Obamacare 2023 Rates for Rockwall County

Obamacare > Rates > Texas > Rockwall 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 Rockwall County, TX.

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, 96 Plans and 2023 Rates for Rockwall County, Texas

Below, you’ll find a summary of the 96 plans for Rockwall County, Texas 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

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Rockwall County Resources

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Oscar Insurance Company

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

Toc - Plan #1 Oscar Insurance Company
Bronze

(EPO) Bronze Simple

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.67
$327.63
$368.91
$515.55
$783.43 		$509.50
$548.46
$589.74
$736.38 		$730.33
$769.29
$810.57
$957.21 		$951.16
$990.12
$1,031.40
$1,178.04 		$220.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.34
$655.26
$737.82
$1,031.10
$1,566.86 		$798.17
$876.09
$958.65
$1,251.93 		$1,019.00
$1,096.92
$1,179.48
$1,472.76 		$1,239.83
$1,317.75
$1,400.31
$1,693.59 		$220.83
Toc - Plan #2 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$290.11
$329.26
$370.74
$518.11
$787.32 		$512.03
$551.18
$592.66
$740.03 		$733.95
$773.10
$814.58
$961.95 		$955.87
$995.02
$1,036.50
$1,183.87 		$221.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.22
$658.52
$741.48
$1,036.22
$1,574.64 		$802.14
$880.44
$963.40
$1,258.14 		$1,024.06
$1,102.36
$1,185.32
$1,480.06 		$1,245.98
$1,324.28
$1,407.24
$1,701.98 		$221.92
Toc - Plan #3 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.81
$373.19
$420.20
$587.23
$892.36 		$580.34
$624.72
$671.73
$838.76 		$831.87
$876.25
$923.26
$1,090.29 		$1,083.40
$1,127.78
$1,174.79
$1,341.82 		$251.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.62
$746.38
$840.40
$1,174.46
$1,784.72 		$909.15
$997.91
$1,091.93
$1,425.99 		$1,160.68
$1,249.44
$1,343.46
$1,677.52 		$1,412.21
$1,500.97
$1,594.99
$1,929.05 		$251.53
Toc - Plan #4 Oscar Insurance Company
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,700 $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 		$422.34
$479.34
$539.74
$754.28
$1,146.20 		$745.42
$802.42
$862.82
$1,077.36 		$1,068.50
$1,125.50
$1,185.90
$1,400.44 		$1,391.58
$1,448.58
$1,508.98
$1,723.52 		$323.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$844.68
$958.68
$1,079.48
$1,508.56
$2,292.40 		$1,167.76
$1,281.76
$1,402.56
$1,831.64 		$1,490.84
$1,604.84
$1,725.64
$2,154.72 		$1,813.92
$1,927.92
$2,048.72
$2,477.80 		$323.08
Toc - Plan #5 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.33
$474.80
$534.62
$747.13
$1,135.33 		$738.35
$794.82
$854.64
$1,067.15 		$1,058.37
$1,114.84
$1,174.66
$1,387.17 		$1,378.39
$1,434.86
$1,494.68
$1,707.19 		$320.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.66
$949.60
$1,069.24
$1,494.26
$2,270.66 		$1,156.68
$1,269.62
$1,389.26
$1,814.28 		$1,476.70
$1,589.64
$1,709.28
$2,134.30 		$1,796.72
$1,909.66
$2,029.30
$2,454.32 		$320.02
Toc - Plan #6 Oscar Insurance Company
Silver

(EPO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$422.81
$479.88
$540.34
$755.12
$1,147.48 		$746.25
$803.32
$863.78
$1,078.56 		$1,069.69
$1,126.76
$1,187.22
$1,402.00 		$1,393.13
$1,450.20
$1,510.66
$1,725.44 		$323.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.62
$959.76
$1,080.68
$1,510.24
$2,294.96 		$1,169.06
$1,283.20
$1,404.12
$1,833.68 		$1,492.50
$1,606.64
$1,727.56
$2,157.12 		$1,815.94
$1,930.08
$2,051.00
$2,480.56 		$323.44
Toc - Plan #7 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$327.64
$371.86
$418.71
$585.14
$889.18 		$578.27
$622.49
$669.34
$835.77 		$828.90
$873.12
$919.97
$1,086.40 		$1,079.53
$1,123.75
$1,170.60
$1,337.03 		$250.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.28
$743.72
$837.42
$1,170.28
$1,778.36 		$905.91
$994.35
$1,088.05
$1,420.91 		$1,156.54
$1,244.98
$1,338.68
$1,671.54 		$1,407.17
$1,495.61
$1,589.31
$1,922.17 		$250.63
Toc - Plan #8 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303.58
$344.55
$387.96
$542.17
$823.88 		$535.81
$576.78
$620.19
$774.40 		$768.04
$809.01
$852.42
$1,006.63 		$1,000.27
$1,041.24
$1,084.65
$1,238.86 		$232.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.16
$689.10
$775.92
$1,084.34
$1,647.76 		$839.39
$921.33
$1,008.15
$1,316.57 		$1,071.62
$1,153.56
$1,240.38
$1,548.80 		$1,303.85
$1,385.79
$1,472.61
$1,781.03 		$232.23
Toc - Plan #9 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$308.39
$350.01
$394.11
$550.77
$836.94 		$544.30
$585.92
$630.02
$786.68 		$780.21
$821.83
$865.93
$1,022.59 		$1,016.12
$1,057.74
$1,101.84
$1,258.50 		$235.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.78
$700.02
$788.22
$1,101.54
$1,673.88 		$852.69
$935.93
$1,024.13
$1,337.45 		$1,088.60
$1,171.84
$1,260.04
$1,573.36 		$1,324.51
$1,407.75
$1,495.95
$1,809.27 		$235.91
Toc - Plan #10 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.89
$467.48
$526.38
$735.61
$1,117.83 		$726.98
$782.57
$841.47
$1,050.70 		$1,042.07
$1,097.66
$1,156.56
$1,365.79 		$1,357.16
$1,412.75
$1,471.65
$1,680.88 		$315.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.78
$934.96
$1,052.76
$1,471.22
$2,235.66 		$1,138.87
$1,250.05
$1,367.85
$1,786.31 		$1,453.96
$1,565.14
$1,682.94
$2,101.40 		$1,769.05
$1,880.23
$1,998.03
$2,416.49 		$315.09
Toc - Plan #11 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$430.64
$488.76
$550.34
$769.10
$1,168.72 		$760.07
$818.19
$879.77
$1,098.53 		$1,089.50
$1,147.62
$1,209.20
$1,427.96 		$1,418.93
$1,477.05
$1,538.63
$1,757.39 		$329.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.28
$977.52
$1,100.68
$1,538.20
$2,337.44 		$1,190.71
$1,306.95
$1,430.11
$1,867.63 		$1,520.14
$1,636.38
$1,759.54
$2,197.06 		$1,849.57
$1,965.81
$2,088.97
$2,526.49 		$329.43
Toc - Plan #12 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.33
$477.06
$537.17
$750.69
$1,140.74 		$741.87
$798.60
$858.71
$1,072.23 		$1,063.41
$1,120.14
$1,180.25
$1,393.77 		$1,384.95
$1,441.68
$1,501.79
$1,715.31 		$321.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.66
$954.12
$1,074.34
$1,501.38
$2,281.48 		$1,162.20
$1,275.66
$1,395.88
$1,822.92 		$1,483.74
$1,597.20
$1,717.42
$2,144.46 		$1,805.28
$1,918.74
$2,038.96
$2,466.00 		$321.54
Toc - Plan #13 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$294.75
$334.53
$376.68
$526.40
$799.92 		$520.22
$560.00
$602.15
$751.87 		$745.69
$785.47
$827.62
$977.34 		$971.16
$1,010.94
$1,053.09
$1,202.81 		$225.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.50
$669.06
$753.36
$1,052.80
$1,599.84 		$814.97
$894.53
$978.83
$1,278.27 		$1,040.44
$1,120.00
$1,204.30
$1,503.74 		$1,265.91
$1,345.47
$1,429.77
$1,729.21 		$225.47
Toc - Plan #14 Oscar Insurance Company
Bronze

(EPO) Bronze Simple- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$277.21
$314.62
$354.26
$495.08
$752.32 		$489.27
$526.68
$566.32
$707.14 		$701.33
$738.74
$778.38
$919.20 		$913.39
$950.80
$990.44
$1,131.26 		$212.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.42
$629.24
$708.52
$990.16
$1,504.64 		$766.48
$841.30
$920.58
$1,202.22 		$978.54
$1,053.36
$1,132.64
$1,414.28 		$1,190.60
$1,265.42
$1,344.70
$1,626.34 		$212.06
Toc - Plan #15 Oscar Insurance Company
Silver

(EPO) Silver Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.29
$467.94
$526.89
$736.33
$1,118.93 		$727.68
$783.33
$842.28
$1,051.72 		$1,043.07
$1,098.72
$1,157.67
$1,367.11 		$1,358.46
$1,414.11
$1,473.06
$1,682.50 		$315.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.58
$935.88
$1,053.78
$1,472.66
$2,237.86 		$1,139.97
$1,251.27
$1,369.17
$1,788.05 		$1,455.36
$1,566.66
$1,684.56
$2,103.44 		$1,770.75
$1,882.05
$1,999.95
$2,418.83 		$315.39
Toc - Plan #16 Oscar Insurance Company
Gold

(EPO) Gold Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375.22
$425.86
$479.52
$670.13
$1,018.32 		$662.26
$712.90
$766.56
$957.17 		$949.30
$999.94
$1,053.60
$1,244.21 		$1,236.34
$1,286.98
$1,340.64
$1,531.25 		$287.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.44
$851.72
$959.04
$1,340.26
$2,036.64 		$1,037.48
$1,138.76
$1,246.08
$1,627.30 		$1,324.52
$1,425.80
$1,533.12
$1,914.34 		$1,611.56
$1,712.84
$1,820.16
$2,201.38 		$287.04

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #17 Ambetter from Superior HealthPlan
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$459.19
$521.17
$586.83
$820.10
$1,246.22 		$810.46
$872.44
$938.10
$1,171.37 		$1,161.73
$1,223.71
$1,289.37
$1,522.64 		$1,513.00
$1,574.98
$1,640.64
$1,873.91 		$351.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.38
$1,042.34
$1,173.66
$1,640.20
$2,492.44 		$1,269.65
$1,393.61
$1,524.93
$1,991.47 		$1,620.92
$1,744.88
$1,876.20
$2,342.74 		$1,972.19
$2,096.15
$2,227.47
$2,694.01 		$351.27
Toc - Plan #18 Ambetter from Superior HealthPlan
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$422.69
$479.74
$540.18
$754.90
$1,147.14 		$746.04
$803.09
$863.53
$1,078.25 		$1,069.39
$1,126.44
$1,186.88
$1,401.60 		$1,392.74
$1,449.79
$1,510.23
$1,724.95 		$323.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.38
$959.48
$1,080.36
$1,509.80
$2,294.28 		$1,168.73
$1,282.83
$1,403.71
$1,833.15 		$1,492.08
$1,606.18
$1,727.06
$2,156.50 		$1,815.43
$1,929.53
$2,050.41
$2,479.85 		$323.35
Toc - Plan #19 Ambetter from Superior HealthPlan
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$454.60
$515.96
$580.96
$811.90
$1,233.75 		$802.36
$863.72
$928.72
$1,159.66 		$1,150.12
$1,211.48
$1,276.48
$1,507.42 		$1,497.88
$1,559.24
$1,624.24
$1,855.18 		$347.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.20
$1,031.92
$1,161.92
$1,623.80
$2,467.50 		$1,256.96
$1,379.68
$1,509.68
$1,971.56 		$1,604.72
$1,727.44
$1,857.44
$2,319.32 		$1,952.48
$2,075.20
$2,205.20
$2,667.08 		$347.76
Toc - Plan #20 Ambetter from Superior HealthPlan
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$452.90
$514.03
$578.79
$808.86
$1,229.14 		$799.36
$860.49
$925.25
$1,155.32 		$1,145.82
$1,206.95
$1,271.71
$1,501.78 		$1,492.28
$1,553.41
$1,618.17
$1,848.24 		$346.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$905.80
$1,028.06
$1,157.58
$1,617.72
$2,458.28 		$1,252.26
$1,374.52
$1,504.04
$1,964.18 		$1,598.72
$1,720.98
$1,850.50
$2,310.64 		$1,945.18
$2,067.44
$2,196.96
$2,657.10 		$346.46
Toc - Plan #21 Ambetter from Superior HealthPlan
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$411.34
$466.86
$525.68
$734.64
$1,116.36 		$726.01
$781.53
$840.35
$1,049.31 		$1,040.68
$1,096.20
$1,155.02
$1,363.98 		$1,355.35
$1,410.87
$1,469.69
$1,678.65 		$314.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.68
$933.72
$1,051.36
$1,469.28
$2,232.72 		$1,137.35
$1,248.39
$1,366.03
$1,783.95 		$1,452.02
$1,563.06
$1,680.70
$2,098.62 		$1,766.69
$1,877.73
$1,995.37
$2,413.29 		$314.67
Toc - Plan #22 Ambetter from Superior HealthPlan
Gold

(EPO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$408.86
$464.05
$522.52
$730.21
$1,109.63 		$721.63
$776.82
$835.29
$1,042.98 		$1,034.40
$1,089.59
$1,148.06
$1,355.75 		$1,347.17
$1,402.36
$1,460.83
$1,668.52 		$312.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817.72
$928.10
$1,045.04
$1,460.42
$2,219.26 		$1,130.49
$1,240.87
$1,357.81
$1,773.19 		$1,443.26
$1,553.64
$1,670.58
$2,085.96 		$1,756.03
$1,866.41
$1,983.35
$2,398.73 		$312.77
Toc - Plan #23 Ambetter from Superior HealthPlan
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$452.58
$513.67
$578.38
$808.29
$1,228.27 		$798.79
$859.88
$924.59
$1,154.50 		$1,145.00
$1,206.09
$1,270.80
$1,500.71 		$1,491.21
$1,552.30
$1,617.01
$1,846.92 		$346.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$905.16
$1,027.34
$1,156.76
$1,616.58
$2,456.54 		$1,251.37
$1,373.55
$1,502.97
$1,962.79 		$1,597.58
$1,719.76
$1,849.18
$2,309.00 		$1,943.79
$2,065.97
$2,195.39
$2,655.21 		$346.21
Toc - Plan #24 Ambetter from Superior HealthPlan
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$408.08
$463.16
$521.52
$728.82
$1,107.51 		$720.26
$775.34
$833.70
$1,041.00 		$1,032.44
$1,087.52
$1,145.88
$1,353.18 		$1,344.62
$1,399.70
$1,458.06
$1,665.36 		$312.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.16
$926.32
$1,043.04
$1,457.64
$2,215.02 		$1,128.34
$1,238.50
$1,355.22
$1,769.82 		$1,440.52
$1,550.68
$1,667.40
$2,082.00 		$1,752.70
$1,862.86
$1,979.58
$2,394.18 		$312.18
Toc - Plan #25 Ambetter from Superior HealthPlan
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$440.27
$499.69
$562.65
$786.30
$1,194.86 		$777.07
$836.49
$899.45
$1,123.10 		$1,113.87
$1,173.29
$1,236.25
$1,459.90 		$1,450.67
$1,510.09
$1,573.05
$1,796.70 		$336.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.54
$999.38
$1,125.30
$1,572.60
$2,389.72 		$1,217.34
$1,336.18
$1,462.10
$1,909.40 		$1,554.14
$1,672.98
$1,798.90
$2,246.20 		$1,890.94
$2,009.78
$2,135.70
$2,583.00 		$336.80
Toc - Plan #26 Ambetter from Superior HealthPlan
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$478.29
$542.85
$611.24
$854.21
$1,298.05 		$844.17
$908.73
$977.12
$1,220.09 		$1,210.05
$1,274.61
$1,343.00
$1,585.97 		$1,575.93
$1,640.49
$1,708.88
$1,951.85 		$365.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$956.58
$1,085.70
$1,222.48
$1,708.42
$2,596.10 		$1,322.46
$1,451.58
$1,588.36
$2,074.30 		$1,688.34
$1,817.46
$1,954.24
$2,440.18 		$2,054.22
$2,183.34
$2,320.12
$2,806.06 		$365.88
Toc - Plan #27 Ambetter from Superior HealthPlan
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$471.74
$535.41
$602.87
$842.51
$1,280.27 		$832.61
$896.28
$963.74
$1,203.38 		$1,193.48
$1,257.15
$1,324.61
$1,564.25 		$1,554.35
$1,618.02
$1,685.48
$1,925.12 		$360.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$943.48
$1,070.82
$1,205.74
$1,685.02
$2,560.54 		$1,304.35
$1,431.69
$1,566.61
$2,045.89 		$1,665.22
$1,792.56
$1,927.48
$2,406.76 		$2,026.09
$2,153.43
$2,288.35
$2,767.63 		$360.87
Toc - Plan #28 Ambetter from Superior HealthPlan
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$428.45
$486.28
$547.55
$765.20
$1,162.79 		$756.21
$814.04
$875.31
$1,092.96 		$1,083.97
$1,141.80
$1,203.07
$1,420.72 		$1,411.73
$1,469.56
$1,530.83
$1,748.48 		$327.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.90
$972.56
$1,095.10
$1,530.40
$2,325.58 		$1,184.66
$1,300.32
$1,422.86
$1,858.16 		$1,512.42
$1,628.08
$1,750.62
$2,185.92 		$1,840.18
$1,955.84
$2,078.38
$2,513.68 		$327.76
Toc - Plan #29 Ambetter from Superior HealthPlan
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$473.51
$537.42
$605.13
$845.67
$1,285.07 		$835.74
$899.65
$967.36
$1,207.90 		$1,197.97
$1,261.88
$1,329.59
$1,570.13 		$1,560.20
$1,624.11
$1,691.82
$1,932.36 		$362.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$947.02
$1,074.84
$1,210.26
$1,691.34
$2,570.14 		$1,309.25
$1,437.07
$1,572.49
$2,053.57 		$1,671.48
$1,799.30
$1,934.72
$2,415.80 		$2,033.71
$2,161.53
$2,296.95
$2,778.03 		$362.23
Toc - Plan #30 Ambetter from Superior HealthPlan
Gold

(EPO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$425.87
$483.35
$544.25
$760.59
$1,155.79 		$751.65
$809.13
$870.03
$1,086.37 		$1,077.43
$1,134.91
$1,195.81
$1,412.15 		$1,403.21
$1,460.69
$1,521.59
$1,737.93 		$325.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.74
$966.70
$1,088.50
$1,521.18
$2,311.58 		$1,177.52
$1,292.48
$1,414.28
$1,846.96 		$1,503.30
$1,618.26
$1,740.06
$2,172.74 		$1,829.08
$1,944.04
$2,065.84
$2,498.52 		$325.78

ADVERTISEMENT

Blue Cross and Blue Shield of Texas

Local: 1-888-697-0683 | Toll Free: 1-888-697-0683 | TTY: 1-800-735-2989
Toc - Plan #31 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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 		$394.53
$447.79
$504.21
$704.63
$1,070.75 		$696.34
$749.60
$806.02
$1,006.44 		$998.15
$1,051.41
$1,107.83
$1,308.25 		$1,299.96
$1,353.22
$1,409.64
$1,610.06 		$301.81
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
$1,409.26
$2,141.50 		$1,090.87
$1,197.39
$1,310.23
$1,711.07 		$1,392.68
$1,499.20
$1,612.04
$2,012.88 		$1,694.49
$1,801.01
$1,913.85
$2,314.69 		$301.81
Toc - Plan #32 Blue Cross and Blue Shield of Texas
Catastrophic

(HMO) Blue Advantage Security HMO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$288.94
$327.95
$369.27
$516.05
$784.19 		$509.98
$548.99
$590.31
$737.09 		$731.02
$770.03
$811.35
$958.13 		$952.06
$991.07
$1,032.39
$1,179.17 		$221.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.88
$655.90
$738.54
$1,032.10
$1,568.38 		$798.92
$876.94
$959.58
$1,253.14 		$1,019.96
$1,097.98
$1,180.62
$1,474.18 		$1,241.00
$1,319.02
$1,401.66
$1,695.22 		$221.04
Toc - Plan #33 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$2,050 $6,150 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 		$474.50
$538.56
$606.41
$847.46
$1,287.79 		$837.49
$901.55
$969.40
$1,210.45 		$1,200.48
$1,264.54
$1,332.39
$1,573.44 		$1,563.47
$1,627.53
$1,695.38
$1,936.43 		$362.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$949.00
$1,077.12
$1,212.82
$1,694.92
$2,575.58 		$1,311.99
$1,440.11
$1,575.81
$2,057.91 		$1,674.98
$1,803.10
$1,938.80
$2,420.90 		$2,037.97
$2,166.09
$2,301.79
$2,783.89 		$362.99
Toc - Plan #34 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$322.86
$366.45
$412.62
$576.64
$876.25 		$569.85
$613.44
$659.61
$823.63 		$816.84
$860.43
$906.60
$1,070.62 		$1,063.83
$1,107.42
$1,153.59
$1,317.61 		$246.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.72
$732.90
$825.24
$1,153.28
$1,752.50 		$892.71
$979.89
$1,072.23
$1,400.27 		$1,139.70
$1,226.88
$1,319.22
$1,647.26 		$1,386.69
$1,473.87
$1,566.21
$1,894.25 		$246.99
Toc - Plan #35 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 302

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$335.79
$381.12
$429.13
$599.71
$911.32 		$592.67
$638.00
$686.01
$856.59 		$849.55
$894.88
$942.89
$1,113.47 		$1,106.43
$1,151.76
$1,199.77
$1,370.35 		$256.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.58
$762.24
$858.26
$1,199.42
$1,822.64 		$928.46
$1,019.12
$1,115.14
$1,456.30 		$1,185.34
$1,276.00
$1,372.02
$1,713.18 		$1,442.22
$1,532.88
$1,628.90
$1,970.06 		$256.88
Toc - Plan #36 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO? 301

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$8,700 $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 		$321.19
$364.55
$410.48
$573.65
$871.71 		$566.90
$610.26
$656.19
$819.36 		$812.61
$855.97
$901.90
$1,065.07 		$1,058.32
$1,101.68
$1,147.61
$1,310.78 		$245.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.38
$729.10
$820.96
$1,147.30
$1,743.42 		$888.09
$974.81
$1,066.67
$1,393.01 		$1,133.80
$1,220.52
$1,312.38
$1,638.72 		$1,379.51
$1,466.23
$1,558.09
$1,884.43 		$245.71
Toc - Plan #37 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 603

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,500 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 		$406.12
$460.94
$519.02
$725.32
$1,102.20 		$716.80
$771.62
$829.70
$1,036.00 		$1,027.48
$1,082.30
$1,140.38
$1,346.68 		$1,338.16
$1,392.98
$1,451.06
$1,657.36 		$310.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.24
$921.88
$1,038.04
$1,450.64
$2,204.40 		$1,122.92
$1,232.56
$1,348.72
$1,761.32 		$1,433.60
$1,543.24
$1,659.40
$2,072.00 		$1,744.28
$1,853.92
$1,970.08
$2,382.68 		$310.68
Toc - Plan #38 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 702

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$336.24
$381.63
$429.72
$600.53
$912.56 		$593.47
$638.86
$686.95
$857.76 		$850.70
$896.09
$944.18
$1,114.99 		$1,107.93
$1,153.32
$1,201.41
$1,372.22 		$257.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.48
$763.26
$859.44
$1,201.06
$1,825.12 		$929.71
$1,020.49
$1,116.67
$1,458.29 		$1,186.94
$1,277.72
$1,373.90
$1,715.52 		$1,444.17
$1,534.95
$1,631.13
$1,972.75 		$257.23
Toc - Plan #39 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 706

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.89
$453.87
$511.05
$714.20
$1,085.29 		$705.80
$759.78
$816.96
$1,020.11 		$1,011.71
$1,065.69
$1,122.87
$1,326.02 		$1,317.62
$1,371.60
$1,428.78
$1,631.93 		$305.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.78
$907.74
$1,022.10
$1,428.40
$2,170.58 		$1,105.69
$1,213.65
$1,328.01
$1,734.31 		$1,411.60
$1,519.56
$1,633.92
$2,040.22 		$1,717.51
$1,825.47
$1,939.83
$2,346.13 		$305.91
Toc - Plan #40 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$476.88
$541.26
$609.45
$851.71
$1,294.25 		$841.69
$906.07
$974.26
$1,216.52 		$1,206.50
$1,270.88
$1,339.07
$1,581.33 		$1,571.31
$1,635.69
$1,703.88
$1,946.14 		$364.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$953.76
$1,082.52
$1,218.90
$1,703.42
$2,588.50 		$1,318.57
$1,447.33
$1,583.71
$2,068.23 		$1,683.38
$1,812.14
$1,948.52
$2,433.04 		$2,048.19
$2,176.95
$2,313.33
$2,797.85 		$364.81
Toc - Plan #41 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO? 704

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$314.15
$356.56
$401.49
$561.08
$852.61 		$554.48
$596.89
$641.82
$801.41 		$794.81
$837.22
$882.15
$1,041.74 		$1,035.14
$1,077.55
$1,122.48
$1,282.07 		$240.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.30
$713.12
$802.98
$1,122.16
$1,705.22 		$868.63
$953.45
$1,043.31
$1,362.49 		$1,108.96
$1,193.78
$1,283.64
$1,602.82 		$1,349.29
$1,434.11
$1,523.97
$1,843.15 		$240.33
Toc - Plan #42 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 707

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$335.13
$380.38
$428.30
$598.55
$909.55 		$591.51
$636.76
$684.68
$854.93 		$847.89
$893.14
$941.06
$1,111.31 		$1,104.27
$1,149.52
$1,197.44
$1,367.69 		$256.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.26
$760.76
$856.60
$1,197.10
$1,819.10 		$926.64
$1,017.14
$1,112.98
$1,453.48 		$1,183.02
$1,273.52
$1,369.36
$1,709.86 		$1,439.40
$1,529.90
$1,625.74
$1,966.24 		$256.38
Toc - Plan #43 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Plus Gold? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$850 $2,550 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 		$427.15
$484.81
$545.89
$762.88
$1,159.27 		$753.92
$811.58
$872.66
$1,089.65 		$1,080.69
$1,138.35
$1,199.43
$1,416.42 		$1,407.46
$1,465.12
$1,526.20
$1,743.19 		$326.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.30
$969.62
$1,091.78
$1,525.76
$2,318.54 		$1,181.07
$1,296.39
$1,418.55
$1,852.53 		$1,507.84
$1,623.16
$1,745.32
$2,179.30 		$1,834.61
$1,949.93
$2,072.09
$2,506.07 		$326.77
Toc - Plan #44 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,250 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 		$511.04
$580.04
$653.11
$912.73
$1,386.97 		$901.99
$970.99
$1,044.06
$1,303.68 		$1,292.94
$1,361.94
$1,435.01
$1,694.63 		$1,683.89
$1,752.89
$1,825.96
$2,085.58 		$390.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,022.08
$1,160.08
$1,306.22
$1,825.46
$2,773.94 		$1,413.03
$1,551.03
$1,697.17
$2,216.41 		$1,803.98
$1,941.98
$2,088.12
$2,607.36 		$2,194.93
$2,332.93
$2,479.07
$2,998.31 		$390.95
Toc - Plan #45 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Plus Bronze? 303

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$5,500 $16,500 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 		$350.37
$397.67
$447.78
$625.77
$950.91 		$618.41
$665.71
$715.82
$893.81 		$886.45
$933.75
$983.86
$1,161.85 		$1,154.49
$1,201.79
$1,251.90
$1,429.89 		$268.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.74
$795.34
$895.56
$1,251.54
$1,901.82 		$968.78
$1,063.38
$1,163.60
$1,519.58 		$1,236.82
$1,331.42
$1,431.64
$1,787.62 		$1,504.86
$1,599.46
$1,699.68
$2,055.66 		$268.04
Toc - Plan #46 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Plus Bronze? 305

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$6,100 $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 		$334.08
$379.18
$426.96
$596.67
$906.70 		$589.65
$634.75
$682.53
$852.24 		$845.22
$890.32
$938.10
$1,107.81 		$1,100.79
$1,145.89
$1,193.67
$1,363.38 		$255.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.16
$758.36
$853.92
$1,193.34
$1,813.40 		$923.73
$1,013.93
$1,109.49
$1,448.91 		$1,179.30
$1,269.50
$1,365.06
$1,704.48 		$1,434.87
$1,525.07
$1,620.63
$1,960.05 		$255.57
Toc - Plan #47 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 605

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$515.91
$585.56
$659.33
$921.41
$1,400.17 		$910.58
$980.23
$1,054.00
$1,316.08 		$1,305.25
$1,374.90
$1,448.67
$1,710.75 		$1,699.92
$1,769.57
$1,843.34
$2,105.42 		$394.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,031.82
$1,171.12
$1,318.66
$1,842.82
$2,800.34 		$1,426.49
$1,565.79
$1,713.33
$2,237.49 		$1,821.16
$1,960.46
$2,108.00
$2,632.16 		$2,215.83
$2,355.13
$2,502.67
$3,026.83 		$394.67
Toc - Plan #48 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Plus Gold? 706

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$425.49
$482.94
$543.78
$759.93
$1,154.79 		$750.99
$808.44
$869.28
$1,085.43 		$1,076.49
$1,133.94
$1,194.78
$1,410.93 		$1,401.99
$1,459.44
$1,520.28
$1,736.43 		$325.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.98
$965.88
$1,087.56
$1,519.86
$2,309.58 		$1,176.48
$1,291.38
$1,413.06
$1,845.36 		$1,501.98
$1,616.88
$1,738.56
$2,170.86 		$1,827.48
$1,942.38
$2,064.06
$2,496.36 		$325.50
Toc - Plan #49 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$507.97
$576.54
$649.18
$907.23
$1,378.62 		$896.56
$965.13
$1,037.77
$1,295.82 		$1,285.15
$1,353.72
$1,426.36
$1,684.41 		$1,673.74
$1,742.31
$1,814.95
$2,073.00 		$388.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,015.94
$1,153.08
$1,298.36
$1,814.46
$2,757.24 		$1,404.53
$1,541.67
$1,686.95
$2,203.05 		$1,793.12
$1,930.26
$2,075.54
$2,591.64 		$2,181.71
$2,318.85
$2,464.13
$2,980.23 		$388.59
Toc - Plan #50 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Plus Bronze? 704

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$335.46
$380.75
$428.72
$599.13
$910.44 		$592.09
$637.38
$685.35
$855.76 		$848.72
$894.01
$941.98
$1,112.39 		$1,105.35
$1,150.64
$1,198.61
$1,369.02 		$256.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.92
$761.50
$857.44
$1,198.26
$1,820.88 		$927.55
$1,018.13
$1,114.07
$1,454.89 		$1,184.18
$1,274.76
$1,370.70
$1,711.52 		$1,440.81
$1,531.39
$1,627.33
$1,968.15 		$256.63
Toc - Plan #51 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Plus Bronze? 707

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

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 		$357.06
$405.26
$456.32
$637.70
$969.05 		$630.21
$678.41
$729.47
$910.85 		$903.36
$951.56
$1,002.62
$1,184.00 		$1,176.51
$1,224.71
$1,275.77
$1,457.15 		$273.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.12
$810.52
$912.64
$1,275.40
$1,938.10 		$987.27
$1,083.67
$1,185.79
$1,548.55 		$1,260.42
$1,356.82
$1,458.94
$1,821.70 		$1,533.57
$1,629.97
$1,732.09
$2,094.85 		$273.15

ADVERTISEMENT

Baylor Scott and White Health Plan

Local: 1-844-633-5325 | Toll Free: 1-844-633-5325 | TTY: 1-800-735-2989
Toc - Plan #52 Baylor Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 001 (CMS Standardized Plan with $0 Pediatric PCP copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$336.04
$381.40
$429.46
$600.16
$912.00 		$593.11
$638.47
$686.53
$857.23 		$850.18
$895.54
$943.60
$1,114.30 		$1,107.25
$1,152.61
$1,200.67
$1,371.37 		$257.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.08
$762.80
$858.92
$1,200.32
$1,824.00 		$929.15
$1,019.87
$1,115.99
$1,457.39 		$1,186.22
$1,276.94
$1,373.06
$1,714.46 		$1,443.29
$1,534.01
$1,630.13
$1,971.53 		$257.07
Toc - Plan #53 Baylor Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$340.28
$386.22
$434.88
$607.74
$923.52 		$600.59
$646.53
$695.19
$868.05 		$860.90
$906.84
$955.50
$1,128.36 		$1,121.21
$1,167.15
$1,215.81
$1,388.67 		$260.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.56
$772.44
$869.76
$1,215.48
$1,847.04 		$940.87
$1,032.75
$1,130.07
$1,475.79 		$1,201.18
$1,293.06
$1,390.38
$1,736.10 		$1,461.49
$1,553.37
$1,650.69
$1,996.41 		$260.31
Toc - Plan #54 Baylor Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 004 (Low deductible, two free PCP visits, $0 Pediatric PCP visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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 		$354.90
$402.82
$453.57
$633.86
$963.21 		$626.40
$674.32
$725.07
$905.36 		$897.90
$945.82
$996.57
$1,176.86 		$1,169.40
$1,217.32
$1,268.07
$1,448.36 		$271.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.80
$805.64
$907.14
$1,267.72
$1,926.42 		$981.30
$1,077.14
$1,178.64
$1,539.22 		$1,252.80
$1,348.64
$1,450.14
$1,810.72 		$1,524.30
$1,620.14
$1,721.64
$2,082.22 		$271.50
Toc - Plan #55 Baylor Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$377.34
$428.28
$482.24
$673.93
$1,024.10 		$666.00
$716.94
$770.90
$962.59 		$954.66
$1,005.60
$1,059.56
$1,251.25 		$1,243.32
$1,294.26
$1,348.22
$1,539.91 		$288.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.68
$856.56
$964.48
$1,347.86
$2,048.20 		$1,043.34
$1,145.22
$1,253.14
$1,636.52 		$1,332.00
$1,433.88
$1,541.80
$1,925.18 		$1,620.66
$1,722.54
$1,830.46
$2,213.84 		$288.66
Toc - Plan #56 Baylor Scott and White Health Plan
Expanded Bronze

(HMO) BSW Savers Bronze HMO H S A 006 ($0 Preventive Care and Preventive Rx Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279.44
$317.16
$357.12
$499.07
$758.39 		$493.21
$530.93
$570.89
$712.84 		$706.98
$744.70
$784.66
$926.61 		$920.75
$958.47
$998.43
$1,140.38 		$213.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558.88
$634.32
$714.24
$998.14
$1,516.78 		$772.65
$848.09
$928.01
$1,211.91 		$986.42
$1,061.86
$1,141.78
$1,425.68 		$1,200.19
$1,275.63
$1,355.55
$1,639.45 		$213.77
Toc - Plan #57 Baylor Scott and White Health Plan
Expanded Bronze

(HMO) BSW Vital Bronze HMO 007 (CMS Standardized Plan with $0 Pediatric PCP copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$275.47
$312.66
$352.05
$491.99
$747.63 		$486.21
$523.40
$562.79
$702.73 		$696.95
$734.14
$773.53
$913.47 		$907.69
$944.88
$984.27
$1,124.21 		$210.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.94
$625.32
$704.10
$983.98
$1,495.26 		$761.68
$836.06
$914.84
$1,194.72 		$972.42
$1,046.80
$1,125.58
$1,405.46 		$1,183.16
$1,257.54
$1,336.32
$1,616.20 		$210.74
Toc - Plan #58 Baylor Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$346.10
$392.83
$442.32
$618.14
$939.33 		$610.87
$657.60
$707.09
$882.91 		$875.64
$922.37
$971.86
$1,147.68 		$1,140.41
$1,187.14
$1,236.63
$1,412.45 		$264.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.20
$785.66
$884.64
$1,236.28
$1,878.66 		$956.97
$1,050.43
$1,149.41
$1,501.05 		$1,221.74
$1,315.20
$1,414.18
$1,765.82 		$1,486.51
$1,579.97
$1,678.95
$2,030.59 		$264.77
Toc - Plan #59 Baylor Scott and White Health Plan
Expanded Bronze

(HMO) BSW Vital Bronze HMO 009 (One free PCP visit, $0 Pediatric PCP visit)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$272.98
$309.83
$348.86
$487.53
$740.86 		$481.81
$518.66
$557.69
$696.36 		$690.64
$727.49
$766.52
$905.19 		$899.47
$936.32
$975.35
$1,114.02 		$208.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$545.96
$619.66
$697.72
$975.06
$1,481.72 		$754.79
$828.49
$906.55
$1,183.89 		$963.62
$1,037.32
$1,115.38
$1,392.72 		$1,172.45
$1,246.15
$1,324.21
$1,601.55 		$208.83
Toc - Plan #60 Baylor Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 012 ($0 PCP unlimited visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$326.37
$370.43
$417.10
$582.89
$885.76 		$576.04
$620.10
$666.77
$832.56 		$825.71
$869.77
$916.44
$1,082.23 		$1,075.38
$1,119.44
$1,166.11
$1,331.90 		$249.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.74
$740.86
$834.20
$1,165.78
$1,771.52 		$902.41
$990.53
$1,083.87
$1,415.45 		$1,152.08
$1,240.20
$1,333.54
$1,665.12 		$1,401.75
$1,489.87
$1,583.21
$1,914.79 		$249.67

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #61 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$292.12
$331.55
$373.33
$521.72
$792.81 		$515.59
$555.02
$596.80
$745.19 		$739.06
$778.49
$820.27
$968.66 		$962.53
$1,001.96
$1,043.74
$1,192.13 		$223.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.24
$663.10
$746.66
$1,043.44
$1,585.62 		$807.71
$886.57
$970.13
$1,266.91 		$1,031.18
$1,110.04
$1,193.60
$1,490.38 		$1,254.65
$1,333.51
$1,417.07
$1,713.85 		$223.47
Toc - Plan #62 Aetna CVS Health
Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$429.71
$487.72
$549.16
$767.45
$1,166.22 		$758.43
$816.44
$877.88
$1,096.17 		$1,087.15
$1,145.16
$1,206.60
$1,424.89 		$1,415.87
$1,473.88
$1,535.32
$1,753.61 		$328.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.42
$975.44
$1,098.32
$1,534.90
$2,332.44 		$1,188.14
$1,304.16
$1,427.04
$1,863.62 		$1,516.86
$1,632.88
$1,755.76
$2,192.34 		$1,845.58
$1,961.60
$2,084.48
$2,521.06 		$328.72
Toc - Plan #63 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$396.04
$449.51
$506.14
$707.33
$1,074.86 		$699.01
$752.48
$809.11
$1,010.30 		$1,001.98
$1,055.45
$1,112.08
$1,313.27 		$1,304.95
$1,358.42
$1,415.05
$1,616.24 		$302.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792.08
$899.02
$1,012.28
$1,414.66
$2,149.72 		$1,095.05
$1,201.99
$1,315.25
$1,717.63 		$1,398.02
$1,504.96
$1,618.22
$2,020.60 		$1,700.99
$1,807.93
$1,921.19
$2,323.57 		$302.97
Toc - Plan #64 Aetna CVS Health
Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 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 		$409.04
$464.26
$522.75
$730.54
$1,110.12 		$721.95
$777.17
$835.66
$1,043.45 		$1,034.86
$1,090.08
$1,148.57
$1,356.36 		$1,347.77
$1,402.99
$1,461.48
$1,669.27 		$312.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.08
$928.52
$1,045.50
$1,461.08
$2,220.24 		$1,130.99
$1,241.43
$1,358.41
$1,773.99 		$1,443.90
$1,554.34
$1,671.32
$2,086.90 		$1,756.81
$1,867.25
$1,984.23
$2,399.81 		$312.91
Toc - Plan #65 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 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 		$407.80
$462.85
$521.16
$728.32
$1,106.76 		$719.76
$774.81
$833.12
$1,040.28 		$1,031.72
$1,086.77
$1,145.08
$1,352.24 		$1,343.68
$1,398.73
$1,457.04
$1,664.20 		$311.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.60
$925.70
$1,042.32
$1,456.64
$2,213.52 		$1,127.56
$1,237.66
$1,354.28
$1,768.60 		$1,439.52
$1,549.62
$1,666.24
$2,080.56 		$1,751.48
$1,861.58
$1,978.20
$2,392.52 		$311.96
Toc - Plan #66 Aetna CVS Health
Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$416.22
$472.42
$531.94
$743.38
$1,129.63 		$734.63
$790.83
$850.35
$1,061.79 		$1,053.04
$1,109.24
$1,168.76
$1,380.20 		$1,371.45
$1,427.65
$1,487.17
$1,698.61 		$318.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.44
$944.84
$1,063.88
$1,486.76
$2,259.26 		$1,150.85
$1,263.25
$1,382.29
$1,805.17 		$1,469.26
$1,581.66
$1,700.70
$2,123.58 		$1,787.67
$1,900.07
$2,019.11
$2,441.99 		$318.41
Toc - Plan #67 Aetna CVS Health
Silver

(HMO) Silver 4: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,950 $17,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$521.28
$591.66
$666.20
$931.01
$1,414.76 		$920.06
$990.44
$1,064.98
$1,329.79 		$1,318.84
$1,389.22
$1,463.76
$1,728.57 		$1,717.62
$1,788.00
$1,862.54
$2,127.35 		$398.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,042.56
$1,183.32
$1,332.40
$1,862.02
$2,829.52 		$1,441.34
$1,582.10
$1,731.18
$2,260.80 		$1,840.12
$1,980.88
$2,129.96
$2,659.58 		$2,238.90
$2,379.66
$2,528.74
$3,058.36 		$398.78
Toc - Plan #68 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.55
$458.03
$515.74
$720.74
$1,095.23 		$712.27
$766.75
$824.46
$1,029.46 		$1,020.99
$1,075.47
$1,133.18
$1,338.18 		$1,329.71
$1,384.19
$1,441.90
$1,646.90 		$308.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.10
$916.06
$1,031.48
$1,441.48
$2,190.46 		$1,115.82
$1,224.78
$1,340.20
$1,750.20 		$1,424.54
$1,533.50
$1,648.92
$2,058.92 		$1,733.26
$1,842.22
$1,957.64
$2,367.64 		$308.72

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #69 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5500

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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 		$256.53
$291.17
$327.85
$458.17
$696.23 		$452.78
$487.42
$524.10
$654.42 		$649.03
$683.67
$720.35
$850.67 		$845.28
$879.92
$916.60
$1,046.92 		$196.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$513.06
$582.34
$655.70
$916.34
$1,392.46 		$709.31
$778.59
$851.95
$1,112.59 		$905.56
$974.84
$1,048.20
$1,308.84 		$1,101.81
$1,171.09
$1,244.45
$1,505.09 		$196.25
Toc - Plan #70 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$257.27
$292.00
$328.79
$459.49
$698.24 		$454.08
$488.81
$525.60
$656.30 		$650.89
$685.62
$722.41
$853.11 		$847.70
$882.43
$919.22
$1,049.92 		$196.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514.54
$584.00
$657.58
$918.98
$1,396.48 		$711.35
$780.81
$854.39
$1,115.79 		$908.16
$977.62
$1,051.20
$1,312.60 		$1,104.97
$1,174.43
$1,248.01
$1,509.41 		$196.81
Toc - Plan #71 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 8200

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

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$261.00
$296.24
$333.56
$466.15
$708.36 		$460.67
$495.91
$533.23
$665.82 		$660.34
$695.58
$732.90
$865.49 		$860.01
$895.25
$932.57
$1,065.16 		$199.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$522.00
$592.48
$667.12
$932.30
$1,416.72 		$721.67
$792.15
$866.79
$1,131.97 		$921.34
$991.82
$1,066.46
$1,331.64 		$1,121.01
$1,191.49
$1,266.13
$1,531.31 		$199.67
Toc - Plan #72 Cigna Healthcare
Silver

(HMO) Cigna Connect 0A

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$368.18
$417.88
$470.53
$657.56
$999.23 		$649.83
$699.53
$752.18
$939.21 		$931.48
$981.18
$1,033.83
$1,220.86 		$1,213.13
$1,262.83
$1,315.48
$1,502.51 		$281.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.36
$835.76
$941.06
$1,315.12
$1,998.46 		$1,018.01
$1,117.41
$1,222.71
$1,596.77 		$1,299.66
$1,399.06
$1,504.36
$1,878.42 		$1,581.31
$1,680.71
$1,786.01
$2,160.07 		$281.65
Toc - Plan #73 Cigna Healthcare
Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361.45
$410.25
$461.94
$645.55
$980.98 		$637.96
$686.76
$738.45
$922.06 		$914.47
$963.27
$1,014.96
$1,198.57 		$1,190.98
$1,239.78
$1,291.47
$1,475.08 		$276.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.90
$820.50
$923.88
$1,291.10
$1,961.96 		$999.41
$1,097.01
$1,200.39
$1,567.61 		$1,275.92
$1,373.52
$1,476.90
$1,844.12 		$1,552.43
$1,650.03
$1,753.41
$2,120.63 		$276.51
Toc - Plan #74 Cigna Healthcare
Silver

(HMO) Cigna Connect 4000

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

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 		$354.58
$402.45
$453.15
$633.28
$962.33 		$625.83
$673.70
$724.40
$904.53 		$897.08
$944.95
$995.65
$1,175.78 		$1,168.33
$1,216.20
$1,266.90
$1,447.03 		$271.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.16
$804.90
$906.30
$1,266.56
$1,924.66 		$980.41
$1,076.15
$1,177.55
$1,537.81 		$1,251.66
$1,347.40
$1,448.80
$1,809.06 		$1,522.91
$1,618.65
$1,720.05
$2,080.31 		$271.25
Toc - Plan #75 Cigna Healthcare
Silver

(HMO) Cigna Connect 5000

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$361.34
$410.12
$461.79
$645.36
$980.68 		$637.77
$686.55
$738.22
$921.79 		$914.20
$962.98
$1,014.65
$1,198.22 		$1,190.63
$1,239.41
$1,291.08
$1,474.65 		$276.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.68
$820.24
$923.58
$1,290.72
$1,961.36 		$999.11
$1,096.67
$1,200.01
$1,567.15 		$1,275.54
$1,373.10
$1,476.44
$1,843.58 		$1,551.97
$1,649.53
$1,752.87
$2,120.01 		$276.43
Toc - Plan #76 Cigna Healthcare
Silver

(HMO) Cigna Connect 7900

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

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 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 		$362.97
$411.97
$463.87
$648.26
$985.09 		$640.64
$689.64
$741.54
$925.93 		$918.31
$967.31
$1,019.21
$1,203.60 		$1,195.98
$1,244.98
$1,296.88
$1,481.27 		$277.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.94
$823.94
$927.74
$1,296.52
$1,970.18 		$1,003.61
$1,101.61
$1,205.41
$1,574.19 		$1,281.28
$1,379.28
$1,483.08
$1,851.86 		$1,558.95
$1,656.95
$1,760.75
$2,129.53 		$277.67
Toc - Plan #77 Cigna Healthcare
Silver

(HMO) Cigna Connect 3000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.00
$397.25
$447.30
$625.10
$949.90 		$617.75
$665.00
$715.05
$892.85 		$885.50
$932.75
$982.80
$1,160.60 		$1,153.25
$1,200.50
$1,250.55
$1,428.35 		$267.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.00
$794.50
$894.60
$1,250.20
$1,899.80 		$967.75
$1,062.25
$1,162.35
$1,517.95 		$1,235.50
$1,330.00
$1,430.10
$1,785.70 		$1,503.25
$1,597.75
$1,697.85
$2,053.45 		$267.75
Toc - Plan #78 Cigna Healthcare
Gold

(HMO) Cigna Connect 2500

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$314.72
$357.21
$402.21
$562.09
$854.15 		$555.48
$597.97
$642.97
$802.85 		$796.24
$838.73
$883.73
$1,043.61 		$1,037.00
$1,079.49
$1,124.49
$1,284.37 		$240.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.44
$714.42
$804.42
$1,124.18
$1,708.30 		$870.20
$955.18
$1,045.18
$1,364.94 		$1,110.96
$1,195.94
$1,285.94
$1,605.70 		$1,351.72
$1,436.70
$1,526.70
$1,846.46 		$240.76
Toc - Plan #79 Cigna Healthcare
Gold

(HMO) Cigna Connect 1900 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$315.83
$358.46
$403.63
$564.07
$857.16 		$557.44
$600.07
$645.24
$805.68 		$799.05
$841.68
$886.85
$1,047.29 		$1,040.66
$1,083.29
$1,128.46
$1,288.90 		$241.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.66
$716.92
$807.26
$1,128.14
$1,714.32 		$873.27
$958.53
$1,048.87
$1,369.75 		$1,114.88
$1,200.14
$1,290.48
$1,611.36 		$1,356.49
$1,441.75
$1,532.09
$1,852.97 		$241.61
Toc - Plan #80 Cigna Healthcare
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.60
$411.55
$463.40
$647.60
$984.09 		$639.99
$688.94
$740.79
$924.99 		$917.38
$966.33
$1,018.18
$1,202.38 		$1,194.77
$1,243.72
$1,295.57
$1,479.77 		$277.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.20
$823.10
$926.80
$1,295.20
$1,968.18 		$1,002.59
$1,100.49
$1,204.19
$1,572.59 		$1,279.98
$1,377.88
$1,481.58
$1,849.98 		$1,557.37
$1,655.27
$1,758.97
$2,127.37 		$277.39
Toc - Plan #81 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Simple Choice 7500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$254.76
$289.15
$325.58
$455.00
$691.42 		$449.65
$484.04
$520.47
$649.89 		$644.54
$678.93
$715.36
$844.78 		$839.43
$873.82
$910.25
$1,039.67 		$194.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$509.52
$578.30
$651.16
$910.00
$1,382.84 		$704.41
$773.19
$846.05
$1,104.89 		$899.30
$968.08
$1,040.94
$1,299.78 		$1,094.19
$1,162.97
$1,235.83
$1,494.67 		$194.89
Toc - Plan #82 Cigna Healthcare
Silver

(HMO) Cigna Simple Choice 5800

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.35
$406.73
$457.97
$640.01
$972.56 		$632.49
$680.87
$732.11
$914.15 		$906.63
$955.01
$1,006.25
$1,188.29 		$1,180.77
$1,229.15
$1,280.39
$1,462.43 		$274.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.70
$813.46
$915.94
$1,280.02
$1,945.12 		$990.84
$1,087.60
$1,190.08
$1,554.16 		$1,264.98
$1,361.74
$1,464.22
$1,828.30 		$1,539.12
$1,635.88
$1,738.36
$2,102.44 		$274.14
Toc - Plan #83 Cigna Healthcare
Gold

(HMO) Cigna Simple Choice 2000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$312.43
$354.61
$399.28
$558.00
$847.93 		$551.44
$593.62
$638.29
$797.01 		$790.45
$832.63
$877.30
$1,036.02 		$1,029.46
$1,071.64
$1,116.31
$1,275.03 		$239.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.86
$709.22
$798.56
$1,116.00
$1,695.86 		$863.87
$948.23
$1,037.57
$1,355.01 		$1,102.88
$1,187.24
$1,276.58
$1,594.02 		$1,341.89
$1,426.25
$1,515.59
$1,833.03 		$239.01
Toc - Plan #84 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect HSA 7050

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

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 		$257.31
$292.05
$328.84
$459.55
$698.34 		$454.15
$488.89
$525.68
$656.39 		$650.99
$685.73
$722.52
$853.23 		$847.83
$882.57
$919.36
$1,050.07 		$196.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514.62
$584.10
$657.68
$919.10
$1,396.68 		$711.46
$780.94
$854.52
$1,115.94 		$908.30
$977.78
$1,051.36
$1,312.78 		$1,105.14
$1,174.62
$1,248.20
$1,509.62 		$196.84
Toc - Plan #85 Cigna Healthcare
Bronze

(HMO) Cigna Simple Choice 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$244.93
$278.00
$313.02
$437.45
$664.75 		$432.30
$465.37
$500.39
$624.82 		$619.67
$652.74
$687.76
$812.19 		$807.04
$840.11
$875.13
$999.56 		$187.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$489.86
$556.00
$626.04
$874.90
$1,329.50 		$677.23
$743.37
$813.41
$1,062.27 		$864.60
$930.74
$1,000.78
$1,249.64 		$1,051.97
$1,118.11
$1,188.15
$1,437.01 		$187.37
Toc - Plan #86 Cigna Healthcare
Bronze

(HMO) Cigna Connect 8900

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$246.15
$279.38
$314.58
$439.63
$668.06 		$434.46
$467.69
$502.89
$627.94 		$622.77
$656.00
$691.20
$816.25 		$811.08
$844.31
$879.51
$1,004.56 		$188.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492.30
$558.76
$629.16
$879.26
$1,336.12 		$680.61
$747.07
$817.47
$1,067.57 		$868.92
$935.38
$1,005.78
$1,255.88 		$1,057.23
$1,123.69
$1,194.09
$1,444.19 		$188.31

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #87 Ambetter from Superior HealthPlan
Silver

(HMO) Ambetter Virtual Access Silver (Virtual PCP Selection Required for $0 Virtual Visits on Ambetter's Telehealth Platform)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 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 		$443.36
$503.21
$566.61
$791.83
$1,203.26 		$782.53
$842.38
$905.78
$1,131.00 		$1,121.70
$1,181.55
$1,244.95
$1,470.17 		$1,460.87
$1,520.72
$1,584.12
$1,809.34 		$339.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.72
$1,006.42
$1,133.22
$1,583.66
$2,406.52 		$1,225.89
$1,345.59
$1,472.39
$1,922.83 		$1,565.06
$1,684.76
$1,811.56
$2,262.00 		$1,904.23
$2,023.93
$2,150.73
$2,601.17 		$339.17
Toc - Plan #88 Ambetter from Superior HealthPlan
Gold

(HMO) Ambetter Virtual Access Gold (Virtual PCP Selection Required for $0 Virtual Visits on Ambetter's Telehealth Platform)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$416.93
$473.21
$532.83
$744.63
$1,131.53 		$735.88
$792.16
$851.78
$1,063.58 		$1,054.83
$1,111.11
$1,170.73
$1,382.53 		$1,373.78
$1,430.06
$1,489.68
$1,701.48 		$318.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$833.86
$946.42
$1,065.66
$1,489.26
$2,263.06 		$1,152.81
$1,265.37
$1,384.61
$1,808.21 		$1,471.76
$1,584.32
$1,703.56
$2,127.16 		$1,790.71
$1,903.27
$2,022.51
$2,446.11 		$318.95
Toc - Plan #89 Ambetter from Superior HealthPlan
Silver

(HMO) CMS Standard Virtual Access Basic Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$457.94
$519.75
$585.23
$817.86
$1,242.82 		$808.26
$870.07
$935.55
$1,168.18 		$1,158.58
$1,220.39
$1,285.87
$1,518.50 		$1,508.90
$1,570.71
$1,636.19
$1,868.82 		$350.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$915.88
$1,039.50
$1,170.46
$1,635.72
$2,485.64 		$1,266.20
$1,389.82
$1,520.78
$1,986.04 		$1,616.52
$1,740.14
$1,871.10
$2,336.36 		$1,966.84
$2,090.46
$2,221.42
$2,686.68 		$350.32
Toc - Plan #90 Ambetter from Superior HealthPlan
Gold

(HMO) CMS Standard Virtual Access Basic Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$412.95
$468.69
$527.74
$737.52
$1,120.73 		$728.85
$784.59
$843.64
$1,053.42 		$1,044.75
$1,100.49
$1,159.54
$1,369.32 		$1,360.65
$1,416.39
$1,475.44
$1,685.22 		$315.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.90
$937.38
$1,055.48
$1,475.04
$2,241.46 		$1,141.80
$1,253.28
$1,371.38
$1,790.94 		$1,457.70
$1,569.18
$1,687.28
$2,106.84 		$1,773.60
$1,885.08
$2,003.18
$2,422.74 		$315.90
Toc - Plan #91 Ambetter from Superior HealthPlan
Silver

(HMO) Complete VALUE Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$389.46
$442.02
$497.71
$695.55
$1,056.96 		$687.39
$739.95
$795.64
$993.48 		$985.32
$1,037.88
$1,093.57
$1,291.41 		$1,283.25
$1,335.81
$1,391.50
$1,589.34 		$297.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.92
$884.04
$995.42
$1,391.10
$2,113.92 		$1,076.85
$1,181.97
$1,293.35
$1,689.03 		$1,374.78
$1,479.90
$1,591.28
$1,986.96 		$1,672.71
$1,777.83
$1,889.21
$2,284.89 		$297.93
Toc - Plan #92 Ambetter from Superior HealthPlan
Silver

(HMO) Clear VALUE Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$385.56
$437.60
$492.74
$688.60
$1,046.39 		$680.51
$732.55
$787.69
$983.55 		$975.46
$1,027.50
$1,082.64
$1,278.50 		$1,270.41
$1,322.45
$1,377.59
$1,573.45 		$294.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.12
$875.20
$985.48
$1,377.20
$2,092.78 		$1,066.07
$1,170.15
$1,280.43
$1,672.15 		$1,361.02
$1,465.10
$1,575.38
$1,967.10 		$1,655.97
$1,760.05
$1,870.33
$2,262.05 		$294.95
Toc - Plan #93 Ambetter from Superior HealthPlan
Silver

(HMO) Focused VALUE Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$384.14
$435.98
$490.92
$686.05
$1,042.52 		$678.00
$729.84
$784.78
$979.91 		$971.86
$1,023.70
$1,078.64
$1,273.77 		$1,265.72
$1,317.56
$1,372.50
$1,567.63 		$293.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$768.28
$871.96
$981.84
$1,372.10
$2,085.04 		$1,062.14
$1,165.82
$1,275.70
$1,665.96 		$1,356.00
$1,459.68
$1,569.56
$1,959.82 		$1,649.86
$1,753.54
$1,863.42
$2,253.68 		$293.86
Toc - Plan #94 Ambetter from Superior HealthPlan
Gold

(HMO) Everyday VALUE Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$348.87
$395.96
$445.84
$623.06
$946.81 		$615.75
$662.84
$712.72
$889.94 		$882.63
$929.72
$979.60
$1,156.82 		$1,149.51
$1,196.60
$1,246.48
$1,423.70 		$266.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.74
$791.92
$891.68
$1,246.12
$1,893.62 		$964.62
$1,058.80
$1,158.56
$1,513.00 		$1,231.50
$1,325.68
$1,425.44
$1,779.88 		$1,498.38
$1,592.56
$1,692.32
$2,046.76 		$266.88
Toc - Plan #95 Ambetter from Superior HealthPlan
Silver

(HMO) CMS Standard Silver VALUE

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$383.84
$435.65
$490.54
$685.53
$1,041.73 		$677.47
$729.28
$784.17
$979.16 		$971.10
$1,022.91
$1,077.80
$1,272.79 		$1,264.73
$1,316.54
$1,371.43
$1,566.42 		$293.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.68
$871.30
$981.08
$1,371.06
$2,083.46 		$1,061.31
$1,164.93
$1,274.71
$1,664.69 		$1,354.94
$1,458.56
$1,568.34
$1,958.32 		$1,648.57
$1,752.19
$1,861.97
$2,251.95 		$293.63
Toc - Plan #96 Ambetter from Superior HealthPlan
Gold

(HMO) CMS Standard Gold VALUE

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

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 		$346.15
$392.87
$442.36
$618.20
$939.42 		$610.95
$657.67
$707.16
$883.00 		$875.75
$922.47
$971.96
$1,147.80 		$1,140.55
$1,187.27
$1,236.76
$1,412.60 		$264.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.30
$785.74
$884.72
$1,236.40
$1,878.84 		$957.10
$1,050.54
$1,149.52
$1,501.20 		$1,221.90
$1,315.34
$1,414.32
$1,766.00 		$1,486.70
$1,580.14
$1,679.12
$2,030.80 		$264.80

‡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 Rockwall County here.

Rockwall County is in “Rating Area 8” of Texas.

Currently, there are 96 plans offered in Rating Area 8.

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2023 Obamacare Plans for Rockwall County, TX

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