Nebraska Obamacare 2023 Rates

Obamacare > Rates > Nebraska

Obamacare Rates and Providers for Other Years

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

ADVERTISEMENT

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-833-7352

Toc - Plan #1 Medica
Expanded Bronze

(EPO) Elevate by Medica Bronze Copay ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.91
$390.33
$439.51
$614.21
$933.35
$607.00
$653.42
$702.60
$877.30
$870.09
$916.51
$965.69
$1,140.39
$1,133.18
$1,179.60
$1,228.78
$1,403.48
$263.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.82
$780.66
$879.02
$1,228.42
$1,866.70
$950.91
$1,043.75
$1,142.11
$1,491.51
$1,214.00
$1,306.84
$1,405.20
$1,754.60
$1,477.09
$1,569.93
$1,668.29
$2,017.69
$263.09
Toc - Plan #2 Medica
Expanded Bronze

(EPO) Elevate by Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$402.67
$457.02
$514.60
$719.15
$1,092.82
$710.70
$765.05
$822.63
$1,027.18
$1,018.73
$1,073.08
$1,130.66
$1,335.21
$1,326.76
$1,381.11
$1,438.69
$1,643.24
$308.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.34
$914.04
$1,029.20
$1,438.30
$2,185.64
$1,113.37
$1,222.07
$1,337.23
$1,746.33
$1,421.40
$1,530.10
$1,645.26
$2,054.36
$1,729.43
$1,838.13
$1,953.29
$2,362.39
$308.03
Toc - Plan #3 Medica
Catastrophic

(EPO) Elevate by Medica Catastrophic ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$255.73
$290.25
$326.82
$456.72
$694.04
$451.36
$485.88
$522.45
$652.35
$646.99
$681.51
$718.08
$847.98
$842.62
$877.14
$913.71
$1,043.61
$195.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$511.46
$580.50
$653.64
$913.44
$1,388.08
$707.09
$776.13
$849.27
$1,109.07
$902.72
$971.76
$1,044.90
$1,304.70
$1,098.35
$1,167.39
$1,240.53
$1,500.33
$195.63
Toc - Plan #4 Medica
Gold

(EPO) Elevate by Medica Gold Share ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$8,450 $16,900 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
$462.32
$524.72
$590.83
$825.69
$1,254.71
$815.99
$878.39
$944.50
$1,179.36
$1,169.66
$1,232.06
$1,298.17
$1,533.03
$1,523.33
$1,585.73
$1,651.84
$1,886.70
$353.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$924.64
$1,049.44
$1,181.66
$1,651.38
$2,509.42
$1,278.31
$1,403.11
$1,535.33
$2,005.05
$1,631.98
$1,756.78
$1,889.00
$2,358.72
$1,985.65
$2,110.45
$2,242.67
$2,712.39
$353.67
Toc - Plan #5 Medica
Silver

(EPO) Elevate by Medica Silver Share ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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
$478.59
$543.19
$611.62
$854.74
$1,298.86
$844.70
$909.30
$977.73
$1,220.85
$1,210.81
$1,275.41
$1,343.84
$1,586.96
$1,576.92
$1,641.52
$1,709.95
$1,953.07
$366.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$957.18
$1,086.38
$1,223.24
$1,709.48
$2,597.72
$1,323.29
$1,452.49
$1,589.35
$2,075.59
$1,689.40
$1,818.60
$1,955.46
$2,441.70
$2,055.51
$2,184.71
$2,321.57
$2,807.81
$366.11
Toc - Plan #6 Medica
Expanded Bronze

(EPO) Elevate by Medica Bronze Share Plus ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$352.17
$399.70
$450.05
$628.95
$955.75
$621.57
$669.10
$719.45
$898.35
$890.97
$938.50
$988.85
$1,167.75
$1,160.37
$1,207.90
$1,258.25
$1,437.15
$269.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704.34
$799.40
$900.10
$1,257.90
$1,911.50
$973.74
$1,068.80
$1,169.50
$1,527.30
$1,243.14
$1,338.20
$1,438.90
$1,796.70
$1,512.54
$1,607.60
$1,708.30
$2,066.10
$269.40
Toc - Plan #7 Medica
Expanded Bronze

(EPO) Elevate by Medica Bronze Copay $0 PCP Office Visits ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $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
$350.28
$397.56
$447.64
$625.58
$950.63
$618.24
$665.52
$715.60
$893.54
$886.20
$933.48
$983.56
$1,161.50
$1,154.16
$1,201.44
$1,251.52
$1,429.46
$267.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700.56
$795.12
$895.28
$1,251.16
$1,901.26
$968.52
$1,063.08
$1,163.24
$1,519.12
$1,236.48
$1,331.04
$1,431.20
$1,787.08
$1,504.44
$1,599.00
$1,699.16
$2,055.04
$267.96
Toc - Plan #8 Medica
Expanded Bronze

(EPO) Elevate by Medica Bronze Premier ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$348.25
$395.25
$445.05
$621.96
$945.13
$614.65
$661.65
$711.45
$888.36
$881.05
$928.05
$977.85
$1,154.76
$1,147.45
$1,194.45
$1,244.25
$1,421.16
$266.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696.50
$790.50
$890.10
$1,243.92
$1,890.26
$962.90
$1,056.90
$1,156.50
$1,510.32
$1,229.30
$1,323.30
$1,422.90
$1,776.72
$1,495.70
$1,589.70
$1,689.30
$2,043.12
$266.40
Toc - Plan #9 Medica
Silver

(EPO) Elevate by Medica Silver Enhanced ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$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
$493.35
$559.94
$630.49
$881.10
$1,338.92
$870.75
$937.34
$1,007.89
$1,258.50
$1,248.15
$1,314.74
$1,385.29
$1,635.90
$1,625.55
$1,692.14
$1,762.69
$2,013.30
$377.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$986.70
$1,119.88
$1,260.98
$1,762.20
$2,677.84
$1,364.10
$1,497.28
$1,638.38
$2,139.60
$1,741.50
$1,874.68
$2,015.78
$2,517.00
$2,118.90
$2,252.08
$2,393.18
$2,894.40
$377.40
Toc - Plan #10 Medica
Gold

(EPO) Elevate by Medica Gold Standard ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$476.89
$541.26
$609.45
$851.71
$1,294.26
$841.70
$906.07
$974.26
$1,216.52
$1,206.51
$1,270.88
$1,339.07
$1,581.33
$1,571.32
$1,635.69
$1,703.88
$1,946.14
$364.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$953.78
$1,082.52
$1,218.90
$1,703.42
$2,588.52
$1,318.59
$1,447.33
$1,583.71
$2,068.23
$1,683.40
$1,812.14
$1,948.52
$2,433.04
$2,048.21
$2,176.95
$2,313.33
$2,797.85
$364.81
Toc - Plan #11 Medica
Silver

(EPO) Elevate by Medica Silver Standard ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$458.55
$520.44
$586.01
$818.95
$1,244.47
$809.33
$871.22
$936.79
$1,169.73
$1,160.11
$1,222.00
$1,287.57
$1,520.51
$1,510.89
$1,572.78
$1,638.35
$1,871.29
$350.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.10
$1,040.88
$1,172.02
$1,637.90
$2,488.94
$1,267.88
$1,391.66
$1,522.80
$1,988.68
$1,618.66
$1,742.44
$1,873.58
$2,339.46
$1,969.44
$2,093.22
$2,224.36
$2,690.24
$350.78
Toc - Plan #12 Medica
Bronze

(EPO) Elevate by Medica Bronze Standard ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$339.01
$384.76
$433.24
$605.45
$920.04
$598.34
$644.09
$692.57
$864.78
$857.67
$903.42
$951.90
$1,124.11
$1,117.00
$1,162.75
$1,211.23
$1,383.44
$259.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$678.02
$769.52
$866.48
$1,210.90
$1,840.08
$937.35
$1,028.85
$1,125.81
$1,470.23
$1,196.68
$1,288.18
$1,385.14
$1,729.56
$1,456.01
$1,547.51
$1,644.47
$1,988.89
$259.33
Toc - Plan #13 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Copay ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.43
$483.98
$544.96
$761.58
$1,157.29
$752.64
$810.19
$871.17
$1,087.79
$1,078.85
$1,136.40
$1,197.38
$1,414.00
$1,405.06
$1,462.61
$1,523.59
$1,740.21
$326.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.86
$967.96
$1,089.92
$1,523.16
$2,314.58
$1,179.07
$1,294.17
$1,416.13
$1,849.37
$1,505.28
$1,620.38
$1,742.34
$2,175.58
$1,831.49
$1,946.59
$2,068.55
$2,501.79
$326.21
Toc - Plan #14 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Copay + Dental Reimbursement ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$448.17
$508.67
$572.75
$800.42
$1,216.32
$791.02
$851.52
$915.60
$1,143.27
$1,133.87
$1,194.37
$1,258.45
$1,486.12
$1,476.72
$1,537.22
$1,601.30
$1,828.97
$342.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.34
$1,017.34
$1,145.50
$1,600.84
$2,432.64
$1,239.19
$1,360.19
$1,488.35
$1,943.69
$1,582.04
$1,703.04
$1,831.20
$2,286.54
$1,924.89
$2,045.89
$2,174.05
$2,629.39
$342.85
Toc - Plan #15 Medica
Expanded Bronze

(EPO) Medica Insure Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$499.28
$566.67
$638.07
$891.69
$1,355.02
$881.22
$948.61
$1,020.01
$1,273.63
$1,263.16
$1,330.55
$1,401.95
$1,655.57
$1,645.10
$1,712.49
$1,783.89
$2,037.51
$381.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$998.56
$1,133.34
$1,276.14
$1,783.38
$2,710.04
$1,380.50
$1,515.28
$1,658.08
$2,165.32
$1,762.44
$1,897.22
$2,040.02
$2,547.26
$2,144.38
$2,279.16
$2,421.96
$2,929.20
$381.94
Toc - Plan #16 Medica
Catastrophic

(EPO) Medica Insure Catastrophic ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.09
$359.89
$405.23
$566.31
$860.56
$559.66
$602.46
$647.80
$808.88
$802.23
$845.03
$890.37
$1,051.45
$1,044.80
$1,087.60
$1,132.94
$1,294.02
$242.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.18
$719.78
$810.46
$1,132.62
$1,721.12
$876.75
$962.35
$1,053.03
$1,375.19
$1,119.32
$1,204.92
$1,295.60
$1,617.76
$1,361.89
$1,447.49
$1,538.17
$1,860.33
$242.57
Toc - Plan #17 Medica
Silver

(EPO) Medica Insure Silver Share ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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
$593.41
$673.51
$758.37
$1,059.82
$1,610.50
$1,047.36
$1,127.46
$1,212.32
$1,513.77
$1,501.31
$1,581.41
$1,666.27
$1,967.72
$1,955.26
$2,035.36
$2,120.22
$2,421.67
$453.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,186.82
$1,347.02
$1,516.74
$2,119.64
$3,221.00
$1,640.77
$1,800.97
$1,970.69
$2,573.59
$2,094.72
$2,254.92
$2,424.64
$3,027.54
$2,548.67
$2,708.87
$2,878.59
$3,481.49
$453.95
Toc - Plan #18 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Share Plus ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$436.66
$495.60
$558.04
$779.85
$1,185.06
$770.70
$829.64
$892.08
$1,113.89
$1,104.74
$1,163.68
$1,226.12
$1,447.93
$1,438.78
$1,497.72
$1,560.16
$1,781.97
$334.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.32
$991.20
$1,116.08
$1,559.70
$2,370.12
$1,207.36
$1,325.24
$1,450.12
$1,893.74
$1,541.40
$1,659.28
$1,784.16
$2,227.78
$1,875.44
$1,993.32
$2,118.20
$2,561.82
$334.04
Toc - Plan #19 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Copay $0 PCP Office Visits ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $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
$434.32
$492.94
$555.05
$775.68
$1,178.72
$766.57
$825.19
$887.30
$1,107.93
$1,098.82
$1,157.44
$1,219.55
$1,440.18
$1,431.07
$1,489.69
$1,551.80
$1,772.43
$332.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.64
$985.88
$1,110.10
$1,551.36
$2,357.44
$1,200.89
$1,318.13
$1,442.35
$1,883.61
$1,533.14
$1,650.38
$1,774.60
$2,215.86
$1,865.39
$1,982.63
$2,106.85
$2,548.11
$332.25
Toc - Plan #20 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Premier ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$431.81
$490.09
$551.83
$771.19
$1,171.89
$762.13
$820.41
$882.15
$1,101.51
$1,092.45
$1,150.73
$1,212.47
$1,431.83
$1,422.77
$1,481.05
$1,542.79
$1,762.15
$330.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$863.62
$980.18
$1,103.66
$1,542.38
$2,343.78
$1,193.94
$1,310.50
$1,433.98
$1,872.70
$1,524.26
$1,640.82
$1,764.30
$2,203.02
$1,854.58
$1,971.14
$2,094.62
$2,533.34
$330.32
Toc - Plan #21 Medica
Gold

(EPO) Medica Insure Gold Standard ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$591.31
$671.12
$755.68
$1,056.06
$1,604.79
$1,043.65
$1,123.46
$1,208.02
$1,508.40
$1,495.99
$1,575.80
$1,660.36
$1,960.74
$1,948.33
$2,028.14
$2,112.70
$2,413.08
$452.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,182.62
$1,342.24
$1,511.36
$2,112.12
$3,209.58
$1,634.96
$1,794.58
$1,963.70
$2,564.46
$2,087.30
$2,246.92
$2,416.04
$3,016.80
$2,539.64
$2,699.26
$2,868.38
$3,469.14
$452.34
Toc - Plan #22 Medica
Silver

(EPO) Medica Insure Silver Standard ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$568.56
$645.31
$726.61
$1,015.44
$1,543.06
$1,003.50
$1,080.25
$1,161.55
$1,450.38
$1,438.44
$1,515.19
$1,596.49
$1,885.32
$1,873.38
$1,950.13
$2,031.43
$2,320.26
$434.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,137.12
$1,290.62
$1,453.22
$2,030.88
$3,086.12
$1,572.06
$1,725.56
$1,888.16
$2,465.82
$2,007.00
$2,160.50
$2,323.10
$2,900.76
$2,441.94
$2,595.44
$2,758.04
$3,335.70
$434.94
Toc - Plan #23 Medica
Bronze

(EPO) Medica Insure Bronze Standard ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$420.35
$477.08
$537.19
$750.72
$1,140.79
$741.91
$798.64
$858.75
$1,072.28
$1,063.47
$1,120.20
$1,180.31
$1,393.84
$1,385.03
$1,441.76
$1,501.87
$1,715.40
$321.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$840.70
$954.16
$1,074.38
$1,501.44
$2,281.58
$1,162.26
$1,275.72
$1,395.94
$1,823.00
$1,483.82
$1,597.28
$1,717.50
$2,144.56
$1,805.38
$1,918.84
$2,039.06
$2,466.12
$321.56
Toc - Plan #24 Medica
Gold

(EPO) Medica Insure Gold HSA ($0 Virtual Care after Deductible with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$6,000 $12,000 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
$704.16
$799.20
$899.90
$1,257.60
$1,911.05
$1,242.83
$1,337.87
$1,438.57
$1,796.27
$1,781.50
$1,876.54
$1,977.24
$2,334.94
$2,320.17
$2,415.21
$2,515.91
$2,873.61
$538.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,408.32
$1,598.40
$1,799.80
$2,515.20
$3,822.10
$1,946.99
$2,137.07
$2,338.47
$3,053.87
$2,485.66
$2,675.74
$2,877.14
$3,592.54
$3,024.33
$3,214.41
$3,415.81
$4,131.21
$538.67
Toc - Plan #25 Medica
Expanded Bronze

(EPO) Medica with CHI Health Bronze Copay ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$326.64
$370.72
$417.43
$583.35
$886.46
$576.51
$620.59
$667.30
$833.22
$826.38
$870.46
$917.17
$1,083.09
$1,076.25
$1,120.33
$1,167.04
$1,332.96
$249.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$653.28
$741.44
$834.86
$1,166.70
$1,772.92
$903.15
$991.31
$1,084.73
$1,416.57
$1,153.02
$1,241.18
$1,334.60
$1,666.44
$1,402.89
$1,491.05
$1,584.47
$1,916.31
$249.87
Toc - Plan #26 Medica
Expanded Bronze

(EPO) Medica with CHI Health Bronze Copay + Dental Reimbursement ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.29
$389.63
$438.72
$613.10
$931.67
$605.90
$652.24
$701.33
$875.71
$868.51
$914.85
$963.94
$1,138.32
$1,131.12
$1,177.46
$1,226.55
$1,400.93
$262.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.58
$779.26
$877.44
$1,226.20
$1,863.34
$949.19
$1,041.87
$1,140.05
$1,488.81
$1,211.80
$1,304.48
$1,402.66
$1,751.42
$1,474.41
$1,567.09
$1,665.27
$2,014.03
$262.61
Toc - Plan #27 Medica
Expanded Bronze

(EPO) Medica with CHI Health Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$382.44
$434.06
$488.74
$683.02
$1,037.91
$675.00
$726.62
$781.30
$975.58
$967.56
$1,019.18
$1,073.86
$1,268.14
$1,260.12
$1,311.74
$1,366.42
$1,560.70
$292.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.88
$868.12
$977.48
$1,366.04
$2,075.82
$1,057.44
$1,160.68
$1,270.04
$1,658.60
$1,350.00
$1,453.24
$1,562.60
$1,951.16
$1,642.56
$1,745.80
$1,855.16
$2,243.72
$292.56
Toc - Plan #28 Medica
Catastrophic

(EPO) Medica with CHI Health Catastrophic ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$242.89
$275.67
$310.40
$433.78
$659.17
$428.69
$461.47
$496.20
$619.58
$614.49
$647.27
$682.00
$805.38
$800.29
$833.07
$867.80
$991.18
$185.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$485.78
$551.34
$620.80
$867.56
$1,318.34
$671.58
$737.14
$806.60
$1,053.36
$857.38
$922.94
$992.40
$1,239.16
$1,043.18
$1,108.74
$1,178.20
$1,424.96
$185.80
Toc - Plan #29 Medica
Silver

(EPO) Medica with CHI Health Silver Share ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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
$454.54
$515.90
$580.90
$811.80
$1,233.61
$802.26
$863.62
$928.62
$1,159.52
$1,149.98
$1,211.34
$1,276.34
$1,507.24
$1,497.70
$1,559.06
$1,624.06
$1,854.96
$347.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$909.08
$1,031.80
$1,161.80
$1,623.60
$2,467.22
$1,256.80
$1,379.52
$1,509.52
$1,971.32
$1,604.52
$1,727.24
$1,857.24
$2,319.04
$1,952.24
$2,074.96
$2,204.96
$2,666.76
$347.72
Toc - Plan #30 Medica
Expanded Bronze

(EPO) Medica with CHI Health Bronze Share Plus ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$334.47
$379.62
$427.44
$597.35
$907.73
$590.33
$635.48
$683.30
$853.21
$846.19
$891.34
$939.16
$1,109.07
$1,102.05
$1,147.20
$1,195.02
$1,364.93
$255.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$668.94
$759.24
$854.88
$1,194.70
$1,815.46
$924.80
$1,015.10
$1,110.74
$1,450.56
$1,180.66
$1,270.96
$1,366.60
$1,706.42
$1,436.52
$1,526.82
$1,622.46
$1,962.28
$255.86
Toc - Plan #31 Medica
Expanded Bronze

(EPO) Medica with CHI Health Bronze Copay $0 PCP Office Visits ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $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
$332.68
$377.58
$425.15
$594.15
$902.87
$587.17
$632.07
$679.64
$848.64
$841.66
$886.56
$934.13
$1,103.13
$1,096.15
$1,141.05
$1,188.62
$1,357.62
$254.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.36
$755.16
$850.30
$1,188.30
$1,805.74
$919.85
$1,009.65
$1,104.79
$1,442.79
$1,174.34
$1,264.14
$1,359.28
$1,697.28
$1,428.83
$1,518.63
$1,613.77
$1,951.77
$254.49
Toc - Plan #32 Medica
Gold

(EPO) Medica with CHI Health Gold Copay $0 PCP Office Visits ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,450 $16,900 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
$456.38
$517.98
$583.24
$815.08
$1,238.59
$805.50
$867.10
$932.36
$1,164.20
$1,154.62
$1,216.22
$1,281.48
$1,513.32
$1,503.74
$1,565.34
$1,630.60
$1,862.44
$349.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$912.76
$1,035.96
$1,166.48
$1,630.16
$2,477.18
$1,261.88
$1,385.08
$1,515.60
$1,979.28
$1,611.00
$1,734.20
$1,864.72
$2,328.40
$1,960.12
$2,083.32
$2,213.84
$2,677.52
$349.12
Toc - Plan #33 Medica
Expanded Bronze

(EPO) Medica with CHI Health Bronze Premier ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$330.76
$375.40
$422.69
$590.71
$897.64
$583.78
$628.42
$675.71
$843.73
$836.80
$881.44
$928.73
$1,096.75
$1,089.82
$1,134.46
$1,181.75
$1,349.77
$253.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$661.52
$750.80
$845.38
$1,181.42
$1,795.28
$914.54
$1,003.82
$1,098.40
$1,434.44
$1,167.56
$1,256.84
$1,351.42
$1,687.46
$1,420.58
$1,509.86
$1,604.44
$1,940.48
$253.02
Toc - Plan #34 Medica
Silver

(EPO) Medica with CHI Health Silver Enhanced ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

Individual Family
$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
$468.56
$531.81
$598.81
$836.84
$1,271.65
$827.00
$890.25
$957.25
$1,195.28
$1,185.44
$1,248.69
$1,315.69
$1,553.72
$1,543.88
$1,607.13
$1,674.13
$1,912.16
$358.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$937.12
$1,063.62
$1,197.62
$1,673.68
$2,543.30
$1,295.56
$1,422.06
$1,556.06
$2,032.12
$1,654.00
$1,780.50
$1,914.50
$2,390.56
$2,012.44
$2,138.94
$2,272.94
$2,749.00
$358.44
Toc - Plan #35 Medica
Gold

(EPO) Medica with CHI Health Gold Standard ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$452.93
$514.07
$578.83
$808.92
$1,229.23
$799.42
$860.56
$925.32
$1,155.41
$1,145.91
$1,207.05
$1,271.81
$1,501.90
$1,492.40
$1,553.54
$1,618.30
$1,848.39
$346.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$905.86
$1,028.14
$1,157.66
$1,617.84
$2,458.46
$1,252.35
$1,374.63
$1,504.15
$1,964.33
$1,598.84
$1,721.12
$1,850.64
$2,310.82
$1,945.33
$2,067.61
$2,197.13
$2,657.31
$346.49
Toc - Plan #36 Medica
Silver

(EPO) Medica with CHI Health Silver Standard ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.51
$494.29
$556.57
$777.80
$1,181.95
$768.67
$827.45
$889.73
$1,110.96
$1,101.83
$1,160.61
$1,222.89
$1,444.12
$1,434.99
$1,493.77
$1,556.05
$1,777.28
$333.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871.02
$988.58
$1,113.14
$1,555.60
$2,363.90
$1,204.18
$1,321.74
$1,446.30
$1,888.76
$1,537.34
$1,654.90
$1,779.46
$2,221.92
$1,870.50
$1,988.06
$2,112.62
$2,555.08
$333.16
Toc - Plan #37 Medica
Bronze

(EPO) Medica with CHI Health Bronze Standard ($0 Virtual Care with Designated Providers)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.98
$365.43
$411.47
$575.03
$873.82
$568.29
$611.74
$657.78
$821.34
$814.60
$858.05
$904.09
$1,067.65
$1,060.91
$1,104.36
$1,150.40
$1,313.96
$246.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.96
$730.86
$822.94
$1,150.06
$1,747.64
$890.27
$977.17
$1,069.25
$1,396.37
$1,136.58
$1,223.48
$1,315.56
$1,642.68
$1,382.89
$1,469.79
$1,561.87
$1,888.99
$246.31

ADVERTISEMENT

Ambetter from Nebraska Total Care

Local: 1-833-890-0329 | Toll Free: 1-833-890-0329 | TTY: 1-833-890-0329

Toc - Plan #38 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$372.26
$422.51
$475.74
$664.85
$1,010.30
$657.03
$707.28
$760.51
$949.62
$941.80
$992.05
$1,045.28
$1,234.39
$1,226.57
$1,276.82
$1,330.05
$1,519.16
$284.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.52
$845.02
$951.48
$1,329.70
$2,020.60
$1,029.29
$1,129.79
$1,236.25
$1,614.47
$1,314.06
$1,414.56
$1,521.02
$1,899.24
$1,598.83
$1,699.33
$1,805.79
$2,184.01
$284.77
Toc - Plan #39 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.28
$412.31
$464.25
$648.79
$985.90
$641.18
$690.21
$742.15
$926.69
$919.08
$968.11
$1,020.05
$1,204.59
$1,196.98
$1,246.01
$1,297.95
$1,482.49
$277.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$726.56
$824.62
$928.50
$1,297.58
$1,971.80
$1,004.46
$1,102.52
$1,206.40
$1,575.48
$1,282.36
$1,380.42
$1,484.30
$1,853.38
$1,560.26
$1,658.32
$1,762.20
$2,131.28
$277.90
Toc - Plan #40 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.21
$462.17
$520.40
$727.25
$1,105.13
$718.72
$773.68
$831.91
$1,038.76
$1,030.23
$1,085.19
$1,143.42
$1,350.27
$1,341.74
$1,396.70
$1,454.93
$1,661.78
$311.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.42
$924.34
$1,040.80
$1,454.50
$2,210.26
$1,125.93
$1,235.85
$1,352.31
$1,766.01
$1,437.44
$1,547.36
$1,663.82
$2,077.52
$1,748.95
$1,858.87
$1,975.33
$2,389.03
$311.51
Toc - Plan #41 Ambetter from Nebraska Total Care
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$440.65
$500.13
$563.14
$786.99
$1,195.90
$777.74
$837.22
$900.23
$1,124.08
$1,114.83
$1,174.31
$1,237.32
$1,461.17
$1,451.92
$1,511.40
$1,574.41
$1,798.26
$337.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$881.30
$1,000.26
$1,126.28
$1,573.98
$2,391.80
$1,218.39
$1,337.35
$1,463.37
$1,911.07
$1,555.48
$1,674.44
$1,800.46
$2,248.16
$1,892.57
$2,011.53
$2,137.55
$2,585.25
$337.09
Toc - Plan #42 Ambetter from Nebraska Total Care
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$436.51
$495.43
$557.85
$779.59
$1,184.66
$770.43
$829.35
$891.77
$1,113.51
$1,104.35
$1,163.27
$1,225.69
$1,447.43
$1,438.27
$1,497.19
$1,559.61
$1,781.35
$333.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.02
$990.86
$1,115.70
$1,559.18
$2,369.32
$1,206.94
$1,324.78
$1,449.62
$1,893.10
$1,540.86
$1,658.70
$1,783.54
$2,227.02
$1,874.78
$1,992.62
$2,117.46
$2,560.94
$333.92
Toc - Plan #43 Ambetter from Nebraska Total Care
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$478.28
$542.84
$611.23
$854.20
$1,298.03
$844.16
$908.72
$977.11
$1,220.08
$1,210.04
$1,274.60
$1,342.99
$1,585.96
$1,575.92
$1,640.48
$1,708.87
$1,951.84
$365.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$956.56
$1,085.68
$1,222.46
$1,708.40
$2,596.06
$1,322.44
$1,451.56
$1,588.34
$2,074.28
$1,688.32
$1,817.44
$1,954.22
$2,440.16
$2,054.20
$2,183.32
$2,320.10
$2,806.04
$365.88
Toc - Plan #44 Ambetter from Nebraska Total Care
Bronze

(HMO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$324.85
$368.69
$415.15
$580.17
$881.62
$573.35
$617.19
$663.65
$828.67
$821.85
$865.69
$912.15
$1,077.17
$1,070.35
$1,114.19
$1,160.65
$1,325.67
$248.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$649.70
$737.38
$830.30
$1,160.34
$1,763.24
$898.20
$985.88
$1,078.80
$1,408.84
$1,146.70
$1,234.38
$1,327.30
$1,657.34
$1,395.20
$1,482.88
$1,575.80
$1,905.84
$248.50
Toc - Plan #45 Ambetter from Nebraska Total Care
Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$526.58
$597.65
$672.95
$940.45
$1,429.10
$929.40
$1,000.47
$1,075.77
$1,343.27
$1,332.22
$1,403.29
$1,478.59
$1,746.09
$1,735.04
$1,806.11
$1,881.41
$2,148.91
$402.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,053.16
$1,195.30
$1,345.90
$1,880.90
$2,858.20
$1,455.98
$1,598.12
$1,748.72
$2,283.72
$1,858.80
$2,000.94
$2,151.54
$2,686.54
$2,261.62
$2,403.76
$2,554.36
$3,089.36
$402.82
Toc - Plan #46 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$355.87
$403.90
$454.79
$635.57
$965.81
$628.10
$676.13
$727.02
$907.80
$900.33
$948.36
$999.25
$1,180.03
$1,172.56
$1,220.59
$1,271.48
$1,452.26
$272.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.74
$807.80
$909.58
$1,271.14
$1,931.62
$983.97
$1,080.03
$1,181.81
$1,543.37
$1,256.20
$1,352.26
$1,454.04
$1,815.60
$1,528.43
$1,624.49
$1,726.27
$2,087.83
$272.23
Toc - Plan #47 Ambetter from Nebraska Total Care
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$430.52
$488.63
$550.19
$768.89
$1,168.40
$759.86
$817.97
$879.53
$1,098.23
$1,089.20
$1,147.31
$1,208.87
$1,427.57
$1,418.54
$1,476.65
$1,538.21
$1,756.91
$329.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$861.04
$977.26
$1,100.38
$1,537.78
$2,336.80
$1,190.38
$1,306.60
$1,429.72
$1,867.12
$1,519.72
$1,635.94
$1,759.06
$2,196.46
$1,849.06
$1,965.28
$2,088.40
$2,525.80
$329.34
Toc - Plan #48 Ambetter from Nebraska Total Care
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$453.21
$514.38
$579.19
$809.42
$1,229.99
$799.91
$861.08
$925.89
$1,156.12
$1,146.61
$1,207.78
$1,272.59
$1,502.82
$1,493.31
$1,554.48
$1,619.29
$1,849.52
$346.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$906.42
$1,028.76
$1,158.38
$1,618.84
$2,459.98
$1,253.12
$1,375.46
$1,505.08
$1,965.54
$1,599.82
$1,722.16
$1,851.78
$2,312.24
$1,946.52
$2,068.86
$2,198.48
$2,658.94
$346.70
Toc - Plan #49 Ambetter from Nebraska Total Care
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$339.88
$385.75
$434.35
$607.00
$922.40
$599.88
$645.75
$694.35
$867.00
$859.88
$905.75
$954.35
$1,127.00
$1,119.88
$1,165.75
$1,214.35
$1,387.00
$260.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$679.76
$771.50
$868.70
$1,214.00
$1,844.80
$939.76
$1,031.50
$1,128.70
$1,474.00
$1,199.76
$1,291.50
$1,388.70
$1,734.00
$1,459.76
$1,551.50
$1,648.70
$1,994.00
$260.00
Toc - Plan #50 Ambetter from Nebraska Total Care
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$432.90
$491.33
$553.23
$773.14
$1,174.85
$764.06
$822.49
$884.39
$1,104.30
$1,095.22
$1,153.65
$1,215.55
$1,435.46
$1,426.38
$1,484.81
$1,546.71
$1,766.62
$331.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$865.80
$982.66
$1,106.46
$1,546.28
$2,349.70
$1,196.96
$1,313.82
$1,437.62
$1,877.44
$1,528.12
$1,644.98
$1,768.78
$2,208.60
$1,859.28
$1,976.14
$2,099.94
$2,539.76
$331.16
Toc - Plan #51 Ambetter from Nebraska Total Care
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$434.97
$493.68
$555.88
$776.83
$1,180.48
$767.71
$826.42
$888.62
$1,109.57
$1,100.45
$1,159.16
$1,221.36
$1,442.31
$1,433.19
$1,491.90
$1,554.10
$1,775.05
$332.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869.94
$987.36
$1,111.76
$1,553.66
$2,360.96
$1,202.68
$1,320.10
$1,444.50
$1,886.40
$1,535.42
$1,652.84
$1,777.24
$2,219.14
$1,868.16
$1,985.58
$2,109.98
$2,551.88
$332.74
Toc - Plan #52 Ambetter from Nebraska Total Care
Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$458.54
$520.43
$586.00
$818.94
$1,244.46
$809.32
$871.21
$936.78
$1,169.72
$1,160.10
$1,221.99
$1,287.56
$1,520.50
$1,510.88
$1,572.77
$1,638.34
$1,871.28
$350.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.08
$1,040.86
$1,172.00
$1,637.88
$2,488.92
$1,267.86
$1,391.64
$1,522.78
$1,988.66
$1,618.64
$1,742.42
$1,873.56
$2,339.44
$1,969.42
$2,093.20
$2,224.34
$2,690.22
$350.78
Toc - Plan #53 Ambetter from Nebraska Total Care
Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$452.86
$513.98
$578.74
$808.79
$1,229.03
$799.29
$860.41
$925.17
$1,155.22
$1,145.72
$1,206.84
$1,271.60
$1,501.65
$1,492.15
$1,553.27
$1,618.03
$1,848.08
$346.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$905.72
$1,027.96
$1,157.48
$1,617.58
$2,458.06
$1,252.15
$1,374.39
$1,503.91
$1,964.01
$1,598.58
$1,720.82
$1,850.34
$2,310.44
$1,945.01
$2,067.25
$2,196.77
$2,656.87
$346.43
Toc - Plan #54 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$387.54
$439.85
$495.27
$692.14
$1,051.77
$684.00
$736.31
$791.73
$988.60
$980.46
$1,032.77
$1,088.19
$1,285.06
$1,276.92
$1,329.23
$1,384.65
$1,581.52
$296.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.08
$879.70
$990.54
$1,384.28
$2,103.54
$1,071.54
$1,176.16
$1,287.00
$1,680.74
$1,368.00
$1,472.62
$1,583.46
$1,977.20
$1,664.46
$1,769.08
$1,879.92
$2,273.66
$296.46
Toc - Plan #55 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$378.19
$429.23
$483.31
$675.42
$1,026.37
$667.49
$718.53
$772.61
$964.72
$956.79
$1,007.83
$1,061.91
$1,254.02
$1,246.09
$1,297.13
$1,351.21
$1,543.32
$289.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.38
$858.46
$966.62
$1,350.84
$2,052.74
$1,045.68
$1,147.76
$1,255.92
$1,640.14
$1,334.98
$1,437.06
$1,545.22
$1,929.44
$1,624.28
$1,726.36
$1,834.52
$2,218.74
$289.30
Toc - Plan #56 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.92
$481.14
$541.76
$757.11
$1,150.50
$748.21
$805.43
$866.05
$1,081.40
$1,072.50
$1,129.72
$1,190.34
$1,405.69
$1,396.79
$1,454.01
$1,514.63
$1,729.98
$324.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$847.84
$962.28
$1,083.52
$1,514.22
$2,301.00
$1,172.13
$1,286.57
$1,407.81
$1,838.51
$1,496.42
$1,610.86
$1,732.10
$2,162.80
$1,820.71
$1,935.15
$2,056.39
$2,487.09
$324.29
Toc - Plan #57 Ambetter from Nebraska Total Care
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$458.74
$520.66
$586.26
$819.29
$1,244.99
$809.67
$871.59
$937.19
$1,170.22
$1,160.60
$1,222.52
$1,288.12
$1,521.15
$1,511.53
$1,573.45
$1,639.05
$1,872.08
$350.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.48
$1,041.32
$1,172.52
$1,638.58
$2,489.98
$1,268.41
$1,392.25
$1,523.45
$1,989.51
$1,619.34
$1,743.18
$1,874.38
$2,340.44
$1,970.27
$2,094.11
$2,225.31
$2,691.37
$350.93
Toc - Plan #58 Ambetter from Nebraska Total Care
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$497.91
$565.12
$636.32
$889.26
$1,351.31
$878.81
$946.02
$1,017.22
$1,270.16
$1,259.71
$1,326.92
$1,398.12
$1,651.06
$1,640.61
$1,707.82
$1,779.02
$2,031.96
$380.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$995.82
$1,130.24
$1,272.64
$1,778.52
$2,702.62
$1,376.72
$1,511.14
$1,653.54
$2,159.42
$1,757.62
$1,892.04
$2,034.44
$2,540.32
$2,138.52
$2,272.94
$2,415.34
$2,921.22
$380.90
Toc - Plan #59 Ambetter from Nebraska Total Care
Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$548.19
$622.19
$700.58
$979.05
$1,487.76
$967.55
$1,041.55
$1,119.94
$1,398.41
$1,386.91
$1,460.91
$1,539.30
$1,817.77
$1,806.27
$1,880.27
$1,958.66
$2,237.13
$419.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,096.38
$1,244.38
$1,401.16
$1,958.10
$2,975.52
$1,515.74
$1,663.74
$1,820.52
$2,377.46
$1,935.10
$2,083.10
$2,239.88
$2,796.82
$2,354.46
$2,502.46
$2,659.24
$3,216.18
$419.36
Toc - Plan #60 Ambetter from Nebraska Total Care
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$454.43
$515.76
$580.75
$811.59
$1,233.29
$802.06
$863.39
$928.38
$1,159.22
$1,149.69
$1,211.02
$1,276.01
$1,506.85
$1,497.32
$1,558.65
$1,623.64
$1,854.48
$347.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$908.86
$1,031.52
$1,161.50
$1,623.18
$2,466.58
$1,256.49
$1,379.15
$1,509.13
$1,970.81
$1,604.12
$1,726.78
$1,856.76
$2,318.44
$1,951.75
$2,074.41
$2,204.39
$2,666.07
$347.63
Toc - Plan #61 Ambetter from Nebraska Total Care
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.83
$401.58
$452.18
$631.92
$960.26
$624.50
$672.25
$722.85
$902.59
$895.17
$942.92
$993.52
$1,173.26
$1,165.84
$1,213.59
$1,264.19
$1,443.93
$270.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.66
$803.16
$904.36
$1,263.84
$1,920.52
$978.33
$1,073.83
$1,175.03
$1,534.51
$1,249.00
$1,344.50
$1,445.70
$1,805.18
$1,519.67
$1,615.17
$1,716.37
$2,075.85
$270.67
Toc - Plan #62 Ambetter from Nebraska Total Care
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$450.67
$511.49
$575.94
$804.87
$1,223.08
$795.42
$856.24
$920.69
$1,149.62
$1,140.17
$1,200.99
$1,265.44
$1,494.37
$1,484.92
$1,545.74
$1,610.19
$1,839.12
$344.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$901.34
$1,022.98
$1,151.88
$1,609.74
$2,446.16
$1,246.09
$1,367.73
$1,496.63
$1,954.49
$1,590.84
$1,712.48
$1,841.38
$2,299.24
$1,935.59
$2,057.23
$2,186.13
$2,643.99
$344.75
Toc - Plan #63 Ambetter from Nebraska Total Care
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$452.82
$513.94
$578.69
$808.72
$1,228.93
$799.22
$860.34
$925.09
$1,155.12
$1,145.62
$1,206.74
$1,271.49
$1,501.52
$1,492.02
$1,553.14
$1,617.89
$1,847.92
$346.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$905.64
$1,027.88
$1,157.38
$1,617.44
$2,457.86
$1,252.04
$1,374.28
$1,503.78
$1,963.84
$1,598.44
$1,720.68
$1,850.18
$2,310.24
$1,944.84
$2,067.08
$2,196.58
$2,656.64
$346.40
Toc - Plan #64 Ambetter from Nebraska Total Care
Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$477.36
$541.80
$610.06
$852.55
$1,295.54
$842.54
$906.98
$975.24
$1,217.73
$1,207.72
$1,272.16
$1,340.42
$1,582.91
$1,572.90
$1,637.34
$1,705.60
$1,948.09
$365.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$954.72
$1,083.60
$1,220.12
$1,705.10
$2,591.08
$1,319.90
$1,448.78
$1,585.30
$2,070.28
$1,685.08
$1,813.96
$1,950.48
$2,435.46
$2,050.26
$2,179.14
$2,315.66
$2,800.64
$365.18
Toc - Plan #65 Ambetter from Nebraska Total Care
Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$471.45
$535.08
$602.50
$841.98
$1,279.48
$832.10
$895.73
$963.15
$1,202.63
$1,192.75
$1,256.38
$1,323.80
$1,563.28
$1,553.40
$1,617.03
$1,684.45
$1,923.93
$360.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$942.90
$1,070.16
$1,205.00
$1,683.96
$2,558.96
$1,303.55
$1,430.81
$1,565.65
$2,044.61
$1,664.20
$1,791.46
$1,926.30
$2,405.26
$2,024.85
$2,152.11
$2,286.95
$2,765.91
$360.65
Toc - Plan #66 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$358.96
$407.40
$458.73
$641.08
$974.18
$633.55
$681.99
$733.32
$915.67
$908.14
$956.58
$1,007.91
$1,190.26
$1,182.73
$1,231.17
$1,282.50
$1,464.85
$274.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.92
$814.80
$917.46
$1,282.16
$1,948.36
$992.51
$1,089.39
$1,192.05
$1,556.75
$1,267.10
$1,363.98
$1,466.64
$1,831.34
$1,541.69
$1,638.57
$1,741.23
$2,105.93
$274.59
Toc - Plan #67 Ambetter from Nebraska Total Care
Silver

(HMO) Ambetter Virtual Access Silver - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$430.96
$489.13
$550.75
$769.67
$1,169.59
$760.64
$818.81
$880.43
$1,099.35
$1,090.32
$1,148.49
$1,210.11
$1,429.03
$1,420.00
$1,478.17
$1,539.79
$1,758.71
$329.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$861.92
$978.26
$1,101.50
$1,539.34
$2,339.18
$1,191.60
$1,307.94
$1,431.18
$1,869.02
$1,521.28
$1,637.62
$1,760.86
$2,198.70
$1,850.96
$1,967.30
$2,090.54
$2,528.38
$329.68
Toc - Plan #68 Ambetter from Nebraska Total Care
Gold

(HMO) Ambetter Virtual Access Gold - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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
$470.97
$534.54
$601.88
$841.13
$1,278.18
$831.25
$894.82
$962.16
$1,201.41
$1,191.53
$1,255.10
$1,322.44
$1,561.69
$1,551.81
$1,615.38
$1,682.72
$1,921.97
$360.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$941.94
$1,069.08
$1,203.76
$1,682.26
$2,556.36
$1,302.22
$1,429.36
$1,564.04
$2,042.54
$1,662.50
$1,789.64
$1,924.32
$2,402.82
$2,022.78
$2,149.92
$2,284.60
$2,763.10
$360.28

ADVERTISEMENT

Blue Cross and Blue Shield of Nebraska

Local: 1-888-592-8960 | Toll Free: 1-888-592-8960 | TTY: 1-800-821-4791

Toc - Plan #69 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze HSA 6000 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$369.14
$418.98
$471.76
$659.29
$1,001.85
$651.53
$701.37
$754.15
$941.68
$933.92
$983.76
$1,036.54
$1,224.07
$1,216.31
$1,266.15
$1,318.93
$1,506.46
$282.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.28
$837.96
$943.52
$1,318.58
$2,003.70
$1,020.67
$1,120.35
$1,225.91
$1,600.97
$1,303.06
$1,402.74
$1,508.30
$1,883.36
$1,585.45
$1,685.13
$1,790.69
$2,165.75
$282.39
Toc - Plan #70 Blue Cross and Blue Shield of Nebraska
Bronze

(EPO) Nebraska HeartlandBlue Bronze 0% Coinsurance 9100 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$336.39
$381.80
$429.91
$600.79
$912.96
$593.73
$639.14
$687.25
$858.13
$851.07
$896.48
$944.59
$1,115.47
$1,108.41
$1,153.82
$1,201.93
$1,372.81
$257.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.78
$763.60
$859.82
$1,201.58
$1,825.92
$930.12
$1,020.94
$1,117.16
$1,458.92
$1,187.46
$1,278.28
$1,374.50
$1,716.26
$1,444.80
$1,535.62
$1,631.84
$1,973.60
$257.34
Toc - Plan #71 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze $0 PCP Visit 8100 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 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
$355.40
$403.38
$454.20
$634.74
$964.55
$627.28
$675.26
$726.08
$906.62
$899.16
$947.14
$997.96
$1,178.50
$1,171.04
$1,219.02
$1,269.84
$1,450.38
$271.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.80
$806.76
$908.40
$1,269.48
$1,929.10
$982.68
$1,078.64
$1,180.28
$1,541.36
$1,254.56
$1,350.52
$1,452.16
$1,813.24
$1,526.44
$1,622.40
$1,724.04
$2,085.12
$271.88
Toc - Plan #72 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze $0 Mental Health Visit 7750 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$349.89
$397.13
$447.16
$624.91
$949.60
$617.56
$664.80
$714.83
$892.58
$885.23
$932.47
$982.50
$1,160.25
$1,152.90
$1,200.14
$1,250.17
$1,427.92
$267.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$699.78
$794.26
$894.32
$1,249.82
$1,899.20
$967.45
$1,061.93
$1,161.99
$1,517.49
$1,235.12
$1,329.60
$1,429.66
$1,785.16
$1,502.79
$1,597.27
$1,697.33
$2,052.83
$267.67
Toc - Plan #73 Blue Cross and Blue Shield of Nebraska
Bronze

(EPO) Nebraska HeartlandBlue Bronze Standard Deductible 9100 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$336.39
$381.80
$429.91
$600.79
$912.96
$593.73
$639.14
$687.25
$858.13
$851.07
$896.48
$944.59
$1,115.47
$1,108.41
$1,153.82
$1,201.93
$1,372.81
$257.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.78
$763.60
$859.82
$1,201.58
$1,825.92
$930.12
$1,020.94
$1,117.16
$1,458.92
$1,187.46
$1,278.28
$1,374.50
$1,716.26
$1,444.80
$1,535.62
$1,631.84
$1,973.60
$257.34
Toc - Plan #74 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze Standard Copay 7500 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$344.82
$391.37
$440.68
$615.85
$935.85
$608.61
$655.16
$704.47
$879.64
$872.40
$918.95
$968.26
$1,143.43
$1,136.19
$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
$689.64
$782.74
$881.36
$1,231.70
$1,871.70
$953.43
$1,046.53
$1,145.15
$1,495.49
$1,217.22
$1,310.32
$1,408.94
$1,759.28
$1,481.01
$1,574.11
$1,672.73
$2,023.07
$263.79
Toc - Plan #75 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver $0 Deductible 9100 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$489.38
$555.45
$625.43
$874.03
$1,328.18
$863.76
$929.83
$999.81
$1,248.41
$1,238.14
$1,304.21
$1,374.19
$1,622.79
$1,612.52
$1,678.59
$1,748.57
$1,997.17
$374.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$978.76
$1,110.90
$1,250.86
$1,748.06
$2,656.36
$1,353.14
$1,485.28
$1,625.24
$2,122.44
$1,727.52
$1,859.66
$1,999.62
$2,496.82
$2,101.90
$2,234.04
$2,374.00
$2,871.20
$374.38
Toc - Plan #76 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver $0 PCP Visit 5000 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$439.86
$499.24
$562.14
$785.59
$1,193.78
$776.35
$835.73
$898.63
$1,122.08
$1,112.84
$1,172.22
$1,235.12
$1,458.57
$1,449.33
$1,508.71
$1,571.61
$1,795.06
$336.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.72
$998.48
$1,124.28
$1,571.18
$2,387.56
$1,216.21
$1,334.97
$1,460.77
$1,907.67
$1,552.70
$1,671.46
$1,797.26
$2,244.16
$1,889.19
$2,007.95
$2,133.75
$2,580.65
$336.49
Toc - Plan #77 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.05
$504.00
$567.50
$793.08
$1,205.16
$783.75
$843.70
$907.20
$1,132.78
$1,123.45
$1,183.40
$1,246.90
$1,472.48
$1,463.15
$1,523.10
$1,586.60
$1,812.18
$339.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.10
$1,008.00
$1,135.00
$1,586.16
$2,410.32
$1,227.80
$1,347.70
$1,474.70
$1,925.86
$1,567.50
$1,687.40
$1,814.40
$2,265.56
$1,907.20
$2,027.10
$2,154.10
$2,605.26
$339.70
Toc - Plan #78 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver Standard 5800 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$439.81
$499.19
$562.08
$785.51
$1,193.65
$776.27
$835.65
$898.54
$1,121.97
$1,112.73
$1,172.11
$1,235.00
$1,458.43
$1,449.19
$1,508.57
$1,571.46
$1,794.89
$336.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.62
$998.38
$1,124.16
$1,571.02
$2,387.30
$1,216.08
$1,334.84
$1,460.62
$1,907.48
$1,552.54
$1,671.30
$1,797.08
$2,243.94
$1,889.00
$2,007.76
$2,133.54
$2,580.40
$336.46
Toc - Plan #79 Blue Cross and Blue Shield of Nebraska
Gold

(EPO) Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$472.47
$536.25
$603.81
$843.83
$1,282.28
$833.91
$897.69
$965.25
$1,205.27
$1,195.35
$1,259.13
$1,326.69
$1,566.71
$1,556.79
$1,620.57
$1,688.13
$1,928.15
$361.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$944.94
$1,072.50
$1,207.62
$1,687.66
$2,564.56
$1,306.38
$1,433.94
$1,569.06
$2,049.10
$1,667.82
$1,795.38
$1,930.50
$2,410.54
$2,029.26
$2,156.82
$2,291.94
$2,771.98
$361.44
Toc - Plan #80 Blue Cross and Blue Shield of Nebraska
Gold

(EPO) Nebraska HeartlandBlue Gold $0 Deductible PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$513.21
$582.50
$655.89
$916.60
$1,392.86
$905.82
$975.11
$1,048.50
$1,309.21
$1,298.43
$1,367.72
$1,441.11
$1,701.82
$1,691.04
$1,760.33
$1,833.72
$2,094.43
$392.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,026.42
$1,165.00
$1,311.78
$1,833.20
$2,785.72
$1,419.03
$1,557.61
$1,704.39
$2,225.81
$1,811.64
$1,950.22
$2,097.00
$2,618.42
$2,204.25
$2,342.83
$2,489.61
$3,011.03
$392.61
Toc - Plan #81 Blue Cross and Blue Shield of Nebraska
Gold

(EPO) Nebraska HeartlandBlue Gold Standard 2000 PSBC

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$466.86
$529.89
$596.65
$833.82
$1,267.06
$824.01
$887.04
$953.80
$1,190.97
$1,181.16
$1,244.19
$1,310.95
$1,548.12
$1,538.31
$1,601.34
$1,668.10
$1,905.27
$357.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$933.72
$1,059.78
$1,193.30
$1,667.64
$2,534.12
$1,290.87
$1,416.93
$1,550.45
$2,024.79
$1,648.02
$1,774.08
$1,907.60
$2,381.94
$2,005.17
$2,131.23
$2,264.75
$2,739.09
$357.15
Toc - Plan #82 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze HSA 6000 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$360.14
$408.76
$460.25
$643.20
$977.41
$635.64
$684.26
$735.75
$918.70
$911.14
$959.76
$1,011.25
$1,194.20
$1,186.64
$1,235.26
$1,286.75
$1,469.70
$275.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.28
$817.52
$920.50
$1,286.40
$1,954.82
$995.78
$1,093.02
$1,196.00
$1,561.90
$1,271.28
$1,368.52
$1,471.50
$1,837.40
$1,546.78
$1,644.02
$1,747.00
$2,112.90
$275.50
Toc - Plan #83 Blue Cross and Blue Shield of Nebraska
Bronze

(EPO) Nebraska HeartlandBlue Bronze 0% Coinsurance 9100 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$328.18
$372.49
$419.42
$586.14
$890.69
$579.24
$623.55
$670.48
$837.20
$830.30
$874.61
$921.54
$1,088.26
$1,081.36
$1,125.67
$1,172.60
$1,339.32
$251.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.36
$744.98
$838.84
$1,172.28
$1,781.38
$907.42
$996.04
$1,089.90
$1,423.34
$1,158.48
$1,247.10
$1,340.96
$1,674.40
$1,409.54
$1,498.16
$1,592.02
$1,925.46
$251.06
Toc - Plan #84 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze $0 PCP Visit 8100 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 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
$346.73
$393.54
$443.12
$619.26
$941.02
$611.98
$658.79
$708.37
$884.51
$877.23
$924.04
$973.62
$1,149.76
$1,142.48
$1,189.29
$1,238.87
$1,415.01
$265.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.46
$787.08
$886.24
$1,238.52
$1,882.04
$958.71
$1,052.33
$1,151.49
$1,503.77
$1,223.96
$1,317.58
$1,416.74
$1,769.02
$1,489.21
$1,582.83
$1,681.99
$2,034.27
$265.25
Toc - Plan #85 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze $0 Mental Health Visit 7750 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$341.36
$387.44
$436.25
$609.66
$926.44
$602.50
$648.58
$697.39
$870.80
$863.64
$909.72
$958.53
$1,131.94
$1,124.78
$1,170.86
$1,219.67
$1,393.08
$261.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.72
$774.88
$872.50
$1,219.32
$1,852.88
$943.86
$1,036.02
$1,133.64
$1,480.46
$1,205.00
$1,297.16
$1,394.78
$1,741.60
$1,466.14
$1,558.30
$1,655.92
$2,002.74
$261.14
Toc - Plan #86 Blue Cross and Blue Shield of Nebraska
Bronze

(EPO) Nebraska HeartlandBlue Bronze Standard Deductible 9100 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$328.18
$372.49
$419.42
$586.14
$890.69
$579.24
$623.55
$670.48
$837.20
$830.30
$874.61
$921.54
$1,088.26
$1,081.36
$1,125.67
$1,172.60
$1,339.32
$251.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.36
$744.98
$838.84
$1,172.28
$1,781.38
$907.42
$996.04
$1,089.90
$1,423.34
$1,158.48
$1,247.10
$1,340.96
$1,674.40
$1,409.54
$1,498.16
$1,592.02
$1,925.46
$251.06
Toc - Plan #87 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze Standard Copay 7500 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$336.41
$381.83
$429.93
$600.83
$913.02
$593.76
$639.18
$687.28
$858.18
$851.11
$896.53
$944.63
$1,115.53
$1,108.46
$1,153.88
$1,201.98
$1,372.88
$257.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.82
$763.66
$859.86
$1,201.66
$1,826.04
$930.17
$1,021.01
$1,117.21
$1,459.01
$1,187.52
$1,278.36
$1,374.56
$1,716.36
$1,444.87
$1,535.71
$1,631.91
$1,973.71
$257.35
Toc - Plan #88 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver $0 Deductible 9100 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$477.44
$541.89
$610.17
$852.71
$1,295.77
$842.68
$907.13
$975.41
$1,217.95
$1,207.92
$1,272.37
$1,340.65
$1,583.19
$1,573.16
$1,637.61
$1,705.89
$1,948.43
$365.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$954.88
$1,083.78
$1,220.34
$1,705.42
$2,591.54
$1,320.12
$1,449.02
$1,585.58
$2,070.66
$1,685.36
$1,814.26
$1,950.82
$2,435.90
$2,050.60
$2,179.50
$2,316.06
$2,801.14
$365.24
Toc - Plan #89 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver $0 PCP Visit 5000 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$429.13
$487.06
$548.43
$766.43
$1,164.66
$757.41
$815.34
$876.71
$1,094.71
$1,085.69
$1,143.62
$1,204.99
$1,422.99
$1,413.97
$1,471.90
$1,533.27
$1,751.27
$328.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.26
$974.12
$1,096.86
$1,532.86
$2,329.32
$1,186.54
$1,302.40
$1,425.14
$1,861.14
$1,514.82
$1,630.68
$1,753.42
$2,189.42
$1,843.10
$1,958.96
$2,081.70
$2,517.70
$328.28
Toc - Plan #90 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.22
$491.70
$553.65
$773.73
$1,175.76
$764.63
$823.11
$885.06
$1,105.14
$1,096.04
$1,154.52
$1,216.47
$1,436.55
$1,427.45
$1,485.93
$1,547.88
$1,767.96
$331.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$866.44
$983.40
$1,107.30
$1,547.46
$2,351.52
$1,197.85
$1,314.81
$1,438.71
$1,878.87
$1,529.26
$1,646.22
$1,770.12
$2,210.28
$1,860.67
$1,977.63
$2,101.53
$2,541.69
$331.41
Toc - Plan #91 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver Standard 5800 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$429.08
$487.01
$548.37
$766.34
$1,164.53
$757.33
$815.26
$876.62
$1,094.59
$1,085.58
$1,143.51
$1,204.87
$1,422.84
$1,413.83
$1,471.76
$1,533.12
$1,751.09
$328.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.16
$974.02
$1,096.74
$1,532.68
$2,329.06
$1,186.41
$1,302.27
$1,424.99
$1,860.93
$1,514.66
$1,630.52
$1,753.24
$2,189.18
$1,842.91
$1,958.77
$2,081.49
$2,517.43
$328.25
Toc - Plan #92 Blue Cross and Blue Shield of Nebraska
Gold

(EPO) Nebraska HeartlandBlue Gold $0 PCP Visit 1500 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$460.94
$523.17
$589.08
$823.24
$1,250.99
$813.56
$875.79
$941.70
$1,175.86
$1,166.18
$1,228.41
$1,294.32
$1,528.48
$1,518.80
$1,581.03
$1,646.94
$1,881.10
$352.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$921.88
$1,046.34
$1,178.16
$1,646.48
$2,501.98
$1,274.50
$1,398.96
$1,530.78
$1,999.10
$1,627.12
$1,751.58
$1,883.40
$2,351.72
$1,979.74
$2,104.20
$2,236.02
$2,704.34
$352.62
Toc - Plan #93 Blue Cross and Blue Shield of Nebraska
Gold

(EPO) Nebraska HeartlandBlue Gold $0 Deductible BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$500.69
$568.29
$639.88
$894.24
$1,358.88
$883.72
$951.32
$1,022.91
$1,277.27
$1,266.75
$1,334.35
$1,405.94
$1,660.30
$1,649.78
$1,717.38
$1,788.97
$2,043.33
$383.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,001.38
$1,136.58
$1,279.76
$1,788.48
$2,717.76
$1,384.41
$1,519.61
$1,662.79
$2,171.51
$1,767.44
$1,902.64
$2,045.82
$2,554.54
$2,150.47
$2,285.67
$2,428.85
$2,937.57
$383.03
Toc - Plan #94 Blue Cross and Blue Shield of Nebraska
Gold

(EPO) Nebraska HeartlandBlue Gold Standard 2000 BP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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
$455.47
$516.96
$582.09
$813.47
$1,236.15
$803.91
$865.40
$930.53
$1,161.91
$1,152.35
$1,213.84
$1,278.97
$1,510.35
$1,500.79
$1,562.28
$1,627.41
$1,858.79
$348.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$910.94
$1,033.92
$1,164.18
$1,626.94
$2,472.30
$1,259.38
$1,382.36
$1,512.62
$1,975.38
$1,607.82
$1,730.80
$1,861.06
$2,323.82
$1,956.26
$2,079.24
$2,209.50
$2,672.26
$348.44

ADVERTISEMENT

Oscar Insurance Company

Local:  | Toll Free: 

Toc - Plan #95 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$424.29
$481.56
$542.24
$757.77
$1,151.51
$748.87
$806.14
$866.82
$1,082.35
$1,073.45
$1,130.72
$1,191.40
$1,406.93
$1,398.03
$1,455.30
$1,515.98
$1,731.51
$324.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$848.58
$963.12
$1,084.48
$1,515.54
$2,303.02
$1,173.16
$1,287.70
$1,409.06
$1,840.12
$1,497.74
$1,612.28
$1,733.64
$2,164.70
$1,822.32
$1,936.86
$2,058.22
$2,489.28
$324.58
Toc - Plan #96 Oscar Insurance Company
Expanded Bronze

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

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
$502.14
$569.92
$641.73
$896.81
$1,362.79
$886.27
$954.05
$1,025.86
$1,280.94
$1,270.40
$1,338.18
$1,409.99
$1,665.07
$1,654.53
$1,722.31
$1,794.12
$2,049.20
$384.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,004.28
$1,139.84
$1,283.46
$1,793.62
$2,725.58
$1,388.41
$1,523.97
$1,667.59
$2,177.75
$1,772.54
$1,908.10
$2,051.72
$2,561.88
$2,156.67
$2,292.23
$2,435.85
$2,946.01
$384.13
Toc - Plan #97 Oscar Insurance Company
Silver

(EPO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$549.45
$623.61
$702.18
$981.30
$1,491.18
$969.77
$1,043.93
$1,122.50
$1,401.62
$1,390.09
$1,464.25
$1,542.82
$1,821.94
$1,810.41
$1,884.57
$1,963.14
$2,242.26
$420.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,098.90
$1,247.22
$1,404.36
$1,962.60
$2,982.36
$1,519.22
$1,667.54
$1,824.68
$2,382.92
$1,939.54
$2,087.86
$2,245.00
$2,803.24
$2,359.86
$2,508.18
$2,665.32
$3,223.56
$420.32
Toc - Plan #98 Oscar Insurance Company
Catastrophic

(EPO) Secure

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
$367.03
$416.56
$469.05
$655.49
$996.08
$647.80
$697.33
$749.82
$936.26
$928.57
$978.10
$1,030.59
$1,217.03
$1,209.34
$1,258.87
$1,311.36
$1,497.80
$280.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.06
$833.12
$938.10
$1,310.98
$1,992.16
$1,014.83
$1,113.89
$1,218.87
$1,591.75
$1,295.60
$1,394.66
$1,499.64
$1,872.52
$1,576.37
$1,675.43
$1,780.41
$2,153.29
$280.77
Toc - Plan #99 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$450.74
$511.58
$576.04
$805.01
$1,223.29
$795.55
$856.39
$920.85
$1,149.82
$1,140.36
$1,201.20
$1,265.66
$1,494.63
$1,485.17
$1,546.01
$1,610.47
$1,839.44
$344.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$901.48
$1,023.16
$1,152.08
$1,610.02
$2,446.58
$1,246.29
$1,367.97
$1,496.89
$1,954.83
$1,591.10
$1,712.78
$1,841.70
$2,299.64
$1,935.91
$2,057.59
$2,186.51
$2,644.45
$344.81
Toc - Plan #100 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$541.41
$614.49
$691.91
$966.95
$1,469.37
$955.58
$1,028.66
$1,106.08
$1,381.12
$1,369.75
$1,442.83
$1,520.25
$1,795.29
$1,783.92
$1,857.00
$1,934.42
$2,209.46
$414.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,082.82
$1,228.98
$1,383.82
$1,933.90
$2,938.74
$1,496.99
$1,643.15
$1,797.99
$2,348.07
$1,911.16
$2,057.32
$2,212.16
$2,762.24
$2,325.33
$2,471.49
$2,626.33
$3,176.41
$414.17
Toc - Plan #101 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$449.70
$510.40
$574.71
$803.15
$1,220.47
$793.72
$854.42
$918.73
$1,147.17
$1,137.74
$1,198.44
$1,262.75
$1,491.19
$1,481.76
$1,542.46
$1,606.77
$1,835.21
$344.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$899.40
$1,020.80
$1,149.42
$1,606.30
$2,440.94
$1,243.42
$1,364.82
$1,493.44
$1,950.32
$1,587.44
$1,708.84
$1,837.46
$2,294.34
$1,931.46
$2,052.86
$2,181.48
$2,638.36
$344.02
Toc - Plan #102 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$458.79
$520.72
$586.32
$819.38
$1,245.13
$809.76
$871.69
$937.29
$1,170.35
$1,160.73
$1,222.66
$1,288.26
$1,521.32
$1,511.70
$1,573.63
$1,639.23
$1,872.29
$350.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.58
$1,041.44
$1,172.64
$1,638.76
$2,490.26
$1,268.55
$1,392.41
$1,523.61
$1,989.73
$1,619.52
$1,743.38
$1,874.58
$2,340.70
$1,970.49
$2,094.35
$2,225.55
$2,691.67
$350.97
Toc - Plan #103 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$528.42
$599.74
$675.31
$943.74
$1,434.10
$932.65
$1,003.97
$1,079.54
$1,347.97
$1,336.88
$1,408.20
$1,483.77
$1,752.20
$1,741.11
$1,812.43
$1,888.00
$2,156.43
$404.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,056.84
$1,199.48
$1,350.62
$1,887.48
$2,868.20
$1,461.07
$1,603.71
$1,754.85
$2,291.71
$1,865.30
$2,007.94
$2,159.08
$2,695.94
$2,269.53
$2,412.17
$2,563.31
$3,100.17
$404.23
Toc - Plan #104 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded

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
$552.27
$626.82
$705.79
$986.34
$1,498.84
$974.75
$1,049.30
$1,128.27
$1,408.82
$1,397.23
$1,471.78
$1,550.75
$1,831.30
$1,819.71
$1,894.26
$1,973.23
$2,253.78
$422.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,104.54
$1,253.64
$1,411.58
$1,972.68
$2,997.68
$1,527.02
$1,676.12
$1,834.06
$2,395.16
$1,949.50
$2,098.60
$2,256.54
$2,817.64
$2,371.98
$2,521.08
$2,679.02
$3,240.12
$422.48
Toc - Plan #105 Oscar Insurance Company
Gold

(EPO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$557.75
$633.03
$712.79
$996.12
$1,513.70
$984.42
$1,059.70
$1,139.46
$1,422.79
$1,411.09
$1,486.37
$1,566.13
$1,849.46
$1,837.76
$1,913.04
$1,992.80
$2,276.13
$426.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,115.50
$1,266.06
$1,425.58
$1,992.24
$3,027.40
$1,542.17
$1,692.73
$1,852.25
$2,418.91
$1,968.84
$2,119.40
$2,278.92
$2,845.58
$2,395.51
$2,546.07
$2,705.59
$3,272.25
$426.67
Toc - Plan #106 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$543.38
$616.73
$694.43
$970.46
$1,474.71
$959.06
$1,032.41
$1,110.11
$1,386.14
$1,374.74
$1,448.09
$1,525.79
$1,801.82
$1,790.42
$1,863.77
$1,941.47
$2,217.50
$415.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,086.76
$1,233.46
$1,388.86
$1,940.92
$2,949.42
$1,502.44
$1,649.14
$1,804.54
$2,356.60
$1,918.12
$2,064.82
$2,220.22
$2,772.28
$2,333.80
$2,480.50
$2,635.90
$3,187.96
$415.68
Toc - Plan #107 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Standard

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
$447.89
$508.35
$572.40
$799.92
$1,215.56
$790.52
$850.98
$915.03
$1,142.55
$1,133.15
$1,193.61
$1,257.66
$1,485.18
$1,475.78
$1,536.24
$1,600.29
$1,827.81
$342.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$895.78
$1,016.70
$1,144.80
$1,599.84
$2,431.12
$1,238.41
$1,359.33
$1,487.43
$1,942.47
$1,581.04
$1,701.96
$1,830.06
$2,285.10
$1,923.67
$2,044.59
$2,172.69
$2,627.73
$342.63
Toc - Plan #108 Oscar Insurance Company
Bronze

(EPO) Bronze Simple- Standard

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
$405.02
$459.68
$517.60
$723.34
$1,099.19
$714.85
$769.51
$827.43
$1,033.17
$1,024.68
$1,079.34
$1,137.26
$1,343.00
$1,334.51
$1,389.17
$1,447.09
$1,652.83
$309.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.04
$919.36
$1,035.20
$1,446.68
$2,198.38
$1,119.87
$1,229.19
$1,345.03
$1,756.51
$1,429.70
$1,539.02
$1,654.86
$2,066.34
$1,739.53
$1,848.85
$1,964.69
$2,376.17
$309.83
Toc - Plan #109 Oscar Insurance Company
Silver

(EPO) Silver Classic- Standard

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
$533.69
$605.73
$682.05
$953.16
$1,448.41
$941.96
$1,014.00
$1,090.32
$1,361.43
$1,350.23
$1,422.27
$1,498.59
$1,769.70
$1,758.50
$1,830.54
$1,906.86
$2,177.97
$408.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,067.38
$1,211.46
$1,364.10
$1,906.32
$2,896.82
$1,475.65
$1,619.73
$1,772.37
$2,314.59
$1,883.92
$2,028.00
$2,180.64
$2,722.86
$2,292.19
$2,436.27
$2,588.91
$3,131.13
$408.27
Toc - Plan #110 Oscar Insurance Company
Gold

(EPO) Gold Classic- Standard

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
$514.93
$584.43
$658.07
$919.65
$1,397.49
$908.84
$978.34
$1,051.98
$1,313.56
$1,302.75
$1,372.25
$1,445.89
$1,707.47
$1,696.66
$1,766.16
$1,839.80
$2,101.38
$393.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,029.86
$1,168.86
$1,316.14
$1,839.30
$2,794.98
$1,423.77
$1,562.77
$1,710.05
$2,233.21
$1,817.68
$1,956.68
$2,103.96
$2,627.12
$2,211.59
$2,350.59
$2,497.87
$3,021.03
$393.91

‡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 Sarpy County here.

Sarpy County is in “Rating Area 1” of Nebraska.

Currently, there are 110 plans offered in Rating Area 1.

Top

2023 Obamacare Plans for Sarpy County, NE

Plan Browser: 110 Plans
scroll down for more
Speak with a Health Insurance Expert 800-943-6832Ads by +HealthNetwork