1,881.52
$2,023.12
$2,526.18 		$2,126.60
$2,260.30
$2,401.90
$2,904.96 		$378.78
Toc - Plan #123 UnitedHealthcare
Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382.96
$434.66
$489.43
$683.97
$1,039.36 		$675.93
$727.63
$782.40
$976.94 		$968.90
$1,020.60
$1,075.37
$1,269.91 		$1,261.87
$1,313.57
$1,368.34
$1,562.88 		$292.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.92
$869.32
$978.86
$1,367.94
$2,078.72 		$1,058.89
$1,162.29
$1,271.83
$1,660.91 		$1,351.86
$1,455.26
$1,564.80
$1,953.88 		$1,644.83
$1,748.23
$1,857.77
$2,246.85 		$292.97
Toc - Plan #124 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$396.87
$450.45
$507.20
$708.81
$1,077.11 		$700.48
$754.06
$810.81
$1,012.42 		$1,004.09
$1,057.67
$1,114.42
$1,316.03 		$1,307.70
$1,361.28
$1,418.03
$1,619.64 		$303.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.74
$900.90
$1,014.40
$1,417.62
$2,154.22 		$1,097.35
$1,204.51
$1,318.01
$1,721.23 		$1,400.96
$1,508.12
$1,621.62
$2,024.84 		$1,704.57
$1,811.73
$1,925.23
$2,328.45 		$303.61
Toc - Plan #125 UnitedHealthcare
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375.13
$425.77
$479.42
$669.99
$1,018.11 		$662.11
$712.75
$766.40
$956.97 		$949.09
$999.73
$1,053.38
$1,243.95 		$1,236.07
$1,286.71
$1,340.36
$1,530.93 		$286.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.26
$851.54
$958.84
$1,339.98
$2,036.22 		$1,037.24
$1,138.52
$1,245.82
$1,626.96 		$1,324.22
$1,425.50
$1,532.80
$1,913.94 		$1,611.20
$1,712.48
$1,819.78
$2,200.92 		$286.98

‡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 Polk County here.

Polk County is in “Rating Area 53” of Florida.

Currently, there are 125 plans offered in Rating Area 53.

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2023 Obamacare Plans for Polk County, FL

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