Florida

Obamacare 2018 Rates

Obamacare 2018 Rates and Health Insurance Providers for Flagler County,Palm Coast,FL


The health insurance rates listed below are for calendar year 2018.

2018 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

(click here for 2017)

This page gives you an overview of the rates for individual and family health insurance plans available from HealthCare.gov, the marketplace for Flagler County, Florida.

Obamacare Providers, Plans and 2018 Rates for Flagler County

Flagler County is in “Rating Area 17” of Florida.

Currently, there are 92 plans offered in Rating Area 17.

Below, you’ll find a summary of plans and rates for each of these providers. This chart is designed to give you a preview of your health insurance options. For detailed information on available subsidies to make your coverage affordable, you must either

  • contact a licensed health insurance agent (by contacting one of the advertisers you see on this website)
  • complete an application at HealthCare.gov, or
  • contact the provider directly.

The table below shows premiums for the following scenarios for:

  • Individual
  • Couple
  • Couple with 1 2 or 3 children
  • Individual with 1 2 or 3 children
  • A child alone

Each scenario is covered for age

  • Age 21, 30, 40, 50
  • Age 60 (Individual and Couple only)

For each plan, there are links that go to the insurance provider's website in a new window. You can find links to:

  • a summary of plan benefits and costs,
  • a plan brochure, and
  • a "Provider Directory" -- where you can find out which doctors and hospitals in the Palm Coast, FL area accept this insurance coverage as within the plan's "network".

2018 Obamacare Rates Providers, Plans for Flagler County

Blue Cross and Blue Shield of Florida

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583

TTY: 1-800-955-8771

Silver

Plan: (EPO) BlueOptions Silver 1423

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $5,950 : Family: $11,900
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$647.82
$735.28
$827.91
$1,157.01
$1,758.18
$1,295.64
$1,470.56
$1,655.82
$2,314.02
$3,516.36
$1,791.22
$1,966.14
$2,151.40
$2,809.60
$2,286.80
$2,461.72
$2,646.98
$3,305.18
$2,782.38
$2,957.30
$3,142.56
$3,800.76
$1,143.40
$1,230.86
$1,323.49
$1,652.59
$1,638.98
$1,726.44
$1,819.07
$2,148.17
$2,134.56
$2,222.02
$2,314.65
$2,643.75
$495.58

Bronze

Plan: (EPO) BlueOptions Bronze 1419

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$363.77
$412.88
$464.90
$649.69
$987.27
$727.54
$825.76
$929.80
$1,299.38
$1,974.54
$1,005.82
$1,104.04
$1,208.08
$1,577.66
$1,284.10
$1,382.32
$1,486.36
$1,855.94
$1,562.38
$1,660.60
$1,764.64
$2,134.22
$642.05
$691.16
$743.18
$927.97
$920.33
$969.44
$1,021.46
$1,206.25
$1,198.61
$1,247.72
$1,299.74
$1,484.53
$278.28

Silver

Plan: (EPO) BlueOptions Silver 1431

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $5,450 : Family: $10,900
Out of Pocket Maximum per year: Individual: $6,800 : Family: $13,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$671.21
$761.82
$857.81
$1,198.78
$1,821.66
$1,342.42
$1,523.64
$1,715.62
$2,397.56
$3,643.32
$1,855.90
$2,037.12
$2,229.10
$2,911.04
$2,369.38
$2,550.60
$2,742.58
$3,424.52
$2,882.86
$3,064.08
$3,256.06
$3,938.00
$1,184.69
$1,275.30
$1,371.29
$1,712.26
$1,698.17
$1,788.78
$1,884.77
$2,225.74
$2,211.65
$2,302.26
$2,398.25
$2,739.22
$513.48

Platinum

Plan: (EPO) BlueOptions Platinum 1418

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $800 : Family: $1,600
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$824.76
$936.10
$1,054.04
$1,473.02
$2,238.40
$1,649.52
$1,872.20
$2,108.08
$2,946.04
$4,476.80
$2,280.46
$2,503.14
$2,739.02
$3,576.98
$2,911.40
$3,134.08
$3,369.96
$4,207.92
$3,542.34
$3,765.02
$4,000.90
$4,838.86
$1,455.70
$1,567.04
$1,684.98
$2,103.96
$2,086.64
$2,197.98
$2,315.92
$2,734.90
$2,717.58
$2,828.92
$2,946.86
$3,365.84
$630.94

Expanded Bronze

Plan: (EPO) BlueOptions Bronze 1416

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $6,400 : Family: $12,800
Out of Pocket Maximum per year: Individual: $6,900 : Family: $13,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$395.83
$449.27
$505.87
$706.95
$1,074.28
$791.66
$898.54
$1,011.74
$1,413.90
$2,148.56
$1,094.47
$1,201.35
$1,314.55
$1,716.71
$1,397.28
$1,504.16
$1,617.36
$2,019.52
$1,700.09
$1,806.97
$1,920.17
$2,322.33
$698.64
$752.08
$808.68
$1,009.76
$1,001.45
$1,054.89
$1,111.49
$1,312.57
$1,304.26
$1,357.70
$1,414.30
$1,615.38
$302.81

Platinum

Plan: (EPO) BlueOptions Platinum 1424

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $2,000 : Family: $4,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$845.44
$959.57
$1,080.47
$1,509.96
$2,294.52
$1,690.88
$1,919.14
$2,160.94
$3,019.92
$4,589.04
$2,337.64
$2,565.90
$2,807.70
$3,666.68
$2,984.40
$3,212.66
$3,454.46
$4,313.44
$3,631.16
$3,859.42
$4,101.22
$4,960.20
$1,492.20
$1,606.33
$1,727.23
$2,156.72
$2,138.96
$2,253.09
$2,373.99
$2,803.48
$2,785.72
$2,899.85
$3,020.75
$3,450.24
$646.76

Silver

Plan: (EPO) BlueOptions Silver 1410

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $6,050 : Family: $12,100
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$602.02
$683.29
$769.38
$1,075.21
$1,633.88
$1,204.04
$1,366.58
$1,538.76
$2,150.42
$3,267.76
$1,664.59
$1,827.13
$1,999.31
$2,610.97
$2,125.14
$2,287.68
$2,459.86
$3,071.52
$2,585.69
$2,748.23
$2,920.41
$3,532.07
$1,062.57
$1,143.84
$1,229.93
$1,535.76
$1,523.12
$1,604.39
$1,690.48
$1,996.31
$1,983.67
$2,064.94
$2,151.03
$2,456.86
$460.55

Gold

Plan: (EPO) BlueOptions Gold 1505

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$655.23
$743.69
$837.38
$1,170.24
$1,778.29
$1,310.46
$1,487.38
$1,674.76
$2,340.48
$3,556.58
$1,811.71
$1,988.63
$2,176.01
$2,841.73
$2,312.96
$2,489.88
$2,677.26
$3,342.98
$2,814.21
$2,991.13
$3,178.51
$3,844.23
$1,156.48
$1,244.94
$1,338.63
$1,671.49
$1,657.73
$1,746.19
$1,839.88
$2,172.74
$2,158.98
$2,247.44
$2,341.13
$2,673.99
$501.25

Bronze

Plan: (EPO) BlueOptions Bronze (HSA) 1705

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$378.57
$429.68
$483.81
$676.13
$1,027.44
$757.14
$859.36
$967.62
$1,352.26
$2,054.88
$1,046.75
$1,148.97
$1,257.23
$1,641.87
$1,336.36
$1,438.58
$1,546.84
$1,931.48
$1,625.97
$1,728.19
$1,836.45
$2,221.09
$668.18
$719.29
$773.42
$965.74
$957.79
$1,008.90
$1,063.03
$1,255.35
$1,247.40
$1,298.51
$1,352.64
$1,544.96
$289.61

Silver

Plan: (EPO) BlueOptions Silver 1706S

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$667.12
$757.18
$852.58
$1,191.48
$1,810.56
$1,334.24
$1,514.36
$1,705.16
$2,382.96
$3,621.12
$1,844.59
$2,024.71
$2,215.51
$2,893.31
$2,354.94
$2,535.06
$2,725.86
$3,403.66
$2,865.29
$3,045.41
$3,236.21
$3,914.01
$1,177.47
$1,267.53
$1,362.93
$1,701.83
$1,687.82
$1,777.88
$1,873.28
$2,212.18
$2,198.17
$2,288.23
$2,383.63
$2,722.53
$510.35

Expanded Bronze

Plan: (EPO) BlueOptions Bronze 1707S

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$381.81
$433.35
$487.95
$681.91
$1,036.23
$763.62
$866.70
$975.90
$1,363.82
$2,072.46
$1,055.70
$1,158.78
$1,267.98
$1,655.90
$1,347.78
$1,450.86
$1,560.06
$1,947.98
$1,639.86
$1,742.94
$1,852.14
$2,240.06
$673.89
$725.43
$780.03
$973.99
$965.97
$1,017.51
$1,072.11
$1,266.07
$1,258.05
$1,309.59
$1,364.19
$1,558.15
$292.08

Gold

Plan: (EPO) BlueOptions Gold 1805

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Blue Cross and Blue Shield of Florida)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$626.07
$710.59
$800.12
$1,118.16
$1,699.15
$1,252.14
$1,421.18
$1,600.24
$2,236.32
$3,398.30
$1,731.08
$1,900.12
$2,079.18
$2,715.26
$2,210.02
$2,379.06
$2,558.12
$3,194.20
$2,688.96
$2,858.00
$3,037.06
$3,673.14
$1,105.01
$1,189.53
$1,279.06
$1,597.10
$1,583.95
$1,668.47
$1,758.00
$2,076.04
$2,062.89
$2,147.41
$2,236.94
$2,554.98
$478.94

Health Options, Inc.

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583

TTY: 1-800-955-8771

Silver

Plan: (HMO) BlueCare Silver 1490

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $5,950 : Family: $11,900
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$503.01
$570.92
$642.85
$898.38
$1,365.17
$1,006.02
$1,141.84
$1,285.70
$1,796.76
$2,730.34
$1,390.82
$1,526.64
$1,670.50
$2,181.56
$1,775.62
$1,911.44
$2,055.30
$2,566.36
$2,160.42
$2,296.24
$2,440.10
$2,951.16
$887.81
$955.72
$1,027.65
$1,283.18
$1,272.61
$1,340.52
$1,412.45
$1,667.98
$1,657.41
$1,725.32
$1,797.25
$2,052.78
$384.80

Bronze

Plan: (HMO) BlueCare Bronze 1486

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$296.22
$336.21
$378.57
$529.05
$803.94
$592.44
$672.42
$757.14
$1,058.10
$1,607.88
$819.05
$899.03
$983.75
$1,284.71
$1,045.66
$1,125.64
$1,210.36
$1,511.32
$1,272.27
$1,352.25
$1,436.97
$1,737.93
$522.83
$562.82
$605.18
$755.66
$749.44
$789.43
$831.79
$982.27
$976.05
$1,016.04
$1,058.40
$1,208.88
$226.61

Silver

Plan: (HMO) BlueCare Silver 1498

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $5,450 : Family: $10,900
Out of Pocket Maximum per year: Individual: $6,800 : Family: $13,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$508.15
$576.75
$649.42
$907.56
$1,379.12
$1,016.30
$1,153.50
$1,298.84
$1,815.12
$2,758.24
$1,405.03
$1,542.23
$1,687.57
$2,203.85
$1,793.76
$1,930.96
$2,076.30
$2,592.58
$2,182.49
$2,319.69
$2,465.03
$2,981.31
$896.88
$965.48
$1,038.15
$1,296.29
$1,285.61
$1,354.21
$1,426.88
$1,685.02
$1,674.34
$1,742.94
$1,815.61
$2,073.75
$388.73

Platinum

Plan: (HMO) BlueCare Platinum 1485

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $800 : Family: $1,600
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$589.21
$668.75
$753.01
$1,052.33
$1,599.12
$1,178.42
$1,337.50
$1,506.02
$2,104.66
$3,198.24
$1,629.17
$1,788.25
$1,956.77
$2,555.41
$2,079.92
$2,239.00
$2,407.52
$3,006.16
$2,530.67
$2,689.75
$2,858.27
$3,456.91
$1,039.96
$1,119.50
$1,203.76
$1,503.08
$1,490.71
$1,570.25
$1,654.51
$1,953.83
$1,941.46
$2,021.00
$2,105.26
$2,404.58
$450.75

Expanded Bronze

Plan: (HMO) BlueCare Bronze 1483

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $6,400 : Family: $12,800
Out of Pocket Maximum per year: Individual: $6,900 : Family: $13,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$331.08
$375.78
$423.12
$591.31
$898.55
$662.16
$751.56
$846.24
$1,182.62
$1,797.10
$915.44
$1,004.84
$1,099.52
$1,435.90
$1,168.72
$1,258.12
$1,352.80
$1,689.18
$1,422.00
$1,511.40
$1,606.08
$1,942.46
$584.36
$629.06
$676.40
$844.59
$837.64
$882.34
$929.68
$1,097.87
$1,090.92
$1,135.62
$1,182.96
$1,351.15
$253.28

Platinum

Plan: (HMO) BlueCare Platinum 1491

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $2,000 : Family: $4,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$610.02
$692.37
$779.61
$1,089.50
$1,655.59
$1,220.04
$1,384.74
$1,559.22
$2,179.00
$3,311.18
$1,686.71
$1,851.41
$2,025.89
$2,645.67
$2,153.38
$2,318.08
$2,492.56
$3,112.34
$2,620.05
$2,784.75
$2,959.23
$3,579.01
$1,076.69
$1,159.04
$1,246.28
$1,556.17
$1,543.36
$1,625.71
$1,712.95
$2,022.84
$2,010.03
$2,092.38
$2,179.62
$2,489.51
$466.67

Silver

Plan: (HMO) BlueCare Silver 1477

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $6,050 : Family: $12,100
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$442.04
$501.72
$564.93
$789.48
$1,199.70
$884.08
$1,003.44
$1,129.86
$1,578.96
$2,399.40
$1,222.24
$1,341.60
$1,468.02
$1,917.12
$1,560.40
$1,679.76
$1,806.18
$2,255.28
$1,898.56
$2,017.92
$2,144.34
$2,593.44
$780.20
$839.88
$903.09
$1,127.64
$1,118.36
$1,178.04
$1,241.25
$1,465.80
$1,456.52
$1,516.20
$1,579.41
$1,803.96
$338.16

Gold

Plan: (HMO) BlueCare Gold 1565

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$523.41
$594.07
$668.92
$934.81
$1,420.53
$1,046.82
$1,188.14
$1,337.84
$1,869.62
$2,841.06
$1,447.23
$1,588.55
$1,738.25
$2,270.03
$1,847.64
$1,988.96
$2,138.66
$2,670.44
$2,248.05
$2,389.37
$2,539.07
$3,070.85
$923.82
$994.48
$1,069.33
$1,335.22
$1,324.23
$1,394.89
$1,469.74
$1,735.63
$1,724.64
$1,795.30
$1,870.15
$2,136.04
$400.41

Bronze

Plan: (HMO) BlueCare Bronze (HSA) 1765

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$311.40
$353.44
$397.97
$556.16
$845.14
$622.80
$706.88
$795.94
$1,112.32
$1,690.28
$861.02
$945.10
$1,034.16
$1,350.54
$1,099.24
$1,183.32
$1,272.38
$1,588.76
$1,337.46
$1,421.54
$1,510.60
$1,826.98
$549.62
$591.66
$636.19
$794.38
$787.84
$829.88
$874.41
$1,032.60
$1,026.06
$1,068.10
$1,112.63
$1,270.82
$238.22

Silver

Plan: (HMO) BlueCare Silver 1766S

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$502.26
$570.07
$641.89
$897.04
$1,363.13
$1,004.52
$1,140.14
$1,283.78
$1,794.08
$2,726.26
$1,388.75
$1,524.37
$1,668.01
$2,178.31
$1,772.98
$1,908.60
$2,052.24
$2,562.54
$2,157.21
$2,292.83
$2,436.47
$2,946.77
$886.49
$954.30
$1,026.12
$1,281.27
$1,270.72
$1,338.53
$1,410.35
$1,665.50
$1,654.95
$1,722.76
$1,794.58
$2,049.73
$384.23

Expanded Bronze

Plan: (HMO) BlueCare Bronze 1767S

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$314.27
$356.70
$401.64
$561.29
$852.93
$628.54
$713.40
$803.28
$1,122.58
$1,705.86
$868.96
$953.82
$1,043.70
$1,363.00
$1,109.38
$1,194.24
$1,284.12
$1,603.42
$1,349.80
$1,434.66
$1,524.54
$1,843.84
$554.69
$597.12
$642.06
$801.71
$795.11
$837.54
$882.48
$1,042.13
$1,035.53
$1,077.96
$1,122.90
$1,282.55
$240.42

Gold

Plan: (HMO) BlueCare Gold 1865

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health Options, Inc.)
Customer Service Phone: 1-800-352-2583

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$495.03
$561.86
$632.65
$884.12
$1,343.51
$990.06
$1,123.72
$1,265.30
$1,768.24
$2,687.02
$1,368.76
$1,502.42
$1,644.00
$2,146.94
$1,747.46
$1,881.12
$2,022.70
$2,525.64
$2,126.16
$2,259.82
$2,401.40
$2,904.34
$873.73
$940.56
$1,011.35
$1,262.82
$1,252.43
$1,319.26
$1,390.05
$1,641.52
$1,631.13
$1,697.96
$1,768.75
$2,020.22
$378.70

Health First Commercial Plans, Inc.

Local: 1-855-443-4735 | Toll Free: 1-855-443-4735

TTY: 1-800-955-8771

Expanded Bronze

Plan: (HMO) Florida Hospital GYM ACCESS Bronze HMO 70 1657

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$292.34
$331.80
$373.61
$522.12
$793.41
$584.68
$663.60
$747.22
$1,044.24
$1,586.82
$808.32
$887.24
$970.86
$1,267.88
$1,031.96
$1,110.88
$1,194.50
$1,491.52
$1,255.60
$1,334.52
$1,418.14
$1,715.16
$515.98
$555.44
$597.25
$745.76
$739.62
$779.08
$820.89
$969.40
$963.26
$1,002.72
$1,044.53
$1,193.04
$223.64

Bronze

Plan: (HMO) Florida Hospital GYM ACCESS Bronze HMO 100 HSA 1660

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $6,350 : Family: $12,700
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$276.01
$313.27
$352.74
$492.95
$749.08
$552.02
$626.54
$705.48
$985.90
$1,498.16
$763.16
$837.68
$916.62
$1,197.04
$974.30
$1,048.82
$1,127.76
$1,408.18
$1,185.44
$1,259.96
$1,338.90
$1,619.32
$487.15
$524.41
$563.88
$704.09
$698.29
$735.55
$775.02
$915.23
$909.43
$946.69
$986.16
$1,126.37
$211.14

Bronze

Plan: (HMO) Florida Hospital GYM ACCESS Bronze HMO 70 HSA 1663

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $5,150 : Family: $10,300
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$276.85
$314.22
$353.81
$494.45
$751.36
$553.70
$628.44
$707.62
$988.90
$1,502.72
$765.49
$840.23
$919.41
$1,200.69
$977.28
$1,052.02
$1,131.20
$1,412.48
$1,189.07
$1,263.81
$1,342.99
$1,624.27
$488.64
$526.01
$565.60
$706.24
$700.43
$737.80
$777.39
$918.03
$912.22
$949.59
$989.18
$1,129.82
$211.79

Silver

Plan: (HMO) Florida Hospital GYM ACCESS Silver HMO 100 1668

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$406.12
$460.94
$519.02
$725.33
$1,102.20
$812.24
$921.88
$1,038.04
$1,450.66
$2,204.40
$1,122.92
$1,232.56
$1,348.72
$1,761.34
$1,433.60
$1,543.24
$1,659.40
$2,072.02
$1,744.28
$1,853.92
$1,970.08
$2,382.70
$716.80
$771.62
$829.70
$1,036.01
$1,027.48
$1,082.30
$1,140.38
$1,346.69
$1,338.16
$1,392.98
$1,451.06
$1,657.37
$310.68

Silver

Plan: (HMO) Florida Hospital GYM ACCESS Silver HMO 100 1676

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $4,750 : Family: $9,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$417.28
$473.62
$533.29
$745.27
$1,132.51
$834.56
$947.24
$1,066.58
$1,490.54
$2,265.02
$1,153.78
$1,266.46
$1,385.80
$1,809.76
$1,473.00
$1,585.68
$1,705.02
$2,128.98
$1,792.22
$1,904.90
$2,024.24
$2,448.20
$736.50
$792.84
$852.51
$1,064.49
$1,055.72
$1,112.06
$1,171.73
$1,383.71
$1,374.94
$1,431.28
$1,490.95
$1,702.93
$319.22

Bronze

Plan: (HMO) Florida Hospital GYM ACCESS Bronze HMO 50 1797

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $6,900 : Family: $13,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$277.82
$315.33
$355.06
$496.19
$754.01
$555.64
$630.66
$710.12
$992.38
$1,508.02
$768.18
$843.20
$922.66
$1,204.92
$980.72
$1,055.74
$1,135.20
$1,417.46
$1,193.26
$1,268.28
$1,347.74
$1,630.00
$490.36
$527.87
$567.60
$708.73
$702.90
$740.41
$780.14
$921.27
$915.44
$952.95
$992.68
$1,133.81
$212.54

Silver

Plan: (HMO) Florida Hospital GYM ACCESS Silver HMO 90 1684

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $4,250 : Family: $8,500
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$434.12
$492.73
$554.81
$775.35
$1,178.21
$868.24
$985.46
$1,109.62
$1,550.70
$2,356.42
$1,200.35
$1,317.57
$1,441.73
$1,882.81
$1,532.46
$1,649.68
$1,773.84
$2,214.92
$1,864.57
$1,981.79
$2,105.95
$2,547.03
$766.23
$824.84
$886.92
$1,107.46
$1,098.34
$1,156.95
$1,219.03
$1,439.57
$1,430.45
$1,489.06
$1,551.14
$1,771.68
$332.11

Silver

Plan: (HMO) Florida Hospital GYM ACCESS Silver HMO 80 1696

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $3,100 : Family: $6,200
Out of Pocket Maximum per year: Individual: $6,050 : Family: $12,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$408.26
$463.38
$521.76
$729.16
$1,108.03
$816.52
$926.76
$1,043.52
$1,458.32
$2,216.06
$1,128.84
$1,239.08
$1,355.84
$1,770.64
$1,441.16
$1,551.40
$1,668.16
$2,082.96
$1,753.48
$1,863.72
$1,980.48
$2,395.28
$720.58
$775.70
$834.08
$1,041.48
$1,032.90
$1,088.02
$1,146.40
$1,353.80
$1,345.22
$1,400.34
$1,458.72
$1,666.12
$312.32

Silver

Plan: (HMO) Florida Hospital GYM ACCESS Silver HMO 70 1712

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$413.77
$469.63
$528.80
$739.00
$1,122.98
$827.54
$939.26
$1,057.60
$1,478.00
$2,245.96
$1,144.08
$1,255.80
$1,374.14
$1,794.54
$1,460.62
$1,572.34
$1,690.68
$2,111.08
$1,777.16
$1,888.88
$2,007.22
$2,427.62
$730.31
$786.17
$845.34
$1,055.54
$1,046.85
$1,102.71
$1,161.88
$1,372.08
$1,363.39
$1,419.25
$1,478.42
$1,688.62
$316.54

Silver

Plan: (HMO) Florida Hospital GYM ACCESS Silver HMO 70 1724

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$415.10
$471.14
$530.49
$741.36
$1,126.57
$830.20
$942.28
$1,060.98
$1,482.72
$2,253.14
$1,147.75
$1,259.83
$1,378.53
$1,800.27
$1,465.30
$1,577.38
$1,696.08
$2,117.82
$1,782.85
$1,894.93
$2,013.63
$2,435.37
$732.65
$788.69
$848.04
$1,058.91
$1,050.20
$1,106.24
$1,165.59
$1,376.46
$1,367.75
$1,423.79
$1,483.14
$1,694.01
$317.55

Silver

Plan: (HMO) Florida Hospital GYM ACCESS Silver HMO 80 HSA 1732

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$406.07
$460.89
$518.96
$725.24
$1,102.07
$812.14
$921.78
$1,037.92
$1,450.48
$2,204.14
$1,122.78
$1,232.42
$1,348.56
$1,761.12
$1,433.42
$1,543.06
$1,659.20
$2,071.76
$1,744.06
$1,853.70
$1,969.84
$2,382.40
$716.71
$771.53
$829.60
$1,035.88
$1,027.35
$1,082.17
$1,140.24
$1,346.52
$1,337.99
$1,392.81
$1,450.88
$1,657.16
$310.64

Gold

Plan: (HMO) Florida Hospital GYM ACCESS Gold HMO 100 1738

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $2,800 : Family: $5,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$397.45
$451.10
$507.94
$709.84
$1,078.67
$794.90
$902.20
$1,015.88
$1,419.68
$2,157.34
$1,098.95
$1,206.25
$1,319.93
$1,723.73
$1,403.00
$1,510.30
$1,623.98
$2,027.78
$1,707.05
$1,814.35
$1,928.03
$2,331.83
$701.50
$755.15
$811.99
$1,013.89
$1,005.55
$1,059.20
$1,116.04
$1,317.94
$1,309.60
$1,363.25
$1,420.09
$1,621.99
$304.05

Gold

Plan: (HMO) Florida Hospital GYM ACCESS Gold HMO 80 1741

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$392.15
$445.09
$501.17
$700.38
$1,064.29
$784.30
$890.18
$1,002.34
$1,400.76
$2,128.58
$1,084.29
$1,190.17
$1,302.33
$1,700.75
$1,384.28
$1,490.16
$1,602.32
$2,000.74
$1,684.27
$1,790.15
$1,902.31
$2,300.73
$692.14
$745.08
$801.16
$1,000.37
$992.13
$1,045.07
$1,101.15
$1,300.36
$1,292.12
$1,345.06
$1,401.14
$1,600.35
$299.99

Gold

Plan: (HMO) Florida Hospital GYM ACCESS Gold HMO 70 1743

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$405.26
$459.97
$517.92
$723.79
$1,099.86
$810.52
$919.94
$1,035.84
$1,447.58
$2,199.72
$1,120.54
$1,229.96
$1,345.86
$1,757.60
$1,430.56
$1,539.98
$1,655.88
$2,067.62
$1,740.58
$1,850.00
$1,965.90
$2,377.64
$715.28
$769.99
$827.94
$1,033.81
$1,025.30
$1,080.01
$1,137.96
$1,343.83
$1,335.32
$1,390.03
$1,447.98
$1,653.85
$310.02

Gold

Plan: (HMO) Florida Hospital GYM ACCESS Gold HMO 90 HSA 1745

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $3,000 : Family: $6,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$390.25
$442.93
$498.74
$696.99
$1,059.14
$780.50
$885.86
$997.48
$1,393.98
$2,118.28
$1,079.04
$1,184.40
$1,296.02
$1,692.52
$1,377.58
$1,482.94
$1,594.56
$1,991.06
$1,676.12
$1,781.48
$1,893.10
$2,289.60
$688.79
$741.47
$797.28
$995.53
$987.33
$1,040.01
$1,095.82
$1,294.07
$1,285.87
$1,338.55
$1,394.36
$1,592.61
$298.54

Catastrophic

Plan: (HMO) Florida Hospital GYM ACCESS Catastrophic HMO 1748

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Catastrophic 21
30
40
50
60
$150.90
$171.27
$192.85
$269.50
$409.54
$301.80
$342.54
$385.70
$539.00
$819.08
$417.24
$457.98
$501.14
$654.44
$532.68
$573.42
$616.58
$769.88
$648.12
$688.86
$732.02
$885.32
$266.34
$286.71
$308.29
$384.94
$381.78
$402.15
$423.73
$500.38
$497.22
$517.59
$539.17
$615.82
$115.44

Bronze

Plan: (POS) Florida Hospital GYM ACCESS Bronze POS 100 HSA 1661

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $6,350 : Family: $12,700
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$293.84
$333.51
$375.53
$524.80
$797.48
$587.68
$667.02
$751.06
$1,049.60
$1,594.96
$812.47
$891.81
$975.85
$1,274.39
$1,037.26
$1,116.60
$1,200.64
$1,499.18
$1,262.05
$1,341.39
$1,425.43
$1,723.97
$518.63
$558.30
$600.32
$749.59
$743.42
$783.09
$825.11
$974.38
$968.21
$1,007.88
$1,049.90
$1,199.17
$224.79

Silver

Plan: (POS) Florida Hospital GYM ACCESS Silver POS 80 1700

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $3,100 : Family: $6,200
Out of Pocket Maximum per year: Individual: $6,050 : Family: $12,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$436.49
$495.42
$557.84
$779.57
$1,184.64
$872.98
$990.84
$1,115.68
$1,559.14
$2,369.28
$1,206.90
$1,324.76
$1,449.60
$1,893.06
$1,540.82
$1,658.68
$1,783.52
$2,226.98
$1,874.74
$1,992.60
$2,117.44
$2,560.90
$770.41
$829.34
$891.76
$1,113.49
$1,104.33
$1,163.26
$1,225.68
$1,447.41
$1,438.25
$1,497.18
$1,559.60
$1,781.33
$333.92

Silver

Plan: (POS) Florida Hospital GYM ACCESS Silver POS 70 1716

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$439.97
$499.37
$562.28
$785.79
$1,194.08
$879.94
$998.74
$1,124.56
$1,571.58
$2,388.16
$1,216.52
$1,335.32
$1,461.14
$1,908.16
$1,553.10
$1,671.90
$1,797.72
$2,244.74
$1,889.68
$2,008.48
$2,134.30
$2,581.32
$776.55
$835.95
$898.86
$1,122.37
$1,113.13
$1,172.53
$1,235.44
$1,458.95
$1,449.71
$1,509.11
$1,572.02
$1,795.53
$336.58

Gold

Plan: (POS) Florida Hospital GYM ACCESS Gold POS 100 1739

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $2,800 : Family: $5,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$426.46
$484.04
$545.02
$761.66
$1,157.42
$852.92
$968.08
$1,090.04
$1,523.32
$2,314.84
$1,179.16
$1,294.32
$1,416.28
$1,849.56
$1,505.40
$1,620.56
$1,742.52
$2,175.80
$1,831.64
$1,946.80
$2,068.76
$2,502.04
$752.70
$810.28
$871.26
$1,087.90
$1,078.94
$1,136.52
$1,197.50
$1,414.14
$1,405.18
$1,462.76
$1,523.74
$1,740.38
$326.24

Catastrophic

Plan: (POS) Florida Hospital GYM ACCESS Catastrophic POS 1749

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Catastrophic 21
30
40
50
60
$160.39
$182.04
$204.98
$286.46
$435.30
$320.78
$364.08
$409.96
$572.92
$870.60
$443.48
$486.78
$532.66
$695.62
$566.18
$609.48
$655.36
$818.32
$688.88
$732.18
$778.06
$941.02
$283.09
$304.74
$327.68
$409.16
$405.79
$427.44
$450.38
$531.86
$528.49
$550.14
$573.08
$654.56
$122.70

Expanded Bronze

Plan: (HMO) Florida Hospital Bronze HMO 60 1752

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$275.98
$313.24
$352.70
$492.90
$749.01
$551.96
$626.48
$705.40
$985.80
$1,498.02
$763.08
$837.60
$916.52
$1,196.92
$974.20
$1,048.72
$1,127.64
$1,408.04
$1,185.32
$1,259.84
$1,338.76
$1,619.16
$487.10
$524.36
$563.82
$704.02
$698.22
$735.48
$774.94
$915.14
$909.34
$946.60
$986.06
$1,126.26
$211.12

Silver

Plan: (HMO) Florida Hospital Silver HMO 80 1762

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$408.56
$463.71
$522.14
$729.69
$1,108.83
$817.12
$927.42
$1,044.28
$1,459.38
$2,217.66
$1,129.67
$1,239.97
$1,356.83
$1,771.93
$1,442.22
$1,552.52
$1,669.38
$2,084.48
$1,754.77
$1,865.07
$1,981.93
$2,397.03
$721.11
$776.26
$834.69
$1,042.24
$1,033.66
$1,088.81
$1,147.24
$1,354.79
$1,346.21
$1,401.36
$1,459.79
$1,667.34
$312.55

Gold

Plan: (HMO) Florida Hospital Gold HMO 80 1772

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $1,400 : Family: $2,800
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$384.20
$436.06
$491.00
$686.17
$1,042.71
$768.40
$872.12
$982.00
$1,372.34
$2,085.42
$1,062.31
$1,166.03
$1,275.91
$1,666.25
$1,356.22
$1,459.94
$1,569.82
$1,960.16
$1,650.13
$1,753.85
$1,863.73
$2,254.07
$678.11
$729.97
$784.91
$980.08
$972.02
$1,023.88
$1,078.82
$1,273.99
$1,265.93
$1,317.79
$1,372.73
$1,567.90
$293.91

Bronze

Plan: (HMO) Florida Hospital Bronze HMO 100 1776

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$261.49
$296.79
$334.19
$467.02
$709.69
$522.98
$593.58
$668.38
$934.04
$1,419.38
$723.02
$793.62
$868.42
$1,134.08
$923.06
$993.66
$1,068.46
$1,334.12
$1,123.10
$1,193.70
$1,268.50
$1,534.16
$461.53
$496.83
$534.23
$667.06
$661.57
$696.87
$734.27
$867.10
$861.61
$896.91
$934.31
$1,067.14
$200.04

Silver

Plan: (HMO) Florida Hospital Silver HMO 80 1786

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $2,900 : Family: $5,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$393.93
$447.12
$503.45
$703.57
$1,069.14
$787.86
$894.24
$1,006.90
$1,407.14
$2,138.28
$1,089.22
$1,195.60
$1,308.26
$1,708.50
$1,390.58
$1,496.96
$1,609.62
$2,009.86
$1,691.94
$1,798.32
$1,910.98
$2,311.22
$695.29
$748.48
$804.81
$1,004.93
$996.65
$1,049.84
$1,106.17
$1,306.29
$1,298.01
$1,351.20
$1,407.53
$1,607.65
$301.36

Gold

Plan: (POS) Florida Hospital Gold POS 80 1773

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $1,400 : Family: $2,800
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$410.50
$465.92
$524.62
$733.16
$1,114.10
$821.00
$931.84
$1,049.24
$1,466.32
$2,228.20
$1,135.03
$1,245.87
$1,363.27
$1,780.35
$1,449.06
$1,559.90
$1,677.30
$2,094.38
$1,763.09
$1,873.93
$1,991.33
$2,408.41
$724.53
$779.95
$838.65
$1,047.19
$1,038.56
$1,093.98
$1,152.68
$1,361.22
$1,352.59
$1,408.01
$1,466.71
$1,675.25
$314.03

Expanded Bronze

Plan: (HMO) Florida Hospital Bronze HMO 100 HSA 1795

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$276.41
$313.72
$353.25
$493.66
$750.17
$552.82
$627.44
$706.50
$987.32
$1,500.34
$764.27
$838.89
$917.95
$1,198.77
$975.72
$1,050.34
$1,129.40
$1,410.22
$1,187.17
$1,261.79
$1,340.85
$1,621.67
$487.86
$525.17
$564.70
$705.11
$699.31
$736.62
$776.15
$916.56
$910.76
$948.07
$987.60
$1,128.01
$211.45

Silver

Plan: (HMO) Florida Hospital Silver HMO 90 1802

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $5,250 : Family: $10,500
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$419.12
$475.70
$535.63
$748.54
$1,137.48
$838.24
$951.40
$1,071.26
$1,497.08
$2,274.96
$1,158.86
$1,272.02
$1,391.88
$1,817.70
$1,479.48
$1,592.64
$1,712.50
$2,138.32
$1,800.10
$1,913.26
$2,033.12
$2,458.94
$739.74
$796.32
$856.25
$1,069.16
$1,060.36
$1,116.94
$1,176.87
$1,389.78
$1,380.98
$1,437.56
$1,497.49
$1,710.40
$320.62

Silver

Plan: (HMO) Florida Hospital Silver HMO 65 1810

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $1,550 : Family: $3,100
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$395.83
$449.27
$505.87
$706.96
$1,074.29
$791.66
$898.54
$1,011.74
$1,413.92
$2,148.58
$1,094.47
$1,201.35
$1,314.55
$1,716.73
$1,397.28
$1,504.16
$1,617.36
$2,019.54
$1,700.09
$1,806.97
$1,920.17
$2,322.35
$698.64
$752.08
$808.68
$1,009.77
$1,001.45
$1,054.89
$1,111.49
$1,312.58
$1,304.26
$1,357.70
$1,414.30
$1,615.39
$302.81

Expanded Bronze

Plan: (POS) Florida Hospital Bronze POS 60 1753

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$293.16
$332.74
$374.66
$523.58
$795.63
$586.32
$665.48
$749.32
$1,047.16
$1,591.26
$810.59
$889.75
$973.59
$1,271.43
$1,034.86
$1,114.02
$1,197.86
$1,495.70
$1,259.13
$1,338.29
$1,422.13
$1,719.97
$517.43
$557.01
$598.93
$747.85
$741.70
$781.28
$823.20
$972.12
$965.97
$1,005.55
$1,047.47
$1,196.39
$224.27

Silver

Plan: (POS) Florida Hospital Silver POS 80 1766

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$433.17
$491.65
$553.59
$773.64
$1,175.62
$866.34
$983.30
$1,107.18
$1,547.28
$2,351.24
$1,197.71
$1,314.67
$1,438.55
$1,878.65
$1,529.08
$1,646.04
$1,769.92
$2,210.02
$1,860.45
$1,977.41
$2,101.29
$2,541.39
$764.54
$823.02
$884.96
$1,105.01
$1,095.91
$1,154.39
$1,216.33
$1,436.38
$1,427.28
$1,485.76
$1,547.70
$1,767.75
$331.37

Bronze

Plan: (POS) Florida Hospital Bronze POS 100 1777

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$278.18
$315.74
$355.52
$496.84
$754.99
$556.36
$631.48
$711.04
$993.68
$1,509.98
$769.17
$844.29
$923.85
$1,206.49
$981.98
$1,057.10
$1,136.66
$1,419.30
$1,194.79
$1,269.91
$1,349.47
$1,632.11
$490.99
$528.55
$568.33
$709.65
$703.80
$741.36
$781.14
$922.46
$916.61
$954.17
$993.95
$1,135.27
$212.81

Silver

Plan: (POS) Florida Hospital Silver POS 80 1790

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Health First Commercial Plans, Inc.)
Customer Service Phone: 1-855-443-4735

Deductible: Individual: $2,900 : Family: $5,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$420.88
$477.70
$537.89
$751.70
$1,142.27
$841.76
$955.40
$1,075.78
$1,503.40
$2,284.54
$1,163.74
$1,277.38
$1,397.76
$1,825.38
$1,485.72
$1,599.36
$1,719.74
$2,147.36
$1,807.70
$1,921.34
$2,041.72
$2,469.34
$742.86
$799.68
$859.87
$1,073.68
$1,064.84
$1,121.66
$1,181.85
$1,395.66
$1,386.82
$1,443.64
$1,503.83
$1,717.64
$321.98
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Florida Health Care Plan, Inc.

Local: 1-386-676-7110 | Toll Free: 1-800-232-0578

TTY: 1-800-955-8771

Catastrophic

Plan: (HMO) Gym Access IND Essential Plus Catastrophic HMO 36

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Catastrophic 21
30
40
50
60
$219.14
$248.73
$280.07
$391.39
$594.75
$438.28
$497.46
$560.14
$782.78
$1,189.50
$605.92
$665.10
$727.78
$950.42
$773.56
$832.74
$895.42
$1,118.06
$941.20
$1,000.38
$1,063.06
$1,285.70
$386.78
$416.37
$447.71
$559.03
$554.42
$584.01
$615.35
$726.67
$722.06
$751.65
$782.99
$894.31
$167.64

Catastrophic

Plan: (POS) Gym Access IND Essential Plus Catastrophic POS 37

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Catastrophic 21
30
40
50
60
$241.05
$273.60
$308.07
$430.52
$654.22
$482.10
$547.20
$616.14
$861.04
$1,308.44
$666.51
$731.61
$800.55
$1,045.45
$850.92
$916.02
$984.96
$1,229.86
$1,035.33
$1,100.43
$1,169.37
$1,414.27
$425.46
$458.01
$492.48
$614.93
$609.87
$642.42
$676.89
$799.34
$794.28
$826.83
$861.30
$983.75
$184.41

Silver

Plan: (HMO) Gym Access IND Essential Plus Silver HMO 53

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$414.49
$470.45
$529.72
$740.28
$1,124.93
$828.98
$940.90
$1,059.44
$1,480.56
$2,249.86
$1,146.06
$1,257.98
$1,376.52
$1,797.64
$1,463.14
$1,575.06
$1,693.60
$2,114.72
$1,780.22
$1,892.14
$2,010.68
$2,431.80
$731.57
$787.53
$846.80
$1,057.36
$1,048.65
$1,104.61
$1,163.88
$1,374.44
$1,365.73
$1,421.69
$1,480.96
$1,691.52
$317.08

Bronze

Plan: (HMO) IND Essential Plus Bronze HMO 41

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,950 : Family: $13,900

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$234.47
$266.13
$299.66
$418.77
$636.36
$468.94
$532.26
$599.32
$837.54
$1,272.72
$648.31
$711.63
$778.69
$1,016.91
$827.68
$891.00
$958.06
$1,196.28
$1,007.05
$1,070.37
$1,137.43
$1,375.65
$413.84
$445.50
$479.03
$598.14
$593.21
$624.87
$658.40
$777.51
$772.58
$804.24
$837.77
$956.88
$179.37

Gold

Plan: (HMO) Gym Access IND Essential Plus Gold HMO 63

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $1,400 : Family: $2,800
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$388.79
$441.28
$496.87
$694.38
$1,055.17
$777.58
$882.56
$993.74
$1,388.76
$2,110.34
$1,075.00
$1,179.98
$1,291.16
$1,686.18
$1,372.42
$1,477.40
$1,588.58
$1,983.60
$1,669.84
$1,774.82
$1,886.00
$2,281.02
$686.21
$738.70
$794.29
$991.80
$983.63
$1,036.12
$1,091.71
$1,289.22
$1,281.05
$1,333.54
$1,389.13
$1,586.64
$297.42

Platinum

Plan: (HMO) Gym Access IND Essential Plus Platinum HMO 65

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $2,000 : Family: $4,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$492.20
$558.65
$629.03
$879.07
$1,335.83
$984.40
$1,117.30
$1,258.06
$1,758.14
$2,671.66
$1,360.93
$1,493.83
$1,634.59
$2,134.67
$1,737.46
$1,870.36
$2,011.12
$2,511.20
$2,113.99
$2,246.89
$2,387.65
$2,887.73
$868.73
$935.18
$1,005.56
$1,255.60
$1,245.26
$1,311.71
$1,382.09
$1,632.13
$1,621.79
$1,688.24
$1,758.62
$2,008.66
$376.53

Silver

Plan: (POS) Gym Access IND Essential Plus Silver POS 54

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$463.98
$526.62
$592.97
$828.67
$1,259.25
$927.96
$1,053.24
$1,185.94
$1,657.34
$2,518.50
$1,282.91
$1,408.19
$1,540.89
$2,012.29
$1,637.86
$1,763.14
$1,895.84
$2,367.24
$1,992.81
$2,118.09
$2,250.79
$2,722.19
$818.93
$881.57
$947.92
$1,183.62
$1,173.88
$1,236.52
$1,302.87
$1,538.57
$1,528.83
$1,591.47
$1,657.82
$1,893.52
$354.95

Bronze

Plan: (POS) Gym Access IND Essential Plus Bronze POS 42

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$265.99
$301.90
$339.94
$475.06
$721.90
$531.98
$603.80
$679.88
$950.12
$1,443.80
$735.46
$807.28
$883.36
$1,153.60
$938.94
$1,010.76
$1,086.84
$1,357.08
$1,142.42
$1,214.24
$1,290.32
$1,560.56
$469.47
$505.38
$543.42
$678.54
$672.95
$708.86
$746.90
$882.02
$876.43
$912.34
$950.38
$1,085.50
$203.48

Platinum

Plan: (HMO) Gym Access IND Platinum HMO 4000

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$485.54
$551.09
$620.52
$867.18
$1,317.76
$971.08
$1,102.18
$1,241.04
$1,734.36
$2,635.52
$1,342.52
$1,473.62
$1,612.48
$2,105.80
$1,713.96
$1,845.06
$1,983.92
$2,477.24
$2,085.40
$2,216.50
$2,355.36
$2,848.68
$856.98
$922.53
$991.96
$1,238.62
$1,228.42
$1,293.97
$1,363.40
$1,610.06
$1,599.86
$1,665.41
$1,734.84
$1,981.50
$371.44

Platinum

Plan: (POS) Gym Access IND Platinum POS 4000

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$534.09
$606.20
$682.57
$953.89
$1,449.53
$1,068.18
$1,212.40
$1,365.14
$1,907.78
$2,899.06
$1,476.76
$1,620.98
$1,773.72
$2,316.36
$1,885.34
$2,029.56
$2,182.30
$2,724.94
$2,293.92
$2,438.14
$2,590.88
$3,133.52
$942.67
$1,014.78
$1,091.15
$1,362.47
$1,351.25
$1,423.36
$1,499.73
$1,771.05
$1,759.83
$1,831.94
$1,908.31
$2,179.63
$408.58

Gold

Plan: (HMO) Gym Access IND Gold HMO 5500

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $2,200 : Family: $4,400
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$400.83
$454.95
$512.27
$715.89
$1,087.86
$801.66
$909.90
$1,024.54
$1,431.78
$2,175.72
$1,108.30
$1,216.54
$1,331.18
$1,738.42
$1,414.94
$1,523.18
$1,637.82
$2,045.06
$1,721.58
$1,829.82
$1,944.46
$2,351.70
$707.47
$761.59
$818.91
$1,022.53
$1,014.11
$1,068.23
$1,125.55
$1,329.17
$1,320.75
$1,374.87
$1,432.19
$1,635.81
$306.64

Gold

Plan: (POS) Gym Access IND Gold POS 5500

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $2,200 : Family: $4,400
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$440.92
$500.44
$563.49
$787.48
$1,196.65
$881.84
$1,000.88
$1,126.98
$1,574.96
$2,393.30
$1,219.14
$1,338.18
$1,464.28
$1,912.26
$1,556.44
$1,675.48
$1,801.58
$2,249.56
$1,893.74
$2,012.78
$2,138.88
$2,586.86
$778.22
$837.74
$900.79
$1,124.78
$1,115.52
$1,175.04
$1,238.09
$1,462.08
$1,452.82
$1,512.34
$1,575.39
$1,799.38
$337.30

Silver

Plan: (HMO) Gym Access IND Silver HMO 6400

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$421.19
$478.05
$538.28
$752.24
$1,143.11
$842.38
$956.10
$1,076.56
$1,504.48
$2,286.22
$1,164.59
$1,278.31
$1,398.77
$1,826.69
$1,486.80
$1,600.52
$1,720.98
$2,148.90
$1,809.01
$1,922.73
$2,043.19
$2,471.11
$743.40
$800.26
$860.49
$1,074.45
$1,065.61
$1,122.47
$1,182.70
$1,396.66
$1,387.82
$1,444.68
$1,504.91
$1,718.87
$322.21

Silver

Plan: (HMO) Gym Access IND Silver HMO 6600

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$416.41
$472.62
$532.17
$743.70
$1,130.12
$832.82
$945.24
$1,064.34
$1,487.40
$2,260.24
$1,151.37
$1,263.79
$1,382.89
$1,805.95
$1,469.92
$1,582.34
$1,701.44
$2,124.50
$1,788.47
$1,900.89
$2,019.99
$2,443.05
$734.96
$791.17
$850.72
$1,062.25
$1,053.51
$1,109.72
$1,169.27
$1,380.80
$1,372.06
$1,428.27
$1,487.82
$1,699.35
$318.55

Gold

Plan: (HMO) IND Gold HMO 4500

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$367.11
$416.67
$469.17
$655.67
$996.35
$734.22
$833.34
$938.34
$1,311.34
$1,992.70
$1,015.06
$1,114.18
$1,219.18
$1,592.18
$1,295.90
$1,395.02
$1,500.02
$1,873.02
$1,576.74
$1,675.86
$1,780.86
$2,153.86
$647.95
$697.51
$750.01
$936.51
$928.79
$978.35
$1,030.85
$1,217.35
$1,209.63
$1,259.19
$1,311.69
$1,498.19
$280.84

Bronze

Plan: (HMO) Gym Access IND Bronze HMO HSA 5000/6550

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$250.94
$284.82
$320.70
$448.18
$681.05
$501.88
$569.64
$641.40
$896.36
$1,362.10
$693.85
$761.61
$833.37
$1,088.33
$885.82
$953.58
$1,025.34
$1,280.30
$1,077.79
$1,145.55
$1,217.31
$1,472.27
$442.91
$476.79
$512.67
$640.15
$634.88
$668.76
$704.64
$832.12
$826.85
$860.73
$896.61
$1,024.09
$191.97

Expanded Bronze

Plan: (HMO) Gym Access IND Bronze HMO HSA 6000/6000

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$251.24
$285.16
$321.08
$448.71
$681.86
$502.48
$570.32
$642.16
$897.42
$1,363.72
$694.68
$762.52
$834.36
$1,089.62
$886.88
$954.72
$1,026.56
$1,281.82
$1,079.08
$1,146.92
$1,218.76
$1,474.02
$443.44
$477.36
$513.28
$640.91
$635.64
$669.56
$705.48
$833.11
$827.84
$861.76
$897.68
$1,025.31
$192.20

Expanded Bronze

Plan: (HMO) Gym Access IND Bronze HMO BC 3841

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $6,400 : Family: $12,800
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$255.13
$289.58
$326.06
$455.67
$692.43
$510.26
$579.16
$652.12
$911.34
$1,384.86
$705.44
$774.34
$847.30
$1,106.52
$900.62
$969.52
$1,042.48
$1,301.70
$1,095.80
$1,164.70
$1,237.66
$1,496.88
$450.31
$484.76
$521.24
$650.85
$645.49
$679.94
$716.42
$846.03
$840.67
$875.12
$911.60
$1,041.21
$195.18

Expanded Bronze

Plan: (POS) Gym Access IND Bronze POS BC 3841

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $6,400 : Family: $12,800
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$280.65
$318.53
$358.66
$501.23
$761.67
$561.30
$637.06
$717.32
$1,002.46
$1,523.34
$775.99
$851.75
$932.01
$1,217.15
$990.68
$1,066.44
$1,146.70
$1,431.84
$1,205.37
$1,281.13
$1,361.39
$1,646.53
$495.34
$533.22
$573.35
$715.92
$710.03
$747.91
$788.04
$930.61
$924.72
$962.60
$1,002.73
$1,145.30
$214.69

Silver

Plan: (HMO) Gym Access IND Silver HMO BC 0941

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $5,600 : Family: $11,200
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$410.21
$465.59
$524.25
$732.64
$1,113.31
$820.42
$931.18
$1,048.50
$1,465.28
$2,226.62
$1,134.23
$1,244.99
$1,362.31
$1,779.09
$1,448.04
$1,558.80
$1,676.12
$2,092.90
$1,761.85
$1,872.61
$1,989.93
$2,406.71
$724.02
$779.40
$838.06
$1,046.45
$1,037.83
$1,093.21
$1,151.87
$1,360.26
$1,351.64
$1,407.02
$1,465.68
$1,674.07
$313.81

Platinum

Plan: (HMO) IND Platinum HMO BC 5841

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $800 : Family: $1,600
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$463.12
$525.64
$591.87
$827.13
$1,256.91
$926.24
$1,051.28
$1,183.74
$1,654.26
$2,513.82
$1,280.53
$1,405.57
$1,538.03
$2,008.55
$1,634.82
$1,759.86
$1,892.32
$2,362.84
$1,989.11
$2,114.15
$2,246.61
$2,717.13
$817.41
$879.93
$946.16
$1,181.42
$1,171.70
$1,234.22
$1,300.45
$1,535.71
$1,525.99
$1,588.51
$1,654.74
$1,890.00
$354.29

Silver

Plan: (POS) Gym Access IND Silver POS BC 0941

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $5,600 : Family: $11,200
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$451.23
$512.15
$576.67
$805.90
$1,224.64
$902.46
$1,024.30
$1,153.34
$1,611.80
$2,449.28
$1,247.65
$1,369.49
$1,498.53
$1,956.99
$1,592.84
$1,714.68
$1,843.72
$2,302.18
$1,938.03
$2,059.87
$2,188.91
$2,647.37
$796.42
$857.34
$921.86
$1,151.09
$1,141.61
$1,202.53
$1,267.05
$1,496.28
$1,486.80
$1,547.72
$1,612.24
$1,841.47
$345.19

Silver

Plan: (HMO) IND Silver HMO BC 7741

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $7,300 : Family: $14,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$356.47
$404.60
$455.57
$636.66
$967.47
$712.94
$809.20
$911.14
$1,273.32
$1,934.94
$985.64
$1,081.90
$1,183.84
$1,546.02
$1,258.34
$1,354.60
$1,456.54
$1,818.72
$1,531.04
$1,627.30
$1,729.24
$2,091.42
$629.17
$677.30
$728.27
$909.36
$901.87
$950.00
$1,000.97
$1,182.06
$1,174.57
$1,222.70
$1,273.67
$1,454.76
$272.70

Silver

Plan: (POS) Gym Access IND Silver POS BC 7741

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $7,300 : Family: $14,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$399.84
$453.82
$511.00
$714.12
$1,085.17
$799.68
$907.64
$1,022.00
$1,428.24
$2,170.34
$1,105.56
$1,213.52
$1,327.88
$1,734.12
$1,411.44
$1,519.40
$1,633.76
$2,040.00
$1,717.32
$1,825.28
$1,939.64
$2,345.88
$705.72
$759.70
$816.88
$1,020.00
$1,011.60
$1,065.58
$1,122.76
$1,325.88
$1,317.48
$1,371.46
$1,428.64
$1,631.76
$305.88

Gold

Plan: (HMO) Gym Access IND Gold HMO BC 5651

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$437.62
$496.70
$559.28
$781.59
$1,187.70
$875.24
$993.40
$1,118.56
$1,563.18
$2,375.40
$1,210.02
$1,328.18
$1,453.34
$1,897.96
$1,544.80
$1,662.96
$1,788.12
$2,232.74
$1,879.58
$1,997.74
$2,122.90
$2,567.52
$772.40
$831.48
$894.06
$1,116.37
$1,107.18
$1,166.26
$1,228.84
$1,451.15
$1,441.96
$1,501.04
$1,563.62
$1,785.93
$334.78

Gold

Plan: (POS) Gym Access IND Gold POS BC 5651

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Gold 21
30
40
50
60
$481.38
$546.37
$615.21
$859.75
$1,306.47
$962.76
$1,092.74
$1,230.42
$1,719.50
$2,612.94
$1,331.02
$1,461.00
$1,598.68
$2,087.76
$1,699.28
$1,829.26
$1,966.94
$2,456.02
$2,067.54
$2,197.52
$2,335.20
$2,824.28
$849.64
$914.63
$983.47
$1,228.01
$1,217.90
$1,282.89
$1,351.73
$1,596.27
$1,586.16
$1,651.15
$1,719.99
$1,964.53
$368.26

Platinum

Plan: (POS) Gym Access IND Platinum POS BC 5841

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $800 : Family: $1,600
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$518.86
$588.91
$663.10
$926.68
$1,408.18
$1,037.72
$1,177.82
$1,326.20
$1,853.36
$2,816.36
$1,434.65
$1,574.75
$1,723.13
$2,250.29
$1,831.58
$1,971.68
$2,120.06
$2,647.22
$2,228.51
$2,368.61
$2,516.99
$3,044.15
$915.79
$985.84
$1,060.03
$1,323.61
$1,312.72
$1,382.77
$1,456.96
$1,720.54
$1,709.65
$1,779.70
$1,853.89
$2,117.47
$396.93

Platinum

Plan: (HMO) Gym Access IND Platinum HMO BC 1941

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $2,000 : Family: $4,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$495.85
$562.79
$633.69
$885.59
$1,345.73
$991.70
$1,125.58
$1,267.38
$1,771.18
$2,691.46
$1,371.02
$1,504.90
$1,646.70
$2,150.50
$1,750.34
$1,884.22
$2,026.02
$2,529.82
$2,129.66
$2,263.54
$2,405.34
$2,909.14
$875.17
$942.11
$1,013.01
$1,264.91
$1,254.49
$1,321.43
$1,392.33
$1,644.23
$1,633.81
$1,700.75
$1,771.65
$2,023.55
$379.32

Platinum

Plan: (POS) Gym Access IND Platinum POS BC 1941

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $2,000 : Family: $4,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$545.43
$619.07
$697.06
$974.14
$1,480.30
$1,090.86
$1,238.14
$1,394.12
$1,948.28
$2,960.60
$1,508.12
$1,655.40
$1,811.38
$2,365.54
$1,925.38
$2,072.66
$2,228.64
$2,782.80
$2,342.64
$2,489.92
$2,645.90
$3,200.06
$962.69
$1,036.33
$1,114.32
$1,391.40
$1,379.95
$1,453.59
$1,531.58
$1,808.66
$1,797.21
$1,870.85
$1,948.84
$2,225.92
$417.26

Platinum

Plan: (HMO) Gym Access IND Platinum HMO 91

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $250 : Family: $500
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$484.20
$549.57
$618.81
$864.78
$1,314.12
$968.40
$1,099.14
$1,237.62
$1,729.56
$2,628.24
$1,338.81
$1,469.55
$1,608.03
$2,099.97
$1,709.22
$1,839.96
$1,978.44
$2,470.38
$2,079.63
$2,210.37
$2,348.85
$2,840.79
$854.61
$919.98
$989.22
$1,235.19
$1,225.02
$1,290.39
$1,359.63
$1,605.60
$1,595.43
$1,660.80
$1,730.04
$1,976.01
$370.41

Platinum

Plan: (HMO) Gym Acccess IND Platinum HMO 92

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $500 : Family: $1,000
Out of Pocket Maximum per year: Individual: $3,000 : Family: $6,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Platinum 21
30
40
50
60
$481.38
$546.37
$615.21
$859.75
$1,306.47
$962.76
$1,092.74
$1,230.42
$1,719.50
$2,612.94
$1,331.02
$1,461.00
$1,598.68
$2,087.76
$1,699.28
$1,829.26
$1,966.94
$2,456.02
$2,067.54
$2,197.52
$2,335.20
$2,824.28
$849.64
$914.63
$983.47
$1,228.01
$1,217.90
$1,282.89
$1,351.73
$1,596.27
$1,586.16
$1,651.15
$1,719.99
$1,964.53
$368.26

Expanded Bronze

Plan: (HMO) IND Bronze Standardized HMO

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Expanded Bronze 21
30
40
50
60
$241.83
$274.48
$309.06
$431.91
$656.33
$483.66
$548.96
$618.12
$863.82
$1,312.66
$668.66
$733.96
$803.12
$1,048.82
$853.66
$918.96
$988.12
$1,233.82
$1,038.66
$1,103.96
$1,173.12
$1,418.82
$426.83
$459.48
$494.06
$616.91
$611.83
$644.48
$679.06
$801.91
$796.83
$829.48
$864.06
$986.91
$185.00

Silver

Plan: (HMO) IND Silver Standardized HMO 1

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Silver 21
30
40
50
60
$410.87
$466.34
$525.09
$733.82
$1,115.10
$821.74
$932.68
$1,050.18
$1,467.64
$2,230.20
$1,136.06
$1,247.00
$1,364.50
$1,781.96
$1,450.38
$1,561.32
$1,678.82
$2,096.28
$1,764.70
$1,875.64
$1,993.14
$2,410.60
$725.19
$780.66
$839.41
$1,048.14
$1,039.51
$1,094.98
$1,153.73
$1,362.46
$1,353.83
$1,409.30
$1,468.05
$1,676.78
$314.32

Bronze

Plan: (HMO) IND Bronze HMO 1340

Summary of Benefits and Coverage - Plan Brochure
Provider Directory for This Plan: (Florida Health Care Plan, Inc.)
Customer Service Phone: 1-800-232-0578

Deductible: Individual: $7,350 : Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 : Family: $14,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
0-14
Bronze 21
30
40
50
60
$233.17
$264.64
$297.99
$416.44
$632.81
$466.34
$529.28
$595.98
$832.88
$1,265.62
$644.71
$707.65
$774.35
$1,011.25
$823.08
$886.02
$952.72
$1,189.62
$1,001.45
$1,064.39
$1,131.09
$1,367.99
$411.54
$443.01
$476.36
$594.81
$589.91
$621.38
$654.73
$773.18
$768.28
$799.75
$833.10
$951.55
$178.37

‡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 Flagler County here.

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