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Obamacare 2023 Rates for Duval County

Obamacare > Rates > Florida > Duval County

Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Duval County, FL.

The health insurance rates listed below are for calendar year 2023.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 158 Plans and 2023 Rates for Duval County, Florida

Below, you’ll find a summary of the 158 plans for Duval County, Florida and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Florida Blue (BlueCross BlueShield FL)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771

Toc - Plan #1 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1423 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 Annual Deductible
$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$674.91
$766.02
$862.53
$1,205.39
$1,831.71
$1,191.22
$1,282.33
$1,378.84
$1,721.70
$1,707.53
$1,798.64
$1,895.15
$2,238.01
$2,223.84
$2,314.95
$2,411.46
$2,754.32
$516.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,349.82
$1,532.04
$1,725.06
$2,410.78
$3,663.42
$1,866.13
$2,048.35
$2,241.37
$2,927.09
$2,382.44
$2,564.66
$2,757.68
$3,443.40
$2,898.75
$3,080.97
$3,273.99
$3,959.71
$516.31
Toc - Plan #2 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 1419 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$436.65
$495.60
$558.04
$779.86
$1,185.07
$770.69
$829.64
$892.08
$1,113.90
$1,104.73
$1,163.68
$1,226.12
$1,447.94
$1,438.77
$1,497.72
$1,560.16
$1,781.98
$334.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.30
$991.20
$1,116.08
$1,559.72
$2,370.14
$1,207.34
$1,325.24
$1,450.12
$1,893.76
$1,541.38
$1,659.28
$1,784.16
$2,227.80
$1,875.42
$1,993.32
$2,118.20
$2,561.84
$334.04
Toc - Plan #3 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1431 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$678.62
$770.23
$867.28
$1,212.02
$1,841.77
$1,197.76
$1,289.37
$1,386.42
$1,731.16
$1,716.90
$1,808.51
$1,905.56
$2,250.30
$2,236.04
$2,327.65
$2,424.70
$2,769.44
$519.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,357.24
$1,540.46
$1,734.56
$2,424.04
$3,683.54
$1,876.38
$2,059.60
$2,253.70
$2,943.18
$2,395.52
$2,578.74
$2,772.84
$3,462.32
$2,914.66
$3,097.88
$3,291.98
$3,981.46
$519.14
Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueOptions Platinum 1418 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,000 $8,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$854.00
$969.29
$1,091.41
$1,525.24
$2,317.76
$1,507.31
$1,622.60
$1,744.72
$2,178.55
$2,160.62
$2,275.91
$2,398.03
$2,831.86
$2,813.93
$2,929.22
$3,051.34
$3,485.17
$653.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,708.00
$1,938.58
$2,182.82
$3,050.48
$4,635.52
$2,361.31
$2,591.89
$2,836.13
$3,703.79
$3,014.62
$3,245.20
$3,489.44
$4,357.10
$3,667.93
$3,898.51
$4,142.75
$5,010.41
$653.31
Toc - Plan #5 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 1416 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$454.82
$516.22
$581.26
$812.31
$1,234.38
$802.76
$864.16
$929.20
$1,160.25
$1,150.70
$1,212.10
$1,277.14
$1,508.19
$1,498.64
$1,560.04
$1,625.08
$1,856.13
$347.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$909.64
$1,032.44
$1,162.52
$1,624.62
$2,468.76
$1,257.58
$1,380.38
$1,510.46
$1,972.56
$1,605.52
$1,728.32
$1,858.40
$2,320.50
$1,953.46
$2,076.26
$2,206.34
$2,668.44
$347.94
Toc - Plan #6 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$894.84
$1,015.64
$1,143.61
$1,598.18
$2,428.60
$1,579.39
$1,700.19
$1,828.16
$2,282.73
$2,263.94
$2,384.74
$2,512.71
$2,967.28
$2,948.49
$3,069.29
$3,197.26
$3,651.83
$684.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,789.68
$2,031.28
$2,287.22
$3,196.36
$4,857.20
$2,474.23
$2,715.83
$2,971.77
$3,880.91
$3,158.78
$3,400.38
$3,656.32
$4,565.46
$3,843.33
$4,084.93
$4,340.87
$5,250.01
$684.55
Toc - Plan #7 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1410 ($0 Virtual Visits / $0 Lab / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$633.51
$719.03
$809.63
$1,131.45
$1,719.35
$1,118.15
$1,203.67
$1,294.27
$1,616.09
$1,602.79
$1,688.31
$1,778.91
$2,100.73
$2,087.43
$2,172.95
$2,263.55
$2,585.37
$484.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,267.02
$1,438.06
$1,619.26
$2,262.90
$3,438.70
$1,751.66
$1,922.70
$2,103.90
$2,747.54
$2,236.30
$2,407.34
$2,588.54
$3,232.18
$2,720.94
$2,891.98
$3,073.18
$3,716.82
$484.64
Toc - Plan #8 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$733.43
$832.44
$937.32
$1,309.91
$1,990.53
$1,294.50
$1,393.51
$1,498.39
$1,870.98
$1,855.57
$1,954.58
$2,059.46
$2,432.05
$2,416.64
$2,515.65
$2,620.53
$2,993.12
$561.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,466.86
$1,664.88
$1,874.64
$2,619.82
$3,981.06
$2,027.93
$2,225.95
$2,435.71
$3,180.89
$2,589.00
$2,787.02
$2,996.78
$3,741.96
$3,150.07
$3,348.09
$3,557.85
$4,303.03
$561.07
Toc - Plan #9 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze (HSA) 1705 (Rewards $$$ / $4 Condition Care Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$442.15
$501.84
$565.07
$789.68
$1,200.00
$780.39
$840.08
$903.31
$1,127.92
$1,118.63
$1,178.32
$1,241.55
$1,466.16
$1,456.87
$1,516.56
$1,579.79
$1,804.40
$338.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$884.30
$1,003.68
$1,130.14
$1,579.36
$2,400.00
$1,222.54
$1,341.92
$1,468.38
$1,917.60
$1,560.78
$1,680.16
$1,806.62
$2,255.84
$1,899.02
$2,018.40
$2,144.86
$2,594.08
$338.24
Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1805 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$709.58
$805.37
$906.84
$1,267.31
$1,925.80
$1,252.41
$1,348.20
$1,449.67
$1,810.14
$1,795.24
$1,891.03
$1,992.50
$2,352.97
$2,338.07
$2,433.86
$2,535.33
$2,895.80
$542.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,419.16
$1,610.74
$1,813.68
$2,534.62
$3,851.60
$1,961.99
$2,153.57
$2,356.51
$3,077.45
$2,504.82
$2,696.40
$2,899.34
$3,620.28
$3,047.65
$3,239.23
$3,442.17
$4,163.11
$542.83
Toc - Plan #11 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 2119 ($0 Deductible / $0 Virtual Visits / $50 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$481.69
$546.72
$615.60
$860.30
$1,307.31
$850.18
$915.21
$984.09
$1,228.79
$1,218.67
$1,283.70
$1,352.58
$1,597.28
$1,587.16
$1,652.19
$1,721.07
$1,965.77
$368.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$963.38
$1,093.44
$1,231.20
$1,720.60
$2,614.62
$1,331.87
$1,461.93
$1,599.69
$2,089.09
$1,700.36
$1,830.42
$1,968.18
$2,457.58
$2,068.85
$2,198.91
$2,336.67
$2,826.07
$368.49
Toc - Plan #12 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueOptions Bronze 2301S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.35
$473.69
$533.37
$745.39
$1,132.69
$736.62
$792.96
$852.64
$1,064.66
$1,055.89
$1,112.23
$1,171.91
$1,383.93
$1,375.16
$1,431.50
$1,491.18
$1,703.20
$319.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.70
$947.38
$1,066.74
$1,490.78
$2,265.38
$1,153.97
$1,266.65
$1,386.01
$1,810.05
$1,473.24
$1,585.92
$1,705.28
$2,129.32
$1,792.51
$1,905.19
$2,024.55
$2,448.59
$319.27
Toc - Plan #13 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 2302S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$448.65
$509.22
$573.37
$801.29
$1,217.64
$791.87
$852.44
$916.59
$1,144.51
$1,135.09
$1,195.66
$1,259.81
$1,487.73
$1,478.31
$1,538.88
$1,603.03
$1,830.95
$343.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$897.30
$1,018.44
$1,146.74
$1,602.58
$2,435.28
$1,240.52
$1,361.66
$1,489.96
$1,945.80
$1,583.74
$1,704.88
$1,833.18
$2,289.02
$1,926.96
$2,048.10
$2,176.40
$2,632.24
$343.22
Toc - Plan #14 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 2303S ($40 PCP Visits / Multilingual Available/ Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$668.02
$758.20
$853.73
$1,193.08
$1,813.01
$1,179.06
$1,269.24
$1,364.77
$1,704.12
$1,690.10
$1,780.28
$1,875.81
$2,215.16
$2,201.14
$2,291.32
$2,386.85
$2,726.20
$511.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,336.04
$1,516.40
$1,707.46
$2,386.16
$3,626.02
$1,847.08
$2,027.44
$2,218.50
$2,897.20
$2,358.12
$2,538.48
$2,729.54
$3,408.24
$2,869.16
$3,049.52
$3,240.58
$3,919.28
$511.04
Toc - Plan #15 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 2304S ($30 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$681.82
$773.87
$871.37
$1,217.73
$1,850.46
$1,203.41
$1,295.46
$1,392.96
$1,739.32
$1,725.00
$1,817.05
$1,914.55
$2,260.91
$2,246.59
$2,338.64
$2,436.14
$2,782.50
$521.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,363.64
$1,547.74
$1,742.74
$2,435.46
$3,700.92
$1,885.23
$2,069.33
$2,264.33
$2,957.05
$2,406.82
$2,590.92
$2,785.92
$3,478.64
$2,928.41
$3,112.51
$3,307.51
$4,000.23
$521.59
Toc - Plan #16 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$892.59
$1,013.09
$1,140.73
$1,594.17
$2,422.49
$1,575.42
$1,695.92
$1,823.56
$2,277.00
$2,258.25
$2,378.75
$2,506.39
$2,959.83
$2,941.08
$3,061.58
$3,189.22
$3,642.66
$682.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,785.18
$2,026.18
$2,281.46
$3,188.34
$4,844.98
$2,468.01
$2,709.01
$2,964.29
$3,871.17
$3,150.84
$3,391.84
$3,647.12
$4,554.00
$3,833.67
$4,074.67
$4,329.95
$5,236.83
$682.83
Toc - Plan #17 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 2319 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$472.22
$535.97
$603.50
$843.38
$1,281.61
$833.47
$897.22
$964.75
$1,204.63
$1,194.72
$1,258.47
$1,326.00
$1,565.88
$1,555.97
$1,619.72
$1,687.25
$1,927.13
$361.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$944.44
$1,071.94
$1,207.00
$1,686.76
$2,563.22
$1,305.69
$1,433.19
$1,568.25
$2,048.01
$1,666.94
$1,794.44
$1,929.50
$2,409.26
$2,028.19
$2,155.69
$2,290.75
$2,770.51
$361.25
Toc - Plan #18 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1456 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 Annual Deductible
$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.33
$500.91
$564.02
$788.22
$1,197.77
$778.95
$838.53
$901.64
$1,125.84
$1,116.57
$1,176.15
$1,239.26
$1,463.46
$1,454.19
$1,513.77
$1,576.88
$1,801.08
$337.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.66
$1,001.82
$1,128.04
$1,576.44
$2,395.54
$1,220.28
$1,339.44
$1,465.66
$1,914.06
$1,557.90
$1,677.06
$1,803.28
$2,251.68
$1,895.52
$2,014.68
$2,140.90
$2,589.30
$337.62
Toc - Plan #19 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1452 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.30
$377.16
$424.68
$593.49
$901.86
$586.51
$631.37
$678.89
$847.70
$840.72
$885.58
$933.10
$1,101.91
$1,094.93
$1,139.79
$1,187.31
$1,356.12
$254.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.60
$754.32
$849.36
$1,186.98
$1,803.72
$918.81
$1,008.53
$1,103.57
$1,441.19
$1,173.02
$1,262.74
$1,357.78
$1,695.40
$1,427.23
$1,516.95
$1,611.99
$1,949.61
$254.21
Toc - Plan #20 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1464 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$439.96
$499.35
$562.27
$785.77
$1,194.05
$776.53
$835.92
$898.84
$1,122.34
$1,113.10
$1,172.49
$1,235.41
$1,458.91
$1,449.67
$1,509.06
$1,571.98
$1,795.48
$336.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.92
$998.70
$1,124.54
$1,571.54
$2,388.10
$1,216.49
$1,335.27
$1,461.11
$1,908.11
$1,553.06
$1,671.84
$1,797.68
$2,244.68
$1,889.63
$2,008.41
$2,134.25
$2,581.25
$336.57
Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1451 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,000 $8,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$558.26
$633.63
$713.46
$997.05
$1,515.12
$985.33
$1,060.70
$1,140.53
$1,424.12
$1,412.40
$1,487.77
$1,567.60
$1,851.19
$1,839.47
$1,914.84
$1,994.67
$2,278.26
$427.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,116.52
$1,267.26
$1,426.92
$1,994.10
$3,030.24
$1,543.59
$1,694.33
$1,853.99
$2,421.17
$1,970.66
$2,121.40
$2,281.06
$2,848.24
$2,397.73
$2,548.47
$2,708.13
$3,275.31
$427.07
Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.25
$389.59
$438.67
$613.04
$931.58
$605.84
$652.18
$701.26
$875.63
$868.43
$914.77
$963.85
$1,138.22
$1,131.02
$1,177.36
$1,226.44
$1,400.81
$262.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.50
$779.18
$877.34
$1,226.08
$1,863.16
$949.09
$1,041.77
$1,139.93
$1,488.67
$1,211.68
$1,304.36
$1,402.52
$1,751.26
$1,474.27
$1,566.95
$1,665.11
$2,013.85
$262.59
Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$584.21
$663.08
$746.62
$1,043.40
$1,585.55
$1,031.13
$1,110.00
$1,193.54
$1,490.32
$1,478.05
$1,556.92
$1,640.46
$1,937.24
$1,924.97
$2,003.84
$2,087.38
$2,384.16
$446.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,168.42
$1,326.16
$1,493.24
$2,086.80
$3,171.10
$1,615.34
$1,773.08
$1,940.16
$2,533.72
$2,062.26
$2,220.00
$2,387.08
$2,980.64
$2,509.18
$2,666.92
$2,834.00
$3,427.56
$446.92
Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1443 ($0 Virtual Visits / $0 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413.00
$468.76
$527.81
$737.62
$1,120.88
$728.95
$784.71
$843.76
$1,053.57
$1,044.90
$1,100.66
$1,159.71
$1,369.52
$1,360.85
$1,416.61
$1,475.66
$1,685.47
$315.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.00
$937.52
$1,055.62
$1,475.24
$2,241.76
$1,141.95
$1,253.47
$1,371.57
$1,791.19
$1,457.90
$1,569.42
$1,687.52
$2,107.14
$1,773.85
$1,885.37
$2,003.47
$2,423.09
$315.95
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1535 ($0 Virtual Visits / $20 PCP Visit / $15 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$487.31
$553.10
$622.78
$870.34
$1,322.56
$860.10
$925.89
$995.57
$1,243.13
$1,232.89
$1,298.68
$1,368.36
$1,615.92
$1,605.68
$1,671.47
$1,741.15
$1,988.71
$372.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$974.62
$1,106.20
$1,245.56
$1,740.68
$2,645.12
$1,347.41
$1,478.99
$1,618.35
$2,113.47
$1,720.20
$1,851.78
$1,991.14
$2,486.26
$2,092.99
$2,224.57
$2,363.93
$2,859.05
$372.79
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$335.88
$381.22
$429.25
$599.88
$911.58
$592.83
$638.17
$686.20
$856.83
$849.78
$895.12
$943.15
$1,113.78
$1,106.73
$1,152.07
$1,200.10
$1,370.73
$256.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$671.76
$762.44
$858.50
$1,199.76
$1,823.16
$928.71
$1,019.39
$1,115.45
$1,456.71
$1,185.66
$1,276.34
$1,372.40
$1,713.66
$1,442.61
$1,533.29
$1,629.35
$1,970.61
$256.95
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1835 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$471.42
$535.06
$602.47
$841.96
$1,279.43
$832.06
$895.70
$963.11
$1,202.60
$1,192.70
$1,256.34
$1,323.75
$1,563.24
$1,553.34
$1,616.98
$1,684.39
$1,923.88
$360.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$942.84
$1,070.12
$1,204.94
$1,683.92
$2,558.86
$1,303.48
$1,430.76
$1,565.58
$2,044.56
$1,664.12
$1,791.40
$1,926.22
$2,405.20
$2,024.76
$2,152.04
$2,286.86
$2,765.84
$360.64
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2139 ($0 Deductible / $0 Virtual Visits / $50 PCP Visit / $30 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.68
$412.78
$464.78
$649.53
$987.03
$641.90
$691.00
$743.00
$927.75
$920.12
$969.22
$1,021.22
$1,205.97
$1,198.34
$1,247.44
$1,299.44
$1,484.19
$278.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.36
$825.56
$929.56
$1,299.06
$1,974.06
$1,005.58
$1,103.78
$1,207.78
$1,577.28
$1,283.80
$1,382.00
$1,486.00
$1,855.50
$1,562.02
$1,660.22
$1,764.22
$2,133.72
$278.22
Toc - Plan #29 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueSelect Bronze 2341S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.21
$357.76
$402.84
$562.97
$855.48
$556.35
$598.90
$643.98
$804.11
$797.49
$840.04
$885.12
$1,045.25
$1,038.63
$1,081.18
$1,126.26
$1,286.39
$241.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.42
$715.52
$805.68
$1,125.94
$1,710.96
$871.56
$956.66
$1,046.82
$1,367.08
$1,112.70
$1,197.80
$1,287.96
$1,608.22
$1,353.84
$1,438.94
$1,529.10
$1,849.36
$241.14
Toc - Plan #30 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2342S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$338.90
$384.65
$433.11
$605.28
$919.77
$598.16
$643.91
$692.37
$864.54
$857.42
$903.17
$951.63
$1,123.80
$1,116.68
$1,162.43
$1,210.89
$1,383.06
$259.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$677.80
$769.30
$866.22
$1,210.56
$1,839.54
$937.06
$1,028.56
$1,125.48
$1,469.82
$1,196.32
$1,287.82
$1,384.74
$1,729.08
$1,455.58
$1,547.08
$1,644.00
$1,988.34
$259.26
Toc - Plan #31 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 2343S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.53
$494.33
$556.61
$777.86
$1,182.03
$768.71
$827.51
$889.79
$1,111.04
$1,101.89
$1,160.69
$1,222.97
$1,444.22
$1,435.07
$1,493.87
$1,556.15
$1,777.40
$333.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871.06
$988.66
$1,113.22
$1,555.72
$2,364.06
$1,204.24
$1,321.84
$1,446.40
$1,888.90
$1,537.42
$1,655.02
$1,779.58
$2,222.08
$1,870.60
$1,988.20
$2,112.76
$2,555.26
$333.18
Toc - Plan #32 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 2344S ($30 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$453.05
$514.21
$579.00
$809.15
$1,229.58
$799.63
$860.79
$925.58
$1,155.73
$1,146.21
$1,207.37
$1,272.16
$1,502.31
$1,492.79
$1,553.95
$1,618.74
$1,848.89
$346.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$906.10
$1,028.42
$1,158.00
$1,618.30
$2,459.16
$1,252.68
$1,375.00
$1,504.58
$1,964.88
$1,599.26
$1,721.58
$1,851.16
$2,311.46
$1,945.84
$2,068.16
$2,197.74
$2,658.04
$346.58
Toc - Plan #33 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 2345S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$582.71
$661.38
$744.70
$1,040.72
$1,581.47
$1,028.48
$1,107.15
$1,190.47
$1,486.49
$1,474.25
$1,552.92
$1,636.24
$1,932.26
$1,920.02
$1,998.69
$2,082.01
$2,378.03
$445.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,165.42
$1,322.76
$1,489.40
$2,081.44
$3,162.94
$1,611.19
$1,768.53
$1,935.17
$2,527.21
$2,056.96
$2,214.30
$2,380.94
$2,972.98
$2,502.73
$2,660.07
$2,826.71
$3,418.75
$445.77
Toc - Plan #34 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2339 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.67
$404.82
$455.82
$637.01
$968.00
$629.52
$677.67
$728.67
$909.86
$902.37
$950.52
$1,001.52
$1,182.71
$1,175.22
$1,223.37
$1,274.37
$1,455.56
$272.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.34
$809.64
$911.64
$1,274.02
$1,936.00
$986.19
$1,082.49
$1,184.49
$1,546.87
$1,259.04
$1,355.34
$1,457.34
$1,819.72
$1,531.89
$1,628.19
$1,730.19
$2,092.57
$272.85

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #35 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.18
$459.88
$517.82
$723.66
$1,099.67
$715.14
$769.84
$827.78
$1,033.62
$1,025.10
$1,079.80
$1,137.74
$1,343.58
$1,335.06
$1,389.76
$1,447.70
$1,653.54
$309.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.36
$919.76
$1,035.64
$1,447.32
$2,199.34
$1,120.32
$1,229.72
$1,345.60
$1,757.28
$1,430.28
$1,539.68
$1,655.56
$2,067.24
$1,740.24
$1,849.64
$1,965.52
$2,377.20
$309.96
Toc - Plan #36 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.57
$401.30
$451.86
$631.47
$959.59
$624.05
$671.78
$722.34
$901.95
$894.53
$942.26
$992.82
$1,172.43
$1,165.01
$1,212.74
$1,263.30
$1,442.91
$270.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.14
$802.60
$903.72
$1,262.94
$1,919.18
$977.62
$1,073.08
$1,174.20
$1,533.42
$1,248.10
$1,343.56
$1,444.68
$1,803.90
$1,518.58
$1,614.04
$1,715.16
$2,074.38
$270.48
Toc - Plan #37 Aetna CVS Health
Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.83
$417.49
$470.09
$656.95
$998.30
$649.22
$698.88
$751.48
$938.34
$930.61
$980.27
$1,032.87
$1,219.73
$1,212.00
$1,261.66
$1,314.26
$1,501.12
$281.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.66
$834.98
$940.18
$1,313.90
$1,996.60
$1,017.05
$1,116.37
$1,221.57
$1,595.29
$1,298.44
$1,397.76
$1,502.96
$1,876.68
$1,579.83
$1,679.15
$1,784.35
$2,158.07
$281.39
Toc - Plan #38 Aetna CVS Health
Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

Individual Family
$4,425 $8,850 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$379.07
$430.24
$484.45
$677.01
$1,028.79
$669.06
$720.23
$774.44
$967.00
$959.05
$1,010.22
$1,064.43
$1,256.99
$1,249.04
$1,300.21
$1,354.42
$1,546.98
$289.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.14
$860.48
$968.90
$1,354.02
$2,057.58
$1,048.13
$1,150.47
$1,258.89
$1,644.01
$1,338.12
$1,440.46
$1,548.88
$1,934.00
$1,628.11
$1,730.45
$1,838.87
$2,223.99
$289.99
Toc - Plan #39 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.16
$329.33
$370.82
$518.22
$787.48
$512.13
$551.30
$592.79
$740.19
$734.10
$773.27
$814.76
$962.16
$956.07
$995.24
$1,036.73
$1,184.13
$221.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.32
$658.66
$741.64
$1,036.44
$1,574.96
$802.29
$880.63
$963.61
$1,258.41
$1,024.26
$1,102.60
$1,185.58
$1,480.38
$1,246.23
$1,324.57
$1,407.55
$1,702.35
$221.97
Toc - Plan #40 Aetna CVS Health
Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$430.96
$489.14
$550.76
$769.69
$1,169.61
$760.64
$818.82
$880.44
$1,099.37
$1,090.32
$1,148.50
$1,210.12
$1,429.05
$1,420.00
$1,478.18
$1,539.80
$1,758.73
$329.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$861.92
$978.28
$1,101.52
$1,539.38
$2,339.22
$1,191.60
$1,307.96
$1,431.20
$1,869.06
$1,521.28
$1,637.64
$1,760.88
$2,198.74
$1,850.96
$1,967.32
$2,090.56
$2,528.42
$329.68
Toc - Plan #41 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.75
$433.28
$487.87
$681.80
$1,036.06
$673.79
$725.32
$779.91
$973.84
$965.83
$1,017.36
$1,071.95
$1,265.88
$1,257.87
$1,309.40
$1,363.99
$1,557.92
$292.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.50
$866.56
$975.74
$1,363.60
$2,072.12
$1,055.54
$1,158.60
$1,267.78
$1,655.64
$1,347.58
$1,450.64
$1,559.82
$1,947.68
$1,639.62
$1,742.68
$1,851.86
$2,239.72
$292.04

ADVERTISEMENT

AvMed

Local: 1-800-477-8768 | Toll Free: 

Toc - Plan #42 AvMed
Gold

(HMO) AvMed Entrust Gold 125 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$527.64
$598.87
$674.32
$942.36
$1,432.01
$931.28
$1,002.51
$1,077.96
$1,346.00
$1,334.92
$1,406.15
$1,481.60
$1,749.64
$1,738.56
$1,809.79
$1,885.24
$2,153.28
$403.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,055.28
$1,197.74
$1,348.64
$1,884.72
$2,864.02
$1,458.92
$1,601.38
$1,752.28
$2,288.36
$1,862.56
$2,005.02
$2,155.92
$2,692.00
$2,266.20
$2,408.66
$2,559.56
$3,095.64
$403.64
Toc - Plan #43 AvMed
Silver

(HMO) AvMed Entrust Silver 300 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,650 $15,300 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
$514.91
$584.42
$658.06
$919.63
$1,397.47
$908.82
$978.33
$1,051.97
$1,313.54
$1,302.73
$1,372.24
$1,445.88
$1,707.45
$1,696.64
$1,766.15
$1,839.79
$2,101.36
$393.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,029.82
$1,168.84
$1,316.12
$1,839.26
$2,794.94
$1,423.73
$1,562.75
$1,710.03
$2,233.17
$1,817.64
$1,956.66
$2,103.94
$2,627.08
$2,211.55
$2,350.57
$2,497.85
$3,020.99
$393.91
Toc - Plan #44 AvMed
Silver

(HMO) AvMed Entrust Silver 350 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$495.59
$562.49
$633.36
$885.12
$1,345.03
$874.72
$941.62
$1,012.49
$1,264.25
$1,253.85
$1,320.75
$1,391.62
$1,643.38
$1,632.98
$1,699.88
$1,770.75
$2,022.51
$379.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$991.18
$1,124.98
$1,266.72
$1,770.24
$2,690.06
$1,370.31
$1,504.11
$1,645.85
$2,149.37
$1,749.44
$1,883.24
$2,024.98
$2,528.50
$2,128.57
$2,262.37
$2,404.11
$2,907.63
$379.13
Toc - Plan #45 AvMed
Silver

(HMO) AvMed Entrust Silver 500 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$492.69
$559.21
$629.66
$879.95
$1,337.17
$869.60
$936.12
$1,006.57
$1,256.86
$1,246.51
$1,313.03
$1,383.48
$1,633.77
$1,623.42
$1,689.94
$1,760.39
$2,010.68
$376.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$985.38
$1,118.42
$1,259.32
$1,759.90
$2,674.34
$1,362.29
$1,495.33
$1,636.23
$2,136.81
$1,739.20
$1,872.24
$2,013.14
$2,513.72
$2,116.11
$2,249.15
$2,390.05
$2,890.63
$376.91
Toc - Plan #46 AvMed
Silver

(HMO) AvMed Entrust Silver 550 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$489.73
$555.84
$625.87
$874.66
$1,329.12
$864.37
$930.48
$1,000.51
$1,249.30
$1,239.01
$1,305.12
$1,375.15
$1,623.94
$1,613.65
$1,679.76
$1,749.79
$1,998.58
$374.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$979.46
$1,111.68
$1,251.74
$1,749.32
$2,658.24
$1,354.10
$1,486.32
$1,626.38
$2,123.96
$1,728.74
$1,860.96
$2,001.02
$2,498.60
$2,103.38
$2,235.60
$2,375.66
$2,873.24
$374.64
Toc - Plan #47 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 600 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$404.20
$458.76
$516.56
$721.89
$1,096.99
$713.41
$767.97
$825.77
$1,031.10
$1,022.62
$1,077.18
$1,134.98
$1,340.31
$1,331.83
$1,386.39
$1,444.19
$1,649.52
$309.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.40
$917.52
$1,033.12
$1,443.78
$2,193.98
$1,117.61
$1,226.73
$1,342.33
$1,752.99
$1,426.82
$1,535.94
$1,651.54
$2,062.20
$1,736.03
$1,845.15
$1,960.75
$2,371.41
$309.21
Toc - Plan #48 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 650 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 Annual Deductible
$8,200 $16,400 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
$390.12
$442.79
$498.58
$696.76
$1,058.79
$688.56
$741.23
$797.02
$995.20
$987.00
$1,039.67
$1,095.46
$1,293.64
$1,285.44
$1,338.11
$1,393.90
$1,592.08
$298.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.24
$885.58
$997.16
$1,393.52
$2,117.58
$1,078.68
$1,184.02
$1,295.60
$1,691.96
$1,377.12
$1,482.46
$1,594.04
$1,990.40
$1,675.56
$1,780.90
$1,892.48
$2,288.84
$298.44
Toc - Plan #49 AvMed
Catastrophic

(HMO) AvMed Entrust Catastrophic 100 (2023)

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
$319.28
$362.39
$408.04
$570.24
$866.54
$563.53
$606.64
$652.29
$814.49
$807.78
$850.89
$896.54
$1,058.74
$1,052.03
$1,095.14
$1,140.79
$1,302.99
$244.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$638.56
$724.78
$816.08
$1,140.48
$1,733.08
$882.81
$969.03
$1,060.33
$1,384.73
$1,127.06
$1,213.28
$1,304.58
$1,628.98
$1,371.31
$1,457.53
$1,548.83
$1,873.23
$244.25
Toc - Plan #50 AvMed
Gold

(HMO) AvMed Entrust Gold Standard (2023)

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
$524.08
$594.83
$669.78
$936.01
$1,422.36
$925.00
$995.75
$1,070.70
$1,336.93
$1,325.92
$1,396.67
$1,471.62
$1,737.85
$1,726.84
$1,797.59
$1,872.54
$2,138.77
$400.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,048.16
$1,189.66
$1,339.56
$1,872.02
$2,844.72
$1,449.08
$1,590.58
$1,740.48
$2,272.94
$1,850.00
$1,991.50
$2,141.40
$2,673.86
$2,250.92
$2,392.42
$2,542.32
$3,074.78
$400.92
Toc - Plan #51 AvMed
Silver

(HMO) AvMed Entrust Silver Standard (2023)

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
$475.19
$539.34
$607.29
$848.68
$1,289.65
$838.71
$902.86
$970.81
$1,212.20
$1,202.23
$1,266.38
$1,334.33
$1,575.72
$1,565.75
$1,629.90
$1,697.85
$1,939.24
$363.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$950.38
$1,078.68
$1,214.58
$1,697.36
$2,579.30
$1,313.90
$1,442.20
$1,578.10
$2,060.88
$1,677.42
$1,805.72
$1,941.62
$2,424.40
$2,040.94
$2,169.24
$2,305.14
$2,787.92
$363.52
Toc - Plan #52 AvMed
Expanded Bronze

(HMO) AvMed Entrust Expanded Bronze Standard (2023)

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
$401.47
$455.67
$513.08
$717.03
$1,089.60
$708.60
$762.80
$820.21
$1,024.16
$1,015.73
$1,069.93
$1,127.34
$1,331.29
$1,322.86
$1,377.06
$1,434.47
$1,638.42
$307.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802.94
$911.34
$1,026.16
$1,434.06
$2,179.20
$1,110.07
$1,218.47
$1,333.29
$1,741.19
$1,417.20
$1,525.60
$1,640.42
$2,048.32
$1,724.33
$1,832.73
$1,947.55
$2,355.45
$307.13
Toc - Plan #53 AvMed
Gold

(HMO) AvMed Entrust Gold 125 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$532.75
$604.68
$680.86
$951.50
$1,445.90
$940.31
$1,012.24
$1,088.42
$1,359.06
$1,347.87
$1,419.80
$1,495.98
$1,766.62
$1,755.43
$1,827.36
$1,903.54
$2,174.18
$407.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,065.50
$1,209.36
$1,361.72
$1,903.00
$2,891.80
$1,473.06
$1,616.92
$1,769.28
$2,310.56
$1,880.62
$2,024.48
$2,176.84
$2,718.12
$2,288.18
$2,432.04
$2,584.40
$3,125.68
$407.56
Toc - Plan #54 AvMed
Silver

(HMO) AvMed Entrust Silver 300 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,650 $15,300 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
$520.01
$590.21
$664.57
$928.73
$1,411.30
$917.81
$988.01
$1,062.37
$1,326.53
$1,315.61
$1,385.81
$1,460.17
$1,724.33
$1,713.41
$1,783.61
$1,857.97
$2,122.13
$397.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,040.02
$1,180.42
$1,329.14
$1,857.46
$2,822.60
$1,437.82
$1,578.22
$1,726.94
$2,255.26
$1,835.62
$1,976.02
$2,124.74
$2,653.06
$2,233.42
$2,373.82
$2,522.54
$3,050.86
$397.80
Toc - Plan #55 AvMed
Silver

(HMO) AvMed Entrust Silver 350 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$500.69
$568.29
$639.89
$894.24
$1,358.88
$883.72
$951.32
$1,022.92
$1,277.27
$1,266.75
$1,334.35
$1,405.95
$1,660.30
$1,649.78
$1,717.38
$1,788.98
$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
$1,279.78
$1,788.48
$2,717.76
$1,384.41
$1,519.61
$1,662.81
$2,171.51
$1,767.44
$1,902.64
$2,045.84
$2,554.54
$2,150.47
$2,285.67
$2,428.87
$2,937.57
$383.03
Toc - Plan #56 AvMed
Silver

(HMO) AvMed Entrust Silver 500 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$497.77
$564.97
$636.15
$889.02
$1,350.95
$878.56
$945.76
$1,016.94
$1,269.81
$1,259.35
$1,326.55
$1,397.73
$1,650.60
$1,640.14
$1,707.34
$1,778.52
$2,031.39
$380.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$995.54
$1,129.94
$1,272.30
$1,778.04
$2,701.90
$1,376.33
$1,510.73
$1,653.09
$2,158.83
$1,757.12
$1,891.52
$2,033.88
$2,539.62
$2,137.91
$2,272.31
$2,414.67
$2,920.41
$380.79
Toc - Plan #57 AvMed
Silver

(HMO) AvMed Entrust Silver 550 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$494.82
$561.63
$632.39
$883.76
$1,342.95
$873.36
$940.17
$1,010.93
$1,262.30
$1,251.90
$1,318.71
$1,389.47
$1,640.84
$1,630.44
$1,697.25
$1,768.01
$2,019.38
$378.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$989.64
$1,123.26
$1,264.78
$1,767.52
$2,685.90
$1,368.18
$1,501.80
$1,643.32
$2,146.06
$1,746.72
$1,880.34
$2,021.86
$2,524.60
$2,125.26
$2,258.88
$2,400.40
$2,903.14
$378.54
Toc - Plan #58 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 625 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,350 $16,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$501.17
$568.83
$640.50
$895.09
$1,360.18
$884.57
$952.23
$1,023.90
$1,278.49
$1,267.97
$1,335.63
$1,407.30
$1,661.89
$1,651.37
$1,719.03
$1,790.70
$2,045.29
$383.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,002.34
$1,137.66
$1,281.00
$1,790.18
$2,720.36
$1,385.74
$1,521.06
$1,664.40
$2,173.58
$1,769.14
$1,904.46
$2,047.80
$2,556.98
$2,152.54
$2,287.86
$2,431.20
$2,940.38
$383.40

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770

Toc - Plan #59 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.67
$404.81
$455.82
$637.00
$967.99
$629.52
$677.66
$728.67
$909.85
$902.37
$950.51
$1,001.52
$1,182.70
$1,175.22
$1,223.36
$1,274.37
$1,455.55
$272.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.34
$809.62
$911.64
$1,274.00
$1,935.98
$986.19
$1,082.47
$1,184.49
$1,546.85
$1,259.04
$1,355.32
$1,457.34
$1,819.70
$1,531.89
$1,628.17
$1,730.19
$2,092.55
$272.85
Toc - Plan #60 Ambetter from Sunshine Health
Bronze

(EPO) Clear Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$265.95
$301.84
$339.87
$474.96
$721.75
$469.39
$505.28
$543.31
$678.40
$672.83
$708.72
$746.75
$881.84
$876.27
$912.16
$950.19
$1,085.28
$203.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$531.90
$603.68
$679.74
$949.92
$1,443.50
$735.34
$807.12
$883.18
$1,153.36
$938.78
$1,010.56
$1,086.62
$1,356.80
$1,142.22
$1,214.00
$1,290.06
$1,560.24
$203.44
Toc - Plan #61 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$292.88
$332.41
$374.29
$523.07
$794.86
$516.93
$556.46
$598.34
$747.12
$740.98
$780.51
$822.39
$971.17
$965.03
$1,004.56
$1,046.44
$1,195.22
$224.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$585.76
$664.82
$748.58
$1,046.14
$1,589.72
$809.81
$888.87
$972.63
$1,270.19
$1,033.86
$1,112.92
$1,196.68
$1,494.24
$1,257.91
$1,336.97
$1,420.73
$1,718.29
$224.05
Toc - Plan #62 Ambetter from Sunshine Health
Silver

(EPO) Everyday Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.48
$409.14
$460.68
$643.80
$978.32
$636.24
$684.90
$736.44
$919.56
$912.00
$960.66
$1,012.20
$1,195.32
$1,187.76
$1,236.42
$1,287.96
$1,471.08
$275.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.96
$818.28
$921.36
$1,287.60
$1,956.64
$996.72
$1,094.04
$1,197.12
$1,563.36
$1,272.48
$1,369.80
$1,472.88
$1,839.12
$1,548.24
$1,645.56
$1,748.64
$2,114.88
$275.76
Toc - Plan #63 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$285.95
$324.54
$365.43
$510.69
$776.05
$504.70
$543.29
$584.18
$729.44
$723.45
$762.04
$802.93
$948.19
$942.20
$980.79
$1,021.68
$1,166.94
$218.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$571.90
$649.08
$730.86
$1,021.38
$1,552.10
$790.65
$867.83
$949.61
$1,240.13
$1,009.40
$1,086.58
$1,168.36
$1,458.88
$1,228.15
$1,305.33
$1,387.11
$1,677.63
$218.75
Toc - Plan #64 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$327.73
$371.96
$418.82
$585.30
$889.42
$578.43
$622.66
$669.52
$836.00
$829.13
$873.36
$920.22
$1,086.70
$1,079.83
$1,124.06
$1,170.92
$1,337.40
$250.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$655.46
$743.92
$837.64
$1,170.60
$1,778.84
$906.16
$994.62
$1,088.34
$1,421.30
$1,156.86
$1,245.32
$1,339.04
$1,672.00
$1,407.56
$1,496.02
$1,589.74
$1,922.70
$250.70
Toc - Plan #65 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.17
$404.24
$455.18
$636.11
$966.62
$628.63
$676.70
$727.64
$908.57
$901.09
$949.16
$1,000.10
$1,181.03
$1,173.55
$1,221.62
$1,272.56
$1,453.49
$272.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.34
$808.48
$910.36
$1,272.22
$1,933.24
$984.80
$1,080.94
$1,182.82
$1,544.68
$1,257.26
$1,353.40
$1,455.28
$1,817.14
$1,529.72
$1,625.86
$1,727.74
$2,089.60
$272.46
Toc - Plan #66 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$359.19
$407.67
$459.03
$641.49
$974.81
$633.96
$682.44
$733.80
$916.26
$908.73
$957.21
$1,008.57
$1,191.03
$1,183.50
$1,231.98
$1,283.34
$1,465.80
$274.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$718.38
$815.34
$918.06
$1,282.98
$1,949.62
$993.15
$1,090.11
$1,192.83
$1,557.75
$1,267.92
$1,364.88
$1,467.60
$1,832.52
$1,542.69
$1,639.65
$1,742.37
$2,107.29
$274.77
Toc - Plan #67 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.37
$386.31
$434.98
$607.88
$923.73
$600.74
$646.68
$695.35
$868.25
$861.11
$907.05
$955.72
$1,128.62
$1,121.48
$1,167.42
$1,216.09
$1,388.99
$260.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.74
$772.62
$869.96
$1,215.76
$1,847.46
$941.11
$1,032.99
$1,130.33
$1,476.13
$1,201.48
$1,293.36
$1,390.70
$1,736.50
$1,461.85
$1,553.73
$1,651.07
$1,996.87
$260.37
Toc - Plan #68 Ambetter from Sunshine Health
Silver

(EPO) Enhanced Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.31
$410.07
$461.74
$645.28
$980.56
$637.70
$686.46
$738.13
$921.67
$914.09
$962.85
$1,014.52
$1,198.06
$1,190.48
$1,239.24
$1,290.91
$1,474.45
$276.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.62
$820.14
$923.48
$1,290.56
$1,961.12
$999.01
$1,096.53
$1,199.87
$1,566.95
$1,275.40
$1,372.92
$1,476.26
$1,843.34
$1,551.79
$1,649.31
$1,752.65
$2,119.73
$276.39
Toc - Plan #69 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.04
$449.50
$506.13
$707.31
$1,074.83
$699.00
$752.46
$809.09
$1,010.27
$1,001.96
$1,055.42
$1,112.05
$1,313.23
$1,304.92
$1,358.38
$1,415.01
$1,616.19
$302.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.08
$899.00
$1,012.26
$1,414.62
$2,149.66
$1,095.04
$1,201.96
$1,315.22
$1,717.58
$1,398.00
$1,504.92
$1,618.18
$2,020.54
$1,700.96
$1,807.88
$1,921.14
$2,323.50
$302.96
Toc - Plan #70 Ambetter from Sunshine Health
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$280.60
$318.47
$358.60
$501.14
$761.52
$495.25
$533.12
$573.25
$715.79
$709.90
$747.77
$787.90
$930.44
$924.55
$962.42
$1,002.55
$1,145.09
$214.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$561.20
$636.94
$717.20
$1,002.28
$1,523.04
$775.85
$851.59
$931.85
$1,216.93
$990.50
$1,066.24
$1,146.50
$1,431.58
$1,205.15
$1,280.89
$1,361.15
$1,646.23
$214.65
Toc - Plan #71 Ambetter from Sunshine Health
Silver

(EPO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.96
$404.00
$454.90
$635.72
$966.04
$628.26
$676.30
$727.20
$908.02
$900.56
$948.60
$999.50
$1,180.32
$1,172.86
$1,220.90
$1,271.80
$1,452.62
$272.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.92
$808.00
$909.80
$1,271.44
$1,932.08
$984.22
$1,080.30
$1,182.10
$1,543.74
$1,256.52
$1,352.60
$1,454.40
$1,816.04
$1,528.82
$1,624.90
$1,726.70
$2,088.34
$272.30
Toc - Plan #72 Ambetter from Sunshine Health
Gold

(EPO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.33
$378.32
$425.98
$595.31
$904.63
$588.32
$633.31
$680.97
$850.30
$843.31
$888.30
$935.96
$1,105.29
$1,098.30
$1,143.29
$1,190.95
$1,360.28
$254.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.66
$756.64
$851.96
$1,190.62
$1,809.26
$921.65
$1,011.63
$1,106.95
$1,445.61
$1,176.64
$1,266.62
$1,361.94
$1,700.60
$1,431.63
$1,521.61
$1,616.93
$1,955.59
$254.99
Toc - Plan #73 Ambetter from Sunshine Health
Silver

(EPO) Everyday Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.85
$424.31
$477.77
$667.69
$1,014.61
$659.84
$710.30
$763.76
$953.68
$945.83
$996.29
$1,049.75
$1,239.67
$1,231.82
$1,282.28
$1,335.74
$1,525.66
$285.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.70
$848.62
$955.54
$1,335.38
$2,029.22
$1,033.69
$1,134.61
$1,241.53
$1,621.37
$1,319.68
$1,420.60
$1,527.52
$1,907.36
$1,605.67
$1,706.59
$1,813.51
$2,193.35
$285.99
Toc - Plan #74 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.75
$344.74
$388.18
$542.48
$824.35
$536.11
$577.10
$620.54
$774.84
$768.47
$809.46
$852.90
$1,007.20
$1,000.83
$1,041.82
$1,085.26
$1,239.56
$232.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$607.50
$689.48
$776.36
$1,084.96
$1,648.70
$839.86
$921.84
$1,008.72
$1,317.32
$1,072.22
$1,154.20
$1,241.08
$1,549.68
$1,304.58
$1,386.56
$1,473.44
$1,782.04
$232.36
Toc - Plan #75 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.91
$419.83
$472.73
$660.63
$1,003.90
$652.88
$702.80
$755.70
$943.60
$935.85
$985.77
$1,038.67
$1,226.57
$1,218.82
$1,268.74
$1,321.64
$1,509.54
$282.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$739.82
$839.66
$945.46
$1,321.26
$2,007.80
$1,022.79
$1,122.63
$1,228.43
$1,604.23
$1,305.76
$1,405.60
$1,511.40
$1,887.20
$1,588.73
$1,688.57
$1,794.37
$2,170.17
$282.97
Toc - Plan #76 Ambetter from Sunshine Health
Bronze

(EPO) Clear Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$275.81
$313.03
$352.47
$492.58
$748.52
$486.80
$524.02
$563.46
$703.57
$697.79
$735.01
$774.45
$914.56
$908.78
$946.00
$985.44
$1,125.55
$210.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$551.62
$626.06
$704.94
$985.16
$1,497.04
$762.61
$837.05
$915.93
$1,196.15
$973.60
$1,048.04
$1,126.92
$1,407.14
$1,184.59
$1,259.03
$1,337.91
$1,618.13
$210.99
Toc - Plan #77 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.38
$419.24
$472.06
$659.70
$1,002.48
$651.95
$701.81
$754.63
$942.27
$934.52
$984.38
$1,037.20
$1,224.84
$1,217.09
$1,266.95
$1,319.77
$1,507.41
$282.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.76
$838.48
$944.12
$1,319.40
$2,004.96
$1,021.33
$1,121.05
$1,226.69
$1,601.97
$1,303.90
$1,403.62
$1,509.26
$1,884.54
$1,586.47
$1,686.19
$1,791.83
$2,167.11
$282.57
Toc - Plan #78 Ambetter from Sunshine Health
Silver

(EPO) Enhanced Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$374.71
$425.29
$478.87
$669.22
$1,016.94
$661.36
$711.94
$765.52
$955.87
$948.01
$998.59
$1,052.17
$1,242.52
$1,234.66
$1,285.24
$1,338.82
$1,529.17
$286.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.42
$850.58
$957.74
$1,338.44
$2,033.88
$1,036.07
$1,137.23
$1,244.39
$1,625.09
$1,322.72
$1,423.88
$1,531.04
$1,911.74
$1,609.37
$1,710.53
$1,817.69
$2,198.39
$286.65
Toc - Plan #79 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.73
$466.17
$524.90
$733.55
$1,114.70
$724.93
$780.37
$839.10
$1,047.75
$1,039.13
$1,094.57
$1,153.30
$1,361.95
$1,353.33
$1,408.77
$1,467.50
$1,676.15
$314.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.46
$932.34
$1,049.80
$1,467.10
$2,229.40
$1,135.66
$1,246.54
$1,364.00
$1,781.30
$1,449.86
$1,560.74
$1,678.20
$2,095.50
$1,764.06
$1,874.94
$1,992.40
$2,409.70
$314.20
Toc - Plan #80 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$296.56
$336.58
$378.99
$529.64
$804.84
$523.42
$563.44
$605.85
$756.50
$750.28
$790.30
$832.71
$983.36
$977.14
$1,017.16
$1,059.57
$1,210.22
$226.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$593.12
$673.16
$757.98
$1,059.28
$1,609.68
$819.98
$900.02
$984.84
$1,286.14
$1,046.84
$1,126.88
$1,211.70
$1,513.00
$1,273.70
$1,353.74
$1,438.56
$1,739.86
$226.86
Toc - Plan #81 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$339.88
$385.75
$434.36
$607.01
$922.41
$599.88
$645.75
$694.36
$867.01
$859.88
$905.75
$954.36
$1,127.01
$1,119.88
$1,165.75
$1,214.36
$1,387.01
$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
$868.72
$1,214.02
$1,844.82
$939.76
$1,031.50
$1,128.72
$1,474.02
$1,199.76
$1,291.50
$1,388.72
$1,734.02
$1,459.76
$1,551.50
$1,648.72
$1,994.02
$260.00
Toc - Plan #82 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.51
$422.79
$476.06
$665.29
$1,010.97
$657.47
$707.75
$761.02
$950.25
$942.43
$992.71
$1,045.98
$1,235.21
$1,227.39
$1,277.67
$1,330.94
$1,520.17
$284.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$745.02
$845.58
$952.12
$1,330.58
$2,021.94
$1,029.98
$1,130.54
$1,237.08
$1,615.54
$1,314.94
$1,415.50
$1,522.04
$1,900.50
$1,599.90
$1,700.46
$1,807.00
$2,185.46
$284.96
Toc - Plan #83 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$352.99
$400.64
$451.11
$630.43
$958.00
$623.02
$670.67
$721.14
$900.46
$893.05
$940.70
$991.17
$1,170.49
$1,163.08
$1,210.73
$1,261.20
$1,440.52
$270.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$705.98
$801.28
$902.22
$1,260.86
$1,916.00
$976.01
$1,071.31
$1,172.25
$1,530.89
$1,246.04
$1,341.34
$1,442.28
$1,800.92
$1,516.07
$1,611.37
$1,712.31
$2,070.95
$270.03

ADVERTISEMENT

Florida Blue HMO (a BlueCross BlueShield FL company)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771

Toc - Plan #84 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 2151 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$830.15
$942.22
$1,060.93
$1,482.65
$2,253.03
$1,465.21
$1,577.28
$1,695.99
$2,117.71
$2,100.27
$2,212.34
$2,331.05
$2,752.77
$2,735.33
$2,847.40
$2,966.11
$3,387.83
$635.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,660.30
$1,884.44
$2,121.86
$2,965.30
$4,506.06
$2,295.36
$2,519.50
$2,756.92
$3,600.36
$2,930.42
$3,154.56
$3,391.98
$4,235.42
$3,565.48
$3,789.62
$4,027.04
$4,870.48
$635.06
Toc - Plan #85 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2153 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$488.04
$553.93
$623.72
$871.64
$1,324.54
$861.39
$927.28
$997.07
$1,244.99
$1,234.74
$1,300.63
$1,370.42
$1,618.34
$1,608.09
$1,673.98
$1,743.77
$1,991.69
$373.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$976.08
$1,107.86
$1,247.44
$1,743.28
$2,649.08
$1,349.43
$1,481.21
$1,620.79
$2,116.63
$1,722.78
$1,854.56
$1,994.14
$2,489.98
$2,096.13
$2,227.91
$2,367.49
$2,863.33
$373.35
Toc - Plan #86 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2154 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$460.44
$522.60
$588.44
$822.35
$1,249.63
$812.68
$874.84
$940.68
$1,174.59
$1,164.92
$1,227.08
$1,292.92
$1,526.83
$1,517.16
$1,579.32
$1,645.16
$1,879.07
$352.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$920.88
$1,045.20
$1,176.88
$1,644.70
$2,499.26
$1,273.12
$1,397.44
$1,529.12
$1,996.94
$1,625.36
$1,749.68
$1,881.36
$2,349.18
$1,977.60
$2,101.92
$2,233.60
$2,701.42
$352.24
Toc - Plan #87 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 2156 ($0 Virtual Visits / $20 PCP Visit / $15 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$732.47
$831.35
$936.10
$1,308.19
$1,987.92
$1,292.81
$1,391.69
$1,496.44
$1,868.53
$1,853.15
$1,952.03
$2,056.78
$2,428.87
$2,413.49
$2,512.37
$2,617.12
$2,989.21
$560.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,464.94
$1,662.70
$1,872.20
$2,616.38
$3,975.84
$2,025.28
$2,223.04
$2,432.54
$3,176.72
$2,585.62
$2,783.38
$2,992.88
$3,737.06
$3,145.96
$3,343.72
$3,553.22
$4,297.40
$560.34
Toc - Plan #88 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 2157 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$7,700 $15,400 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
$603.25
$684.69
$770.95
$1,077.40
$1,637.22
$1,064.74
$1,146.18
$1,232.44
$1,538.89
$1,526.23
$1,607.67
$1,693.93
$2,000.38
$1,987.72
$2,069.16
$2,155.42
$2,461.87
$461.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,206.50
$1,369.38
$1,541.90
$2,154.80
$3,274.44
$1,667.99
$1,830.87
$2,003.39
$2,616.29
$2,129.48
$2,292.36
$2,464.88
$3,077.78
$2,590.97
$2,753.85
$2,926.37
$3,539.27
$461.49
Toc - Plan #89 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2159 ($0 Deductible / $0 Virtual Visits / $50 PCP Visit / $30 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$529.64
$601.14
$676.88
$945.94
$1,437.44
$934.81
$1,006.31
$1,082.05
$1,351.11
$1,339.98
$1,411.48
$1,487.22
$1,756.28
$1,745.15
$1,816.65
$1,892.39
$2,161.45
$405.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,059.28
$1,202.28
$1,353.76
$1,891.88
$2,874.88
$1,464.45
$1,607.45
$1,758.93
$2,297.05
$1,869.62
$2,012.62
$2,164.10
$2,702.22
$2,274.79
$2,417.79
$2,569.27
$3,107.39
$405.17
Toc - Plan #90 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) BlueCare Bronze 2351S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.77
$493.46
$555.64
$776.50
$1,179.97
$767.37
$826.06
$888.24
$1,109.10
$1,099.97
$1,158.66
$1,220.84
$1,441.70
$1,432.57
$1,491.26
$1,553.44
$1,774.30
$332.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869.54
$986.92
$1,111.28
$1,553.00
$2,359.94
$1,202.14
$1,319.52
$1,443.88
$1,885.60
$1,534.74
$1,652.12
$1,776.48
$2,218.20
$1,867.34
$1,984.72
$2,109.08
$2,550.80
$332.60
Toc - Plan #91 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2352S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$479.00
$543.67
$612.16
$855.49
$1,300.01
$845.44
$910.11
$978.60
$1,221.93
$1,211.88
$1,276.55
$1,345.04
$1,588.37
$1,578.32
$1,642.99
$1,711.48
$1,954.81
$366.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$958.00
$1,087.34
$1,224.32
$1,710.98
$2,600.02
$1,324.44
$1,453.78
$1,590.76
$2,077.42
$1,690.88
$1,820.22
$1,957.20
$2,443.86
$2,057.32
$2,186.66
$2,323.64
$2,810.30
$366.44
Toc - Plan #92 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 2353S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$643.95
$730.88
$822.97
$1,150.09
$1,747.68
$1,136.57
$1,223.50
$1,315.59
$1,642.71
$1,629.19
$1,716.12
$1,808.21
$2,135.33
$2,121.81
$2,208.74
$2,300.83
$2,627.95
$492.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,287.90
$1,461.76
$1,645.94
$2,300.18
$3,495.36
$1,780.52
$1,954.38
$2,138.56
$2,792.80
$2,273.14
$2,447.00
$2,631.18
$3,285.42
$2,765.76
$2,939.62
$3,123.80
$3,778.04
$492.62
Toc - Plan #93 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 2354S ($30 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$663.89
$753.52
$848.45
$1,185.71
$1,801.80
$1,171.77
$1,261.40
$1,356.33
$1,693.59
$1,679.65
$1,769.28
$1,864.21
$2,201.47
$2,187.53
$2,277.16
$2,372.09
$2,709.35
$507.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,327.78
$1,507.04
$1,696.90
$2,371.42
$3,603.60
$1,835.66
$2,014.92
$2,204.78
$2,879.30
$2,343.54
$2,522.80
$2,712.66
$3,387.18
$2,851.42
$3,030.68
$3,220.54
$3,895.06
$507.88
Toc - Plan #94 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 2355S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$827.88
$939.64
$1,058.03
$1,478.59
$2,246.87
$1,461.21
$1,572.97
$1,691.36
$2,111.92
$2,094.54
$2,206.30
$2,324.69
$2,745.25
$2,727.87
$2,839.63
$2,958.02
$3,378.58
$633.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,655.76
$1,879.28
$2,116.06
$2,957.18
$4,493.74
$2,289.09
$2,512.61
$2,749.39
$3,590.51
$2,922.42
$3,145.94
$3,382.72
$4,223.84
$3,555.75
$3,779.27
$4,016.05
$4,857.17
$633.33
Toc - Plan #95 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2359 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 Not Applicable Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$512.18
$581.32
$654.57
$914.75
$1,390.06
$904.00
$973.14
$1,046.39
$1,306.57
$1,295.82
$1,364.96
$1,438.21
$1,698.39
$1,687.64
$1,756.78
$1,830.03
$2,090.21
$391.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,024.36
$1,162.64
$1,309.14
$1,829.50
$2,780.12
$1,416.18
$1,554.46
$1,700.96
$2,221.32
$1,808.00
$1,946.28
$2,092.78
$2,613.14
$2,199.82
$2,338.10
$2,484.60
$3,004.96
$391.82
Toc - Plan #96 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$339.91
$385.80
$434.40
$607.08
$922.52
$599.94
$645.83
$694.43
$867.11
$859.97
$905.86
$954.46
$1,127.14
$1,120.00
$1,165.89
$1,214.49
$1,387.17
$260.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$679.82
$771.60
$868.80
$1,214.16
$1,845.04
$939.85
$1,031.63
$1,128.83
$1,474.19
$1,199.88
$1,291.66
$1,388.86
$1,734.22
$1,459.91
$1,551.69
$1,648.89
$1,994.25
$260.03
Toc - Plan #97 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1602 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.98
$363.18
$408.93
$571.48
$868.43
$564.76
$607.96
$653.71
$816.26
$809.54
$852.74
$898.49
$1,061.04
$1,054.32
$1,097.52
$1,143.27
$1,305.82
$244.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$639.96
$726.36
$817.86
$1,142.96
$1,736.86
$884.74
$971.14
$1,062.64
$1,387.74
$1,129.52
$1,215.92
$1,307.42
$1,632.52
$1,374.30
$1,460.70
$1,552.20
$1,877.30
$244.78
Toc - Plan #98 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1603 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.62
$475.13
$535.00
$747.66
$1,136.13
$738.86
$795.37
$855.24
$1,067.90
$1,059.10
$1,115.61
$1,175.48
$1,388.14
$1,379.34
$1,435.85
$1,495.72
$1,708.38
$320.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$837.24
$950.26
$1,070.00
$1,495.32
$2,272.26
$1,157.48
$1,270.50
$1,390.24
$1,815.56
$1,477.72
$1,590.74
$1,710.48
$2,135.80
$1,797.96
$1,910.98
$2,030.72
$2,456.04
$320.24
Toc - Plan #99 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1604 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$399.04
$452.91
$509.97
$712.69
$1,082.99
$704.31
$758.18
$815.24
$1,017.96
$1,009.58
$1,063.45
$1,120.51
$1,323.23
$1,314.85
$1,368.72
$1,425.78
$1,628.50
$305.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798.08
$905.82
$1,019.94
$1,425.38
$2,165.98
$1,103.35
$1,211.09
$1,325.21
$1,730.65
$1,408.62
$1,516.36
$1,630.48
$2,035.92
$1,713.89
$1,821.63
$1,935.75
$2,341.19
$305.27
Toc - Plan #100 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 1605 ($0 Virtual Visits / $0 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$940 $1,880 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$473.91
$537.89
$605.66
$846.40
$1,286.19
$836.45
$900.43
$968.20
$1,208.94
$1,198.99
$1,262.97
$1,330.74
$1,571.48
$1,561.53
$1,625.51
$1,693.28
$1,934.02
$362.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$947.82
$1,075.78
$1,211.32
$1,692.80
$2,572.38
$1,310.36
$1,438.32
$1,573.86
$2,055.34
$1,672.90
$1,800.86
$1,936.40
$2,417.88
$2,035.44
$2,163.40
$2,298.94
$2,780.42
$362.54
Toc - Plan #101 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1710 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$425.30
$482.72
$543.53
$759.59
$1,154.26
$750.65
$808.07
$868.88
$1,084.94
$1,076.00
$1,133.42
$1,194.23
$1,410.29
$1,401.35
$1,458.77
$1,519.58
$1,735.64
$325.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$850.60
$965.44
$1,087.06
$1,519.18
$2,308.52
$1,175.95
$1,290.79
$1,412.41
$1,844.53
$1,501.30
$1,616.14
$1,737.76
$2,169.88
$1,826.65
$1,941.49
$2,063.11
$2,495.23
$325.35
Toc - Plan #102 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2017 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,400 $14,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.82
$449.26
$505.86
$706.93
$1,074.26
$698.62
$752.06
$808.66
$1,009.73
$1,001.42
$1,054.86
$1,111.46
$1,312.53
$1,304.22
$1,357.66
$1,414.26
$1,615.33
$302.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.64
$898.52
$1,011.72
$1,413.86
$2,148.52
$1,094.44
$1,201.32
$1,314.52
$1,716.66
$1,397.24
$1,504.12
$1,617.32
$2,019.46
$1,700.04
$1,806.92
$1,920.12
$2,322.26
$302.80
Toc - Plan #103 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2127 ($0 Virtual Visits / $25 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$7,600 $15,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.33
$447.56
$503.95
$704.27
$1,070.21
$695.99
$749.22
$805.61
$1,005.93
$997.65
$1,050.88
$1,107.27
$1,307.59
$1,299.31
$1,352.54
$1,408.93
$1,609.25
$301.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.66
$895.12
$1,007.90
$1,408.54
$2,140.42
$1,090.32
$1,196.78
$1,309.56
$1,710.20
$1,391.98
$1,498.44
$1,611.22
$2,011.86
$1,693.64
$1,800.10
$1,912.88
$2,313.52
$301.66
Toc - Plan #104 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Deductible / $0 Virtual Visits / $35 PCP Visit / $80 Specialist Visits / $25 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.72
$417.36
$469.95
$656.75
$997.99
$649.03
$698.67
$751.26
$938.06
$930.34
$979.98
$1,032.57
$1,219.37
$1,211.65
$1,261.29
$1,313.88
$1,500.68
$281.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.44
$834.72
$939.90
$1,313.50
$1,995.98
$1,016.75
$1,116.03
$1,221.21
$1,594.81
$1,298.06
$1,397.34
$1,502.52
$1,876.12
$1,579.37
$1,678.65
$1,783.83
$2,157.43
$281.31
Toc - Plan #105 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2126 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.31
$386.25
$434.92
$607.79
$923.60
$600.65
$646.59
$695.26
$868.13
$860.99
$906.93
$955.60
$1,128.47
$1,121.33
$1,167.27
$1,215.94
$1,388.81
$260.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.62
$772.50
$869.84
$1,215.58
$1,847.20
$940.96
$1,032.84
$1,130.18
$1,475.92
$1,201.30
$1,293.18
$1,390.52
$1,736.26
$1,461.64
$1,553.52
$1,650.86
$1,996.60
$260.34
Toc - Plan #106 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237 ($0 Virtual Visits / $80 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$387.42
$439.72
$495.12
$691.93
$1,051.46
$683.80
$736.10
$791.50
$988.31
$980.18
$1,032.48
$1,087.88
$1,284.69
$1,276.56
$1,328.86
$1,384.26
$1,581.07
$296.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774.84
$879.44
$990.24
$1,383.86
$2,102.92
$1,071.22
$1,175.82
$1,286.62
$1,680.24
$1,367.60
$1,472.20
$1,583.00
$1,976.62
$1,663.98
$1,768.58
$1,879.38
$2,273.00
$296.38
Toc - Plan #107 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2219 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.61
$377.51
$425.08
$594.04
$902.70
$587.06
$631.96
$679.53
$848.49
$841.51
$886.41
$933.98
$1,102.94
$1,095.96
$1,140.86
$1,188.43
$1,357.39
$254.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.22
$755.02
$850.16
$1,188.08
$1,805.40
$919.67
$1,009.47
$1,104.61
$1,442.53
$1,174.12
$1,263.92
$1,359.06
$1,696.98
$1,428.57
$1,518.37
$1,613.51
$1,951.43
$254.45
Toc - Plan #108 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2266 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.31
$378.31
$425.97
$595.29
$904.60
$588.29
$633.29
$680.95
$850.27
$843.27
$888.27
$935.93
$1,105.25
$1,098.25
$1,143.25
$1,190.91
$1,360.23
$254.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.62
$756.62
$851.94
$1,190.58
$1,809.20
$921.60
$1,011.60
$1,106.92
$1,445.56
$1,176.58
$1,266.58
$1,361.90
$1,700.54
$1,431.56
$1,521.56
$1,616.88
$1,955.52
$254.98
Toc - Plan #109 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) myBlue Bronze 2311S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$302.83
$343.71
$387.02
$540.85
$821.88
$534.49
$575.37
$618.68
$772.51
$766.15
$807.03
$850.34
$1,004.17
$997.81
$1,038.69
$1,082.00
$1,235.83
$231.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$605.66
$687.42
$774.04
$1,081.70
$1,643.76
$837.32
$919.08
$1,005.70
$1,313.36
$1,068.98
$1,150.74
$1,237.36
$1,545.02
$1,300.64
$1,382.40
$1,469.02
$1,776.68
$231.66
Toc - Plan #110 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2312S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.87
$368.73
$415.18
$580.22
$881.70
$573.40
$617.26
$663.71
$828.75
$821.93
$865.79
$912.24
$1,077.28
$1,070.46
$1,114.32
$1,160.77
$1,325.81
$248.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$649.74
$737.46
$830.36
$1,160.44
$1,763.40
$898.27
$985.99
$1,078.89
$1,408.97
$1,146.80
$1,234.52
$1,327.42
$1,657.50
$1,395.33
$1,483.05
$1,575.95
$1,906.03
$248.53
Toc - Plan #111 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2329 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.06
$404.13
$455.04
$635.92
$966.35
$628.45
$676.52
$727.43
$908.31
$900.84
$948.91
$999.82
$1,180.70
$1,173.23
$1,221.30
$1,272.21
$1,453.09
$272.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.12
$808.26
$910.08
$1,271.84
$1,932.70
$984.51
$1,080.65
$1,182.47
$1,544.23
$1,256.90
$1,353.04
$1,454.86
$1,816.62
$1,529.29
$1,625.43
$1,727.25
$2,089.01
$272.39
Toc - Plan #112 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2337 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.02
$425.65
$479.28
$669.79
$1,017.80
$661.91
$712.54
$766.17
$956.68
$948.80
$999.43
$1,053.06
$1,243.57
$1,235.69
$1,286.32
$1,339.95
$1,530.46
$286.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.04
$851.30
$958.56
$1,339.58
$2,035.60
$1,036.93
$1,138.19
$1,245.45
$1,626.47
$1,323.82
$1,425.08
$1,532.34
$1,913.36
$1,610.71
$1,711.97
$1,819.23
$2,200.25
$286.89
Toc - Plan #113 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2313S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389.97
$442.62
$498.38
$696.49
$1,058.38
$688.30
$740.95
$796.71
$994.82
$986.63
$1,039.28
$1,095.04
$1,293.15
$1,284.96
$1,337.61
$1,393.37
$1,591.48
$298.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$779.94
$885.24
$996.76
$1,392.98
$2,116.76
$1,078.27
$1,183.57
$1,295.09
$1,691.31
$1,376.60
$1,481.90
$1,593.42
$1,989.64
$1,674.93
$1,780.23
$1,891.75
$2,287.97
$298.33
Toc - Plan #114 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 2314S ($30 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$448.57
$509.13
$573.27
$801.15
$1,217.42
$791.73
$852.29
$916.43
$1,144.31
$1,134.89
$1,195.45
$1,259.59
$1,487.47
$1,478.05
$1,538.61
$1,602.75
$1,830.63
$343.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$897.14
$1,018.26
$1,146.54
$1,602.30
$2,434.84
$1,240.30
$1,361.42
$1,489.70
$1,945.46
$1,583.46
$1,704.58
$1,832.86
$2,288.62
$1,926.62
$2,047.74
$2,176.02
$2,631.78
$343.16
Toc - Plan #115 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237D ($0 Virtual Visits / $80 PCP Visits / Adult Dental / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.30
$448.67
$505.19
$706.01
$1,072.84
$697.70
$751.07
$807.59
$1,008.41
$1,000.10
$1,053.47
$1,109.99
$1,310.81
$1,302.50
$1,355.87
$1,412.39
$1,613.21
$302.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$790.60
$897.34
$1,010.38
$1,412.02
$2,145.68
$1,093.00
$1,199.74
$1,312.78
$1,714.42
$1,395.40
$1,502.14
$1,615.18
$2,016.82
$1,697.80
$1,804.54
$1,917.58
$2,319.22
$302.40
Toc - Plan #116 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2337D ($0 Virtual Visits / Adult Dental / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.87
$434.56
$489.31
$683.81
$1,039.11
$675.77
$727.46
$782.21
$976.71
$968.67
$1,020.36
$1,075.11
$1,269.61
$1,261.57
$1,313.26
$1,368.01
$1,562.51
$292.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.74
$869.12
$978.62
$1,367.62
$2,078.22
$1,058.64
$1,162.02
$1,271.52
$1,660.52
$1,351.54
$1,454.92
$1,564.42
$1,953.42
$1,644.44
$1,747.82
$1,857.32
$2,246.32
$292.90

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #117 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$335.13
$380.36
$428.28
$598.52
$909.51
$591.50
$636.73
$684.65
$854.89
$847.87
$893.10
$941.02
$1,111.26
$1,104.24
$1,149.47
$1,197.39
$1,367.63
$256.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.26
$760.72
$856.56
$1,197.04
$1,819.02
$926.63
$1,017.09
$1,112.93
$1,453.41
$1,183.00
$1,273.46
$1,369.30
$1,709.78
$1,439.37
$1,529.83
$1,625.67
$1,966.15
$256.37
Toc - Plan #118 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$325.06
$368.93
$415.41
$580.54
$882.19
$573.72
$617.59
$664.07
$829.20
$822.38
$866.25
$912.73
$1,077.86
$1,071.04
$1,114.91
$1,161.39
$1,326.52
$248.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$650.12
$737.86
$830.82
$1,161.08
$1,764.38
$898.78
$986.52
$1,079.48
$1,409.74
$1,147.44
$1,235.18
$1,328.14
$1,658.40
$1,396.10
$1,483.84
$1,576.80
$1,907.06
$248.66
Toc - Plan #119 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- Deductible+PCP Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.81
$449.24
$505.84
$706.91
$1,074.21
$698.60
$752.03
$808.63
$1,009.70
$1,001.39
$1,054.82
$1,111.42
$1,312.49
$1,304.18
$1,357.61
$1,414.21
$1,615.28
$302.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.62
$898.48
$1,011.68
$1,413.82
$2,148.42
$1,094.41
$1,201.27
$1,314.47
$1,716.61
$1,397.20
$1,504.06
$1,617.26
$2,019.40
$1,699.99
$1,806.85
$1,920.05
$2,322.19
$302.79
Toc - Plan #120 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $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
$440.03
$499.42
$562.35
$785.88
$1,194.22
$776.65
$836.04
$898.97
$1,122.50
$1,113.27
$1,172.66
$1,235.59
$1,459.12
$1,449.89
$1,509.28
$1,572.21
$1,795.74
$336.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$880.06
$998.84
$1,124.70
$1,571.76
$2,388.44
$1,216.68
$1,335.46
$1,461.32
$1,908.38
$1,553.30
$1,672.08
$1,797.94
$2,245.00
$1,889.92
$2,008.70
$2,134.56
$2,581.62
$336.62
Toc - Plan #121 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$437.48
$496.52
$559.08
$781.31
$1,187.28
$772.14
$831.18
$893.74
$1,115.97
$1,106.80
$1,165.84
$1,228.40
$1,450.63
$1,441.46
$1,500.50
$1,563.06
$1,785.29
$334.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.96
$993.04
$1,118.16
$1,562.62
$2,374.56
$1,209.62
$1,327.70
$1,452.82
$1,897.28
$1,544.28
$1,662.36
$1,787.48
$2,231.94
$1,878.94
$1,997.02
$2,122.14
$2,566.60
$334.66
Toc - Plan #122 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$440.67
$500.15
$563.16
$787.02
$1,195.95
$777.78
$837.26
$900.27
$1,124.13
$1,114.89
$1,174.37
$1,237.38
$1,461.24
$1,452.00
$1,511.48
$1,574.49
$1,798.35
$337.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$881.34
$1,000.30
$1,126.32
$1,574.04
$2,391.90
$1,218.45
$1,337.41
$1,463.43
$1,911.15
$1,555.56
$1,674.52
$1,800.54
$2,248.26
$1,892.67
$2,011.63
$2,137.65
$2,585.37
$337.11
Toc - Plan #123 Oscar Insurance Company of Florida
Catastrophic

(EPO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$250.95
$284.82
$320.71
$448.19
$681.06
$442.92
$476.79
$512.68
$640.16
$634.89
$668.76
$704.65
$832.13
$826.86
$860.73
$896.62
$1,024.10
$191.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$501.90
$569.64
$641.42
$896.38
$1,362.12
$693.87
$761.61
$833.39
$1,088.35
$885.84
$953.58
$1,025.36
$1,280.32
$1,077.81
$1,145.55
$1,217.33
$1,472.29
$191.97
Toc - Plan #124 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- Deductible+Specialist Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.78
$448.07
$504.52
$705.06
$1,071.41
$696.78
$750.07
$806.52
$1,007.06
$998.78
$1,052.07
$1,108.52
$1,309.06
$1,300.78
$1,354.07
$1,410.52
$1,611.06
$302.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$789.56
$896.14
$1,009.04
$1,410.12
$2,142.82
$1,091.56
$1,198.14
$1,311.04
$1,712.12
$1,393.56
$1,500.14
$1,613.04
$2,014.12
$1,695.56
$1,802.14
$1,915.04
$2,316.12
$302.00
Toc - Plan #125 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$465.88
$528.76
$595.38
$832.04
$1,264.37
$822.27
$885.15
$951.77
$1,188.43
$1,178.66
$1,241.54
$1,308.16
$1,544.82
$1,535.05
$1,597.93
$1,664.55
$1,901.21
$356.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$931.76
$1,057.52
$1,190.76
$1,664.08
$2,528.74
$1,288.15
$1,413.91
$1,547.15
$2,020.47
$1,644.54
$1,770.30
$1,903.54
$2,376.86
$2,000.93
$2,126.69
$2,259.93
$2,733.25
$356.39
Toc - Plan #126 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$347.62
$394.53
$444.24
$620.82
$943.40
$613.54
$660.45
$710.16
$886.74
$879.46
$926.37
$976.08
$1,152.66
$1,145.38
$1,192.29
$1,242.00
$1,418.58
$265.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$695.24
$789.06
$888.48
$1,241.64
$1,886.80
$961.16
$1,054.98
$1,154.40
$1,507.56
$1,227.08
$1,320.90
$1,420.32
$1,773.48
$1,493.00
$1,586.82
$1,686.24
$2,039.40
$265.92
Toc - Plan #127 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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
$436.84
$495.80
$558.26
$780.17
$1,185.55
$771.01
$829.97
$892.43
$1,114.34
$1,105.18
$1,164.14
$1,226.60
$1,448.51
$1,439.35
$1,498.31
$1,560.77
$1,782.68
$334.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.68
$991.60
$1,116.52
$1,560.34
$2,371.10
$1,207.85
$1,325.77
$1,450.69
$1,894.51
$1,542.02
$1,659.94
$1,784.86
$2,228.68
$1,876.19
$1,994.11
$2,119.03
$2,562.85
$334.17
Toc - Plan #128 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$445.79
$505.96
$569.71
$796.16
$1,209.84
$786.81
$846.98
$910.73
$1,137.18
$1,127.83
$1,188.00
$1,251.75
$1,478.20
$1,468.85
$1,529.02
$1,592.77
$1,819.22
$341.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$891.58
$1,011.92
$1,139.42
$1,592.32
$2,419.68
$1,232.60
$1,352.94
$1,480.44
$1,933.34
$1,573.62
$1,693.96
$1,821.46
$2,274.36
$1,914.64
$2,034.98
$2,162.48
$2,615.38
$341.02
Toc - Plan #129 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- Deductible Saver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $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
$448.99
$509.59
$573.80
$801.88
$1,218.54
$792.46
$853.06
$917.27
$1,145.35
$1,135.93
$1,196.53
$1,260.74
$1,488.82
$1,479.40
$1,540.00
$1,604.21
$1,832.29
$343.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$897.98
$1,019.18
$1,147.60
$1,603.76
$2,437.08
$1,241.45
$1,362.65
$1,491.07
$1,947.23
$1,584.92
$1,706.12
$1,834.54
$2,290.70
$1,928.39
$2,049.59
$2,178.01
$2,634.17
$343.47
Toc - Plan #130 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- PCP Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$345.74
$392.40
$441.84
$617.47
$938.31
$610.22
$656.88
$706.32
$881.95
$874.70
$921.36
$970.80
$1,146.43
$1,139.18
$1,185.84
$1,235.28
$1,410.91
$264.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$691.48
$784.80
$883.68
$1,234.94
$1,876.62
$955.96
$1,049.28
$1,148.16
$1,499.42
$1,220.44
$1,313.76
$1,412.64
$1,763.90
$1,484.92
$1,578.24
$1,677.12
$2,028.38
$264.48
Toc - Plan #131 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- Deductible Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.89
$403.92
$454.81
$635.59
$965.85
$628.13
$676.16
$727.05
$907.83
$900.37
$948.40
$999.29
$1,180.07
$1,172.61
$1,220.64
$1,271.53
$1,452.31
$272.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.78
$807.84
$909.62
$1,271.18
$1,931.70
$984.02
$1,080.08
$1,181.86
$1,543.42
$1,256.26
$1,352.32
$1,454.10
$1,815.66
$1,528.50
$1,624.56
$1,726.34
$2,087.90
$272.24
Toc - Plan #132 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.65
$492.18
$554.19
$774.47
$1,176.89
$765.38
$823.91
$885.92
$1,106.20
$1,097.11
$1,155.64
$1,217.65
$1,437.93
$1,428.84
$1,487.37
$1,549.38
$1,769.66
$331.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.30
$984.36
$1,108.38
$1,548.94
$2,353.78
$1,199.03
$1,316.09
$1,440.11
$1,880.67
$1,530.76
$1,647.82
$1,771.84
$2,212.40
$1,862.49
$1,979.55
$2,103.57
$2,544.13
$331.73
Toc - Plan #133 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- PCP Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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
$450.92
$511.78
$576.26
$805.32
$1,223.76
$795.86
$856.72
$921.20
$1,150.26
$1,140.80
$1,201.66
$1,266.14
$1,495.20
$1,485.74
$1,546.60
$1,611.08
$1,840.14
$344.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$901.84
$1,023.56
$1,152.52
$1,610.64
$2,447.52
$1,246.78
$1,368.50
$1,497.46
$1,955.58
$1,591.72
$1,713.44
$1,842.40
$2,300.52
$1,936.66
$2,058.38
$2,187.34
$2,645.46
$344.94
Toc - Plan #134 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$440.03
$499.42
$562.35
$785.88
$1,194.22
$776.65
$836.04
$898.97
$1,122.50
$1,113.27
$1,172.66
$1,235.59
$1,459.12
$1,449.89
$1,509.28
$1,572.21
$1,795.74
$336.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$880.06
$998.84
$1,124.70
$1,571.76
$2,388.44
$1,216.68
$1,335.46
$1,461.32
$1,908.38
$1,553.30
$1,672.08
$1,797.94
$2,245.00
$1,889.92
$2,008.70
$2,134.56
$2,581.62
$336.62
Toc - Plan #135 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite- Deductible Saver Plus

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

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
$510.74
$579.68
$652.72
$912.17
$1,386.13
$901.45
$970.39
$1,043.43
$1,302.88
$1,292.16
$1,361.10
$1,434.14
$1,693.59
$1,682.87
$1,751.81
$1,824.85
$2,084.30
$390.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,021.48
$1,159.36
$1,305.44
$1,824.34
$2,772.26
$1,412.19
$1,550.07
$1,696.15
$2,215.05
$1,802.90
$1,940.78
$2,086.86
$2,605.76
$2,193.61
$2,331.49
$2,477.57
$2,996.47
$390.71
Toc - Plan #136 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite

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

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
$478.21
$542.76
$611.15
$854.07
$1,297.85
$844.04
$908.59
$976.98
$1,219.90
$1,209.87
$1,274.42
$1,342.81
$1,585.73
$1,575.70
$1,640.25
$1,708.64
$1,951.56
$365.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$956.42
$1,085.52
$1,222.30
$1,708.14
$2,595.70
$1,322.25
$1,451.35
$1,588.13
$2,073.97
$1,688.08
$1,817.18
$1,953.96
$2,439.80
$2,053.91
$2,183.01
$2,319.79
$2,805.63
$365.83
Toc - Plan #137 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.52
$437.55
$492.68
$688.52
$1,046.28
$680.44
$732.47
$787.60
$983.44
$975.36
$1,027.39
$1,082.52
$1,278.36
$1,270.28
$1,322.31
$1,377.44
$1,573.28
$294.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.04
$875.10
$985.36
$1,377.04
$2,092.56
$1,065.96
$1,170.02
$1,280.28
$1,671.96
$1,360.88
$1,464.94
$1,575.20
$1,966.88
$1,655.80
$1,759.86
$1,870.12
$2,261.80
$294.92
Toc - Plan #138 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$438.75
$497.97
$560.71
$783.60
$1,190.75
$774.39
$833.61
$896.35
$1,119.24
$1,110.03
$1,169.25
$1,231.99
$1,454.88
$1,445.67
$1,504.89
$1,567.63
$1,790.52
$335.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$877.50
$995.94
$1,121.42
$1,567.20
$2,381.50
$1,213.14
$1,331.58
$1,457.06
$1,902.84
$1,548.78
$1,667.22
$1,792.70
$2,238.48
$1,884.42
$2,002.86
$2,128.34
$2,574.12
$335.64
Toc - Plan #139 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$352.33
$399.88
$450.26
$629.24
$956.20
$621.85
$669.40
$719.78
$898.76
$891.37
$938.92
$989.30
$1,168.28
$1,160.89
$1,208.44
$1,258.82
$1,437.80
$269.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704.66
$799.76
$900.52
$1,258.48
$1,912.40
$974.18
$1,069.28
$1,170.04
$1,528.00
$1,243.70
$1,338.80
$1,439.56
$1,797.52
$1,513.22
$1,608.32
$1,709.08
$2,067.04
$269.52
Toc - Plan #140 Oscar Insurance Company of Florida
Bronze

(EPO) Bronze Simple- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.03
$351.87
$396.20
$553.69
$841.39
$547.19
$589.03
$633.36
$790.85
$784.35
$826.19
$870.52
$1,028.01
$1,021.51
$1,063.35
$1,107.68
$1,265.17
$237.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.06
$703.74
$792.40
$1,107.38
$1,682.78
$857.22
$940.90
$1,029.56
$1,344.54
$1,094.38
$1,178.06
$1,266.72
$1,581.70
$1,331.54
$1,415.22
$1,503.88
$1,818.86
$237.16
Toc - Plan #141 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.28
$492.90
$555.00
$775.61
$1,178.62
$766.50
$825.12
$887.22
$1,107.83
$1,098.72
$1,157.34
$1,219.44
$1,440.05
$1,430.94
$1,489.56
$1,551.66
$1,772.27
$332.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.56
$985.80
$1,110.00
$1,551.22
$2,357.24
$1,200.78
$1,318.02
$1,442.22
$1,883.44
$1,533.00
$1,650.24
$1,774.44
$2,215.66
$1,865.22
$1,982.46
$2,106.66
$2,547.88
$332.22
Toc - Plan #142 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.26
$504.23
$567.75
$793.43
$1,205.70
$784.11
$844.08
$907.60
$1,133.28
$1,123.96
$1,183.93
$1,247.45
$1,473.13
$1,463.81
$1,523.78
$1,587.30
$1,812.98
$339.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.52
$1,008.46
$1,135.50
$1,586.86
$2,411.40
$1,228.37
$1,348.31
$1,475.35
$1,926.71
$1,568.22
$1,688.16
$1,815.20
$2,266.56
$1,908.07
$2,028.01
$2,155.05
$2,606.41
$339.85

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-5716 | Toll Free: 1-888-560-5716 | TTY: 1-800-955-8771

Toc - Plan #143 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.65
$466.09
$524.81
$733.42
$1,114.51
$724.80
$780.24
$838.96
$1,047.57
$1,038.95
$1,094.39
$1,153.11
$1,361.72
$1,353.10
$1,408.54
$1,467.26
$1,675.87
$314.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.30
$932.18
$1,049.62
$1,466.84
$2,229.02
$1,135.45
$1,246.33
$1,363.77
$1,780.99
$1,449.60
$1,560.48
$1,677.92
$2,095.14
$1,763.75
$1,874.63
$1,992.07
$2,409.29
$314.15
Toc - Plan #144 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.05
$405.25
$456.31
$637.69
$969.04
$630.19
$678.39
$729.45
$910.83
$903.33
$951.53
$1,002.59
$1,183.97
$1,176.47
$1,224.67
$1,275.73
$1,457.11
$273.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714.10
$810.50
$912.62
$1,275.38
$1,938.08
$987.24
$1,083.64
$1,185.76
$1,548.52
$1,260.38
$1,356.78
$1,458.90
$1,821.66
$1,533.52
$1,629.92
$1,732.04
$2,094.80
$273.14
Toc - Plan #145 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$327.76
$372.01
$418.88
$585.38
$889.54
$578.50
$622.75
$669.62
$836.12
$829.24
$873.49
$920.36
$1,086.86
$1,079.98
$1,124.23
$1,171.10
$1,337.60
$250.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$655.52
$744.02
$837.76
$1,170.76
$1,779.08
$906.26
$994.76
$1,088.50
$1,421.50
$1,157.00
$1,245.50
$1,339.24
$1,672.24
$1,407.74
$1,496.24
$1,589.98
$1,922.98
$250.74
Toc - Plan #146 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419.20
$475.79
$535.74
$748.69
$1,137.71
$739.89
$796.48
$856.43
$1,069.38
$1,060.58
$1,117.17
$1,177.12
$1,390.07
$1,381.27
$1,437.86
$1,497.81
$1,710.76
$320.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$838.40
$951.58
$1,071.48
$1,497.38
$2,275.42
$1,159.09
$1,272.27
$1,392.17
$1,818.07
$1,479.78
$1,592.96
$1,712.86
$2,138.76
$1,800.47
$1,913.65
$2,033.55
$2,459.45
$320.69
Toc - Plan #147 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.81
$412.92
$464.95
$649.76
$987.37
$642.12
$691.23
$743.26
$928.07
$920.43
$969.54
$1,021.57
$1,206.38
$1,198.74
$1,247.85
$1,299.88
$1,484.69
$278.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.62
$825.84
$929.90
$1,299.52
$1,974.74
$1,005.93
$1,104.15
$1,208.21
$1,577.83
$1,284.24
$1,382.46
$1,486.52
$1,856.14
$1,562.55
$1,660.77
$1,764.83
$2,134.45
$278.31
Toc - Plan #148 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 8

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$283.54
$321.82
$362.37
$506.41
$769.54
$500.45
$538.73
$579.28
$723.32
$717.36
$755.64
$796.19
$940.23
$934.27
$972.55
$1,013.10
$1,157.14
$216.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$567.08
$643.64
$724.74
$1,012.82
$1,539.08
$783.99
$860.55
$941.65
$1,229.73
$1,000.90
$1,077.46
$1,158.56
$1,446.64
$1,217.81
$1,294.37
$1,375.47
$1,663.55
$216.91
Toc - Plan #149 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414.51
$470.47
$529.74
$740.31
$1,124.97
$731.61
$787.57
$846.84
$1,057.41
$1,048.71
$1,104.67
$1,163.94
$1,374.51
$1,365.81
$1,421.77
$1,481.04
$1,691.61
$317.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$829.02
$940.94
$1,059.48
$1,480.62
$2,249.94
$1,146.12
$1,258.04
$1,376.58
$1,797.72
$1,463.22
$1,575.14
$1,693.68
$2,114.82
$1,780.32
$1,892.24
$2,010.78
$2,431.92
$317.10
Toc - Plan #150 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.91
$409.64
$461.25
$644.59
$979.52
$637.01
$685.74
$737.35
$920.69
$913.11
$961.84
$1,013.45
$1,196.79
$1,189.21
$1,237.94
$1,289.55
$1,472.89
$276.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.82
$819.28
$922.50
$1,289.18
$1,959.04
$997.92
$1,095.38
$1,198.60
$1,565.28
$1,274.02
$1,371.48
$1,474.70
$1,841.38
$1,550.12
$1,647.58
$1,750.80
$2,117.48
$276.10

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770

Toc - Plan #151 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Elite VALUE Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.09
$359.88
$405.23
$566.30
$860.55
$559.66
$602.45
$647.80
$808.87
$802.23
$845.02
$890.37
$1,051.44
$1,044.80
$1,087.59
$1,132.94
$1,294.01
$242.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.18
$719.76
$810.46
$1,132.60
$1,721.10
$876.75
$962.33
$1,053.03
$1,375.17
$1,119.32
$1,204.90
$1,295.60
$1,617.74
$1,361.89
$1,447.47
$1,538.17
$1,860.31
$242.57
Toc - Plan #152 Ambetter from Sunshine Health
Silver

(HMO) Complete VALUE Silver

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

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
$352.79
$400.41
$450.86
$630.07
$957.45
$622.67
$670.29
$720.74
$899.95
$892.55
$940.17
$990.62
$1,169.83
$1,162.43
$1,210.05
$1,260.50
$1,439.71
$269.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$705.58
$800.82
$901.72
$1,260.14
$1,914.90
$975.46
$1,070.70
$1,171.60
$1,530.02
$1,245.34
$1,340.58
$1,441.48
$1,799.90
$1,515.22
$1,610.46
$1,711.36
$2,069.78
$269.88
Toc - Plan #153 Ambetter from Sunshine Health
Silver

(HMO) Clear VALUE Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$344.61
$391.12
$440.40
$615.46
$935.25
$608.23
$654.74
$704.02
$879.08
$871.85
$918.36
$967.64
$1,142.70
$1,135.47
$1,181.98
$1,231.26
$1,406.32
$263.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$689.22
$782.24
$880.80
$1,230.92
$1,870.50
$952.84
$1,045.86
$1,144.42
$1,494.54
$1,216.46
$1,309.48
$1,408.04
$1,758.16
$1,480.08
$1,573.10
$1,671.66
$2,021.78
$263.62
Toc - Plan #154 Ambetter from Sunshine Health
Silver

(HMO) Focused VALUE Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$347.56
$394.47
$444.17
$620.72
$943.24
$613.43
$660.34
$710.04
$886.59
$879.30
$926.21
$975.91
$1,152.46
$1,145.17
$1,192.08
$1,241.78
$1,418.33
$265.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$695.12
$788.94
$888.34
$1,241.44
$1,886.48
$960.99
$1,054.81
$1,154.21
$1,507.31
$1,226.86
$1,320.68
$1,420.08
$1,773.18
$1,492.73
$1,586.55
$1,685.95
$2,039.05
$265.87
Toc - Plan #155 Ambetter from Sunshine Health
Gold

(HMO) Complete VALUE Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$345.12
$391.70
$441.05
$616.37
$936.63
$609.13
$655.71
$705.06
$880.38
$873.14
$919.72
$969.07
$1,144.39
$1,137.15
$1,183.73
$1,233.08
$1,408.40
$264.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$690.24
$783.40
$882.10
$1,232.74
$1,873.26
$954.25
$1,047.41
$1,146.11
$1,496.75
$1,218.26
$1,311.42
$1,410.12
$1,760.76
$1,482.27
$1,575.43
$1,674.13
$2,024.77
$264.01
Toc - Plan #156 Ambetter from Sunshine Health
Expanded Bronze

(HMO) CMS Standard Expanded Bronze VALUE

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$271.53
$308.18
$347.01
$484.94
$736.91
$479.24
$515.89
$554.72
$692.65
$686.95
$723.60
$762.43
$900.36
$894.66
$931.31
$970.14
$1,108.07
$207.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$543.06
$616.36
$694.02
$969.88
$1,473.82
$750.77
$824.07
$901.73
$1,177.59
$958.48
$1,031.78
$1,109.44
$1,385.30
$1,166.19
$1,239.49
$1,317.15
$1,593.01
$207.71
Toc - Plan #157 Ambetter from Sunshine Health
Silver

(HMO) CMS Standard Silver VALUE

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$344.43
$390.92
$440.17
$615.14
$934.76
$607.91
$654.40
$703.65
$878.62
$871.39
$917.88
$967.13
$1,142.10
$1,134.87
$1,181.36
$1,230.61
$1,405.58
$263.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.86
$781.84
$880.34
$1,230.28
$1,869.52
$952.34
$1,045.32
$1,143.82
$1,493.76
$1,215.82
$1,308.80
$1,407.30
$1,757.24
$1,479.30
$1,572.28
$1,670.78
$2,020.72
$263.48
Toc - Plan #158 Ambetter from Sunshine Health
Gold

(HMO) CMS Standard Gold VALUE

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322.54
$366.07
$412.20
$576.04
$875.35
$569.28
$612.81
$658.94
$822.78
$816.02
$859.55
$905.68
$1,069.52
$1,062.76
$1,106.29
$1,152.42
$1,316.26
$246.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$645.08
$732.14
$824.40
$1,152.08
$1,750.70
$891.82
$978.88
$1,071.14
$1,398.82
$1,138.56
$1,225.62
$1,317.88
$1,645.56
$1,385.30
$1,472.36
$1,564.62
$1,892.30
$246.74

‡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 Duval County here.

Duval County is in “Rating Area 15” of Florida.

Currently, there are 158 plans offered in Rating Area 15.

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2023 Obamacare Plans for Duval County, FL

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