Obamacare 2023 Rates for Rogers County

Obamacare > Rates > Oklahoma > Rogers County

ADVERTISEMENT

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 Rogers County, OK.

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, 99 Plans and 2023 Rates for Rogers County, Oklahoma

Below, you’ll find a summary of the 99 plans for Rogers County, Oklahoma 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 |

Rogers County Resources

ADVERTISEMENT

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-676-3777
Toc - Plan #1 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.20
$459.89
$517.83
$723.66
$1,099.68 		$715.17
$769.86
$827.80
$1,033.63 		$1,025.14
$1,079.83
$1,137.77
$1,343.60 		$1,335.11
$1,389.80
$1,447.74
$1,653.57 		$309.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.40
$919.78
$1,035.66
$1,447.32
$2,199.36 		$1,120.37
$1,229.75
$1,345.63
$1,757.29 		$1,430.34
$1,539.72
$1,655.60
$2,067.26 		$1,740.31
$1,849.69
$1,965.57
$2,377.23 		$309.97
Toc - Plan #2 Medica
Catastrophic

(PPO) Harmony by Medica Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$234.94
$266.64
$300.24
$419.58
$637.60 		$414.66
$446.36
$479.96
$599.30 		$594.38
$626.08
$659.68
$779.02 		$774.10
$805.80
$839.40
$958.74 		$179.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$469.88
$533.28
$600.48
$839.16
$1,275.20 		$649.60
$713.00
$780.20
$1,018.88 		$829.32
$892.72
$959.92
$1,198.60 		$1,009.04
$1,072.44
$1,139.64
$1,378.32 		$179.72
Toc - Plan #3 Medica
Silver

(PPO) Harmony by Medica Silver Share ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$464.55
$527.24
$593.67
$829.66
$1,260.74 		$819.92
$882.61
$949.04
$1,185.03 		$1,175.29
$1,237.98
$1,304.41
$1,540.40 		$1,530.66
$1,593.35
$1,659.78
$1,895.77 		$355.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.10
$1,054.48
$1,187.34
$1,659.32
$2,521.48 		$1,284.47
$1,409.85
$1,542.71
$2,014.69 		$1,639.84
$1,765.22
$1,898.08
$2,370.06 		$1,995.21
$2,120.59
$2,253.45
$2,725.43 		$355.37
Toc - Plan #4 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$342.93
$389.22
$438.25
$612.46
$930.69 		$605.26
$651.55
$700.58
$874.79 		$867.59
$913.88
$962.91
$1,137.12 		$1,129.92
$1,176.21
$1,225.24
$1,399.45 		$262.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.86
$778.44
$876.50
$1,224.92
$1,861.38 		$948.19
$1,040.77
$1,138.83
$1,487.25 		$1,210.52
$1,303.10
$1,401.16
$1,749.58 		$1,472.85
$1,565.43
$1,663.49
$2,011.91 		$262.33
Toc - Plan #5 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$331.45
$376.18
$423.57
$591.94
$899.51 		$585.00
$629.73
$677.12
$845.49 		$838.55
$883.28
$930.67
$1,099.04 		$1,092.10
$1,136.83
$1,184.22
$1,352.59 		$253.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662.90
$752.36
$847.14
$1,183.88
$1,799.02 		$916.45
$1,005.91
$1,100.69
$1,437.43 		$1,170.00
$1,259.46
$1,354.24
$1,690.98 		$1,423.55
$1,513.01
$1,607.79
$1,944.53 		$253.55
Toc - Plan #6 Medica
Gold

(PPO) Harmony by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$424.06
$481.29
$541.93
$757.34
$1,150.85 		$748.45
$805.68
$866.32
$1,081.73 		$1,072.84
$1,130.07
$1,190.71
$1,406.12 		$1,397.23
$1,454.46
$1,515.10
$1,730.51 		$324.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.12
$962.58
$1,083.86
$1,514.68
$2,301.70 		$1,172.51
$1,286.97
$1,408.25
$1,839.07 		$1,496.90
$1,611.36
$1,732.64
$2,163.46 		$1,821.29
$1,935.75
$2,057.03
$2,487.85 		$324.39
Toc - Plan #7 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze Premier ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$334.78
$379.96
$427.83
$597.90
$908.56 		$590.88
$636.06
$683.93
$854.00 		$846.98
$892.16
$940.03
$1,110.10 		$1,103.08
$1,148.26
$1,196.13
$1,366.20 		$256.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.56
$759.92
$855.66
$1,195.80
$1,817.12 		$925.66
$1,016.02
$1,111.76
$1,451.90 		$1,181.76
$1,272.12
$1,367.86
$1,708.00 		$1,437.86
$1,528.22
$1,623.96
$1,964.10 		$256.10
Toc - Plan #8 Medica
Gold

(PPO) Harmony by Medica Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$404.18
$458.73
$516.53
$721.84
$1,096.91 		$713.37
$767.92
$825.72
$1,031.03 		$1,022.56
$1,077.11
$1,134.91
$1,340.22 		$1,331.75
$1,386.30
$1,444.10
$1,649.41 		$309.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.36
$917.46
$1,033.06
$1,443.68
$2,193.82 		$1,117.55
$1,226.65
$1,342.25
$1,752.87 		$1,426.74
$1,535.84
$1,651.44
$2,062.06 		$1,735.93
$1,845.03
$1,960.63
$2,371.25 		$309.19
Toc - Plan #9 Medica
Silver

(PPO) Harmony by Medica Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$403.16
$457.57
$515.22
$720.02
$1,094.14 		$711.57
$765.98
$823.63
$1,028.43 		$1,019.98
$1,074.39
$1,132.04
$1,336.84 		$1,328.39
$1,382.80
$1,440.45
$1,645.25 		$308.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.32
$915.14
$1,030.44
$1,440.04
$2,188.28 		$1,114.73
$1,223.55
$1,338.85
$1,748.45 		$1,423.14
$1,531.96
$1,647.26
$2,056.86 		$1,731.55
$1,840.37
$1,955.67
$2,365.27 		$308.41
Toc - Plan #10 Medica
Bronze

(PPO) Harmony by Medica Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$316.81
$359.56
$404.86
$565.79
$859.77 		$559.16
$601.91
$647.21
$808.14 		$801.51
$844.26
$889.56
$1,050.49 		$1,043.86
$1,086.61
$1,131.91
$1,292.84 		$242.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.62
$719.12
$809.72
$1,131.58
$1,719.54 		$875.97
$961.47
$1,052.07
$1,373.93 		$1,118.32
$1,203.82
$1,294.42
$1,616.28 		$1,360.67
$1,446.17
$1,536.77
$1,858.63 		$242.35

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-980-5319 | Toll Free: 1-800-980-5319

Toc - Plan #11 UnitedHealthcare
Gold

(HMO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 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 		$478.01
$542.54
$610.90
$853.72
$1,297.32 		$843.69
$908.22
$976.58
$1,219.40 		$1,209.37
$1,273.90
$1,342.26
$1,585.08 		$1,575.05
$1,639.58
$1,707.94
$1,950.76 		$365.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$956.02
$1,085.08
$1,221.80
$1,707.44
$2,594.64 		$1,321.70
$1,450.76
$1,587.48
$2,073.12 		$1,687.38
$1,816.44
$1,953.16
$2,438.80 		$2,053.06
$2,182.12
$2,318.84
$2,804.48 		$365.68
Toc - Plan #12 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$464.59
$527.31
$593.75
$829.76
$1,260.90 		$820.00
$882.72
$949.16
$1,185.17 		$1,175.41
$1,238.13
$1,304.57
$1,540.58 		$1,530.82
$1,593.54
$1,659.98
$1,895.99 		$355.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.18
$1,054.62
$1,187.50
$1,659.52
$2,521.80 		$1,284.59
$1,410.03
$1,542.91
$2,014.93 		$1,640.00
$1,765.44
$1,898.32
$2,370.34 		$1,995.41
$2,120.85
$2,253.73
$2,725.75 		$355.41
Toc - Plan #13 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,400 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$467.34
$530.43
$597.26
$834.67
$1,268.36 		$824.85
$887.94
$954.77
$1,192.18 		$1,182.36
$1,245.45
$1,312.28
$1,549.69 		$1,539.87
$1,602.96
$1,669.79
$1,907.20 		$357.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.68
$1,060.86
$1,194.52
$1,669.34
$2,536.72 		$1,292.19
$1,418.37
$1,552.03
$2,026.85 		$1,649.70
$1,775.88
$1,909.54
$2,384.36 		$2,007.21
$2,133.39
$2,267.05
$2,741.87 		$357.51
Toc - Plan #14 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$467.39
$530.48
$597.32
$834.75
$1,268.49 		$824.94
$888.03
$954.87
$1,192.30 		$1,182.49
$1,245.58
$1,312.42
$1,549.85 		$1,540.04
$1,603.13
$1,669.97
$1,907.40 		$357.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.78
$1,060.96
$1,194.64
$1,669.50
$2,536.98 		$1,292.33
$1,418.51
$1,552.19
$2,027.05 		$1,649.88
$1,776.06
$1,909.74
$2,384.60 		$2,007.43
$2,133.61
$2,267.29
$2,742.15 		$357.55
Toc - Plan #15 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$365.79
$415.17
$467.48
$653.30
$992.75 		$645.62
$695.00
$747.31
$933.13 		$925.45
$974.83
$1,027.14
$1,212.96 		$1,205.28
$1,254.66
$1,306.97
$1,492.79 		$279.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.58
$830.34
$934.96
$1,306.60
$1,985.50 		$1,011.41
$1,110.17
$1,214.79
$1,586.43 		$1,291.24
$1,390.00
$1,494.62
$1,866.26 		$1,571.07
$1,669.83
$1,774.45
$2,146.09 		$279.83
Toc - Plan #16 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$498.93
$566.29
$637.64
$891.10
$1,354.11 		$880.61
$947.97
$1,019.32
$1,272.78 		$1,262.29
$1,329.65
$1,401.00
$1,654.46 		$1,643.97
$1,711.33
$1,782.68
$2,036.14 		$381.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$997.86
$1,132.58
$1,275.28
$1,782.20
$2,708.22 		$1,379.54
$1,514.26
$1,656.96
$2,163.88 		$1,761.22
$1,895.94
$2,038.64
$2,545.56 		$2,142.90
$2,277.62
$2,420.32
$2,927.24 		$381.68
Toc - Plan #17 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$462.95
$525.44
$591.65
$826.82
$1,256.44 		$817.10
$879.59
$945.80
$1,180.97 		$1,171.25
$1,233.74
$1,299.95
$1,535.12 		$1,525.40
$1,587.89
$1,654.10
$1,889.27 		$354.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.90
$1,050.88
$1,183.30
$1,653.64
$2,512.88 		$1,280.05
$1,405.03
$1,537.45
$2,007.79 		$1,634.20
$1,759.18
$1,891.60
$2,361.94 		$1,988.35
$2,113.33
$2,245.75
$2,716.09 		$354.15
Toc - Plan #18 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$477.60
$542.07
$610.37
$852.99
$1,296.20 		$842.96
$907.43
$975.73
$1,218.35 		$1,208.32
$1,272.79
$1,341.09
$1,583.71 		$1,573.68
$1,638.15
$1,706.45
$1,949.07 		$365.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$955.20
$1,084.14
$1,220.74
$1,705.98
$2,592.40 		$1,320.56
$1,449.50
$1,586.10
$2,071.34 		$1,685.92
$1,814.86
$1,951.46
$2,436.70 		$2,051.28
$2,180.22
$2,316.82
$2,802.06 		$365.36
Toc - Plan #19 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$359.15
$407.63
$458.99
$641.44
$974.73 		$633.90
$682.38
$733.74
$916.19 		$908.65
$957.13
$1,008.49
$1,190.94 		$1,183.40
$1,231.88
$1,283.24
$1,465.69 		$274.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.30
$815.26
$917.98
$1,282.88
$1,949.46 		$993.05
$1,090.01
$1,192.73
$1,557.63 		$1,267.80
$1,364.76
$1,467.48
$1,832.38 		$1,542.55
$1,639.51
$1,742.23
$2,107.13 		$274.75
Toc - Plan #20 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded Saver ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$369.57
$419.46
$472.31
$660.05
$1,003.01 		$652.29
$702.18
$755.03
$942.77 		$935.01
$984.90
$1,037.75
$1,225.49 		$1,217.73
$1,267.62
$1,320.47
$1,508.21 		$282.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.14
$838.92
$944.62
$1,320.10
$2,006.02 		$1,021.86
$1,121.64
$1,227.34
$1,602.82 		$1,304.58
$1,404.36
$1,510.06
$1,885.54 		$1,587.30
$1,687.08
$1,792.78
$2,168.26 		$282.72
Toc - Plan #21 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 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 		$364.06
$413.21
$465.27
$650.21
$988.06 		$642.57
$691.72
$743.78
$928.72 		$921.08
$970.23
$1,022.29
$1,207.23 		$1,199.59
$1,248.74
$1,300.80
$1,485.74 		$278.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.12
$826.42
$930.54
$1,300.42
$1,976.12 		$1,006.63
$1,104.93
$1,209.05
$1,578.93 		$1,285.14
$1,383.44
$1,487.56
$1,857.44 		$1,563.65
$1,661.95
$1,766.07
$2,135.95 		$278.51
Toc - Plan #22 UnitedHealthcare
Gold

(HMO) UHC Gold Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$483.63
$548.92
$618.08
$863.77
$1,312.58 		$853.61
$918.90
$988.06
$1,233.75 		$1,223.59
$1,288.88
$1,358.04
$1,603.73 		$1,593.57
$1,658.86
$1,728.02
$1,973.71 		$369.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$967.26
$1,097.84
$1,236.16
$1,727.54
$2,625.16 		$1,337.24
$1,467.82
$1,606.14
$2,097.52 		$1,707.22
$1,837.80
$1,976.12
$2,467.50 		$2,077.20
$2,207.78
$2,346.10
$2,837.48 		$369.98
Toc - Plan #23 UnitedHealthcare
Silver

(HMO) UHC Silver Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$467.25
$530.33
$597.15
$834.51
$1,268.12 		$824.70
$887.78
$954.60
$1,191.96 		$1,182.15
$1,245.23
$1,312.05
$1,549.41 		$1,539.60
$1,602.68
$1,669.50
$1,906.86 		$357.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.50
$1,060.66
$1,194.30
$1,669.02
$2,536.24 		$1,291.95
$1,418.11
$1,551.75
$2,026.47 		$1,649.40
$1,775.56
$1,909.20
$2,383.92 		$2,006.85
$2,133.01
$2,266.65
$2,741.37 		$357.45
Toc - Plan #24 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$368.14
$417.84
$470.49
$657.51
$999.14 		$649.77
$699.47
$752.12
$939.14 		$931.40
$981.10
$1,033.75
$1,220.77 		$1,213.03
$1,262.73
$1,315.38
$1,502.40 		$281.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.28
$835.68
$940.98
$1,315.02
$1,998.28 		$1,017.91
$1,117.31
$1,222.61
$1,596.65 		$1,299.54
$1,398.94
$1,504.24
$1,878.28 		$1,581.17
$1,680.57
$1,785.87
$2,159.91 		$281.63
Toc - Plan #25 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5319

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 		$351.07
$398.46
$448.67
$627.01
$952.80 		$619.64
$667.03
$717.24
$895.58 		$888.21
$935.60
$985.81
$1,164.15 		$1,156.78
$1,204.17
$1,254.38
$1,432.72 		$268.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.14
$796.92
$897.34
$1,254.02
$1,905.60 		$970.71
$1,065.49
$1,165.91
$1,522.59 		$1,239.28
$1,334.06
$1,434.48
$1,791.16 		$1,507.85
$1,602.63
$1,703.05
$2,059.73 		$268.57

ADVERTISEMENT

Ambetter of Oklahoma

Local: 1-833-492-0679 | Toll Free: 1-833-492-0679

Toc - Plan #26 Ambetter of Oklahoma
Bronze

(PPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$302.48
$343.30
$386.55
$540.20
$820.89 		$533.87
$574.69
$617.94
$771.59 		$765.26
$806.08
$849.33
$1,002.98 		$996.65
$1,037.47
$1,080.72
$1,234.37 		$231.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.96
$686.60
$773.10
$1,080.40
$1,641.78 		$836.35
$917.99
$1,004.49
$1,311.79 		$1,067.74
$1,149.38
$1,235.88
$1,543.18 		$1,299.13
$1,380.77
$1,467.27
$1,774.57 		$231.39
Toc - Plan #27 Ambetter of Oklahoma
Expanded Bronze

(PPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$326.32
$370.37
$417.03
$582.80
$885.62 		$575.95
$620.00
$666.66
$832.43 		$825.58
$869.63
$916.29
$1,082.06 		$1,075.21
$1,119.26
$1,165.92
$1,331.69 		$249.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.64
$740.74
$834.06
$1,165.60
$1,771.24 		$902.27
$990.37
$1,083.69
$1,415.23 		$1,151.90
$1,240.00
$1,333.32
$1,664.86 		$1,401.53
$1,489.63
$1,582.95
$1,914.49 		$249.63
Toc - Plan #28 Ambetter of Oklahoma
Expanded Bronze

(PPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$368.96
$418.76
$471.52
$658.95
$1,001.34 		$651.21
$701.01
$753.77
$941.20 		$933.46
$983.26
$1,036.02
$1,223.45 		$1,215.71
$1,265.51
$1,318.27
$1,505.70 		$282.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.92
$837.52
$943.04
$1,317.90
$2,002.68 		$1,020.17
$1,119.77
$1,225.29
$1,600.15 		$1,302.42
$1,402.02
$1,507.54
$1,882.40 		$1,584.67
$1,684.27
$1,789.79
$2,164.65 		$282.25
Toc - Plan #29 Ambetter of Oklahoma
Silver

(PPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$380.37
$431.71
$486.11
$679.33
$1,032.31 		$671.35
$722.69
$777.09
$970.31 		$962.33
$1,013.67
$1,068.07
$1,261.29 		$1,253.31
$1,304.65
$1,359.05
$1,552.27 		$290.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.74
$863.42
$972.22
$1,358.66
$2,064.62 		$1,051.72
$1,154.40
$1,263.20
$1,649.64 		$1,342.70
$1,445.38
$1,554.18
$1,940.62 		$1,633.68
$1,736.36
$1,845.16
$2,231.60 		$290.98
Toc - Plan #30 Ambetter of Oklahoma
Silver

(PPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$369.31
$419.15
$471.96
$659.56
$1,002.27 		$651.82
$701.66
$754.47
$942.07 		$934.33
$984.17
$1,036.98
$1,224.58 		$1,216.84
$1,266.68
$1,319.49
$1,507.09 		$282.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.62
$838.30
$943.92
$1,319.12
$2,004.54 		$1,021.13
$1,120.81
$1,226.43
$1,601.63 		$1,303.64
$1,403.32
$1,508.94
$1,884.14 		$1,586.15
$1,685.83
$1,791.45
$2,166.65 		$282.51
Toc - Plan #31 Ambetter of Oklahoma
Silver

(PPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$374.67
$425.24
$478.81
$669.14
$1,016.82 		$661.28
$711.85
$765.42
$955.75 		$947.89
$998.46
$1,052.03
$1,242.36 		$1,234.50
$1,285.07
$1,338.64
$1,528.97 		$286.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.34
$850.48
$957.62
$1,338.28
$2,033.64 		$1,035.95
$1,137.09
$1,244.23
$1,624.89 		$1,322.56
$1,423.70
$1,530.84
$1,911.50 		$1,609.17
$1,710.31
$1,817.45
$2,198.11 		$286.61
Toc - Plan #32 Ambetter of Oklahoma
Gold

(PPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$419.02
$475.58
$535.49
$748.35
$1,137.19 		$739.56
$796.12
$856.03
$1,068.89 		$1,060.10
$1,116.66
$1,176.57
$1,389.43 		$1,380.64
$1,437.20
$1,497.11
$1,709.97 		$320.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.04
$951.16
$1,070.98
$1,496.70
$2,274.38 		$1,158.58
$1,271.70
$1,391.52
$1,817.24 		$1,479.12
$1,592.24
$1,712.06
$2,137.78 		$1,799.66
$1,912.78
$2,032.60
$2,458.32 		$320.54
Toc - Plan #33 Ambetter of Oklahoma
Gold

(PPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$484.63
$550.05
$619.35
$865.53
$1,315.26 		$855.37
$920.79
$990.09
$1,236.27 		$1,226.11
$1,291.53
$1,360.83
$1,607.01 		$1,596.85
$1,662.27
$1,731.57
$1,977.75 		$370.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969.26
$1,100.10
$1,238.70
$1,731.06
$2,630.52 		$1,340.00
$1,470.84
$1,609.44
$2,101.80 		$1,710.74
$1,841.58
$1,980.18
$2,472.54 		$2,081.48
$2,212.32
$2,350.92
$2,843.28 		$370.74
Toc - Plan #34 Ambetter of Oklahoma
Gold

(PPO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.26
$470.18
$529.42
$739.86
$1,124.29 		$731.16
$787.08
$846.32
$1,056.76 		$1,048.06
$1,103.98
$1,163.22
$1,373.66 		$1,364.96
$1,420.88
$1,480.12
$1,690.56 		$316.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.52
$940.36
$1,058.84
$1,479.72
$2,248.58 		$1,145.42
$1,257.26
$1,375.74
$1,796.62 		$1,462.32
$1,574.16
$1,692.64
$2,113.52 		$1,779.22
$1,891.06
$2,009.54
$2,430.42 		$316.90
Toc - Plan #35 Ambetter of Oklahoma
Expanded Bronze

(PPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$319.02
$362.08
$407.70
$569.75
$865.80 		$563.06
$606.12
$651.74
$813.79 		$807.10
$850.16
$895.78
$1,057.83 		$1,051.14
$1,094.20
$1,139.82
$1,301.87 		$244.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.04
$724.16
$815.40
$1,139.50
$1,731.60 		$882.08
$968.20
$1,059.44
$1,383.54 		$1,126.12
$1,212.24
$1,303.48
$1,627.58 		$1,370.16
$1,456.28
$1,547.52
$1,871.62 		$244.04
Toc - Plan #36 Ambetter of Oklahoma
Silver

(PPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$370.64
$420.66
$473.66
$661.94
$1,005.88 		$654.17
$704.19
$757.19
$945.47 		$937.70
$987.72
$1,040.72
$1,229.00 		$1,221.23
$1,271.25
$1,324.25
$1,512.53 		$283.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.28
$841.32
$947.32
$1,323.88
$2,011.76 		$1,024.81
$1,124.85
$1,230.85
$1,607.41 		$1,308.34
$1,408.38
$1,514.38
$1,890.94 		$1,591.87
$1,691.91
$1,797.91
$2,174.47 		$283.53
Toc - Plan #37 Ambetter of Oklahoma
Gold

(PPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$413.09
$468.84
$527.91
$737.75
$1,121.09 		$729.09
$784.84
$843.91
$1,053.75 		$1,045.09
$1,100.84
$1,159.91
$1,369.75 		$1,361.09
$1,416.84
$1,475.91
$1,685.75 		$316.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.18
$937.68
$1,055.82
$1,475.50
$2,242.18 		$1,142.18
$1,253.68
$1,371.82
$1,791.50 		$1,458.18
$1,569.68
$1,687.82
$2,107.50 		$1,774.18
$1,885.68
$2,003.82
$2,423.50 		$316.00
Toc - Plan #38 Ambetter of Oklahoma
Bronze

(PPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$317.40
$360.24
$405.63
$566.87
$861.41 		$560.21
$603.05
$648.44
$809.68 		$803.02
$845.86
$891.25
$1,052.49 		$1,045.83
$1,088.67
$1,134.06
$1,295.30 		$242.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.80
$720.48
$811.26
$1,133.74
$1,722.82 		$877.61
$963.29
$1,054.07
$1,376.55 		$1,120.42
$1,206.10
$1,296.88
$1,619.36 		$1,363.23
$1,448.91
$1,539.69
$1,862.17 		$242.81
Toc - Plan #39 Ambetter of Oklahoma
Expanded Bronze

(PPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$342.43
$388.65
$437.61
$611.56
$929.33 		$604.38
$650.60
$699.56
$873.51 		$866.33
$912.55
$961.51
$1,135.46 		$1,128.28
$1,174.50
$1,223.46
$1,397.41 		$261.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.86
$777.30
$875.22
$1,223.12
$1,858.66 		$946.81
$1,039.25
$1,137.17
$1,485.07 		$1,208.76
$1,301.20
$1,399.12
$1,747.02 		$1,470.71
$1,563.15
$1,661.07
$2,008.97 		$261.95
Toc - Plan #40 Ambetter of Oklahoma
Expanded Bronze

(PPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$387.17
$439.43
$494.80
$691.47
$1,050.76 		$683.35
$735.61
$790.98
$987.65 		$979.53
$1,031.79
$1,087.16
$1,283.83 		$1,275.71
$1,327.97
$1,383.34
$1,580.01 		$296.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.34
$878.86
$989.60
$1,382.94
$2,101.52 		$1,070.52
$1,175.04
$1,285.78
$1,679.12 		$1,366.70
$1,471.22
$1,581.96
$1,975.30 		$1,662.88
$1,767.40
$1,878.14
$2,271.48 		$296.18
Toc - Plan #41 Ambetter of Oklahoma
Silver

(PPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.15
$453.02
$510.10
$712.86
$1,083.26 		$704.49
$758.36
$815.44
$1,018.20 		$1,009.83
$1,063.70
$1,120.78
$1,323.54 		$1,315.17
$1,369.04
$1,426.12
$1,628.88 		$305.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.30
$906.04
$1,020.20
$1,425.72
$2,166.52 		$1,103.64
$1,211.38
$1,325.54
$1,731.06 		$1,408.98
$1,516.72
$1,630.88
$2,036.40 		$1,714.32
$1,822.06
$1,936.22
$2,341.74 		$305.34
Toc - Plan #42 Ambetter of Oklahoma
Silver

(PPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$393.16
$446.23
$502.45
$702.17
$1,067.01 		$693.92
$746.99
$803.21
$1,002.93 		$994.68
$1,047.75
$1,103.97
$1,303.69 		$1,295.44
$1,348.51
$1,404.73
$1,604.45 		$300.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.32
$892.46
$1,004.90
$1,404.34
$2,134.02 		$1,087.08
$1,193.22
$1,305.66
$1,705.10 		$1,387.84
$1,493.98
$1,606.42
$2,005.86 		$1,688.60
$1,794.74
$1,907.18
$2,306.62 		$300.76
Toc - Plan #43 Ambetter of Oklahoma
Gold

(PPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$439.70
$499.05
$561.92
$785.29
$1,193.32 		$776.06
$835.41
$898.28
$1,121.65 		$1,112.42
$1,171.77
$1,234.64
$1,458.01 		$1,448.78
$1,508.13
$1,571.00
$1,794.37 		$336.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.40
$998.10
$1,123.84
$1,570.58
$2,386.64 		$1,215.76
$1,334.46
$1,460.20
$1,906.94 		$1,552.12
$1,670.82
$1,796.56
$2,243.30 		$1,888.48
$2,007.18
$2,132.92
$2,579.66 		$336.36
Toc - Plan #44 Ambetter of Oklahoma
Silver

(PPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$387.53
$439.84
$495.25
$692.12
$1,051.74 		$683.99
$736.30
$791.71
$988.58 		$980.45
$1,032.76
$1,088.17
$1,285.04 		$1,276.91
$1,329.22
$1,384.63
$1,581.50 		$296.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.06
$879.68
$990.50
$1,384.24
$2,103.48 		$1,071.52
$1,176.14
$1,286.96
$1,680.70 		$1,367.98
$1,472.60
$1,583.42
$1,977.16 		$1,664.44
$1,769.06
$1,879.88
$2,273.62 		$296.46
Toc - Plan #45 Ambetter of Oklahoma
Gold

(PPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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 		$508.55
$577.19
$649.92
$908.26
$1,380.18 		$897.58
$966.22
$1,038.95
$1,297.29 		$1,286.61
$1,355.25
$1,427.98
$1,686.32 		$1,675.64
$1,744.28
$1,817.01
$2,075.35 		$389.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,017.10
$1,154.38
$1,299.84
$1,816.52
$2,760.36 		$1,406.13
$1,543.41
$1,688.87
$2,205.55 		$1,795.16
$1,932.44
$2,077.90
$2,594.58 		$2,184.19
$2,321.47
$2,466.93
$2,983.61 		$389.03
Toc - Plan #46 Ambetter of Oklahoma
Gold

(PPO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$434.71
$493.39
$555.55
$776.38
$1,179.78 		$767.26
$825.94
$888.10
$1,108.93 		$1,099.81
$1,158.49
$1,220.65
$1,441.48 		$1,432.36
$1,491.04
$1,553.20
$1,774.03 		$332.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869.42
$986.78
$1,111.10
$1,552.76
$2,359.56 		$1,201.97
$1,319.33
$1,443.65
$1,885.31 		$1,534.52
$1,651.88
$1,776.20
$2,217.86 		$1,867.07
$1,984.43
$2,108.75
$2,550.41 		$332.55

ADVERTISEMENT

Blue Cross and Blue Shield of Oklahoma

Local: 1-866-520-2507 | Toll Free: 1-866-520-2507 | TTY: 1-800-722-0353
Toc - Plan #47 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Preferred Silver PPO? 201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,750 $5,250 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 		$584.55
$663.47
$747.06
$1,044.01
$1,586.47 		$1,031.73
$1,110.65
$1,194.24
$1,491.19 		$1,478.91
$1,557.83
$1,641.42
$1,938.37 		$1,926.09
$2,005.01
$2,088.60
$2,385.55 		$447.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,169.10
$1,326.94
$1,494.12
$2,088.02
$3,172.94 		$1,616.28
$1,774.12
$1,941.30
$2,535.20 		$2,063.46
$2,221.30
$2,388.48
$2,982.38 		$2,510.64
$2,668.48
$2,835.66
$3,429.56 		$447.18
Toc - Plan #48 Blue Cross and Blue Shield of Oklahoma
Catastrophic

(PPO) Blue Preferred Security PPO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$362.28
$411.19
$463.00
$647.04
$983.23 		$639.43
$688.34
$740.15
$924.19 		$916.58
$965.49
$1,017.30
$1,201.34 		$1,193.73
$1,242.64
$1,294.45
$1,478.49 		$277.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.56
$822.38
$926.00
$1,294.08
$1,966.46 		$1,001.71
$1,099.53
$1,203.15
$1,571.23 		$1,278.86
$1,376.68
$1,480.30
$1,848.38 		$1,556.01
$1,653.83
$1,757.45
$2,125.53 		$277.15
Toc - Plan #49 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Preferred Gold PPO? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$550 $1,650 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 		$539.09
$611.86
$688.95
$962.81
$1,463.08 		$951.49
$1,024.26
$1,101.35
$1,375.21 		$1,363.89
$1,436.66
$1,513.75
$1,787.61 		$1,776.29
$1,849.06
$1,926.15
$2,200.01 		$412.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,078.18
$1,223.72
$1,377.90
$1,925.62
$2,926.16 		$1,490.58
$1,636.12
$1,790.30
$2,338.02 		$1,902.98
$2,048.52
$2,202.70
$2,750.42 		$2,315.38
$2,460.92
$2,615.10
$3,162.82 		$412.40
Toc - Plan #50 Blue Cross and Blue Shield of Oklahoma
Bronze

(PPO) Blue Preferred Bronze PPO? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$6,000 $17,400 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 		$422.59
$479.64
$540.07
$754.75
$1,146.92 		$745.87
$802.92
$863.35
$1,078.03 		$1,069.15
$1,126.20
$1,186.63
$1,401.31 		$1,392.43
$1,449.48
$1,509.91
$1,724.59 		$323.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.18
$959.28
$1,080.14
$1,509.50
$2,293.84 		$1,168.46
$1,282.56
$1,403.42
$1,832.78 		$1,491.74
$1,605.84
$1,726.70
$2,156.06 		$1,815.02
$1,929.12
$2,049.98
$2,479.34 		$323.28
Toc - Plan #51 Blue Cross and Blue Shield of Oklahoma
Bronze

(PPO) Blue Preferred Bronze PPO? 603

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$7,500 $17,400 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 		$407.31
$462.29
$520.54
$727.45
$1,105.43 		$718.90
$773.88
$832.13
$1,039.04 		$1,030.49
$1,085.47
$1,143.72
$1,350.63 		$1,342.08
$1,397.06
$1,455.31
$1,662.22 		$311.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.62
$924.58
$1,041.08
$1,454.90
$2,210.86 		$1,126.21
$1,236.17
$1,352.67
$1,766.49 		$1,437.80
$1,547.76
$1,664.26
$2,078.08 		$1,749.39
$1,859.35
$1,975.85
$2,389.67 		$311.59
Toc - Plan #52 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Preferred Gold PPO? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$553.20
$627.88
$706.99
$988.02
$1,501.38 		$976.40
$1,051.08
$1,130.19
$1,411.22 		$1,399.60
$1,474.28
$1,553.39
$1,834.42 		$1,822.80
$1,897.48
$1,976.59
$2,257.62 		$423.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,106.40
$1,255.76
$1,413.98
$1,976.04
$3,002.76 		$1,529.60
$1,678.96
$1,837.18
$2,399.24 		$1,952.80
$2,102.16
$2,260.38
$2,822.44 		$2,376.00
$2,525.36
$2,683.58
$3,245.64 		$423.20
Toc - Plan #53 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Preferred Silver PPO? 701

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$566.55
$643.03
$724.05
$1,011.86
$1,537.61 		$999.96
$1,076.44
$1,157.46
$1,445.27 		$1,433.37
$1,509.85
$1,590.87
$1,878.68 		$1,866.78
$1,943.26
$2,024.28
$2,312.09 		$433.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,133.10
$1,286.06
$1,448.10
$2,023.72
$3,075.22 		$1,566.51
$1,719.47
$1,881.51
$2,457.13 		$1,999.92
$2,152.88
$2,314.92
$2,890.54 		$2,433.33
$2,586.29
$2,748.33
$3,323.95 		$433.41
Toc - Plan #54 Blue Cross and Blue Shield of Oklahoma
Bronze

(PPO) Blue Preferred Bronze PPO? 706

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$432.72
$491.14
$553.02
$772.85
$1,174.41 		$763.75
$822.17
$884.05
$1,103.88 		$1,094.78
$1,153.20
$1,215.08
$1,434.91 		$1,425.81
$1,484.23
$1,546.11
$1,765.94 		$331.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$865.44
$982.28
$1,106.04
$1,545.70
$2,348.82 		$1,196.47
$1,313.31
$1,437.07
$1,876.73 		$1,527.50
$1,644.34
$1,768.10
$2,207.76 		$1,858.53
$1,975.37
$2,099.13
$2,538.79 		$331.03
Toc - Plan #55 Blue Cross and Blue Shield of Oklahoma
Expanded Bronze

(PPO) Blue Preferred Bronze PPO? 707

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$474.00
$537.99
$605.77
$846.56
$1,286.43 		$836.61
$900.60
$968.38
$1,209.17 		$1,199.22
$1,263.21
$1,330.99
$1,571.78 		$1,561.83
$1,625.82
$1,693.60
$1,934.39 		$362.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$948.00
$1,075.98
$1,211.54
$1,693.12
$2,572.86 		$1,310.61
$1,438.59
$1,574.15
$2,055.73 		$1,673.22
$1,801.20
$1,936.76
$2,418.34 		$2,035.83
$2,163.81
$2,299.37
$2,780.95 		$362.61
Toc - Plan #56 Blue Cross and Blue Shield of Oklahoma
Expanded Bronze

(PPO) Blue Advantage Bronze PPO? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$4,500 $13,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.81
$453.78
$510.95
$714.06
$1,085.08 		$705.66
$759.63
$816.80
$1,019.91 		$1,011.51
$1,065.48
$1,122.65
$1,325.76 		$1,317.36
$1,371.33
$1,428.50
$1,631.61 		$305.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.62
$907.56
$1,021.90
$1,428.12
$2,170.16 		$1,105.47
$1,213.41
$1,327.75
$1,733.97 		$1,411.32
$1,519.26
$1,633.60
$2,039.82 		$1,717.17
$1,825.11
$1,939.45
$2,345.67 		$305.85
Toc - Plan #57 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Advantage Silver PPO? 204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,200 $3,600 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 		$479.07
$543.74
$612.25
$855.61
$1,300.19 		$845.56
$910.23
$978.74
$1,222.10 		$1,212.05
$1,276.72
$1,345.23
$1,588.59 		$1,578.54
$1,643.21
$1,711.72
$1,955.08 		$366.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.14
$1,087.48
$1,224.50
$1,711.22
$2,600.38 		$1,324.63
$1,453.97
$1,590.99
$2,077.71 		$1,691.12
$1,820.46
$1,957.48
$2,444.20 		$2,057.61
$2,186.95
$2,323.97
$2,810.69 		$366.49
Toc - Plan #58 Blue Cross and Blue Shield of Oklahoma
Bronze

(PPO) Blue Advantage Bronze PPO? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345.31
$391.93
$441.31
$616.73
$937.18 		$609.47
$656.09
$705.47
$880.89 		$873.63
$920.25
$969.63
$1,145.05 		$1,137.79
$1,184.41
$1,233.79
$1,409.21 		$264.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.62
$783.86
$882.62
$1,233.46
$1,874.36 		$954.78
$1,048.02
$1,146.78
$1,497.62 		$1,218.94
$1,312.18
$1,410.94
$1,761.78 		$1,483.10
$1,576.34
$1,675.10
$2,025.94 		$264.16
Toc - Plan #59 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Advantage Gold PPO? 309

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,200 $3,600 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 		$454.58
$515.95
$580.96
$811.88
$1,233.74 		$802.34
$863.71
$928.72
$1,159.64 		$1,150.10
$1,211.47
$1,276.48
$1,507.40 		$1,497.86
$1,559.23
$1,624.24
$1,855.16 		$347.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.16
$1,031.90
$1,161.92
$1,623.76
$2,467.48 		$1,256.92
$1,379.66
$1,509.68
$1,971.52 		$1,604.68
$1,727.42
$1,857.44
$2,319.28 		$1,952.44
$2,075.18
$2,205.20
$2,667.04 		$347.76
Toc - Plan #60 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Advantage Silver PPO? 605

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$498.24
$565.50
$636.75
$889.85
$1,352.22 		$879.39
$946.65
$1,017.90
$1,271.00 		$1,260.54
$1,327.80
$1,399.05
$1,652.15 		$1,641.69
$1,708.95
$1,780.20
$2,033.30 		$381.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$996.48
$1,131.00
$1,273.50
$1,779.70
$2,704.44 		$1,377.63
$1,512.15
$1,654.65
$2,160.85 		$1,758.78
$1,893.30
$2,035.80
$2,542.00 		$2,139.93
$2,274.45
$2,416.95
$2,923.15 		$381.15
Toc - Plan #61 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Advantage Gold PPO? 604

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,150 $3,450 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 		$444.14
$504.10
$567.62
$793.24
$1,205.41 		$783.91
$843.87
$907.39
$1,133.01 		$1,123.68
$1,183.64
$1,247.16
$1,472.78 		$1,463.45
$1,523.41
$1,586.93
$1,812.55 		$339.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.28
$1,008.20
$1,135.24
$1,586.48
$2,410.82 		$1,228.05
$1,347.97
$1,475.01
$1,926.25 		$1,567.82
$1,687.74
$1,814.78
$2,266.02 		$1,907.59
$2,027.51
$2,154.55
$2,605.79 		$339.77
Toc - Plan #62 Blue Cross and Blue Shield of Oklahoma
Gold

(HMO) MyBlue Gold HMO? 704

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,100 $3,300 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 		$395.97
$449.43
$506.05
$707.20
$1,074.67 		$698.89
$752.35
$808.97
$1,010.12 		$1,001.81
$1,055.27
$1,111.89
$1,313.04 		$1,304.73
$1,358.19
$1,414.81
$1,615.96 		$302.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.94
$898.86
$1,012.10
$1,414.40
$2,149.34 		$1,094.86
$1,201.78
$1,315.02
$1,717.32 		$1,397.78
$1,504.70
$1,617.94
$2,020.24 		$1,700.70
$1,807.62
$1,920.86
$2,323.16 		$302.92
Toc - Plan #63 Blue Cross and Blue Shield of Oklahoma
Silver

(HMO) MyBlue Silver HMO? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$2,600 $7,800 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 		$411.48
$467.03
$525.87
$734.90
$1,116.76 		$726.26
$781.81
$840.65
$1,049.68 		$1,041.04
$1,096.59
$1,155.43
$1,364.46 		$1,355.82
$1,411.37
$1,470.21
$1,679.24 		$314.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.96
$934.06
$1,051.74
$1,469.80
$2,233.52 		$1,137.74
$1,248.84
$1,366.52
$1,784.58 		$1,452.52
$1,563.62
$1,681.30
$2,099.36 		$1,767.30
$1,878.40
$1,996.08
$2,414.14 		$314.78
Toc - Plan #64 Blue Cross and Blue Shield of Oklahoma
Gold

(HMO) MyBlue Gold HMO? 708

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$417.78
$474.18
$533.93
$746.16
$1,133.86 		$737.38
$793.78
$853.53
$1,065.76 		$1,056.98
$1,113.38
$1,173.13
$1,385.36 		$1,376.58
$1,432.98
$1,492.73
$1,704.96 		$319.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.56
$948.36
$1,067.86
$1,492.32
$2,267.72 		$1,155.16
$1,267.96
$1,387.46
$1,811.92 		$1,474.76
$1,587.56
$1,707.06
$2,131.52 		$1,794.36
$1,907.16
$2,026.66
$2,451.12 		$319.60
Toc - Plan #65 Blue Cross and Blue Shield of Oklahoma
Silver

(HMO) MyBlue Silver HMO? 709

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

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 		$418.94
$475.50
$535.40
$748.23
$1,137.00 		$739.43
$795.99
$855.89
$1,068.72 		$1,059.92
$1,116.48
$1,176.38
$1,389.21 		$1,380.41
$1,436.97
$1,496.87
$1,709.70 		$320.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.88
$951.00
$1,070.80
$1,496.46
$2,274.00 		$1,158.37
$1,271.49
$1,391.29
$1,816.95 		$1,478.86
$1,591.98
$1,711.78
$2,137.44 		$1,799.35
$1,912.47
$2,032.27
$2,457.93 		$320.49

ADVERTISEMENT

Friday Health Plans

Local: 1-844-817-1600 | Toll Free: 1-844-817-1600 | TTY: 1-800-659-2656
Toc - Plan #66 Friday Health Plans
Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

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 		$258.56
$293.47
$330.44
$461.79
$701.74 		$456.36
$491.27
$528.24
$659.59 		$654.16
$689.07
$726.04
$857.39 		$851.96
$886.87
$923.84
$1,055.19 		$197.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$517.12
$586.94
$660.88
$923.58
$1,403.48 		$714.92
$784.74
$858.68
$1,121.38 		$912.72
$982.54
$1,056.48
$1,319.18 		$1,110.52
$1,180.34
$1,254.28
$1,516.98 		$197.80
Toc - Plan #67 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic +Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.99
$354.11
$398.72
$557.22
$846.74 		$550.66
$592.78
$637.39
$795.89 		$789.33
$831.45
$876.06
$1,034.56 		$1,028.00
$1,070.12
$1,114.73
$1,273.23 		$238.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.98
$708.22
$797.44
$1,114.44
$1,693.48 		$862.65
$946.89
$1,036.11
$1,353.11 		$1,101.32
$1,185.56
$1,274.78
$1,591.78 		$1,339.99
$1,424.23
$1,513.45
$1,830.45 		$238.67
Toc - Plan #68 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus +Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

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 		$313.12
$355.39
$400.16
$559.23
$849.80 		$552.66
$594.93
$639.70
$798.77 		$792.20
$834.47
$879.24
$1,038.31 		$1,031.74
$1,074.01
$1,118.78
$1,277.85 		$239.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.24
$710.78
$800.32
$1,118.46
$1,699.60 		$865.78
$950.32
$1,039.86
$1,358.00 		$1,105.32
$1,189.86
$1,279.40
$1,597.54 		$1,344.86
$1,429.40
$1,518.94
$1,837.08 		$239.54
Toc - Plan #69 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$331.57
$376.34
$423.75
$592.19
$899.89 		$585.22
$629.99
$677.40
$845.84 		$838.87
$883.64
$931.05
$1,099.49 		$1,092.52
$1,137.29
$1,184.70
$1,353.14 		$253.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663.14
$752.68
$847.50
$1,184.38
$1,799.78 		$916.79
$1,006.33
$1,101.15
$1,438.03 		$1,170.44
$1,259.98
$1,354.80
$1,691.68 		$1,424.09
$1,513.63
$1,608.45
$1,945.33 		$253.65
Toc - Plan #70 Friday Health Plans
Silver

(HMO) Friday Silver + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$416.88
$473.15
$532.77
$744.54
$1,131.40 		$735.79
$792.06
$851.68
$1,063.45 		$1,054.70
$1,110.97
$1,170.59
$1,382.36 		$1,373.61
$1,429.88
$1,489.50
$1,701.27 		$318.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$833.76
$946.30
$1,065.54
$1,489.08
$2,262.80 		$1,152.67
$1,265.21
$1,384.45
$1,807.99 		$1,471.58
$1,584.12
$1,703.36
$2,126.90 		$1,790.49
$1,903.03
$2,022.27
$2,445.81 		$318.91
Toc - Plan #71 Friday Health Plans
Gold

(HMO) Friday Gold+ Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.22
$448.58
$505.09
$705.87
$1,072.63 		$697.56
$750.92
$807.43
$1,008.21 		$999.90
$1,053.26
$1,109.77
$1,310.55 		$1,302.24
$1,355.60
$1,412.11
$1,612.89 		$302.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.44
$897.16
$1,010.18
$1,411.74
$2,145.26 		$1,092.78
$1,199.50
$1,312.52
$1,714.08 		$1,395.12
$1,501.84
$1,614.86
$2,016.42 		$1,697.46
$1,804.18
$1,917.20
$2,318.76 		$302.34
Toc - Plan #72 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.48
$351.25
$395.51
$552.72
$839.92 		$546.23
$588.00
$632.26
$789.47 		$782.98
$824.75
$869.01
$1,026.22 		$1,019.73
$1,061.50
$1,105.76
$1,262.97 		$236.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.96
$702.50
$791.02
$1,105.44
$1,679.84 		$855.71
$939.25
$1,027.77
$1,342.19 		$1,092.46
$1,176.00
$1,264.52
$1,578.94 		$1,329.21
$1,412.75
$1,501.27
$1,815.69 		$236.75
Toc - Plan #73 Friday Health Plans
Silver

(HMO) Friday Silver Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.81
$483.30
$544.19
$760.51
$1,155.66 		$751.56
$809.05
$869.94
$1,086.26 		$1,077.31
$1,134.80
$1,195.69
$1,412.01 		$1,403.06
$1,460.55
$1,521.44
$1,737.76 		$325.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.62
$966.60
$1,088.38
$1,521.02
$2,311.32 		$1,177.37
$1,292.35
$1,414.13
$1,846.77 		$1,503.12
$1,618.10
$1,739.88
$2,172.52 		$1,828.87
$1,943.85
$2,065.63
$2,498.27 		$325.75
Toc - Plan #74 Friday Health Plans
Gold

(HMO) Friday Gold Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408.13
$463.23
$521.59
$728.92
$1,107.67 		$720.35
$775.45
$833.81
$1,041.14 		$1,032.57
$1,087.67
$1,146.03
$1,353.36 		$1,344.79
$1,399.89
$1,458.25
$1,665.58 		$312.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.26
$926.46
$1,043.18
$1,457.84
$2,215.34 		$1,128.48
$1,238.68
$1,355.40
$1,770.06 		$1,440.70
$1,550.90
$1,667.62
$2,082.28 		$1,752.92
$1,863.12
$1,979.84
$2,394.50 		$312.22
Toc - Plan #75 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.59
$353.66
$398.22
$556.51
$845.67 		$549.96
$592.03
$636.59
$794.88 		$788.33
$830.40
$874.96
$1,033.25 		$1,026.70
$1,068.77
$1,113.33
$1,271.62 		$238.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.18
$707.32
$796.44
$1,113.02
$1,691.34 		$861.55
$945.69
$1,034.81
$1,351.39 		$1,099.92
$1,184.06
$1,273.18
$1,589.76 		$1,338.29
$1,422.43
$1,511.55
$1,828.13 		$238.37
Toc - Plan #76 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

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 		$312.72
$354.94
$399.66
$558.52
$848.72 		$551.95
$594.17
$638.89
$797.75 		$791.18
$833.40
$878.12
$1,036.98 		$1,030.41
$1,072.63
$1,117.35
$1,276.21 		$239.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.44
$709.88
$799.32
$1,117.04
$1,697.44 		$864.67
$949.11
$1,038.55
$1,356.27 		$1,103.90
$1,188.34
$1,277.78
$1,595.50 		$1,343.13
$1,427.57
$1,517.01
$1,834.73 		$239.23
Toc - Plan #77 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.08
$350.80
$395.00
$552.01
$838.84 		$545.53
$587.25
$631.45
$788.46 		$781.98
$823.70
$867.90
$1,024.91 		$1,018.43
$1,060.15
$1,104.35
$1,261.36 		$236.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.16
$701.60
$790.00
$1,104.02
$1,677.68 		$854.61
$938.05
$1,026.45
$1,340.47 		$1,091.06
$1,174.50
$1,262.90
$1,576.92 		$1,327.51
$1,410.95
$1,499.35
$1,813.37 		$236.45
Toc - Plan #78 Friday Health Plans
Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$416.48
$472.70
$532.26
$743.83
$1,130.32 		$735.09
$791.31
$850.87
$1,062.44 		$1,053.70
$1,109.92
$1,169.48
$1,381.05 		$1,372.31
$1,428.53
$1,488.09
$1,699.66 		$318.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.96
$945.40
$1,064.52
$1,487.66
$2,260.64 		$1,151.57
$1,264.01
$1,383.13
$1,806.27 		$1,470.18
$1,582.62
$1,701.74
$2,124.88 		$1,788.79
$1,901.23
$2,020.35
$2,443.49 		$318.61
Toc - Plan #79 Friday Health Plans
Silver

(HMO) Friday Silver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.08
$476.79
$536.86
$750.26
$1,140.09 		$741.44
$798.15
$858.22
$1,071.62 		$1,062.80
$1,119.51
$1,179.58
$1,392.98 		$1,384.16
$1,440.87
$1,500.94
$1,714.34 		$321.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.16
$953.58
$1,073.72
$1,500.52
$2,280.18 		$1,161.52
$1,274.94
$1,395.08
$1,821.88 		$1,482.88
$1,596.30
$1,716.44
$2,143.24 		$1,804.24
$1,917.66
$2,037.80
$2,464.60 		$321.36
Toc - Plan #80 Friday Health Plans
Silver

(HMO) Friday Silver Zero Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

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 		$426.72
$484.33
$545.35
$762.13
$1,158.13 		$753.16
$810.77
$871.79
$1,088.57 		$1,079.60
$1,137.21
$1,198.23
$1,415.01 		$1,406.04
$1,463.65
$1,524.67
$1,741.45 		$326.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.44
$968.66
$1,090.70
$1,524.26
$2,316.26 		$1,179.88
$1,295.10
$1,417.14
$1,850.70 		$1,506.32
$1,621.54
$1,743.58
$2,177.14 		$1,832.76
$1,947.98
$2,070.02
$2,503.58 		$326.44
Toc - Plan #81 Friday Health Plans
Silver

(HMO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.42
$482.85
$543.68
$759.80
$1,154.58 		$750.86
$808.29
$869.12
$1,085.24 		$1,076.30
$1,133.73
$1,194.56
$1,410.68 		$1,401.74
$1,459.17
$1,520.00
$1,736.12 		$325.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.84
$965.70
$1,087.36
$1,519.60
$2,309.16 		$1,176.28
$1,291.14
$1,412.80
$1,845.04 		$1,501.72
$1,616.58
$1,738.24
$2,170.48 		$1,827.16
$1,942.02
$2,063.68
$2,495.92 		$325.44
Toc - Plan #82 Friday Health Plans
Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.82
$448.13
$504.59
$705.16
$1,071.55 		$696.86
$750.17
$806.63
$1,007.20 		$998.90
$1,052.21
$1,108.67
$1,309.24 		$1,300.94
$1,354.25
$1,410.71
$1,611.28 		$302.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.64
$896.26
$1,009.18
$1,410.32
$2,143.10 		$1,091.68
$1,198.30
$1,311.22
$1,712.36 		$1,393.72
$1,500.34
$1,613.26
$2,014.40 		$1,695.76
$1,802.38
$1,915.30
$2,316.44 		$302.04
Toc - Plan #83 Friday Health Plans
Gold

(HMO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.73
$462.78
$521.08
$728.21
$1,106.59 		$719.65
$774.70
$833.00
$1,040.13 		$1,031.57
$1,086.62
$1,144.92
$1,352.05 		$1,343.49
$1,398.54
$1,456.84
$1,663.97 		$311.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.46
$925.56
$1,042.16
$1,456.42
$2,213.18 		$1,127.38
$1,237.48
$1,354.08
$1,768.34 		$1,439.30
$1,549.40
$1,666.00
$2,080.26 		$1,751.22
$1,861.32
$1,977.92
$2,392.18 		$311.92
Toc - Plan #84 Friday Health Plans
Bronze

(HMO) Friday Standard Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.59
$353.66
$398.22
$556.51
$845.67 		$549.96
$592.03
$636.59
$794.88 		$788.33
$830.40
$874.96
$1,033.25 		$1,026.70
$1,068.77
$1,113.33
$1,271.62 		$238.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.18
$707.32
$796.44
$1,113.02
$1,691.34 		$861.55
$945.69
$1,034.81
$1,351.39 		$1,099.92
$1,184.06
$1,273.18
$1,589.76 		$1,338.29
$1,422.43
$1,511.55
$1,828.13 		$238.37
Toc - Plan #85 Friday Health Plans
Expanded Bronze

(HMO) Friday Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

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 		$309.29
$351.05
$395.28
$552.40
$839.42 		$545.90
$587.66
$631.89
$789.01 		$782.51
$824.27
$868.50
$1,025.62 		$1,019.12
$1,060.88
$1,105.11
$1,262.23 		$236.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.58
$702.10
$790.56
$1,104.80
$1,678.84 		$855.19
$938.71
$1,027.17
$1,341.41 		$1,091.80
$1,175.32
$1,263.78
$1,578.02 		$1,328.41
$1,411.93
$1,500.39
$1,814.63 		$236.61
Toc - Plan #86 Friday Health Plans
Silver

(HMO) Friday Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

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 		$413.99
$469.87
$529.07
$739.38
$1,123.56 		$730.69
$786.57
$845.77
$1,056.08 		$1,047.39
$1,103.27
$1,162.47
$1,372.78 		$1,364.09
$1,419.97
$1,479.17
$1,689.48 		$316.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.98
$939.74
$1,058.14
$1,478.76
$2,247.12 		$1,144.68
$1,256.44
$1,374.84
$1,795.46 		$1,461.38
$1,573.14
$1,691.54
$2,112.16 		$1,778.08
$1,889.84
$2,008.24
$2,428.86 		$316.70
Toc - Plan #87 Friday Health Plans
Gold

(HMO) Friday Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-817-1600

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 		$405.82
$460.60
$518.64
$724.79
$1,101.39 		$716.27
$771.05
$829.09
$1,035.24 		$1,026.72
$1,081.50
$1,139.54
$1,345.69 		$1,337.17
$1,391.95
$1,449.99
$1,656.14 		$310.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.64
$921.20
$1,037.28
$1,449.58
$2,202.78 		$1,122.09
$1,231.65
$1,347.73
$1,760.03 		$1,432.54
$1,542.10
$1,658.18
$2,070.48 		$1,742.99
$1,852.55
$1,968.63
$2,380.93 		$310.45

ADVERTISEMENT

CommunityCare

Local: 1-918-594-5242 | Toll Free: 1-800-777-4890 | TTY: 1-800-722-0353
Toc - Plan #88 CommunityCare
Catastrophic

(HMO) CommunityCare Catastrophic Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

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 		$210.01
$238.36
$268.39
$375.07
$569.96 		$370.67
$399.02
$429.05
$535.73 		$531.33
$559.68
$589.71
$696.39 		$691.99
$720.34
$750.37
$857.05 		$160.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$420.02
$476.72
$536.78
$750.14
$1,139.92 		$580.68
$637.38
$697.44
$910.80 		$741.34
$798.04
$858.10
$1,071.46 		$902.00
$958.70
$1,018.76
$1,232.12 		$160.66
Toc - Plan #89 CommunityCare
Gold

(HMO) CommunityCare Gold L21 Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$4,000 $12,000 Annual Deductible
$8,300 $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 		$419.22
$475.81
$535.76
$748.73
$1,137.76 		$739.92
$796.51
$856.46
$1,069.43 		$1,060.62
$1,117.21
$1,177.16
$1,390.13 		$1,381.32
$1,437.91
$1,497.86
$1,710.83 		$320.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.44
$951.62
$1,071.52
$1,497.46
$2,275.52 		$1,159.14
$1,272.32
$1,392.22
$1,818.16 		$1,479.84
$1,593.02
$1,712.92
$2,138.86 		$1,800.54
$1,913.72
$2,033.62
$2,459.56 		$320.70
Toc - Plan #90 CommunityCare
Silver

(HMO) CommunityCare Silver L21 Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$7,700 $17,100 Annual Deductible
$8,500 $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 		$450.87
$511.74
$576.21
$805.26
$1,223.67 		$795.79
$856.66
$921.13
$1,150.18 		$1,140.71
$1,201.58
$1,266.05
$1,495.10 		$1,485.63
$1,546.50
$1,610.97
$1,840.02 		$344.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901.74
$1,023.48
$1,152.42
$1,610.52
$2,447.34 		$1,246.66
$1,368.40
$1,497.34
$1,955.44 		$1,591.58
$1,713.32
$1,842.26
$2,300.36 		$1,936.50
$2,058.24
$2,187.18
$2,645.28 		$344.92
Toc - Plan #91 CommunityCare
Gold

(HMO) CommunityCare Gold IH221

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$1,100 $3,300 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 		$427.00
$484.65
$545.71
$762.63
$1,158.89 		$753.66
$811.31
$872.37
$1,089.29 		$1,080.32
$1,137.97
$1,199.03
$1,415.95 		$1,406.98
$1,464.63
$1,525.69
$1,742.61 		$326.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.00
$969.30
$1,091.42
$1,525.26
$2,317.78 		$1,180.66
$1,295.96
$1,418.08
$1,851.92 		$1,507.32
$1,622.62
$1,744.74
$2,178.58 		$1,833.98
$1,949.28
$2,071.40
$2,505.24 		$326.66
Toc - Plan #92 CommunityCare
Gold

(HMO) CommunityCare Gold IH222

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$2,200 $6,600 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 		$420.59
$477.37
$537.51
$751.17
$1,141.48 		$742.34
$799.12
$859.26
$1,072.92 		$1,064.09
$1,120.87
$1,181.01
$1,394.67 		$1,385.84
$1,442.62
$1,502.76
$1,716.42 		$321.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.18
$954.74
$1,075.02
$1,502.34
$2,282.96 		$1,162.93
$1,276.49
$1,396.77
$1,824.09 		$1,484.68
$1,598.24
$1,718.52
$2,145.84 		$1,806.43
$1,919.99
$2,040.27
$2,467.59 		$321.75
Toc - Plan #93 CommunityCare
Expanded Bronze

(HMO) CommunityCare Bronze IH223

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$5,000 $14,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.59
$351.39
$395.66
$552.93
$840.23 		$546.43
$588.23
$632.50
$789.77 		$783.27
$825.07
$869.34
$1,026.61 		$1,020.11
$1,061.91
$1,106.18
$1,263.45 		$236.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.18
$702.78
$791.32
$1,105.86
$1,680.46 		$856.02
$939.62
$1,028.16
$1,342.70 		$1,092.86
$1,176.46
$1,265.00
$1,579.54 		$1,329.70
$1,413.30
$1,501.84
$1,816.38 		$236.84
Toc - Plan #94 CommunityCare
Expanded Bronze

(HMO) CommunityCare Bronze IH224

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.20
$358.88
$404.10
$564.73
$858.15 		$558.09
$600.77
$645.99
$806.62 		$799.98
$842.66
$887.88
$1,048.51 		$1,041.87
$1,084.55
$1,129.77
$1,290.40 		$241.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.40
$717.76
$808.20
$1,129.46
$1,716.30 		$874.29
$959.65
$1,050.09
$1,371.35 		$1,116.18
$1,201.54
$1,291.98
$1,613.24 		$1,358.07
$1,443.43
$1,533.87
$1,855.13 		$241.89
Toc - Plan #95 CommunityCare
Gold

(HMO) CommunityCare Gold Standardized Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.51
$475.01
$534.86
$747.46
$1,135.84 		$738.67
$795.17
$855.02
$1,067.62 		$1,058.83
$1,115.33
$1,175.18
$1,387.78 		$1,378.99
$1,435.49
$1,495.34
$1,707.94 		$320.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.02
$950.02
$1,069.72
$1,494.92
$2,271.68 		$1,157.18
$1,270.18
$1,389.88
$1,815.08 		$1,477.34
$1,590.34
$1,710.04
$2,135.24 		$1,797.50
$1,910.50
$2,030.20
$2,455.40 		$320.16
Toc - Plan #96 CommunityCare
Silver

(HMO) CommunityCare Silver Standardized Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

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 		$412.71
$468.43
$527.44
$737.10
$1,120.10 		$728.43
$784.15
$843.16
$1,052.82 		$1,044.15
$1,099.87
$1,158.88
$1,368.54 		$1,359.87
$1,415.59
$1,474.60
$1,684.26 		$315.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.42
$936.86
$1,054.88
$1,474.20
$2,240.20 		$1,141.14
$1,252.58
$1,370.60
$1,789.92 		$1,456.86
$1,568.30
$1,686.32
$2,105.64 		$1,772.58
$1,884.02
$2,002.04
$2,421.36 		$315.72
Toc - Plan #97 CommunityCare
Bronze

(HMO) CommunityCare Bronze Standardized Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

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 		$282.04
$320.12
$360.45
$503.73
$765.46 		$497.80
$535.88
$576.21
$719.49 		$713.56
$751.64
$791.97
$935.25 		$929.32
$967.40
$1,007.73
$1,151.01 		$215.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.08
$640.24
$720.90
$1,007.46
$1,530.92 		$779.84
$856.00
$936.66
$1,223.22 		$995.60
$1,071.76
$1,152.42
$1,438.98 		$1,211.36
$1,287.52
$1,368.18
$1,654.74 		$215.76
Toc - Plan #98 CommunityCare
Expanded Bronze

(HMO) CommunityCare Expanded Bronze Standardized Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

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 		$301.81
$342.55
$385.71
$539.03
$819.11 		$532.69
$573.43
$616.59
$769.91 		$763.57
$804.31
$847.47
$1,000.79 		$994.45
$1,035.19
$1,078.35
$1,231.67 		$230.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.62
$685.10
$771.42
$1,078.06
$1,638.22 		$834.50
$915.98
$1,002.30
$1,308.94 		$1,065.38
$1,146.86
$1,233.18
$1,539.82 		$1,296.26
$1,377.74
$1,464.06
$1,770.70 		$230.88
Toc - Plan #99 CommunityCare
Silver

(HMO) CommunityCare Silver SLIH23 Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$6,600 $17,900 Annual Deductible
$8,900 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.28
$474.74
$534.56
$747.04
$1,135.20 		$738.26
$794.72
$854.54
$1,067.02 		$1,058.24
$1,114.70
$1,174.52
$1,387.00 		$1,378.22
$1,434.68
$1,494.50
$1,706.98 		$319.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.56
$949.48
$1,069.12
$1,494.08
$2,270.40 		$1,156.54
$1,269.46
$1,389.10
$1,814.06 		$1,476.52
$1,589.44
$1,709.08
$2,134.04 		$1,796.50
$1,909.42
$2,029.06
$2,454.02 		$319.98

‡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 Rogers County here.

Rogers County is in “Rating Area 4” of Oklahoma.

Currently, there are 99 plans offered in Rating Area 4.

Top

2023 Obamacare Plans for Rogers County, OK

Plan Browser: 99 Plans
scroll down for more
Speak with a Health Insurance Expert 800-943-6832Ads by +HealthNetwork