Obamacare 2023 Rates for Travis County

Obamacare > Rates > Texas > Travis 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 Travis 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, 127 Plans and 2023 Rates for Travis County, Texas

Below, you’ll find a summary of the 127 plans for Travis 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

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

Travis County Resources

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Moda Health, Inc.

Local: 1-844-827-6571 | Toll Free: 1-844-827-6571 | TTY: 1-844-827-6571
Toc - Plan #1 Moda Health, Inc.
Gold

(EPO) Moda Select Gold 1000 ($0 Virtual Care $2 Rx Value Tier)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$359.00
$407.00
$459.00
$641.00
$974.00 		$634.00
$682.00
$734.00
$916.00 		$909.00
$957.00
$1,009.00
$1,191.00 		$1,184.00
$1,232.00
$1,284.00
$1,466.00 		$275.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.00
$814.00
$918.00
$1,282.00
$1,948.00 		$993.00
$1,089.00
$1,193.00
$1,557.00 		$1,268.00
$1,364.00
$1,468.00
$1,832.00 		$1,543.00
$1,639.00
$1,743.00
$2,107.00 		$275.00
Toc - Plan #2 Moda Health, Inc.
Gold

(EPO) Moda Select Gold 1800 ($0 Virtual Care $2 Rx Value Tier)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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 		$351.00
$398.00
$449.00
$627.00
$953.00 		$620.00
$667.00
$718.00
$896.00 		$889.00
$936.00
$987.00
$1,165.00 		$1,158.00
$1,205.00
$1,256.00
$1,434.00 		$269.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.00
$796.00
$898.00
$1,254.00
$1,906.00 		$971.00
$1,065.00
$1,167.00
$1,523.00 		$1,240.00
$1,334.00
$1,436.00
$1,792.00 		$1,509.00
$1,603.00
$1,705.00
$2,061.00 		$269.00
Toc - Plan #3 Moda Health, Inc.
Silver

(EPO) Moda Select Silver 3500 ($0 Virtual Care $2 Rx Value Tier)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$408.00
$464.00
$522.00
$730.00
$1,109.00 		$720.00
$776.00
$834.00
$1,042.00 		$1,032.00
$1,088.00
$1,146.00
$1,354.00 		$1,344.00
$1,400.00
$1,458.00
$1,666.00 		$312.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.00
$928.00
$1,044.00
$1,460.00
$2,218.00 		$1,128.00
$1,240.00
$1,356.00
$1,772.00 		$1,440.00
$1,552.00
$1,668.00
$2,084.00 		$1,752.00
$1,864.00
$1,980.00
$2,396.00 		$312.00
Toc - Plan #4 Moda Health, Inc.
Silver

(EPO) Moda Select Silver 4800 ($0 Virtual Care $2 Rx Value Tier)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$7,850 $15,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.00
$465.00
$524.00
$732.00
$1,112.00 		$723.00
$778.00
$837.00
$1,045.00 		$1,036.00
$1,091.00
$1,150.00
$1,358.00 		$1,349.00
$1,404.00
$1,463.00
$1,671.00 		$313.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.00
$930.00
$1,048.00
$1,464.00
$2,224.00 		$1,133.00
$1,243.00
$1,361.00
$1,777.00 		$1,446.00
$1,556.00
$1,674.00
$2,090.00 		$1,759.00
$1,869.00
$1,987.00
$2,403.00 		$313.00
Toc - Plan #5 Moda Health, Inc.
Silver

(EPO) Moda Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 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 		$414.00
$470.00
$530.00
$740.00
$1,125.00 		$731.00
$787.00
$847.00
$1,057.00 		$1,048.00
$1,104.00
$1,164.00
$1,374.00 		$1,365.00
$1,421.00
$1,481.00
$1,691.00 		$317.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.00
$940.00
$1,060.00
$1,480.00
$2,250.00 		$1,145.00
$1,257.00
$1,377.00
$1,797.00 		$1,462.00
$1,574.00
$1,694.00
$2,114.00 		$1,779.00
$1,891.00
$2,011.00
$2,431.00 		$317.00
Toc - Plan #6 Moda Health, Inc.
Expanded Bronze

(EPO) Moda Select Bronze 8700 ($0 Virtual Care $2 Rx Value Tier)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$261.00
$296.00
$333.00
$466.00
$708.00 		$461.00
$496.00
$533.00
$666.00 		$661.00
$696.00
$733.00
$866.00 		$861.00
$896.00
$933.00
$1,066.00 		$200.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$522.00
$592.00
$666.00
$932.00
$1,416.00 		$722.00
$792.00
$866.00
$1,132.00 		$922.00
$992.00
$1,066.00
$1,332.00 		$1,122.00
$1,192.00
$1,266.00
$1,532.00 		$200.00
Toc - Plan #7 Moda Health, Inc.
Expanded Bronze

(EPO) Moda Select Bronze HSA 6900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$274.00
$311.00
$351.00
$490.00
$745.00 		$484.00
$521.00
$561.00
$700.00 		$694.00
$731.00
$771.00
$910.00 		$904.00
$941.00
$981.00
$1,120.00 		$210.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.00
$622.00
$702.00
$980.00
$1,490.00 		$758.00
$832.00
$912.00
$1,190.00 		$968.00
$1,042.00
$1,122.00
$1,400.00 		$1,178.00
$1,252.00
$1,332.00
$1,610.00 		$210.00
Toc - Plan #8 Moda Health, Inc.
Silver

(EPO) Moda Select Texas Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

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 		$404.00
$459.00
$517.00
$722.00
$1,098.00 		$713.00
$768.00
$826.00
$1,031.00 		$1,022.00
$1,077.00
$1,135.00
$1,340.00 		$1,331.00
$1,386.00
$1,444.00
$1,649.00 		$309.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.00
$918.00
$1,034.00
$1,444.00
$2,196.00 		$1,117.00
$1,227.00
$1,343.00
$1,753.00 		$1,426.00
$1,536.00
$1,652.00
$2,062.00 		$1,735.00
$1,845.00
$1,961.00
$2,371.00 		$309.00
Toc - Plan #9 Moda Health, Inc.
Gold

(EPO) Moda Select Texas Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

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 		$356.00
$404.00
$454.00
$635.00
$965.00 		$628.00
$676.00
$726.00
$907.00 		$900.00
$948.00
$998.00
$1,179.00 		$1,172.00
$1,220.00
$1,270.00
$1,451.00 		$272.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.00
$808.00
$908.00
$1,270.00
$1,930.00 		$984.00
$1,080.00
$1,180.00
$1,542.00 		$1,256.00
$1,352.00
$1,452.00
$1,814.00 		$1,528.00
$1,624.00
$1,724.00
$2,086.00 		$272.00
Toc - Plan #10 Moda Health, Inc.
Bronze

(EPO) Moda Select Texas Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

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 		$251.00
$285.00
$321.00
$448.00
$681.00 		$443.00
$477.00
$513.00
$640.00 		$635.00
$669.00
$705.00
$832.00 		$827.00
$861.00
$897.00
$1,024.00 		$192.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$502.00
$570.00
$642.00
$896.00
$1,362.00 		$694.00
$762.00
$834.00
$1,088.00 		$886.00
$954.00
$1,026.00
$1,280.00 		$1,078.00
$1,146.00
$1,218.00
$1,472.00 		$192.00

ADVERTISEMENT

Oscar Insurance Company

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

Toc - Plan #11 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 		$322.78
$366.35
$412.51
$576.48
$876.01 		$569.70
$613.27
$659.43
$823.40 		$816.62
$860.19
$906.35
$1,070.32 		$1,063.54
$1,107.11
$1,153.27
$1,317.24 		$246.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.56
$732.70
$825.02
$1,152.96
$1,752.02 		$892.48
$979.62
$1,071.94
$1,399.88 		$1,139.40
$1,226.54
$1,318.86
$1,646.80 		$1,386.32
$1,473.46
$1,565.78
$1,893.72 		$246.92
Toc - Plan #12 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 		$324.39
$368.17
$414.55
$579.34
$880.36 		$572.54
$616.32
$662.70
$827.49 		$820.69
$864.47
$910.85
$1,075.64 		$1,068.84
$1,112.62
$1,159.00
$1,323.79 		$248.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.78
$736.34
$829.10
$1,158.68
$1,760.72 		$896.93
$984.49
$1,077.25
$1,406.83 		$1,145.08
$1,232.64
$1,325.40
$1,654.98 		$1,393.23
$1,480.79
$1,573.55
$1,903.13 		$248.15
Toc - Plan #13 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 		$367.66
$417.29
$469.86
$656.63
$997.81 		$648.91
$698.54
$751.11
$937.88 		$930.16
$979.79
$1,032.36
$1,219.13 		$1,211.41
$1,261.04
$1,313.61
$1,500.38 		$281.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.32
$834.58
$939.72
$1,313.26
$1,995.62 		$1,016.57
$1,115.83
$1,220.97
$1,594.51 		$1,297.82
$1,397.08
$1,502.22
$1,875.76 		$1,579.07
$1,678.33
$1,783.47
$2,157.01 		$281.25
Toc - Plan #14 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 		$472.25
$535.99
$603.52
$843.41
$1,281.65 		$833.51
$897.25
$964.78
$1,204.67 		$1,194.77
$1,258.51
$1,326.04
$1,565.93 		$1,556.03
$1,619.77
$1,687.30
$1,927.19 		$361.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$944.50
$1,071.98
$1,207.04
$1,686.82
$2,563.30 		$1,305.76
$1,433.24
$1,568.30
$2,048.08 		$1,667.02
$1,794.50
$1,929.56
$2,409.34 		$2,028.28
$2,155.76
$2,290.82
$2,770.60 		$361.26
Toc - Plan #15 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 		$467.77
$530.90
$597.79
$835.41
$1,269.49 		$825.60
$888.73
$955.62
$1,193.24 		$1,183.43
$1,246.56
$1,313.45
$1,551.07 		$1,541.26
$1,604.39
$1,671.28
$1,908.90 		$357.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$935.54
$1,061.80
$1,195.58
$1,670.82
$2,538.98 		$1,293.37
$1,419.63
$1,553.41
$2,028.65 		$1,651.20
$1,777.46
$1,911.24
$2,386.48 		$2,009.03
$2,135.29
$2,269.07
$2,744.31 		$357.83
Toc - Plan #16 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 		$472.77
$536.59
$604.19
$844.36
$1,283.08 		$834.43
$898.25
$965.85
$1,206.02 		$1,196.09
$1,259.91
$1,327.51
$1,567.68 		$1,557.75
$1,621.57
$1,689.17
$1,929.34 		$361.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945.54
$1,073.18
$1,208.38
$1,688.72
$2,566.16 		$1,307.20
$1,434.84
$1,570.04
$2,050.38 		$1,668.86
$1,796.50
$1,931.70
$2,412.04 		$2,030.52
$2,158.16
$2,293.36
$2,773.70 		$361.66
Toc - Plan #17 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 		$366.35
$415.80
$468.19
$654.29
$994.25 		$646.60
$696.05
$748.44
$934.54 		$926.85
$976.30
$1,028.69
$1,214.79 		$1,207.10
$1,256.55
$1,308.94
$1,495.04 		$280.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.70
$831.60
$936.38
$1,308.58
$1,988.50 		$1,012.95
$1,111.85
$1,216.63
$1,588.83 		$1,293.20
$1,392.10
$1,496.88
$1,869.08 		$1,573.45
$1,672.35
$1,777.13
$2,149.33 		$280.25
Toc - Plan #18 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 		$339.45
$385.26
$433.80
$606.24
$921.24 		$599.12
$644.93
$693.47
$865.91 		$858.79
$904.60
$953.14
$1,125.58 		$1,118.46
$1,164.27
$1,212.81
$1,385.25 		$259.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.90
$770.52
$867.60
$1,212.48
$1,842.48 		$938.57
$1,030.19
$1,127.27
$1,472.15 		$1,198.24
$1,289.86
$1,386.94
$1,731.82 		$1,457.91
$1,549.53
$1,646.61
$1,991.49 		$259.67
Toc - Plan #19 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 		$344.83
$391.37
$440.68
$615.85
$935.85 		$608.62
$655.16
$704.47
$879.64 		$872.41
$918.95
$968.26
$1,143.43 		$1,136.20
$1,182.74
$1,232.05
$1,407.22 		$263.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689.66
$782.74
$881.36
$1,231.70
$1,871.70 		$953.45
$1,046.53
$1,145.15
$1,495.49 		$1,217.24
$1,310.32
$1,408.94
$1,759.28 		$1,481.03
$1,574.11
$1,672.73
$2,023.07 		$263.79
Toc - Plan #20 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 		$460.56
$522.72
$588.58
$822.54
$1,249.93 		$812.88
$875.04
$940.90
$1,174.86 		$1,165.20
$1,227.36
$1,293.22
$1,527.18 		$1,517.52
$1,579.68
$1,645.54
$1,879.50 		$352.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.12
$1,045.44
$1,177.16
$1,645.08
$2,499.86 		$1,273.44
$1,397.76
$1,529.48
$1,997.40 		$1,625.76
$1,750.08
$1,881.80
$2,349.72 		$1,978.08
$2,102.40
$2,234.12
$2,702.04 		$352.32
Toc - Plan #21 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 		$481.53
$546.52
$615.38
$859.99
$1,306.83 		$849.89
$914.88
$983.74
$1,228.35 		$1,218.25
$1,283.24
$1,352.10
$1,596.71 		$1,586.61
$1,651.60
$1,720.46
$1,965.07 		$368.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$963.06
$1,093.04
$1,230.76
$1,719.98
$2,613.66 		$1,331.42
$1,461.40
$1,599.12
$2,088.34 		$1,699.78
$1,829.76
$1,967.48
$2,456.70 		$2,068.14
$2,198.12
$2,335.84
$2,825.06 		$368.36
Toc - Plan #22 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 		$470.00
$533.43
$600.64
$839.40
$1,275.54 		$829.54
$892.97
$960.18
$1,198.94 		$1,189.08
$1,252.51
$1,319.72
$1,558.48 		$1,548.62
$1,612.05
$1,679.26
$1,918.02 		$359.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$940.00
$1,066.86
$1,201.28
$1,678.80
$2,551.08 		$1,299.54
$1,426.40
$1,560.82
$2,038.34 		$1,659.08
$1,785.94
$1,920.36
$2,397.88 		$2,018.62
$2,145.48
$2,279.90
$2,757.42 		$359.54
Toc - Plan #23 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 		$329.58
$374.06
$421.19
$588.61
$894.45 		$581.70
$626.18
$673.31
$840.73 		$833.82
$878.30
$925.43
$1,092.85 		$1,085.94
$1,130.42
$1,177.55
$1,344.97 		$252.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.16
$748.12
$842.38
$1,177.22
$1,788.90 		$911.28
$1,000.24
$1,094.50
$1,429.34 		$1,163.40
$1,252.36
$1,346.62
$1,681.46 		$1,415.52
$1,504.48
$1,598.74
$1,933.58 		$252.12
Toc - Plan #24 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 		$309.97
$351.80
$396.13
$553.59
$841.23 		$547.09
$588.92
$633.25
$790.71 		$784.21
$826.04
$870.37
$1,027.83 		$1,021.33
$1,063.16
$1,107.49
$1,264.95 		$237.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.94
$703.60
$792.26
$1,107.18
$1,682.46 		$857.06
$940.72
$1,029.38
$1,344.30 		$1,094.18
$1,177.84
$1,266.50
$1,581.42 		$1,331.30
$1,414.96
$1,503.62
$1,818.54 		$237.12
Toc - Plan #25 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 		$461.01
$523.23
$589.16
$823.35
$1,251.15 		$813.67
$875.89
$941.82
$1,176.01 		$1,166.33
$1,228.55
$1,294.48
$1,528.67 		$1,518.99
$1,581.21
$1,647.14
$1,881.33 		$352.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.02
$1,046.46
$1,178.32
$1,646.70
$2,502.30 		$1,274.68
$1,399.12
$1,530.98
$1,999.36 		$1,627.34
$1,751.78
$1,883.64
$2,352.02 		$1,980.00
$2,104.44
$2,236.30
$2,704.68 		$352.66
Toc - Plan #26 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 		$419.56
$476.19
$536.19
$749.32
$1,138.66 		$740.52
$797.15
$857.15
$1,070.28 		$1,061.48
$1,118.11
$1,178.11
$1,391.24 		$1,382.44
$1,439.07
$1,499.07
$1,712.20 		$320.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.12
$952.38
$1,072.38
$1,498.64
$2,277.32 		$1,160.08
$1,273.34
$1,393.34
$1,819.60 		$1,481.04
$1,594.30
$1,714.30
$2,140.56 		$1,802.00
$1,915.26
$2,035.26
$2,461.52 		$320.96

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #27 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 		$504.89
$573.04
$645.24
$901.72
$1,370.25 		$891.12
$959.27
$1,031.47
$1,287.95 		$1,277.35
$1,345.50
$1,417.70
$1,674.18 		$1,663.58
$1,731.73
$1,803.93
$2,060.41 		$386.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,009.78
$1,146.08
$1,290.48
$1,803.44
$2,740.50 		$1,396.01
$1,532.31
$1,676.71
$2,189.67 		$1,782.24
$1,918.54
$2,062.94
$2,575.90 		$2,168.47
$2,304.77
$2,449.17
$2,962.13 		$386.23
Toc - Plan #28 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 		$464.75
$527.48
$593.94
$830.03
$1,261.31 		$820.28
$883.01
$949.47
$1,185.56 		$1,175.81
$1,238.54
$1,305.00
$1,541.09 		$1,531.34
$1,594.07
$1,660.53
$1,896.62 		$355.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.50
$1,054.96
$1,187.88
$1,660.06
$2,522.62 		$1,285.03
$1,410.49
$1,543.41
$2,015.59 		$1,640.56
$1,766.02
$1,898.94
$2,371.12 		$1,996.09
$2,121.55
$2,254.47
$2,726.65 		$355.53
Toc - Plan #29 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 		$499.84
$567.31
$638.78
$892.70
$1,356.54 		$882.21
$949.68
$1,021.15
$1,275.07 		$1,264.58
$1,332.05
$1,403.52
$1,657.44 		$1,646.95
$1,714.42
$1,785.89
$2,039.81 		$382.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$999.68
$1,134.62
$1,277.56
$1,785.40
$2,713.08 		$1,382.05
$1,516.99
$1,659.93
$2,167.77 		$1,764.42
$1,899.36
$2,042.30
$2,550.14 		$2,146.79
$2,281.73
$2,424.67
$2,932.51 		$382.37
Toc - Plan #30 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 		$497.97
$565.19
$636.40
$889.36
$1,351.47 		$878.91
$946.13
$1,017.34
$1,270.30 		$1,259.85
$1,327.07
$1,398.28
$1,651.24 		$1,640.79
$1,708.01
$1,779.22
$2,032.18 		$380.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$995.94
$1,130.38
$1,272.80
$1,778.72
$2,702.94 		$1,376.88
$1,511.32
$1,653.74
$2,159.66 		$1,757.82
$1,892.26
$2,034.68
$2,540.60 		$2,138.76
$2,273.20
$2,415.62
$2,921.54 		$380.94
Toc - Plan #31 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 		$452.28
$513.33
$578.00
$807.76
$1,227.47 		$798.27
$859.32
$923.99
$1,153.75 		$1,144.26
$1,205.31
$1,269.98
$1,499.74 		$1,490.25
$1,551.30
$1,615.97
$1,845.73 		$345.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.56
$1,026.66
$1,156.00
$1,615.52
$2,454.94 		$1,250.55
$1,372.65
$1,501.99
$1,961.51 		$1,596.54
$1,718.64
$1,847.98
$2,307.50 		$1,942.53
$2,064.63
$2,193.97
$2,653.49 		$345.99
Toc - Plan #32 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 		$449.56
$510.23
$574.52
$802.89
$1,220.07 		$793.46
$854.13
$918.42
$1,146.79 		$1,137.36
$1,198.03
$1,262.32
$1,490.69 		$1,481.26
$1,541.93
$1,606.22
$1,834.59 		$343.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$899.12
$1,020.46
$1,149.04
$1,605.78
$2,440.14 		$1,243.02
$1,364.36
$1,492.94
$1,949.68 		$1,586.92
$1,708.26
$1,836.84
$2,293.58 		$1,930.82
$2,052.16
$2,180.74
$2,637.48 		$343.90
Toc - Plan #33 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 		$497.62
$564.79
$635.95
$888.73
$1,350.51 		$878.29
$945.46
$1,016.62
$1,269.40 		$1,258.96
$1,326.13
$1,397.29
$1,650.07 		$1,639.63
$1,706.80
$1,777.96
$2,030.74 		$380.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$995.24
$1,129.58
$1,271.90
$1,777.46
$2,701.02 		$1,375.91
$1,510.25
$1,652.57
$2,158.13 		$1,756.58
$1,890.92
$2,033.24
$2,538.80 		$2,137.25
$2,271.59
$2,413.91
$2,919.47 		$380.67
Toc - Plan #34 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 		$448.70
$509.26
$573.42
$801.36
$1,217.74 		$791.95
$852.51
$916.67
$1,144.61 		$1,135.20
$1,195.76
$1,259.92
$1,487.86 		$1,478.45
$1,539.01
$1,603.17
$1,831.11 		$343.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$897.40
$1,018.52
$1,146.84
$1,602.72
$2,435.48 		$1,240.65
$1,361.77
$1,490.09
$1,945.97 		$1,583.90
$1,705.02
$1,833.34
$2,289.22 		$1,927.15
$2,048.27
$2,176.59
$2,632.47 		$343.25
Toc - Plan #35 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 		$484.08
$549.42
$618.65
$864.55
$1,313.77 		$854.40
$919.74
$988.97
$1,234.87 		$1,224.72
$1,290.06
$1,359.29
$1,605.19 		$1,595.04
$1,660.38
$1,729.61
$1,975.51 		$370.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$968.16
$1,098.84
$1,237.30
$1,729.10
$2,627.54 		$1,338.48
$1,469.16
$1,607.62
$2,099.42 		$1,708.80
$1,839.48
$1,977.94
$2,469.74 		$2,079.12
$2,209.80
$2,348.26
$2,840.06 		$370.32
Toc - Plan #36 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 		$525.89
$596.87
$672.08
$939.22
$1,427.24 		$928.19
$999.17
$1,074.38
$1,341.52 		$1,330.49
$1,401.47
$1,476.68
$1,743.82 		$1,732.79
$1,803.77
$1,878.98
$2,146.12 		$402.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,051.78
$1,193.74
$1,344.16
$1,878.44
$2,854.48 		$1,454.08
$1,596.04
$1,746.46
$2,280.74 		$1,856.38
$1,998.34
$2,148.76
$2,683.04 		$2,258.68
$2,400.64
$2,551.06
$3,085.34 		$402.30
Toc - Plan #37 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 		$518.69
$588.70
$662.87
$926.35
$1,407.69 		$915.48
$985.49
$1,059.66
$1,323.14 		$1,312.27
$1,382.28
$1,456.45
$1,719.93 		$1,709.06
$1,779.07
$1,853.24
$2,116.72 		$396.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,037.38
$1,177.40
$1,325.74
$1,852.70
$2,815.38 		$1,434.17
$1,574.19
$1,722.53
$2,249.49 		$1,830.96
$1,970.98
$2,119.32
$2,646.28 		$2,227.75
$2,367.77
$2,516.11
$3,043.07 		$396.79
Toc - Plan #38 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 		$471.09
$534.68
$602.04
$841.36
$1,278.52 		$831.47
$895.06
$962.42
$1,201.74 		$1,191.85
$1,255.44
$1,322.80
$1,562.12 		$1,552.23
$1,615.82
$1,683.18
$1,922.50 		$360.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942.18
$1,069.36
$1,204.08
$1,682.72
$2,557.04 		$1,302.56
$1,429.74
$1,564.46
$2,043.10 		$1,662.94
$1,790.12
$1,924.84
$2,403.48 		$2,023.32
$2,150.50
$2,285.22
$2,763.86 		$360.38
Toc - Plan #39 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 		$520.63
$590.91
$665.35
$929.83
$1,412.97 		$918.91
$989.19
$1,063.63
$1,328.11 		$1,317.19
$1,387.47
$1,461.91
$1,726.39 		$1,715.47
$1,785.75
$1,860.19
$2,124.67 		$398.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,041.26
$1,181.82
$1,330.70
$1,859.66
$2,825.94 		$1,439.54
$1,580.10
$1,728.98
$2,257.94 		$1,837.82
$1,978.38
$2,127.26
$2,656.22 		$2,236.10
$2,376.66
$2,525.54
$3,054.50 		$398.28
Toc - Plan #40 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 		$468.25
$531.46
$598.42
$836.28
$1,270.81 		$826.46
$889.67
$956.63
$1,194.49 		$1,184.67
$1,247.88
$1,314.84
$1,552.70 		$1,542.88
$1,606.09
$1,673.05
$1,910.91 		$358.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$936.50
$1,062.92
$1,196.84
$1,672.56
$2,541.62 		$1,294.71
$1,421.13
$1,555.05
$2,030.77 		$1,652.92
$1,779.34
$1,913.26
$2,388.98 		$2,011.13
$2,137.55
$2,271.47
$2,747.19 		$358.21

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 #41 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 		$438.53
$497.73
$560.44
$783.21
$1,190.17 		$774.00
$833.20
$895.91
$1,118.68 		$1,109.47
$1,168.67
$1,231.38
$1,454.15 		$1,444.94
$1,504.14
$1,566.85
$1,789.62 		$335.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$877.06
$995.46
$1,120.88
$1,566.42
$2,380.34 		$1,212.53
$1,330.93
$1,456.35
$1,901.89 		$1,548.00
$1,666.40
$1,791.82
$2,237.36 		$1,883.47
$2,001.87
$2,127.29
$2,572.83 		$335.47
Toc - Plan #42 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 		$321.17
$364.53
$410.45
$573.61
$871.65 		$566.86
$610.22
$656.14
$819.30 		$812.55
$855.91
$901.83
$1,064.99 		$1,058.24
$1,101.60
$1,147.52
$1,310.68 		$245.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.34
$729.06
$820.90
$1,147.22
$1,743.30 		$888.03
$974.75
$1,066.59
$1,392.91 		$1,133.72
$1,220.44
$1,312.28
$1,638.60 		$1,379.41
$1,466.13
$1,557.97
$1,884.29 		$245.69
Toc - Plan #43 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 		$527.42
$598.62
$674.04
$941.97
$1,431.41 		$930.90
$1,002.10
$1,077.52
$1,345.45 		$1,334.38
$1,405.58
$1,481.00
$1,748.93 		$1,737.86
$1,809.06
$1,884.48
$2,152.41 		$403.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,054.84
$1,197.24
$1,348.08
$1,883.94
$2,862.82 		$1,458.32
$1,600.72
$1,751.56
$2,287.42 		$1,861.80
$2,004.20
$2,155.04
$2,690.90 		$2,265.28
$2,407.68
$2,558.52
$3,094.38 		$403.48
Toc - Plan #44 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 		$358.87
$407.32
$458.64
$640.95
$973.98 		$633.41
$681.86
$733.18
$915.49 		$907.95
$956.40
$1,007.72
$1,190.03 		$1,182.49
$1,230.94
$1,282.26
$1,464.57 		$274.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.74
$814.64
$917.28
$1,281.90
$1,947.96 		$992.28
$1,089.18
$1,191.82
$1,556.44 		$1,266.82
$1,363.72
$1,466.36
$1,830.98 		$1,541.36
$1,638.26
$1,740.90
$2,105.52 		$274.54
Toc - Plan #45 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 		$373.24
$423.62
$476.99
$666.60
$1,012.96 		$658.76
$709.14
$762.51
$952.12 		$944.28
$994.66
$1,048.03
$1,237.64 		$1,229.80
$1,280.18
$1,333.55
$1,523.16 		$285.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.48
$847.24
$953.98
$1,333.20
$2,025.92 		$1,032.00
$1,132.76
$1,239.50
$1,618.72 		$1,317.52
$1,418.28
$1,525.02
$1,904.24 		$1,603.04
$1,703.80
$1,810.54
$2,189.76 		$285.52
Toc - Plan #46 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 		$357.01
$405.21
$456.26
$637.63
$968.94 		$630.13
$678.33
$729.38
$910.75 		$903.25
$951.45
$1,002.50
$1,183.87 		$1,176.37
$1,224.57
$1,275.62
$1,456.99 		$273.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.02
$810.42
$912.52
$1,275.26
$1,937.88 		$987.14
$1,083.54
$1,185.64
$1,548.38 		$1,260.26
$1,356.66
$1,458.76
$1,821.50 		$1,533.38
$1,629.78
$1,731.88
$2,094.62 		$273.12
Toc - Plan #47 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 		$451.41
$512.35
$576.90
$806.22
$1,225.12 		$796.74
$857.68
$922.23
$1,151.55 		$1,142.07
$1,203.01
$1,267.56
$1,496.88 		$1,487.40
$1,548.34
$1,612.89
$1,842.21 		$345.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902.82
$1,024.70
$1,153.80
$1,612.44
$2,450.24 		$1,248.15
$1,370.03
$1,499.13
$1,957.77 		$1,593.48
$1,715.36
$1,844.46
$2,303.10 		$1,938.81
$2,060.69
$2,189.79
$2,648.43 		$345.33
Toc - Plan #48 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 		$373.74
$424.20
$477.64
$667.50
$1,014.34 		$659.65
$710.11
$763.55
$953.41 		$945.56
$996.02
$1,049.46
$1,239.32 		$1,231.47
$1,281.93
$1,335.37
$1,525.23 		$285.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.48
$848.40
$955.28
$1,335.00
$2,028.68 		$1,033.39
$1,134.31
$1,241.19
$1,620.91 		$1,319.30
$1,420.22
$1,527.10
$1,906.82 		$1,605.21
$1,706.13
$1,813.01
$2,192.73 		$285.91
Toc - Plan #49 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 		$444.48
$504.49
$568.05
$793.85
$1,206.33 		$784.51
$844.52
$908.08
$1,133.88 		$1,124.54
$1,184.55
$1,248.11
$1,473.91 		$1,464.57
$1,524.58
$1,588.14
$1,813.94 		$340.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.96
$1,008.98
$1,136.10
$1,587.70
$2,412.66 		$1,228.99
$1,349.01
$1,476.13
$1,927.73 		$1,569.02
$1,689.04
$1,816.16
$2,267.76 		$1,909.05
$2,029.07
$2,156.19
$2,607.79 		$340.03
Toc - Plan #50 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 		$530.06
$601.62
$677.42
$946.69
$1,438.59 		$935.56
$1,007.12
$1,082.92
$1,352.19 		$1,341.06
$1,412.62
$1,488.42
$1,757.69 		$1,746.56
$1,818.12
$1,893.92
$2,163.19 		$405.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,060.12
$1,203.24
$1,354.84
$1,893.38
$2,877.18 		$1,465.62
$1,608.74
$1,760.34
$2,298.88 		$1,871.12
$2,014.24
$2,165.84
$2,704.38 		$2,276.62
$2,419.74
$2,571.34
$3,109.88 		$405.50
Toc - Plan #51 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 		$349.19
$396.33
$446.26
$623.65
$947.70 		$616.32
$663.46
$713.39
$890.78 		$883.45
$930.59
$980.52
$1,157.91 		$1,150.58
$1,197.72
$1,247.65
$1,425.04 		$267.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.38
$792.66
$892.52
$1,247.30
$1,895.40 		$965.51
$1,059.79
$1,159.65
$1,514.43 		$1,232.64
$1,326.92
$1,426.78
$1,781.56 		$1,499.77
$1,594.05
$1,693.91
$2,048.69 		$267.13
Toc - Plan #52 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 		$372.51
$422.80
$476.07
$665.30
$1,010.99 		$657.48
$707.77
$761.04
$950.27 		$942.45
$992.74
$1,046.01
$1,235.24 		$1,227.42
$1,277.71
$1,330.98
$1,520.21 		$284.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.02
$845.60
$952.14
$1,330.60
$2,021.98 		$1,029.99
$1,130.57
$1,237.11
$1,615.57 		$1,314.96
$1,415.54
$1,522.08
$1,900.54 		$1,599.93
$1,700.51
$1,807.05
$2,185.51 		$284.97
Toc - Plan #53 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 		$492.83
$559.36
$629.84
$880.20
$1,337.55 		$869.85
$936.38
$1,006.86
$1,257.22 		$1,246.87
$1,313.40
$1,383.88
$1,634.24 		$1,623.89
$1,690.42
$1,760.90
$2,011.26 		$377.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.66
$1,118.72
$1,259.68
$1,760.40
$2,675.10 		$1,362.68
$1,495.74
$1,636.70
$2,137.42 		$1,739.70
$1,872.76
$2,013.72
$2,514.44 		$2,116.72
$2,249.78
$2,390.74
$2,891.46 		$377.02
Toc - Plan #54 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 		$589.63
$669.23
$753.55
$1,053.08
$1,600.26 		$1,040.70
$1,120.30
$1,204.62
$1,504.15 		$1,491.77
$1,571.37
$1,655.69
$1,955.22 		$1,942.84
$2,022.44
$2,106.76
$2,406.29 		$451.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,179.26
$1,338.46
$1,507.10
$2,106.16
$3,200.52 		$1,630.33
$1,789.53
$1,958.17
$2,557.23 		$2,081.40
$2,240.60
$2,409.24
$3,008.30 		$2,532.47
$2,691.67
$2,860.31
$3,459.37 		$451.07
Toc - Plan #55 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 		$404.25
$458.83
$516.64
$722.00
$1,097.15 		$713.50
$768.08
$825.89
$1,031.25 		$1,022.75
$1,077.33
$1,135.14
$1,340.50 		$1,332.00
$1,386.58
$1,444.39
$1,649.75 		$309.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.50
$917.66
$1,033.28
$1,444.00
$2,194.30 		$1,117.75
$1,226.91
$1,342.53
$1,753.25 		$1,427.00
$1,536.16
$1,651.78
$2,062.50 		$1,736.25
$1,845.41
$1,961.03
$2,371.75 		$309.25
Toc - Plan #56 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 		$385.46
$437.49
$492.61
$688.43
$1,046.13 		$680.33
$732.36
$787.48
$983.30 		$975.20
$1,027.23
$1,082.35
$1,278.17 		$1,270.07
$1,322.10
$1,377.22
$1,573.04 		$294.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.92
$874.98
$985.22
$1,376.86
$2,092.26 		$1,065.79
$1,169.85
$1,280.09
$1,671.73 		$1,360.66
$1,464.72
$1,574.96
$1,966.60 		$1,655.53
$1,759.59
$1,869.83
$2,261.47 		$294.87
Toc - Plan #57 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 		$595.24
$675.60
$760.72
$1,063.11
$1,615.49 		$1,050.60
$1,130.96
$1,216.08
$1,518.47 		$1,505.96
$1,586.32
$1,671.44
$1,973.83 		$1,961.32
$2,041.68
$2,126.80
$2,429.19 		$455.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,190.48
$1,351.20
$1,521.44
$2,126.22
$3,230.98 		$1,645.84
$1,806.56
$1,976.80
$2,581.58 		$2,101.20
$2,261.92
$2,432.16
$3,036.94 		$2,556.56
$2,717.28
$2,887.52
$3,492.30 		$455.36
Toc - Plan #58 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 		$490.93
$557.20
$627.40
$876.79
$1,332.37 		$866.49
$932.76
$1,002.96
$1,252.35 		$1,242.05
$1,308.32
$1,378.52
$1,627.91 		$1,617.61
$1,683.88
$1,754.08
$2,003.47 		$375.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$981.86
$1,114.40
$1,254.80
$1,753.58
$2,664.74 		$1,357.42
$1,489.96
$1,630.36
$2,129.14 		$1,732.98
$1,865.52
$2,005.92
$2,504.70 		$2,108.54
$2,241.08
$2,381.48
$2,880.26 		$375.56
Toc - Plan #59 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 		$586.08
$665.20
$749.01
$1,046.74
$1,590.63 		$1,034.43
$1,113.55
$1,197.36
$1,495.09 		$1,482.78
$1,561.90
$1,645.71
$1,943.44 		$1,931.13
$2,010.25
$2,094.06
$2,391.79 		$448.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,172.16
$1,330.40
$1,498.02
$2,093.48
$3,181.26 		$1,620.51
$1,778.75
$1,946.37
$2,541.83 		$2,068.86
$2,227.10
$2,394.72
$2,990.18 		$2,517.21
$2,675.45
$2,843.07
$3,438.53 		$448.35
Toc - Plan #60 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 		$387.05
$439.30
$494.64
$691.26
$1,050.44 		$683.14
$735.39
$790.73
$987.35 		$979.23
$1,031.48
$1,086.82
$1,283.44 		$1,275.32
$1,327.57
$1,382.91
$1,579.53 		$296.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.10
$878.60
$989.28
$1,382.52
$2,100.88 		$1,070.19
$1,174.69
$1,285.37
$1,678.61 		$1,366.28
$1,470.78
$1,581.46
$1,974.70 		$1,662.37
$1,766.87
$1,877.55
$2,270.79 		$296.09
Toc - Plan #61 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 		$411.97
$467.58
$526.49
$735.77
$1,118.07 		$727.12
$782.73
$841.64
$1,050.92 		$1,042.27
$1,097.88
$1,156.79
$1,366.07 		$1,357.42
$1,413.03
$1,471.94
$1,681.22 		$315.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.94
$935.16
$1,052.98
$1,471.54
$2,236.14 		$1,139.09
$1,250.31
$1,368.13
$1,786.69 		$1,454.24
$1,565.46
$1,683.28
$2,101.84 		$1,769.39
$1,880.61
$1,998.43
$2,416.99 		$315.15
Toc - Plan #62 Blue Cross and Blue Shield of Texas
Gold

(HMO) MyBlue Health? Gold 403

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

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 		$370.80
$420.86
$473.88
$662.25
$1,006.35 		$654.46
$704.52
$757.54
$945.91 		$938.12
$988.18
$1,041.20
$1,229.57 		$1,221.78
$1,271.84
$1,324.86
$1,513.23 		$283.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.60
$841.72
$947.76
$1,324.50
$2,012.70 		$1,025.26
$1,125.38
$1,231.42
$1,608.16 		$1,308.92
$1,409.04
$1,515.08
$1,891.82 		$1,592.58
$1,692.70
$1,798.74
$2,175.48 		$283.66
Toc - Plan #63 Blue Cross and Blue Shield of Texas
Silver

(HMO) MyBlue Health Silver? 405

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

Annual Out of Pocket Expenses:

Individual Family
$2,700 $8,100 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 		$450.91
$511.79
$576.27
$805.33
$1,223.78 		$795.86
$856.74
$921.22
$1,150.28 		$1,140.81
$1,201.69
$1,266.17
$1,495.23 		$1,485.76
$1,546.64
$1,611.12
$1,840.18 		$344.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901.82
$1,023.58
$1,152.54
$1,610.66
$2,447.56 		$1,246.77
$1,368.53
$1,497.49
$1,955.61 		$1,591.72
$1,713.48
$1,842.44
$2,300.56 		$1,936.67
$2,058.43
$2,187.39
$2,645.51 		$344.95
Toc - Plan #64 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) MyBlue Health? Bronze 402

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $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 		$305.84
$347.13
$390.86
$546.23
$830.05 		$539.81
$581.10
$624.83
$780.20 		$773.78
$815.07
$858.80
$1,014.17 		$1,007.75
$1,049.04
$1,092.77
$1,248.14 		$233.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.68
$694.26
$781.72
$1,092.46
$1,660.10 		$845.65
$928.23
$1,015.69
$1,326.43 		$1,079.62
$1,162.20
$1,249.66
$1,560.40 		$1,313.59
$1,396.17
$1,483.63
$1,794.37 		$233.97

ADVERTISEMENT

UnitedHealthcare

Local: 1-866-811-2704 | Toll Free: 1-866-811-2704 | TTY: 1-866-811-2704
Toc - Plan #65 UnitedHealthcare
Gold

(HMO) UHC Gold Value $1,900 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$376.33
$427.13
$480.95
$672.12
$1,021.35 		$664.22
$715.02
$768.84
$960.01 		$952.11
$1,002.91
$1,056.73
$1,247.90 		$1,240.00
$1,290.80
$1,344.62
$1,535.79 		$287.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.66
$854.26
$961.90
$1,344.24
$2,042.70 		$1,040.55
$1,142.15
$1,249.79
$1,632.13 		$1,328.44
$1,430.04
$1,537.68
$1,920.02 		$1,616.33
$1,717.93
$1,825.57
$2,207.91 		$287.89
Toc - Plan #66 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$427.38
$485.08
$546.19
$763.30
$1,159.91 		$754.33
$812.03
$873.14
$1,090.25 		$1,081.28
$1,138.98
$1,200.09
$1,417.20 		$1,408.23
$1,465.93
$1,527.04
$1,744.15 		$326.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.76
$970.16
$1,092.38
$1,526.60
$2,319.82 		$1,181.71
$1,297.11
$1,419.33
$1,853.55 		$1,508.66
$1,624.06
$1,746.28
$2,180.50 		$1,835.61
$1,951.01
$2,073.23
$2,507.45 		$326.95
Toc - Plan #67 UnitedHealthcare
Silver

(HMO) UHC Silver Value HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$433.00
$491.45
$553.37
$773.33
$1,175.15 		$764.24
$822.69
$884.61
$1,104.57 		$1,095.48
$1,153.93
$1,215.85
$1,435.81 		$1,426.72
$1,485.17
$1,547.09
$1,767.05 		$331.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.00
$982.90
$1,106.74
$1,546.66
$2,350.30 		$1,197.24
$1,314.14
$1,437.98
$1,877.90 		$1,528.48
$1,645.38
$1,769.22
$2,209.14 		$1,859.72
$1,976.62
$2,100.46
$2,540.38 		$331.24
Toc - Plan #68 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$415.52
$471.62
$531.03
$742.12
$1,127.72 		$733.39
$789.49
$848.90
$1,059.99 		$1,051.26
$1,107.36
$1,166.77
$1,377.86 		$1,369.13
$1,425.23
$1,484.64
$1,695.73 		$317.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.04
$943.24
$1,062.06
$1,484.24
$2,255.44 		$1,148.91
$1,261.11
$1,379.93
$1,802.11 		$1,466.78
$1,578.98
$1,697.80
$2,119.98 		$1,784.65
$1,896.85
$2,015.67
$2,437.85 		$317.87
Toc - Plan #69 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$305.29
$346.50
$390.16
$545.25
$828.56 		$538.84
$580.05
$623.71
$778.80 		$772.39
$813.60
$857.26
$1,012.35 		$1,005.94
$1,047.15
$1,090.81
$1,245.90 		$233.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.58
$693.00
$780.32
$1,090.50
$1,657.12 		$844.13
$926.55
$1,013.87
$1,324.05 		$1,077.68
$1,160.10
$1,247.42
$1,557.60 		$1,311.23
$1,393.65
$1,480.97
$1,791.15 		$233.55
Toc - Plan #70 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$298.15
$338.40
$381.04
$532.50
$809.18 		$526.24
$566.49
$609.13
$760.59 		$754.33
$794.58
$837.22
$988.68 		$982.42
$1,022.67
$1,065.31
$1,216.77 		$228.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596.30
$676.80
$762.08
$1,065.00
$1,618.36 		$824.39
$904.89
$990.17
$1,293.09 		$1,052.48
$1,132.98
$1,218.26
$1,521.18 		$1,280.57
$1,361.07
$1,446.35
$1,749.27 		$228.09
Toc - Plan #71 UnitedHealthcare
Gold

(HMO) UHC Gold Standard $0 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$379.90
$431.18
$485.51
$678.49
$1,031.04 		$670.52
$721.80
$776.13
$969.11 		$961.14
$1,012.42
$1,066.75
$1,259.73 		$1,251.76
$1,303.04
$1,357.37
$1,550.35 		$290.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$759.80
$862.36
$971.02
$1,356.98
$2,062.08 		$1,050.42
$1,152.98
$1,261.64
$1,647.60 		$1,341.04
$1,443.60
$1,552.26
$1,938.22 		$1,631.66
$1,734.22
$1,842.88
$2,228.84 		$290.62
Toc - Plan #72 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$297.59
$337.76
$380.32
$531.49
$807.66 		$525.25
$565.42
$607.98
$759.15 		$752.91
$793.08
$835.64
$986.81 		$980.57
$1,020.74
$1,063.30
$1,214.47 		$227.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$595.18
$675.52
$760.64
$1,062.98
$1,615.32 		$822.84
$903.18
$988.30
$1,290.64 		$1,050.50
$1,130.84
$1,215.96
$1,518.30 		$1,278.16
$1,358.50
$1,443.62
$1,745.96 		$227.66
Toc - Plan #73 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$305.03
$346.21
$389.83
$544.79
$827.86 		$538.38
$579.56
$623.18
$778.14 		$771.73
$812.91
$856.53
$1,011.49 		$1,005.08
$1,046.26
$1,089.88
$1,244.84 		$233.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.06
$692.42
$779.66
$1,089.58
$1,655.72 		$843.41
$925.77
$1,013.01
$1,322.93 		$1,076.76
$1,159.12
$1,246.36
$1,556.28 		$1,310.11
$1,392.47
$1,479.71
$1,789.63 		$233.35
Toc - Plan #74 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$288.79
$327.77
$369.07
$515.77
$783.77 		$509.71
$548.69
$589.99
$736.69 		$730.63
$769.61
$810.91
$957.61 		$951.55
$990.53
$1,031.83
$1,178.53 		$220.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.58
$655.54
$738.14
$1,031.54
$1,567.54 		$798.50
$876.46
$959.06
$1,252.46 		$1,019.42
$1,097.38
$1,179.98
$1,473.38 		$1,240.34
$1,318.30
$1,400.90
$1,694.30 		$220.92
Toc - Plan #75 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$426.57
$484.16
$545.16
$761.86
$1,157.72 		$752.90
$810.49
$871.49
$1,088.19 		$1,079.23
$1,136.82
$1,197.82
$1,414.52 		$1,405.56
$1,463.15
$1,524.15
$1,740.85 		$326.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.14
$968.32
$1,090.32
$1,523.72
$2,315.44 		$1,179.47
$1,294.65
$1,416.65
$1,850.05 		$1,505.80
$1,620.98
$1,742.98
$2,176.38 		$1,832.13
$1,947.31
$2,069.31
$2,502.71 		$326.33
Toc - Plan #76 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$445.31
$505.43
$569.11
$795.33
$1,208.58 		$785.98
$846.10
$909.78
$1,136.00 		$1,126.65
$1,186.77
$1,250.45
$1,476.67 		$1,467.32
$1,527.44
$1,591.12
$1,817.34 		$340.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.62
$1,010.86
$1,138.22
$1,590.66
$2,417.16 		$1,231.29
$1,351.53
$1,478.89
$1,931.33 		$1,571.96
$1,692.20
$1,819.56
$2,272.00 		$1,912.63
$2,032.87
$2,160.23
$2,612.67 		$340.67
Toc - Plan #77 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$444.43
$504.43
$567.98
$793.76
$1,206.19 		$784.42
$844.42
$907.97
$1,133.75 		$1,124.41
$1,184.41
$1,247.96
$1,473.74 		$1,464.40
$1,524.40
$1,587.95
$1,813.73 		$339.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.86
$1,008.86
$1,135.96
$1,587.52
$2,412.38 		$1,228.85
$1,348.85
$1,475.95
$1,927.51 		$1,568.84
$1,688.84
$1,815.94
$2,267.50 		$1,908.83
$2,028.83
$2,155.93
$2,607.49 		$339.99
Toc - Plan #78 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$427.78
$485.53
$546.70
$764.01
$1,160.99 		$755.03
$812.78
$873.95
$1,091.26 		$1,082.28
$1,140.03
$1,201.20
$1,418.51 		$1,409.53
$1,467.28
$1,528.45
$1,745.76 		$327.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.56
$971.06
$1,093.40
$1,528.02
$2,321.98 		$1,182.81
$1,298.31
$1,420.65
$1,855.27 		$1,510.06
$1,625.56
$1,747.90
$2,182.52 		$1,837.31
$1,952.81
$2,075.15
$2,509.77 		$327.25
Toc - Plan #79 UnitedHealthcare
Gold

(HMO) UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$1,800 $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 		$375.80
$426.53
$480.27
$671.17
$1,019.92 		$663.29
$714.02
$767.76
$958.66 		$950.78
$1,001.51
$1,055.25
$1,246.15 		$1,238.27
$1,289.00
$1,342.74
$1,533.64 		$287.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.60
$853.06
$960.54
$1,342.34
$2,039.84 		$1,039.09
$1,140.55
$1,248.03
$1,629.83 		$1,326.58
$1,428.04
$1,535.52
$1,917.32 		$1,614.07
$1,715.53
$1,823.01
$2,204.81 		$287.49
Toc - Plan #80 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$375.39
$426.06
$479.74
$670.44
$1,018.80 		$662.56
$713.23
$766.91
$957.61 		$949.73
$1,000.40
$1,054.08
$1,244.78 		$1,236.90
$1,287.57
$1,341.25
$1,531.95 		$287.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.78
$852.12
$959.48
$1,340.88
$2,037.60 		$1,037.95
$1,139.29
$1,246.65
$1,628.05 		$1,325.12
$1,426.46
$1,533.82
$1,915.22 		$1,612.29
$1,713.63
$1,820.99
$2,202.39 		$287.17
Toc - Plan #81 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$394.13
$447.33
$503.69
$703.91
$1,069.66 		$695.64
$748.84
$805.20
$1,005.42 		$997.15
$1,050.35
$1,106.71
$1,306.93 		$1,298.66
$1,351.86
$1,408.22
$1,608.44 		$301.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.26
$894.66
$1,007.38
$1,407.82
$2,139.32 		$1,089.77
$1,196.17
$1,308.89
$1,709.33 		$1,391.28
$1,497.68
$1,610.40
$2,010.84 		$1,692.79
$1,799.19
$1,911.91
$2,312.35 		$301.51
Toc - Plan #82 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

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 		$385.55
$437.60
$492.73
$688.59
$1,046.38 		$680.49
$732.54
$787.67
$983.53 		$975.43
$1,027.48
$1,082.61
$1,278.47 		$1,270.37
$1,322.42
$1,377.55
$1,573.41 		$294.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.10
$875.20
$985.46
$1,377.18
$2,092.76 		$1,066.04
$1,170.14
$1,280.40
$1,672.12 		$1,360.98
$1,465.08
$1,575.34
$1,967.06 		$1,655.92
$1,760.02
$1,870.28
$2,262.00 		$294.94

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Baylor Scott and White Health Plan

Local: 1-844-633-5325 | Toll Free: 1-844-633-5325 | TTY: 1-800-735-2989
Toc - Plan #83 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 		$353.55
$401.28
$451.84
$631.44
$959.54 		$624.02
$671.75
$722.31
$901.91 		$894.49
$942.22
$992.78
$1,172.38 		$1,164.96
$1,212.69
$1,263.25
$1,442.85 		$270.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.10
$802.56
$903.68
$1,262.88
$1,919.08 		$977.57
$1,073.03
$1,174.15
$1,533.35 		$1,248.04
$1,343.50
$1,444.62
$1,803.82 		$1,518.51
$1,613.97
$1,715.09
$2,074.29 		$270.47
Toc - Plan #84 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 		$358.01
$406.34
$457.54
$639.41
$971.65 		$631.89
$680.22
$731.42
$913.29 		$905.77
$954.10
$1,005.30
$1,187.17 		$1,179.65
$1,227.98
$1,279.18
$1,461.05 		$273.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.02
$812.68
$915.08
$1,278.82
$1,943.30 		$989.90
$1,086.56
$1,188.96
$1,552.70 		$1,263.78
$1,360.44
$1,462.84
$1,826.58 		$1,537.66
$1,634.32
$1,736.72
$2,100.46 		$273.88
Toc - Plan #85 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 		$373.40
$423.81
$477.21
$666.89
$1,013.41 		$659.05
$709.46
$762.86
$952.54 		$944.70
$995.11
$1,048.51
$1,238.19 		$1,230.35
$1,280.76
$1,334.16
$1,523.84 		$285.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.80
$847.62
$954.42
$1,333.78
$2,026.82 		$1,032.45
$1,133.27
$1,240.07
$1,619.43 		$1,318.10
$1,418.92
$1,525.72
$1,905.08 		$1,603.75
$1,704.57
$1,811.37
$2,190.73 		$285.65
Toc - Plan #86 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 		$397.00
$450.60
$507.37
$709.05
$1,077.47 		$700.71
$754.31
$811.08
$1,012.76 		$1,004.42
$1,058.02
$1,114.79
$1,316.47 		$1,308.13
$1,361.73
$1,418.50
$1,620.18 		$303.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.00
$901.20
$1,014.74
$1,418.10
$2,154.94 		$1,097.71
$1,204.91
$1,318.45
$1,721.81 		$1,401.42
$1,508.62
$1,622.16
$2,025.52 		$1,705.13
$1,812.33
$1,925.87
$2,329.23 		$303.71
Toc - Plan #87 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 		$294.00
$333.69
$375.73
$525.08
$797.92 		$518.91
$558.60
$600.64
$749.99 		$743.82
$783.51
$825.55
$974.90 		$968.73
$1,008.42
$1,050.46
$1,199.81 		$224.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$588.00
$667.38
$751.46
$1,050.16
$1,595.84 		$812.91
$892.29
$976.37
$1,275.07 		$1,037.82
$1,117.20
$1,201.28
$1,499.98 		$1,262.73
$1,342.11
$1,426.19
$1,724.89 		$224.91
Toc - Plan #88 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 		$289.83
$328.96
$370.40
$517.64
$786.60 		$511.55
$550.68
$592.12
$739.36 		$733.27
$772.40
$813.84
$961.08 		$954.99
$994.12
$1,035.56
$1,182.80 		$221.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.66
$657.92
$740.80
$1,035.28
$1,573.20 		$801.38
$879.64
$962.52
$1,257.00 		$1,023.10
$1,101.36
$1,184.24
$1,478.72 		$1,244.82
$1,323.08
$1,405.96
$1,700.44 		$221.72
Toc - Plan #89 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 		$364.14
$413.30
$465.37
$650.36
$988.28 		$642.71
$691.87
$743.94
$928.93 		$921.28
$970.44
$1,022.51
$1,207.50 		$1,199.85
$1,249.01
$1,301.08
$1,486.07 		$278.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.28
$826.60
$930.74
$1,300.72
$1,976.56 		$1,006.85
$1,105.17
$1,209.31
$1,579.29 		$1,285.42
$1,383.74
$1,487.88
$1,857.86 		$1,563.99
$1,662.31
$1,766.45
$2,136.43 		$278.57
Toc - Plan #90 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 		$287.20
$325.97
$367.04
$512.94
$779.47 		$506.91
$545.68
$586.75
$732.65 		$726.62
$765.39
$806.46
$952.36 		$946.33
$985.10
$1,026.17
$1,172.07 		$219.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.40
$651.94
$734.08
$1,025.88
$1,558.94 		$794.11
$871.65
$953.79
$1,245.59 		$1,013.82
$1,091.36
$1,173.50
$1,465.30 		$1,233.53
$1,311.07
$1,393.21
$1,685.01 		$219.71
Toc - Plan #91 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 		$343.38
$389.73
$438.83
$613.27
$931.92 		$606.06
$652.41
$701.51
$875.95 		$868.74
$915.09
$964.19
$1,138.63 		$1,131.42
$1,177.77
$1,226.87
$1,401.31 		$262.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.76
$779.46
$877.66
$1,226.54
$1,863.84 		$949.44
$1,042.14
$1,140.34
$1,489.22 		$1,212.12
$1,304.82
$1,403.02
$1,751.90 		$1,474.80
$1,567.50
$1,665.70
$2,014.58 		$262.68

ADVERTISEMENT

US Health and Life

Local: 1-833-600-1311 | Toll Free: 

Toc - Plan #92 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Balanced Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$261.34
$296.62
$334.00
$466.76
$709.29 		$461.27
$496.55
$533.93
$666.69 		$661.20
$696.48
$733.86
$866.62 		$861.13
$896.41
$933.79
$1,066.55 		$199.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$522.68
$593.24
$668.00
$933.52
$1,418.58 		$722.61
$793.17
$867.93
$1,133.45 		$922.54
$993.10
$1,067.86
$1,333.38 		$1,122.47
$1,193.03
$1,267.79
$1,533.31 		$199.93
Toc - Plan #93 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Balanced Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$261.34
$296.62
$334.00
$466.76
$709.29 		$461.27
$496.55
$533.93
$666.69 		$661.20
$696.48
$733.86
$866.62 		$861.13
$896.41
$933.79
$1,066.55 		$199.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$522.68
$593.24
$668.00
$933.52
$1,418.58 		$722.61
$793.17
$867.93
$1,133.45 		$922.54
$993.10
$1,067.86
$1,333.38 		$1,122.47
$1,193.03
$1,267.79
$1,533.31 		$199.93
Toc - Plan #94 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care No Deductible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$262.94
$298.43
$336.03
$469.61
$713.61 		$464.09
$499.58
$537.18
$670.76 		$665.24
$700.73
$738.33
$871.91 		$866.39
$901.88
$939.48
$1,073.06 		$201.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$525.88
$596.86
$672.06
$939.22
$1,427.22 		$727.03
$798.01
$873.21
$1,140.37 		$928.18
$999.16
$1,074.36
$1,341.52 		$1,129.33
$1,200.31
$1,275.51
$1,542.67 		$201.15
Toc - Plan #95 US Health and Life
Silver

(EPO) Ascension Personalized Care Balanced Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$395.97
$449.43
$506.05
$707.21
$1,074.67 		$698.89
$752.35
$808.97
$1,010.13 		$1,001.81
$1,055.27
$1,111.89
$1,313.05 		$1,304.73
$1,358.19
$1,414.81
$1,615.97 		$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
$1,414.42
$2,149.34 		$1,094.86
$1,201.78
$1,315.02
$1,717.34 		$1,397.78
$1,504.70
$1,617.94
$2,020.26 		$1,700.70
$1,807.62
$1,920.86
$2,323.18 		$302.92
Toc - Plan #96 US Health and Life
Silver

(EPO) Ascension Personalized Care No Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$400.53
$454.60
$511.88
$715.34
$1,087.03 		$706.93
$761.00
$818.28
$1,021.74 		$1,013.33
$1,067.40
$1,124.68
$1,328.14 		$1,319.73
$1,373.80
$1,431.08
$1,634.54 		$306.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.06
$909.20
$1,023.76
$1,430.68
$2,174.06 		$1,107.46
$1,215.60
$1,330.16
$1,737.08 		$1,413.86
$1,522.00
$1,636.56
$2,043.48 		$1,720.26
$1,828.40
$1,942.96
$2,349.88 		$306.40
Toc - Plan #97 US Health and Life
Silver

(EPO) Ascension Personalized Care Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$395.45
$448.83
$505.38
$706.27
$1,073.24 		$697.97
$751.35
$807.90
$1,008.79 		$1,000.49
$1,053.87
$1,110.42
$1,311.31 		$1,303.01
$1,356.39
$1,412.94
$1,613.83 		$302.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.90
$897.66
$1,010.76
$1,412.54
$2,146.48 		$1,093.42
$1,200.18
$1,313.28
$1,715.06 		$1,395.94
$1,502.70
$1,615.80
$2,017.58 		$1,698.46
$1,805.22
$1,918.32
$2,320.10 		$302.52
Toc - Plan #98 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$260.94
$296.16
$333.48
$466.03
$708.18 		$460.56
$495.78
$533.10
$665.65 		$660.18
$695.40
$732.72
$865.27 		$859.80
$895.02
$932.34
$1,064.89 		$199.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.88
$592.32
$666.96
$932.06
$1,416.36 		$721.50
$791.94
$866.58
$1,131.68 		$921.12
$991.56
$1,066.20
$1,331.30 		$1,120.74
$1,191.18
$1,265.82
$1,530.92 		$199.62
Toc - Plan #99 US Health and Life
Silver

(EPO) Ascension Personalized Care Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$395.97
$449.43
$506.05
$707.21
$1,074.67 		$698.89
$752.35
$808.97
$1,010.13 		$1,001.81
$1,055.27
$1,111.89
$1,313.05 		$1,304.73
$1,358.19
$1,414.81
$1,615.97 		$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
$1,414.42
$2,149.34 		$1,094.86
$1,201.78
$1,315.02
$1,717.34 		$1,397.78
$1,504.70
$1,617.94
$2,020.26 		$1,700.70
$1,807.62
$1,920.86
$2,323.18 		$302.92
Toc - Plan #100 US Health and Life
Gold

(EPO) Ascension Personalized Care Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$342.27
$388.47
$437.42
$611.29
$928.91 		$604.10
$650.30
$699.25
$873.12 		$865.93
$912.13
$961.08
$1,134.95 		$1,127.76
$1,173.96
$1,222.91
$1,396.78 		$261.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.54
$776.94
$874.84
$1,222.58
$1,857.82 		$946.37
$1,038.77
$1,136.67
$1,484.41 		$1,208.20
$1,300.60
$1,398.50
$1,746.24 		$1,470.03
$1,562.43
$1,660.33
$2,008.07 		$261.83

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #101 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 		$415.55
$471.65
$531.07
$742.17
$1,127.79 		$733.44
$789.54
$848.96
$1,060.06 		$1,051.33
$1,107.43
$1,166.85
$1,377.95 		$1,369.22
$1,425.32
$1,484.74
$1,695.84 		$317.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.10
$943.30
$1,062.14
$1,484.34
$2,255.58 		$1,148.99
$1,261.19
$1,380.03
$1,802.23 		$1,466.88
$1,579.08
$1,697.92
$2,120.12 		$1,784.77
$1,896.97
$2,015.81
$2,438.01 		$317.89
Toc - Plan #102 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 		$394.36
$447.60
$503.99
$704.33
$1,070.29 		$696.04
$749.28
$805.67
$1,006.01 		$997.72
$1,050.96
$1,107.35
$1,307.69 		$1,299.40
$1,352.64
$1,409.03
$1,609.37 		$301.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.72
$895.20
$1,007.98
$1,408.66
$2,140.58 		$1,090.40
$1,196.88
$1,309.66
$1,710.34 		$1,392.08
$1,498.56
$1,611.34
$2,012.02 		$1,693.76
$1,800.24
$1,913.02
$2,313.70 		$301.68
Toc - Plan #103 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 		$395.56
$448.96
$505.52
$706.47
$1,073.55 		$698.16
$751.56
$808.12
$1,009.07 		$1,000.76
$1,054.16
$1,110.72
$1,311.67 		$1,303.36
$1,356.76
$1,413.32
$1,614.27 		$302.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.12
$897.92
$1,011.04
$1,412.94
$2,147.10 		$1,093.72
$1,200.52
$1,313.64
$1,715.54 		$1,396.32
$1,503.12
$1,616.24
$2,018.14 		$1,698.92
$1,805.72
$1,918.84
$2,320.74 		$302.60
Toc - Plan #104 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 		$282.49
$320.63
$361.02
$504.53
$766.68 		$498.60
$536.74
$577.13
$720.64 		$714.71
$752.85
$793.24
$936.75 		$930.82
$968.96
$1,009.35
$1,152.86 		$216.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.98
$641.26
$722.04
$1,009.06
$1,533.36 		$781.09
$857.37
$938.15
$1,225.17 		$997.20
$1,073.48
$1,154.26
$1,441.28 		$1,213.31
$1,289.59
$1,370.37
$1,657.39 		$216.11
Toc - Plan #105 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 		$382.99
$434.70
$489.46
$684.02
$1,039.44 		$675.98
$727.69
$782.45
$977.01 		$968.97
$1,020.68
$1,075.44
$1,270.00 		$1,261.96
$1,313.67
$1,368.43
$1,562.99 		$292.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.98
$869.40
$978.92
$1,368.04
$2,078.88 		$1,058.97
$1,162.39
$1,271.91
$1,661.03 		$1,351.96
$1,455.38
$1,564.90
$1,954.02 		$1,644.95
$1,748.37
$1,857.89
$2,247.01 		$292.99
Toc - Plan #106 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 		$402.51
$456.85
$514.41
$718.88
$1,092.41 		$710.43
$764.77
$822.33
$1,026.80 		$1,018.35
$1,072.69
$1,130.25
$1,334.72 		$1,326.27
$1,380.61
$1,438.17
$1,642.64 		$307.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.02
$913.70
$1,028.82
$1,437.76
$2,184.82 		$1,112.94
$1,221.62
$1,336.74
$1,745.68 		$1,420.86
$1,529.54
$1,644.66
$2,053.60 		$1,728.78
$1,837.46
$1,952.58
$2,361.52 		$307.92
Toc - Plan #107 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 		$504.11
$572.16
$644.25
$900.33
$1,368.15 		$889.75
$957.80
$1,029.89
$1,285.97 		$1,275.39
$1,343.44
$1,415.53
$1,671.61 		$1,661.03
$1,729.08
$1,801.17
$2,057.25 		$385.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,008.22
$1,144.32
$1,288.50
$1,800.66
$2,736.30 		$1,393.86
$1,529.96
$1,674.14
$2,186.30 		$1,779.50
$1,915.60
$2,059.78
$2,571.94 		$2,165.14
$2,301.24
$2,445.42
$2,957.58 		$385.64
Toc - Plan #108 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 		$390.25
$442.94
$498.74
$696.99
$1,059.15 		$688.79
$741.48
$797.28
$995.53 		$987.33
$1,040.02
$1,095.82
$1,294.07 		$1,285.87
$1,338.56
$1,394.36
$1,592.61 		$298.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.50
$885.88
$997.48
$1,393.98
$2,118.30 		$1,079.04
$1,184.42
$1,296.02
$1,692.52 		$1,377.58
$1,482.96
$1,594.56
$1,991.06 		$1,676.12
$1,781.50
$1,893.10
$2,289.60 		$298.54

ADVERTISEMENT

Sendero Health Plans, Local Nonprofit

Local: 1-844-800-4693 | Toll Free: 1-844-800-4693 | TTY: 1-800-855-2880
Toc - Plan #109 Sendero Health Plans, Local Nonprofit
Silver

(HMO) Sendero IdealCare Silver 100 / $20 PCP / $10 Gen Rx + Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + No Pre-existing Condition Restrictions + Free 24/7 Virtual MD Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$4,250 $8,500 Annual Deductible
$8,050 $16,100 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 		$481.09
$546.04
$614.83
$859.22
$1,305.68 		$849.12
$914.07
$982.86
$1,227.25 		$1,217.15
$1,282.10
$1,350.89
$1,595.28 		$1,585.18
$1,650.13
$1,718.92
$1,963.31 		$368.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$962.18
$1,092.08
$1,229.66
$1,718.44
$2,611.36 		$1,330.21
$1,460.11
$1,597.69
$2,086.47 		$1,698.24
$1,828.14
$1,965.72
$2,454.50 		$2,066.27
$2,196.17
$2,333.75
$2,822.53 		$368.03
Toc - Plan #110 Sendero Health Plans, Local Nonprofit
Gold

(HMO) Sendero IdealCare Gold 200 / Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + Free 24/7 Virtual MD Visits + No Pre-existing Condition Restrictions

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$350 $700 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 		$452.17
$513.21
$577.87
$807.57
$1,227.18 		$798.08
$859.12
$923.78
$1,153.48 		$1,143.99
$1,205.03
$1,269.69
$1,499.39 		$1,489.90
$1,550.94
$1,615.60
$1,845.30 		$345.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.34
$1,026.42
$1,155.74
$1,615.14
$2,454.36 		$1,250.25
$1,372.33
$1,501.65
$1,961.05 		$1,596.16
$1,718.24
$1,847.56
$2,306.96 		$1,942.07
$2,064.15
$2,193.47
$2,652.87 		$345.91
Toc - Plan #111 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero IdealCare Bronze 300 / $25 PCP / $11 Gen Rx + Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + Free 24/7 Virtual MDVisits + No Pre-existing Condition Restrictions

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$312.75
$354.98
$399.70
$558.58
$848.81 		$552.01
$594.24
$638.96
$797.84 		$791.27
$833.50
$878.22
$1,037.10 		$1,030.53
$1,072.76
$1,117.48
$1,276.36 		$239.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.50
$709.96
$799.40
$1,117.16
$1,697.62 		$864.76
$949.22
$1,038.66
$1,356.42 		$1,104.02
$1,188.48
$1,277.92
$1,595.68 		$1,343.28
$1,427.74
$1,517.18
$1,834.94 		$239.26
Toc - Plan #112 Sendero Health Plans, Local Nonprofit
Bronze

(HMO) Sendero IdealCare Bronze High Deductible 700 / Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + Free 24/7 Virtual MD Visits + No Pre-existing Condition Restrictions

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$301.80
$342.55
$385.70
$539.02
$819.09 		$532.68
$573.43
$616.58
$769.90 		$763.56
$804.31
$847.46
$1,000.78 		$994.44
$1,035.19
$1,078.34
$1,231.66 		$230.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.60
$685.10
$771.40
$1,078.04
$1,638.18 		$834.48
$915.98
$1,002.28
$1,308.92 		$1,065.36
$1,146.86
$1,233.16
$1,539.80 		$1,296.24
$1,377.74
$1,464.04
$1,770.68 		$230.88
Toc - Plan #113 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero IdealCare Bronze 800 / $25 PCP / $22 Gen Rx + Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + Free 24/7 Virtual MD Visits + No Pre-existing Condition Restrictions

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$324.01
$367.76
$414.09
$578.69
$879.38 		$571.88
$615.63
$661.96
$826.56 		$819.75
$863.50
$909.83
$1,074.43 		$1,067.62
$1,111.37
$1,157.70
$1,322.30 		$247.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.02
$735.52
$828.18
$1,157.38
$1,758.76 		$895.89
$983.39
$1,076.05
$1,405.25 		$1,143.76
$1,231.26
$1,323.92
$1,653.12 		$1,391.63
$1,479.13
$1,571.79
$1,900.99 		$247.87
Toc - Plan #114 Sendero Health Plans, Local Nonprofit
Silver

(HMO) Sendero IdealCare Silver 1700 / Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + No Pre-existing Condition Restrictions + Free 24/7 Virtual MD Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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 		$523.51
$594.19
$669.05
$934.99
$1,420.81 		$924.00
$994.68
$1,069.54
$1,335.48 		$1,324.49
$1,395.17
$1,470.03
$1,735.97 		$1,724.98
$1,795.66
$1,870.52
$2,136.46 		$400.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,047.02
$1,188.38
$1,338.10
$1,869.98
$2,841.62 		$1,447.51
$1,588.87
$1,738.59
$2,270.47 		$1,848.00
$1,989.36
$2,139.08
$2,670.96 		$2,248.49
$2,389.85
$2,539.57
$3,071.45 		$400.49
Toc - Plan #115 Sendero Health Plans, Local Nonprofit
Gold

(HMO) Sendero IdealCare Gold 1800 / Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + Free 24/7 Virtual MD Visits + No Pre-existing Condition Restrictions

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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 		$434.40
$493.05
$555.17
$775.85
$1,178.97 		$766.72
$825.37
$887.49
$1,108.17 		$1,099.04
$1,157.69
$1,219.81
$1,440.49 		$1,431.36
$1,490.01
$1,552.13
$1,772.81 		$332.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.80
$986.10
$1,110.34
$1,551.70
$2,357.94 		$1,201.12
$1,318.42
$1,442.66
$1,884.02 		$1,533.44
$1,650.74
$1,774.98
$2,216.34 		$1,865.76
$1,983.06
$2,107.30
$2,548.66 		$332.32
Toc - Plan #116 Sendero Health Plans, Local Nonprofit
Bronze

(HMO) Sendero IdealCare Bronze 1900 / $11 Gen Rx + Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + Free 24/7 Virtual MDVisits + No Pre-existing Condition Restrictions

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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 		$289.36
$328.43
$369.81
$516.80
$785.33 		$510.72
$549.79
$591.17
$738.16 		$732.08
$771.15
$812.53
$959.52 		$953.44
$992.51
$1,033.89
$1,180.88 		$221.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.72
$656.86
$739.62
$1,033.60
$1,570.66 		$800.08
$878.22
$960.98
$1,254.96 		$1,021.44
$1,099.58
$1,182.34
$1,476.32 		$1,242.80
$1,320.94
$1,403.70
$1,697.68 		$221.36
Toc - Plan #117 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero IdealCare Bronze 2000 / Free Wellness & Preventive Screening + Free Dedicated Healthcare Team + Free 24/7 Virtual MDVisits + No Pre-existing Condition Restrictions

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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 		$333.07
$378.03
$425.66
$594.86
$903.94 		$587.87
$632.83
$680.46
$849.66 		$842.67
$887.63
$935.26
$1,104.46 		$1,097.47
$1,142.43
$1,190.06
$1,359.26 		$254.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.14
$756.06
$851.32
$1,189.72
$1,807.88 		$920.94
$1,010.86
$1,106.12
$1,444.52 		$1,175.74
$1,265.66
$1,360.92
$1,699.32 		$1,430.54
$1,520.46
$1,615.72
$1,954.12 		$254.80

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #118 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 		$497.09
$564.18
$635.27
$887.78
$1,349.07 		$877.35
$944.44
$1,015.53
$1,268.04 		$1,257.61
$1,324.70
$1,395.79
$1,648.30 		$1,637.87
$1,704.96
$1,776.05
$2,028.56 		$380.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$994.18
$1,128.36
$1,270.54
$1,775.56
$2,698.14 		$1,374.44
$1,508.62
$1,650.80
$2,155.82 		$1,754.70
$1,888.88
$2,031.06
$2,536.08 		$2,134.96
$2,269.14
$2,411.32
$2,916.34 		$380.26
Toc - Plan #119 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 		$467.46
$530.55
$597.40
$834.86
$1,268.65 		$825.06
$888.15
$955.00
$1,192.46 		$1,182.66
$1,245.75
$1,312.60
$1,550.06 		$1,540.26
$1,603.35
$1,670.20
$1,907.66 		$357.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.92
$1,061.10
$1,194.80
$1,669.72
$2,537.30 		$1,292.52
$1,418.70
$1,552.40
$2,027.32 		$1,650.12
$1,776.30
$1,910.00
$2,384.92 		$2,007.72
$2,133.90
$2,267.60
$2,742.52 		$357.60
Toc - Plan #120 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 		$513.43
$582.73
$656.15
$916.97
$1,393.42 		$906.20
$975.50
$1,048.92
$1,309.74 		$1,298.97
$1,368.27
$1,441.69
$1,702.51 		$1,691.74
$1,761.04
$1,834.46
$2,095.28 		$392.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,026.86
$1,165.46
$1,312.30
$1,833.94
$2,786.84 		$1,419.63
$1,558.23
$1,705.07
$2,226.71 		$1,812.40
$1,951.00
$2,097.84
$2,619.48 		$2,205.17
$2,343.77
$2,490.61
$3,012.25 		$392.77
Toc - Plan #121 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 		$462.99
$525.49
$591.69
$826.89
$1,256.54 		$817.17
$879.67
$945.87
$1,181.07 		$1,171.35
$1,233.85
$1,300.05
$1,535.25 		$1,525.53
$1,588.03
$1,654.23
$1,889.43 		$354.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.98
$1,050.98
$1,183.38
$1,653.78
$2,513.08 		$1,280.16
$1,405.16
$1,537.56
$2,007.96 		$1,634.34
$1,759.34
$1,891.74
$2,362.14 		$1,988.52
$2,113.52
$2,245.92
$2,716.32 		$354.18
Toc - Plan #122 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 		$469.62
$533.00
$600.16
$838.72
$1,274.51 		$828.87
$892.25
$959.41
$1,197.97 		$1,188.12
$1,251.50
$1,318.66
$1,557.22 		$1,547.37
$1,610.75
$1,677.91
$1,916.47 		$359.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.24
$1,066.00
$1,200.32
$1,677.44
$2,549.02 		$1,298.49
$1,425.25
$1,559.57
$2,036.69 		$1,657.74
$1,784.50
$1,918.82
$2,395.94 		$2,016.99
$2,143.75
$2,278.07
$2,755.19 		$359.25
Toc - Plan #123 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 		$464.92
$527.67
$594.15
$830.33
$1,261.77 		$820.58
$883.33
$949.81
$1,185.99 		$1,176.24
$1,238.99
$1,305.47
$1,541.65 		$1,531.90
$1,594.65
$1,661.13
$1,897.31 		$355.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.84
$1,055.34
$1,188.30
$1,660.66
$2,523.54 		$1,285.50
$1,411.00
$1,543.96
$2,016.32 		$1,641.16
$1,766.66
$1,899.62
$2,371.98 		$1,996.82
$2,122.32
$2,255.28
$2,727.64 		$355.66
Toc - Plan #124 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 		$463.18
$525.70
$591.93
$827.23
$1,257.05 		$817.51
$880.03
$946.26
$1,181.56 		$1,171.84
$1,234.36
$1,300.59
$1,535.89 		$1,526.17
$1,588.69
$1,654.92
$1,890.22 		$354.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$926.36
$1,051.40
$1,183.86
$1,654.46
$2,514.10 		$1,280.69
$1,405.73
$1,538.19
$2,008.79 		$1,635.02
$1,760.06
$1,892.52
$2,363.12 		$1,989.35
$2,114.39
$2,246.85
$2,717.45 		$354.33
Toc - Plan #125 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 		$420.68
$477.46
$537.62
$751.32
$1,141.71 		$742.49
$799.27
$859.43
$1,073.13 		$1,064.30
$1,121.08
$1,181.24
$1,394.94 		$1,386.11
$1,442.89
$1,503.05
$1,716.75 		$321.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.36
$954.92
$1,075.24
$1,502.64
$2,283.42 		$1,163.17
$1,276.73
$1,397.05
$1,824.45 		$1,484.98
$1,598.54
$1,718.86
$2,146.26 		$1,806.79
$1,920.35
$2,040.67
$2,468.07 		$321.81
Toc - Plan #126 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 		$462.85
$525.33
$591.51
$826.64
$1,256.16 		$816.93
$879.41
$945.59
$1,180.72 		$1,171.01
$1,233.49
$1,299.67
$1,534.80 		$1,525.09
$1,587.57
$1,653.75
$1,888.88 		$354.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.70
$1,050.66
$1,183.02
$1,653.28
$2,512.32 		$1,279.78
$1,404.74
$1,537.10
$2,007.36 		$1,633.86
$1,758.82
$1,891.18
$2,361.44 		$1,987.94
$2,112.90
$2,245.26
$2,715.52 		$354.08
Toc - Plan #127 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 		$417.35
$473.68
$533.36
$745.37
$1,132.66 		$736.61
$792.94
$852.62
$1,064.63 		$1,055.87
$1,112.20
$1,171.88
$1,383.89 		$1,375.13
$1,431.46
$1,491.14
$1,703.15 		$319.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.70
$947.36
$1,066.72
$1,490.74
$2,265.32 		$1,153.96
$1,266.62
$1,385.98
$1,810.00 		$1,473.22
$1,585.88
$1,705.24
$2,129.26 		$1,792.48
$1,905.14
$2,024.50
$2,448.52 		$319.26

‡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 Travis County here.

Travis County is in “Rating Area 3” of Texas.

Currently, there are 127 plans offered in Rating Area 3.

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2023 Obamacare Plans for Travis County, TX

Plan Browser: 127 Plans
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