Obamacare 2023 Rates for Miami-Dade County

Obamacare > Rates > Florida > Miami-Dade 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 Miami-Dade 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, 226 Plans and 2023 Rates for Miami-Dade County, Florida

Below, you’ll find a summary of the 226 plans for Miami-Dade County, Florida and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

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

$844.65
$958.68
$1,079.46
$1,508.54
$2,292.38

$1,490.81
$1,604.84
$1,725.62
$2,154.70

$2,136.97
$2,251.00
$2,371.78
$2,800.86

$2,783.13
$2,897.16
$3,017.94
$3,447.02

$646.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,689.30
$1,917.36
$2,158.92
$3,017.08
$4,584.76

$2,335.46
$2,563.52
$2,805.08
$3,663.24

$2,981.62
$3,209.68
$3,451.24
$4,309.40

$3,627.78
$3,855.84
$4,097.40
$4,955.56

$646.16

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

$546.46
$620.23
$698.38
$975.98
$1,483.09

$964.50
$1,038.27
$1,116.42
$1,394.02

$1,382.54
$1,456.31
$1,534.46
$1,812.06

$1,800.58
$1,874.35
$1,952.50
$2,230.10

$418.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,092.92
$1,240.46
$1,396.76
$1,951.96
$2,966.18

$1,510.96
$1,658.50
$1,814.80
$2,370.00

$1,929.00
$2,076.54
$2,232.84
$2,788.04

$2,347.04
$2,494.58
$2,650.88
$3,206.08

$418.04

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

$849.29
$963.94
$1,085.39
$1,516.83
$2,304.97

$1,499.00
$1,613.65
$1,735.10
$2,166.54

$2,148.71
$2,263.36
$2,384.81
$2,816.25

$2,798.42
$2,913.07
$3,034.52
$3,465.96

$649.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,698.58
$1,927.88
$2,170.78
$3,033.66
$4,609.94

$2,348.29
$2,577.59
$2,820.49
$3,683.37

$2,998.00
$3,227.30
$3,470.20
$4,333.08

$3,647.71
$3,877.01
$4,119.91
$4,982.79

$649.71

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

$1,068.77
$1,213.05
$1,365.89
$1,908.82
$2,900.64

$1,886.38
$2,030.66
$2,183.50
$2,726.43

$2,703.99
$2,848.27
$3,001.11
$3,544.04

$3,521.60
$3,665.88
$3,818.72
$4,361.65

$817.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$2,137.54
$2,426.10
$2,731.78
$3,817.64
$5,801.28

$2,955.15
$3,243.71
$3,549.39
$4,635.25

$3,772.76
$4,061.32
$4,367.00
$5,452.86

$4,590.37
$4,878.93
$5,184.61
$6,270.47

$817.61

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

$569.21
$646.05
$727.45
$1,016.61
$1,544.84

$1,004.66
$1,081.50
$1,162.90
$1,452.06

$1,440.11
$1,516.95
$1,598.35
$1,887.51

$1,875.56
$1,952.40
$2,033.80
$2,322.96

$435.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,138.42
$1,292.10
$1,454.90
$2,033.22
$3,089.68

$1,573.87
$1,727.55
$1,890.35
$2,468.67

$2,009.32
$2,163.00
$2,325.80
$2,904.12

$2,444.77
$2,598.45
$2,761.25
$3,339.57

$435.45

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

$1,119.88
$1,271.06
$1,431.21
$2,000.11
$3,039.35

$1,976.59
$2,127.77
$2,287.92
$2,856.82

$2,833.30
$2,984.48
$3,144.63
$3,713.53

$3,690.01
$3,841.19
$4,001.34
$4,570.24

$856.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$2,239.76
$2,542.12
$2,862.42
$4,000.22
$6,078.70

$3,096.47
$3,398.83
$3,719.13
$4,856.93

$3,953.18
$4,255.54
$4,575.84
$5,713.64

$4,809.89
$5,112.25
$5,432.55
$6,570.35

$856.71

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

$792.84
$899.87
$1,013.25
$1,416.01
$2,151.77

$1,399.36
$1,506.39
$1,619.77
$2,022.53

$2,005.88
$2,112.91
$2,226.29
$2,629.05

$2,612.40
$2,719.43
$2,832.81
$3,235.57

$606.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,585.68
$1,799.74
$2,026.50
$2,832.02
$4,303.54

$2,192.20
$2,406.26
$2,633.02
$3,438.54

$2,798.72
$3,012.78
$3,239.54
$4,045.06

$3,405.24
$3,619.30
$3,846.06
$4,651.58

$606.52

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

$917.89
$1,041.81
$1,173.06
$1,639.35
$2,491.15

$1,620.08
$1,744.00
$1,875.25
$2,341.54

$2,322.27
$2,446.19
$2,577.44
$3,043.73

$3,024.46
$3,148.38
$3,279.63
$3,745.92

$702.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,835.78
$2,083.62
$2,346.12
$3,278.70
$4,982.30

$2,537.97
$2,785.81
$3,048.31
$3,980.89

$3,240.16
$3,488.00
$3,750.50
$4,683.08

$3,942.35
$4,190.19
$4,452.69
$5,385.27

$702.19

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

$553.35
$628.05
$707.18
$988.28
$1,501.79

$976.66
$1,051.36
$1,130.49
$1,411.59

$1,399.97
$1,474.67
$1,553.80
$1,834.90

$1,823.28
$1,897.98
$1,977.11
$2,258.21

$423.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,106.70
$1,256.10
$1,414.36
$1,976.56
$3,003.58

$1,530.01
$1,679.41
$1,837.67
$2,399.87

$1,953.32
$2,102.72
$2,260.98
$2,823.18

$2,376.63
$2,526.03
$2,684.29
$3,246.49

$423.31

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

$888.04
$1,007.93
$1,134.92
$1,586.04
$2,410.14

$1,567.39
$1,687.28
$1,814.27
$2,265.39

$2,246.74
$2,366.63
$2,493.62
$2,944.74

$2,926.09
$3,045.98
$3,172.97
$3,624.09

$679.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,776.08
$2,015.86
$2,269.84
$3,172.08
$4,820.28

$2,455.43
$2,695.21
$2,949.19
$3,851.43

$3,134.78
$3,374.56
$3,628.54
$4,530.78

$3,814.13
$4,053.91
$4,307.89
$5,210.13

$679.35

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

$602.84
$684.22
$770.43
$1,076.67
$1,636.11

$1,064.01
$1,145.39
$1,231.60
$1,537.84

$1,525.18
$1,606.56
$1,692.77
$1,999.01

$1,986.35
$2,067.73
$2,153.94
$2,460.18

$461.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,205.68
$1,368.44
$1,540.86
$2,153.34
$3,272.22

$1,666.85
$1,829.61
$2,002.03
$2,614.51

$2,128.02
$2,290.78
$2,463.20
$3,075.68

$2,589.19
$2,751.95
$2,924.37
$3,536.85

$461.17

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

$522.31
$592.82
$667.51
$932.85
$1,417.55

$921.88
$992.39
$1,067.08
$1,332.42

$1,321.45
$1,391.96
$1,466.65
$1,731.99

$1,721.02
$1,791.53
$1,866.22
$2,131.56

$399.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,044.62
$1,185.64
$1,335.02
$1,865.70
$2,835.10

$1,444.19
$1,585.21
$1,734.59
$2,265.27

$1,843.76
$1,984.78
$2,134.16
$2,664.84

$2,243.33
$2,384.35
$2,533.73
$3,064.41

$399.57

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

$561.49
$637.29
$717.58
$1,002.82
$1,523.88

$991.03
$1,066.83
$1,147.12
$1,432.36

$1,420.57
$1,496.37
$1,576.66
$1,861.90

$1,850.11
$1,925.91
$2,006.20
$2,291.44

$429.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,122.98
$1,274.58
$1,435.16
$2,005.64
$3,047.76

$1,552.52
$1,704.12
$1,864.70
$2,435.18

$1,982.06
$2,133.66
$2,294.24
$2,864.72

$2,411.60
$2,563.20
$2,723.78
$3,294.26

$429.54

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

$836.02
$948.88
$1,068.43
$1,493.13
$2,268.96

$1,475.58
$1,588.44
$1,707.99
$2,132.69

$2,115.14
$2,228.00
$2,347.55
$2,772.25

$2,754.70
$2,867.56
$2,987.11
$3,411.81

$639.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,672.04
$1,897.76
$2,136.86
$2,986.26
$4,537.92

$2,311.60
$2,537.32
$2,776.42
$3,625.82

$2,951.16
$3,176.88
$3,415.98
$4,265.38

$3,590.72
$3,816.44
$4,055.54
$4,904.94

$639.56

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

$853.29
$968.48
$1,090.50
$1,523.98
$2,315.83

$1,506.06
$1,621.25
$1,743.27
$2,176.75

$2,158.83
$2,274.02
$2,396.04
$2,829.52

$2,811.60
$2,926.79
$3,048.81
$3,482.29

$652.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,706.58
$1,936.96
$2,181.00
$3,047.96
$4,631.66

$2,359.35
$2,589.73
$2,833.77
$3,700.73

$3,012.12
$3,242.50
$3,486.54
$4,353.50

$3,664.89
$3,895.27
$4,139.31
$5,006.27

$652.77

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

$1,117.07
$1,267.87
$1,427.62
$1,995.09
$3,031.73

$1,971.63
$2,122.43
$2,282.18
$2,849.65

$2,826.19
$2,976.99
$3,136.74
$3,704.21

$3,680.75
$3,831.55
$3,991.30
$4,558.77

$854.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$2,234.14
$2,535.74
$2,855.24
$3,990.18
$6,063.46

$3,088.70
$3,390.30
$3,709.80
$4,844.74

$3,943.26
$4,244.86
$4,564.36
$5,699.30

$4,797.82
$5,099.42
$5,418.92
$6,553.86

$854.56

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

$590.98
$670.76
$755.27
$1,055.49
$1,603.92

$1,043.08
$1,122.86
$1,207.37
$1,507.59

$1,495.18
$1,574.96
$1,659.47
$1,959.69

$1,947.28
$2,027.06
$2,111.57
$2,411.79

$452.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,181.96
$1,341.52
$1,510.54
$2,110.98
$3,207.84

$1,634.06
$1,793.62
$1,962.64
$2,563.08

$2,086.16
$2,245.72
$2,414.74
$3,015.18

$2,538.26
$2,697.82
$2,866.84
$3,467.28

$452.10

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

$552.32
$626.88
$705.86
$986.44
$1,499.00

$974.84
$1,049.40
$1,128.38
$1,408.96

$1,397.36
$1,471.92
$1,550.90
$1,831.48

$1,819.88
$1,894.44
$1,973.42
$2,254.00

$422.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,104.64
$1,253.76
$1,411.72
$1,972.88
$2,998.00

$1,527.16
$1,676.28
$1,834.24
$2,395.40

$1,949.68
$2,098.80
$2,256.76
$2,817.92

$2,372.20
$2,521.32
$2,679.28
$3,240.44

$422.52

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

$415.87
$472.01
$531.48
$742.74
$1,128.67

$734.01
$790.15
$849.62
$1,060.88

$1,052.15
$1,108.29
$1,167.76
$1,379.02

$1,370.29
$1,426.43
$1,485.90
$1,697.16

$318.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$831.74
$944.02
$1,062.96
$1,485.48
$2,257.34

$1,149.88
$1,262.16
$1,381.10
$1,803.62

$1,468.02
$1,580.30
$1,699.24
$2,121.76

$1,786.16
$1,898.44
$2,017.38
$2,439.90

$318.14

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

$550.61
$624.94
$703.68
$983.39
$1,494.36

$971.83
$1,046.16
$1,124.90
$1,404.61

$1,393.05
$1,467.38
$1,546.12
$1,825.83

$1,814.27
$1,888.60
$1,967.34
$2,247.05

$421.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,101.22
$1,249.88
$1,407.36
$1,966.78
$2,988.72

$1,522.44
$1,671.10
$1,828.58
$2,388.00

$1,943.66
$2,092.32
$2,249.80
$2,809.22

$2,364.88
$2,513.54
$2,671.02
$3,230.44

$421.22

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

$698.66
$792.98
$892.89
$1,247.81
$1,896.16

$1,233.13
$1,327.45
$1,427.36
$1,782.28

$1,767.60
$1,861.92
$1,961.83
$2,316.75

$2,302.07
$2,396.39
$2,496.30
$2,851.22

$534.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,397.32
$1,585.96
$1,785.78
$2,495.62
$3,792.32

$1,931.79
$2,120.43
$2,320.25
$3,030.09

$2,466.26
$2,654.90
$2,854.72
$3,564.56

$3,000.73
$3,189.37
$3,389.19
$4,099.03

$534.47

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

$429.58
$487.57
$549.00
$767.23
$1,165.88

$758.21
$816.20
$877.63
$1,095.86

$1,086.84
$1,144.83
$1,206.26
$1,424.49

$1,415.47
$1,473.46
$1,534.89
$1,753.12

$328.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$859.16
$975.14
$1,098.00
$1,534.46
$2,331.76

$1,187.79
$1,303.77
$1,426.63
$1,863.09

$1,516.42
$1,632.40
$1,755.26
$2,191.72

$1,845.05
$1,961.03
$2,083.89
$2,520.35

$328.63

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

$731.13
$829.83
$934.38
$1,305.80
$1,984.29

$1,290.44
$1,389.14
$1,493.69
$1,865.11

$1,849.75
$1,948.45
$2,053.00
$2,424.42

$2,409.06
$2,507.76
$2,612.31
$2,983.73

$559.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,462.26
$1,659.66
$1,868.76
$2,611.60
$3,968.58

$2,021.57
$2,218.97
$2,428.07
$3,170.91

$2,580.88
$2,778.28
$2,987.38
$3,730.22

$3,140.19
$3,337.59
$3,546.69
$4,289.53

$559.31

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

$516.87
$586.65
$660.56
$923.13
$1,402.79

$912.28
$982.06
$1,055.97
$1,318.54

$1,307.69
$1,377.47
$1,451.38
$1,713.95

$1,703.10
$1,772.88
$1,846.79
$2,109.36

$395.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,033.74
$1,173.30
$1,321.12
$1,846.26
$2,805.58

$1,429.15
$1,568.71
$1,716.53
$2,241.67

$1,824.56
$1,964.12
$2,111.94
$2,637.08

$2,219.97
$2,359.53
$2,507.35
$3,032.49

$395.41

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

$609.86
$692.19
$779.40
$1,089.21
$1,655.16

$1,076.40
$1,158.73
$1,245.94
$1,555.75

$1,542.94
$1,625.27
$1,712.48
$2,022.29

$2,009.48
$2,091.81
$2,179.02
$2,488.83

$466.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,219.72
$1,384.38
$1,558.80
$2,178.42
$3,310.32

$1,686.26
$1,850.92
$2,025.34
$2,644.96

$2,152.80
$2,317.46
$2,491.88
$3,111.50

$2,619.34
$2,784.00
$2,958.42
$3,578.04

$466.54

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

$420.35
$477.10
$537.21
$750.75
$1,140.83

$741.92
$798.67
$858.78
$1,072.32

$1,063.49
$1,120.24
$1,180.35
$1,393.89

$1,385.06
$1,441.81
$1,501.92
$1,715.46

$321.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$840.70
$954.20
$1,074.42
$1,501.50
$2,281.66

$1,162.27
$1,275.77
$1,395.99
$1,823.07

$1,483.84
$1,597.34
$1,717.56
$2,144.64

$1,805.41
$1,918.91
$2,039.13
$2,466.21

$321.57

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

$589.99
$669.64
$754.01
$1,053.72
$1,601.23

$1,041.33
$1,120.98
$1,205.35
$1,505.06

$1,492.67
$1,572.32
$1,656.69
$1,956.40

$1,944.01
$2,023.66
$2,108.03
$2,407.74

$451.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,179.98
$1,339.28
$1,508.02
$2,107.44
$3,202.46

$1,631.32
$1,790.62
$1,959.36
$2,558.78

$2,082.66
$2,241.96
$2,410.70
$3,010.12

$2,534.00
$2,693.30
$2,862.04
$3,461.46

$451.34

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

$455.15
$516.60
$581.68
$812.90
$1,235.28

$803.34
$864.79
$929.87
$1,161.09

$1,151.53
$1,212.98
$1,278.06
$1,509.28

$1,499.72
$1,561.17
$1,626.25
$1,857.47

$348.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$910.30
$1,033.20
$1,163.36
$1,625.80
$2,470.56

$1,258.49
$1,381.39
$1,511.55
$1,973.99

$1,606.68
$1,729.58
$1,859.74
$2,322.18

$1,954.87
$2,077.77
$2,207.93
$2,670.37

$348.19

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

$394.49
$447.75
$504.16
$704.56
$1,070.65

$696.27
$749.53
$805.94
$1,006.34

$998.05
$1,051.31
$1,107.72
$1,308.12

$1,299.83
$1,353.09
$1,409.50
$1,609.90

$301.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$788.98
$895.50
$1,008.32
$1,409.12
$2,141.30

$1,090.76
$1,197.28
$1,310.10
$1,710.90

$1,392.54
$1,499.06
$1,611.88
$2,012.68

$1,694.32
$1,800.84
$1,913.66
$2,314.46

$301.78

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

$424.13
$481.39
$542.04
$757.50
$1,151.09

$748.59
$805.85
$866.50
$1,081.96

$1,073.05
$1,130.31
$1,190.96
$1,406.42

$1,397.51
$1,454.77
$1,515.42
$1,730.88

$324.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$848.26
$962.78
$1,084.08
$1,515.00
$2,302.18

$1,172.72
$1,287.24
$1,408.54
$1,839.46

$1,497.18
$1,611.70
$1,733.00
$2,163.92

$1,821.64
$1,936.16
$2,057.46
$2,488.38

$324.46

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

$545.06
$618.64
$696.59
$973.48
$1,479.29

$962.03
$1,035.61
$1,113.56
$1,390.45

$1,379.00
$1,452.58
$1,530.53
$1,807.42

$1,795.97
$1,869.55
$1,947.50
$2,224.39

$416.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,090.12
$1,237.28
$1,393.18
$1,946.96
$2,958.58

$1,507.09
$1,654.25
$1,810.15
$2,363.93

$1,924.06
$2,071.22
$2,227.12
$2,780.90

$2,341.03
$2,488.19
$2,644.09
$3,197.87

$416.97

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

$567.00
$643.55
$724.63
$1,012.66
$1,538.84

$1,000.76
$1,077.31
$1,158.39
$1,446.42

$1,434.52
$1,511.07
$1,592.15
$1,880.18

$1,868.28
$1,944.83
$2,025.91
$2,313.94

$433.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,134.00
$1,287.10
$1,449.26
$2,025.32
$3,077.68

$1,567.76
$1,720.86
$1,883.02
$2,459.08

$2,001.52
$2,154.62
$2,316.78
$2,892.84

$2,435.28
$2,588.38
$2,750.54
$3,326.60

$433.76

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

$729.26
$827.71
$931.99
$1,302.46
$1,979.21

$1,287.14
$1,385.59
$1,489.87
$1,860.34

$1,845.02
$1,943.47
$2,047.75
$2,418.22

$2,402.90
$2,501.35
$2,605.63
$2,976.10

$557.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,458.52
$1,655.42
$1,863.98
$2,604.92
$3,958.42

$2,016.40
$2,213.30
$2,421.86
$3,162.80

$2,574.28
$2,771.18
$2,979.74
$3,720.68

$3,132.16
$3,329.06
$3,537.62
$4,278.56

$557.88

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

$446.37
$506.63
$570.46
$797.22
$1,211.45

$787.84
$848.10
$911.93
$1,138.69

$1,129.31
$1,189.57
$1,253.40
$1,480.16

$1,470.78
$1,531.04
$1,594.87
$1,821.63

$341.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$892.74
$1,013.26
$1,140.92
$1,594.44
$2,422.90

$1,234.21
$1,354.73
$1,482.39
$1,935.91

$1,575.68
$1,696.20
$1,823.86
$2,277.38

$1,917.15
$2,037.67
$2,165.33
$2,618.85

$341.47

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

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

$394.15
$447.37
$503.73
$703.96
$1,069.74

$695.68
$748.90
$805.26
$1,005.49

$997.21
$1,050.43
$1,106.79
$1,307.02

$1,298.74
$1,351.96
$1,408.32
$1,608.55

$301.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$788.30
$894.74
$1,007.46
$1,407.92
$2,139.48

$1,089.83
$1,196.27
$1,308.99
$1,709.45

$1,391.36
$1,497.80
$1,610.52
$2,010.98

$1,692.89
$1,799.33
$1,912.05
$2,312.51

$301.53

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

$365.06
$414.34
$466.55
$652.00
$990.77

$644.33
$693.61
$745.82
$931.27

$923.60
$972.88
$1,025.09
$1,210.54

$1,202.87
$1,252.15
$1,304.36
$1,489.81

$279.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$730.12
$828.68
$933.10
$1,304.00
$1,981.54

$1,009.39
$1,107.95
$1,212.37
$1,583.27

$1,288.66
$1,387.22
$1,491.64
$1,862.54

$1,567.93
$1,666.49
$1,770.91
$2,141.81

$279.27

Toc - Plan #37 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

$299.59
$340.03
$382.87
$535.06
$813.07

$528.77
$569.21
$612.05
$764.24

$757.95
$798.39
$841.23
$993.42

$987.13
$1,027.57
$1,070.41
$1,222.60

$229.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$599.18
$680.06
$765.74
$1,070.12
$1,626.14

$828.36
$909.24
$994.92
$1,299.30

$1,057.54
$1,138.42
$1,224.10
$1,528.48

$1,286.72
$1,367.60
$1,453.28
$1,757.66

$229.18

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

$391.39
$444.22
$500.19
$699.02
$1,062.22

$690.80
$743.63
$799.60
$998.43

$990.21
$1,043.04
$1,099.01
$1,297.84

$1,289.62
$1,342.45
$1,398.42
$1,597.25

$299.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$782.78
$888.44
$1,000.38
$1,398.04
$2,124.44

$1,082.19
$1,187.85
$1,299.79
$1,697.45

$1,381.60
$1,487.26
$1,599.20
$1,996.86

$1,681.01
$1,786.67
$1,898.61
$2,296.27

$299.41

Toc - Plan #39 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

$418.35
$474.83
$534.65
$747.18
$1,135.41

$738.39
$794.87
$854.69
$1,067.22

$1,058.43
$1,114.91
$1,174.73
$1,387.26

$1,378.47
$1,434.95
$1,494.77
$1,707.30

$320.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$836.70
$949.66
$1,069.30
$1,494.36
$2,270.82

$1,156.74
$1,269.70
$1,389.34
$1,814.40

$1,476.78
$1,589.74
$1,709.38
$2,134.44

$1,796.82
$1,909.78
$2,029.42
$2,454.48

$320.04

Toc - Plan #40 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

$379.79
$431.06
$485.37
$678.30
$1,030.75

$670.33
$721.60
$775.91
$968.84

$960.87
$1,012.14
$1,066.45
$1,259.38

$1,251.41
$1,302.68
$1,356.99
$1,549.92

$290.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$759.58
$862.12
$970.74
$1,356.60
$2,061.50

$1,050.12
$1,152.66
$1,261.28
$1,647.14

$1,340.66
$1,443.20
$1,551.82
$1,937.68

$1,631.20
$1,733.74
$1,842.36
$2,228.22

$290.54

Toc - Plan #41 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

$444.96
$505.03
$568.66
$794.70
$1,207.63

$785.36
$845.43
$909.06
$1,135.10

$1,125.76
$1,185.83
$1,249.46
$1,475.50

$1,466.16
$1,526.23
$1,589.86
$1,815.90

$340.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$889.92
$1,010.06
$1,137.32
$1,589.40
$2,415.26

$1,230.32
$1,350.46
$1,477.72
$1,929.80

$1,570.72
$1,690.86
$1,818.12
$2,270.20

$1,911.12
$2,031.26
$2,158.52
$2,610.60

$340.40

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

$499.58
$567.02
$638.46
$892.24
$1,355.85

$881.76
$949.20
$1,020.64
$1,274.42

$1,263.94
$1,331.38
$1,402.82
$1,656.60

$1,646.12
$1,713.56
$1,785.00
$2,038.78

$382.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$999.16
$1,134.04
$1,276.92
$1,784.48
$2,711.70

$1,381.34
$1,516.22
$1,659.10
$2,166.66

$1,763.52
$1,898.40
$2,041.28
$2,548.84

$2,145.70
$2,280.58
$2,423.46
$2,931.02

$382.18

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

$487.53
$553.34
$623.06
$870.72
$1,323.14

$860.49
$926.30
$996.02
$1,243.68

$1,233.45
$1,299.26
$1,368.98
$1,616.64

$1,606.41
$1,672.22
$1,741.94
$1,989.60

$372.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$975.06
$1,106.68
$1,246.12
$1,741.44
$2,646.28

$1,348.02
$1,479.64
$1,619.08
$2,114.40

$1,720.98
$1,852.60
$1,992.04
$2,487.36

$2,093.94
$2,225.56
$2,365.00
$2,860.32

$372.96

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

$469.23
$532.58
$599.68
$838.05
$1,273.49

$828.19
$891.54
$958.64
$1,197.01

$1,187.15
$1,250.50
$1,317.60
$1,555.97

$1,546.11
$1,609.46
$1,676.56
$1,914.93

$358.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$938.46
$1,065.16
$1,199.36
$1,676.10
$2,546.98

$1,297.42
$1,424.12
$1,558.32
$2,035.06

$1,656.38
$1,783.08
$1,917.28
$2,394.02

$2,015.34
$2,142.04
$2,276.24
$2,752.98

$358.96

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

$466.49
$529.47
$596.17
$833.15
$1,266.06

$823.36
$886.34
$953.04
$1,190.02

$1,180.23
$1,243.21
$1,309.91
$1,546.89

$1,537.10
$1,600.08
$1,666.78
$1,903.76

$356.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$932.98
$1,058.94
$1,192.34
$1,666.30
$2,532.12

$1,289.85
$1,415.81
$1,549.21
$2,023.17

$1,646.72
$1,772.68
$1,906.08
$2,380.04

$2,003.59
$2,129.55
$2,262.95
$2,736.91

$356.87

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

$463.68
$526.28
$592.59
$828.14
$1,258.43

$818.40
$881.00
$947.31
$1,182.86

$1,173.12
$1,235.72
$1,302.03
$1,537.58

$1,527.84
$1,590.44
$1,656.75
$1,892.30

$354.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$927.36
$1,052.56
$1,185.18
$1,656.28
$2,516.86

$1,282.08
$1,407.28
$1,539.90
$2,011.00

$1,636.80
$1,762.00
$1,894.62
$2,365.72

$1,991.52
$2,116.72
$2,249.34
$2,720.44

$354.72

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

$382.70
$434.36
$489.09
$683.50
$1,038.64

$675.46
$727.12
$781.85
$976.26

$968.22
$1,019.88
$1,074.61
$1,269.02

$1,260.98
$1,312.64
$1,367.37
$1,561.78

$292.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.40
$868.72
$978.18
$1,367.00
$2,077.28

$1,058.16
$1,161.48
$1,270.94
$1,659.76

$1,350.92
$1,454.24
$1,563.70
$1,952.52

$1,643.68
$1,747.00
$1,856.46
$2,245.28

$292.76

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

$369.37
$419.24
$472.06
$659.70
$1,002.48

$651.94
$701.81
$754.63
$942.27

$934.51
$984.38
$1,037.20
$1,224.84

$1,217.08
$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

$738.74
$838.48
$944.12
$1,319.40
$2,004.96

$1,021.31
$1,121.05
$1,226.69
$1,601.97

$1,303.88
$1,403.62
$1,509.26
$1,884.54

$1,586.45
$1,686.19
$1,791.83
$2,167.11

$282.57

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

$302.30
$343.11
$386.34
$539.91
$820.45

$533.56
$574.37
$617.60
$771.17

$764.82
$805.63
$848.86
$1,002.43

$996.08
$1,036.89
$1,080.12
$1,233.69

$231.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$604.60
$686.22
$772.68
$1,079.82
$1,640.90

$835.86
$917.48
$1,003.94
$1,311.08

$1,067.12
$1,148.74
$1,235.20
$1,542.34

$1,298.38
$1,380.00
$1,466.46
$1,773.60

$231.26

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

$496.21
$563.20
$634.16
$886.23
$1,346.71

$875.81
$942.80
$1,013.76
$1,265.83

$1,255.41
$1,322.40
$1,393.36
$1,645.43

$1,635.01
$1,702.00
$1,772.96
$2,025.03

$379.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$992.42
$1,126.40
$1,268.32
$1,772.46
$2,693.42

$1,372.02
$1,506.00
$1,647.92
$2,152.06

$1,751.62
$1,885.60
$2,027.52
$2,531.66

$2,131.22
$2,265.20
$2,407.12
$2,911.26

$379.60

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

$449.91
$510.65
$574.99
$803.55
$1,221.07

$794.09
$854.83
$919.17
$1,147.73

$1,138.27
$1,199.01
$1,263.35
$1,491.91

$1,482.45
$1,543.19
$1,607.53
$1,836.09

$344.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$899.82
$1,021.30
$1,149.98
$1,607.10
$2,442.14

$1,244.00
$1,365.48
$1,494.16
$1,951.28

$1,588.18
$1,709.66
$1,838.34
$2,295.46

$1,932.36
$2,053.84
$2,182.52
$2,639.64

$344.18

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

$380.12
$431.44
$485.80
$678.90
$1,031.65

$670.91
$722.23
$776.59
$969.69

$961.70
$1,013.02
$1,067.38
$1,260.48

$1,252.49
$1,303.81
$1,358.17
$1,551.27

$290.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$760.24
$862.88
$971.60
$1,357.80
$2,063.30

$1,051.03
$1,153.67
$1,262.39
$1,648.59

$1,341.82
$1,444.46
$1,553.18
$1,939.38

$1,632.61
$1,735.25
$1,843.97
$2,230.17

$290.79

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

$504.42
$572.52
$644.65
$900.90
$1,369.00

$890.30
$958.40
$1,030.53
$1,286.78

$1,276.18
$1,344.28
$1,416.41
$1,672.66

$1,662.06
$1,730.16
$1,802.29
$2,058.54

$385.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,008.84
$1,145.04
$1,289.30
$1,801.80
$2,738.00

$1,394.72
$1,530.92
$1,675.18
$2,187.68

$1,780.60
$1,916.80
$2,061.06
$2,573.56

$2,166.48
$2,302.68
$2,446.94
$2,959.44

$385.88

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

$492.35
$558.82
$629.22
$879.34
$1,336.24

$869.00
$935.47
$1,005.87
$1,255.99

$1,245.65
$1,312.12
$1,382.52
$1,632.64

$1,622.30
$1,688.77
$1,759.17
$2,009.29

$376.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$984.70
$1,117.64
$1,258.44
$1,758.68
$2,672.48

$1,361.35
$1,494.29
$1,635.09
$2,135.33

$1,738.00
$1,870.94
$2,011.74
$2,511.98

$2,114.65
$2,247.59
$2,388.39
$2,888.63

$376.65

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

$474.07
$538.06
$605.86
$846.68
$1,286.61

$836.73
$900.72
$968.52
$1,209.34

$1,199.39
$1,263.38
$1,331.18
$1,572.00

$1,562.05
$1,626.04
$1,693.84
$1,934.66

$362.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$948.14
$1,076.12
$1,211.72
$1,693.36
$2,573.22

$1,310.80
$1,438.78
$1,574.38
$2,056.02

$1,673.46
$1,801.44
$1,937.04
$2,418.68

$2,036.12
$2,164.10
$2,299.70
$2,781.34

$362.66

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

$471.30
$534.92
$602.32
$841.73
$1,279.10

$831.84
$895.46
$962.86
$1,202.27

$1,192.38
$1,256.00
$1,323.40
$1,562.81

$1,552.92
$1,616.54
$1,683.94
$1,923.35

$360.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$942.60
$1,069.84
$1,204.64
$1,683.46
$2,558.20

$1,303.14
$1,430.38
$1,565.18
$2,044.00

$1,663.68
$1,790.92
$1,925.72
$2,404.54

$2,024.22
$2,151.46
$2,286.26
$2,765.08

$360.54

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

$468.51
$531.76
$598.75
$836.75
$1,271.53

$826.92
$890.17
$957.16
$1,195.16

$1,185.33
$1,248.58
$1,315.57
$1,553.57

$1,543.74
$1,606.99
$1,673.98
$1,911.98

$358.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$937.02
$1,063.52
$1,197.50
$1,673.50
$2,543.06

$1,295.43
$1,421.93
$1,555.91
$2,031.91

$1,653.84
$1,780.34
$1,914.32
$2,390.32

$2,012.25
$2,138.75
$2,272.73
$2,748.73

$358.41

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

$474.52
$538.58
$606.43
$847.49
$1,287.84

$837.53
$901.59
$969.44
$1,210.50

$1,200.54
$1,264.60
$1,332.45
$1,573.51

$1,563.55
$1,627.61
$1,695.46
$1,936.52

$363.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$949.04
$1,077.16
$1,212.86
$1,694.98
$2,575.68

$1,312.05
$1,440.17
$1,575.87
$2,057.99

$1,675.06
$1,803.18
$1,938.88
$2,421.00

$2,038.07
$2,166.19
$2,301.89
$2,784.01

$363.01

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

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

$320.91
$364.22
$410.11
$573.13
$870.93

$566.40
$609.71
$655.60
$818.62

$811.89
$855.20
$901.09
$1,064.11

$1,057.38
$1,100.69
$1,146.58
$1,309.60

$245.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$641.82
$728.44
$820.22
$1,146.26
$1,741.86

$887.31
$973.93
$1,065.71
$1,391.75

$1,132.80
$1,219.42
$1,311.20
$1,637.24

$1,378.29
$1,464.91
$1,556.69
$1,882.73

$245.49

Toc - Plan #60 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

$430.39
$488.48
$550.03
$768.66
$1,168.06

$759.63
$817.72
$879.27
$1,097.90

$1,088.87
$1,146.96
$1,208.51
$1,427.14

$1,418.11
$1,476.20
$1,537.75
$1,756.38

$329.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$860.78
$976.96
$1,100.06
$1,537.32
$2,336.12

$1,190.02
$1,306.20
$1,429.30
$1,866.56

$1,519.26
$1,635.44
$1,758.54
$2,195.80

$1,848.50
$1,964.68
$2,087.78
$2,525.04

$329.24

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

$353.42
$401.12
$451.66
$631.19
$959.15

$623.78
$671.48
$722.02
$901.55

$894.14
$941.84
$992.38
$1,171.91

$1,164.50
$1,212.20
$1,262.74
$1,442.27

$270.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$706.84
$802.24
$903.32
$1,262.38
$1,918.30

$977.20
$1,072.60
$1,173.68
$1,532.74

$1,247.56
$1,342.96
$1,444.04
$1,803.10

$1,517.92
$1,613.32
$1,714.40
$2,073.46

$270.36

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

$434.99
$493.70
$555.90
$776.87
$1,180.53

$767.75
$826.46
$888.66
$1,109.63

$1,100.51
$1,159.22
$1,221.42
$1,442.39

$1,433.27
$1,491.98
$1,554.18
$1,775.15

$332.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$869.98
$987.40
$1,111.80
$1,553.74
$2,361.06

$1,202.74
$1,320.16
$1,444.56
$1,886.50

$1,535.50
$1,652.92
$1,777.32
$2,219.26

$1,868.26
$1,985.68
$2,110.08
$2,552.02

$332.76

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

$345.05
$391.62
$440.96
$616.25
$936.45

$609.01
$655.58
$704.92
$880.21

$872.97
$919.54
$968.88
$1,144.17

$1,136.93
$1,183.50
$1,232.84
$1,408.13

$263.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$690.10
$783.24
$881.92
$1,232.50
$1,872.90

$954.06
$1,047.20
$1,145.88
$1,496.46

$1,218.02
$1,311.16
$1,409.84
$1,760.42

$1,481.98
$1,575.12
$1,673.80
$2,024.38

$263.96

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

$395.46
$448.84
$505.38
$706.27
$1,073.25

$697.98
$751.36
$807.90
$1,008.79

$1,000.50
$1,053.88
$1,110.42
$1,311.31

$1,303.02
$1,356.40
$1,412.94
$1,613.83

$302.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$790.92
$897.68
$1,010.76
$1,412.54
$2,146.50

$1,093.44
$1,200.20
$1,313.28
$1,715.06

$1,395.96
$1,502.72
$1,615.80
$2,017.58

$1,698.48
$1,805.24
$1,918.32
$2,320.10

$302.52

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

$429.79
$487.80
$549.25
$767.58
$1,166.41

$758.57
$816.58
$878.03
$1,096.36

$1,087.35
$1,145.36
$1,206.81
$1,425.14

$1,416.13
$1,474.14
$1,535.59
$1,753.92

$328.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$859.58
$975.60
$1,098.50
$1,535.16
$2,332.82

$1,188.36
$1,304.38
$1,427.28
$1,863.94

$1,517.14
$1,633.16
$1,756.06
$2,192.72

$1,845.92
$1,961.94
$2,084.84
$2,521.50

$328.78

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

$433.43
$491.93
$553.91
$774.08
$1,176.29

$764.99
$823.49
$885.47
$1,105.64

$1,096.55
$1,155.05
$1,217.03
$1,437.20

$1,428.11
$1,486.61
$1,548.59
$1,768.76

$331.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$866.86
$983.86
$1,107.82
$1,548.16
$2,352.58

$1,198.42
$1,315.42
$1,439.38
$1,879.72

$1,529.98
$1,646.98
$1,770.94
$2,211.28

$1,861.54
$1,978.54
$2,102.50
$2,542.84

$331.56

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

$410.72
$466.15
$524.88
$733.52
$1,114.66

$724.91
$780.34
$839.07
$1,047.71

$1,039.10
$1,094.53
$1,153.26
$1,361.90

$1,353.29
$1,408.72
$1,467.45
$1,676.09

$314.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$821.44
$932.30
$1,049.76
$1,467.04
$2,229.32

$1,135.63
$1,246.49
$1,363.95
$1,781.23

$1,449.82
$1,560.68
$1,678.14
$2,095.42

$1,764.01
$1,874.87
$1,992.33
$2,409.61

$314.19

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

$435.98
$494.83
$557.17
$778.65
$1,183.23

$769.50
$828.35
$890.69
$1,112.17

$1,103.02
$1,161.87
$1,224.21
$1,445.69

$1,436.54
$1,495.39
$1,557.73
$1,779.21

$333.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$871.96
$989.66
$1,114.34
$1,557.30
$2,366.46

$1,205.48
$1,323.18
$1,447.86
$1,890.82

$1,539.00
$1,656.70
$1,781.38
$2,224.34

$1,872.52
$1,990.22
$2,114.90
$2,557.86

$333.52

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

$477.90
$542.40
$610.74
$853.50
$1,296.98

$843.48
$907.98
$976.32
$1,219.08

$1,209.06
$1,273.56
$1,341.90
$1,584.66

$1,574.64
$1,639.14
$1,707.48
$1,950.24

$365.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$955.80
$1,084.80
$1,221.48
$1,707.00
$2,593.96

$1,321.38
$1,450.38
$1,587.06
$2,072.58

$1,686.96
$1,815.96
$1,952.64
$2,438.16

$2,052.54
$2,181.54
$2,318.22
$2,803.74

$365.58

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

$338.60
$384.29
$432.71
$604.71
$918.92

$597.62
$643.31
$691.73
$863.73

$856.64
$902.33
$950.75
$1,122.75

$1,115.66
$1,161.35
$1,209.77
$1,381.77

$259.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$677.20
$768.58
$865.42
$1,209.42
$1,837.84

$936.22
$1,027.60
$1,124.44
$1,468.44

$1,195.24
$1,286.62
$1,383.46
$1,727.46

$1,454.26
$1,545.64
$1,642.48
$1,986.48

$259.02

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

$429.53
$487.50
$548.92
$767.12
$1,165.71

$758.11
$816.08
$877.50
$1,095.70

$1,086.69
$1,144.66
$1,206.08
$1,424.28

$1,415.27
$1,473.24
$1,534.66
$1,752.86

$328.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$859.06
$975.00
$1,097.84
$1,534.24
$2,331.42

$1,187.64
$1,303.58
$1,426.42
$1,862.82

$1,516.22
$1,632.16
$1,755.00
$2,191.40

$1,844.80
$1,960.74
$2,083.58
$2,519.98

$328.58

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

$402.22
$456.51
$514.03
$718.35
$1,091.60

$709.91
$764.20
$821.72
$1,026.04

$1,017.60
$1,071.89
$1,129.41
$1,333.73

$1,325.29
$1,379.58
$1,437.10
$1,641.42

$307.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$804.44
$913.02
$1,028.06
$1,436.70
$2,183.20

$1,112.13
$1,220.71
$1,335.75
$1,744.39

$1,419.82
$1,528.40
$1,643.44
$2,052.08

$1,727.51
$1,836.09
$1,951.13
$2,359.77

$307.69

Toc - Plan #73 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

$366.53
$416.00
$468.41
$654.60
$994.73

$646.92
$696.39
$748.80
$934.99

$927.31
$976.78
$1,029.19
$1,215.38

$1,207.70
$1,257.17
$1,309.58
$1,495.77

$280.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$733.06
$832.00
$936.82
$1,309.20
$1,989.46

$1,013.45
$1,112.39
$1,217.21
$1,589.59

$1,293.84
$1,392.78
$1,497.60
$1,869.98

$1,574.23
$1,673.17
$1,777.99
$2,150.37

$280.39

Toc - Plan #74 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

$451.12
$512.01
$576.52
$805.69
$1,224.32

$796.22
$857.11
$921.62
$1,150.79

$1,141.32
$1,202.21
$1,266.72
$1,495.89

$1,486.42
$1,547.31
$1,611.82
$1,840.99

$345.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$902.24
$1,024.02
$1,153.04
$1,611.38
$2,448.64

$1,247.34
$1,369.12
$1,498.14
$1,956.48

$1,592.44
$1,714.22
$1,843.24
$2,301.58

$1,937.54
$2,059.32
$2,188.34
$2,646.68

$345.10

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

$446.36
$506.60
$570.43
$797.18
$1,211.39

$787.82
$848.06
$911.89
$1,138.64

$1,129.28
$1,189.52
$1,253.35
$1,480.10

$1,470.74
$1,530.98
$1,594.81
$1,821.56

$341.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$892.72
$1,013.20
$1,140.86
$1,594.36
$2,422.78

$1,234.18
$1,354.66
$1,482.32
$1,935.82

$1,575.64
$1,696.12
$1,823.78
$2,277.28

$1,917.10
$2,037.58
$2,165.24
$2,618.74

$341.46

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

$332.82
$377.73
$425.33
$594.39
$903.23

$587.42
$632.33
$679.93
$848.99

$842.02
$886.93
$934.53
$1,103.59

$1,096.62
$1,141.53
$1,189.13
$1,358.19

$254.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$665.64
$755.46
$850.66
$1,188.78
$1,806.46

$920.24
$1,010.06
$1,105.26
$1,443.38

$1,174.84
$1,264.66
$1,359.86
$1,697.98

$1,429.44
$1,519.26
$1,614.46
$1,952.58

$254.60

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

$445.73
$505.89
$569.63
$796.05
$1,209.68

$786.70
$846.86
$910.60
$1,137.02

$1,127.67
$1,187.83
$1,251.57
$1,477.99

$1,468.64
$1,528.80
$1,592.54
$1,818.96

$340.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$891.46
$1,011.78
$1,139.26
$1,592.10
$2,419.36

$1,232.43
$1,352.75
$1,480.23
$1,933.07

$1,573.40
$1,693.72
$1,821.20
$2,274.04

$1,914.37
$2,034.69
$2,162.17
$2,615.01

$340.97

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

$452.16
$513.19
$577.84
$807.53
$1,227.12

$798.05
$859.08
$923.73
$1,153.42

$1,143.94
$1,204.97
$1,269.62
$1,499.31

$1,489.83
$1,550.86
$1,615.51
$1,845.20

$345.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$904.32
$1,026.38
$1,155.68
$1,615.06
$2,454.24

$1,250.21
$1,372.27
$1,501.57
$1,960.95

$1,596.10
$1,718.16
$1,847.46
$2,306.84

$1,941.99
$2,064.05
$2,193.35
$2,652.73

$345.89

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

$495.62
$562.52
$633.39
$885.16
$1,345.09

$874.76
$941.66
$1,012.53
$1,264.30

$1,253.90
$1,320.80
$1,391.67
$1,643.44

$1,633.04
$1,699.94
$1,770.81
$2,022.58

$379.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$991.24
$1,125.04
$1,266.78
$1,770.32
$2,690.18

$1,370.38
$1,504.18
$1,645.92
$2,149.46

$1,749.52
$1,883.32
$2,025.06
$2,528.60

$2,128.66
$2,262.46
$2,404.20
$2,907.74

$379.14

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

$357.85
$406.15
$457.32
$639.11
$971.18

$631.60
$679.90
$731.07
$912.86

$905.35
$953.65
$1,004.82
$1,186.61

$1,179.10
$1,227.40
$1,278.57
$1,460.36

$273.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.70
$812.30
$914.64
$1,278.22
$1,942.36

$989.45
$1,086.05
$1,188.39
$1,551.97

$1,263.20
$1,359.80
$1,462.14
$1,825.72

$1,536.95
$1,633.55
$1,735.89
$2,099.47

$273.75

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

$410.13
$465.48
$524.13
$732.47
$1,113.06

$723.87
$779.22
$837.87
$1,046.21

$1,037.61
$1,092.96
$1,151.61
$1,359.95

$1,351.35
$1,406.70
$1,465.35
$1,673.69

$313.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$820.26
$930.96
$1,048.26
$1,464.94
$2,226.12

$1,134.00
$1,244.70
$1,362.00
$1,778.68

$1,447.74
$1,558.44
$1,675.74
$2,092.42

$1,761.48
$1,872.18
$1,989.48
$2,406.16

$313.74

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

$449.50
$510.18
$574.45
$802.80
$1,219.93

$793.36
$854.04
$918.31
$1,146.66

$1,137.22
$1,197.90
$1,262.17
$1,490.52

$1,481.08
$1,541.76
$1,606.03
$1,834.38

$343.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$899.00
$1,020.36
$1,148.90
$1,605.60
$2,439.86

$1,242.86
$1,364.22
$1,492.76
$1,949.46

$1,586.72
$1,708.08
$1,836.62
$2,293.32

$1,930.58
$2,051.94
$2,180.48
$2,637.18

$343.86

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

$425.95
$483.44
$544.35
$760.73
$1,156.00

$751.79
$809.28
$870.19
$1,086.57

$1,077.63
$1,135.12
$1,196.03
$1,412.41

$1,403.47
$1,460.96
$1,521.87
$1,738.25

$325.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$851.90
$966.88
$1,088.70
$1,521.46
$2,312.00

$1,177.74
$1,292.72
$1,414.54
$1,847.30

$1,503.58
$1,618.56
$1,740.38
$2,173.14

$1,829.42
$1,944.40
$2,066.22
$2,498.98

$325.84

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

$807.18
$916.15
$1,031.58
$1,441.62
$2,190.69

$1,424.67
$1,533.64
$1,649.07
$2,059.11

$2,042.16
$2,151.13
$2,266.56
$2,676.60

$2,659.65
$2,768.62
$2,884.05
$3,294.09

$617.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,614.36
$1,832.30
$2,063.16
$2,883.24
$4,381.38

$2,231.85
$2,449.79
$2,680.65
$3,500.73

$2,849.34
$3,067.28
$3,298.14
$4,118.22

$3,466.83
$3,684.77
$3,915.63
$4,735.71

$617.49

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

$474.53
$538.59
$606.45
$847.51
$1,287.87

$837.55
$901.61
$969.47
$1,210.53

$1,200.57
$1,264.63
$1,332.49
$1,573.55

$1,563.59
$1,627.65
$1,695.51
$1,936.57

$363.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$949.06
$1,077.18
$1,212.90
$1,695.02
$2,575.74

$1,312.08
$1,440.20
$1,575.92
$2,058.04

$1,675.10
$1,803.22
$1,938.94
$2,421.06

$2,038.12
$2,166.24
$2,301.96
$2,784.08

$363.02

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

$447.70
$508.14
$572.16
$799.59
$1,215.06

$790.19
$850.63
$914.65
$1,142.08

$1,132.68
$1,193.12
$1,257.14
$1,484.57

$1,475.17
$1,535.61
$1,599.63
$1,827.06

$342.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$895.40
$1,016.28
$1,144.32
$1,599.18
$2,430.12

$1,237.89
$1,358.77
$1,486.81
$1,941.67

$1,580.38
$1,701.26
$1,829.30
$2,284.16

$1,922.87
$2,043.75
$2,171.79
$2,626.65

$342.49

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

$712.20
$808.35
$910.19
$1,271.99
$1,932.91

$1,257.03
$1,353.18
$1,455.02
$1,816.82

$1,801.86
$1,898.01
$1,999.85
$2,361.65

$2,346.69
$2,442.84
$2,544.68
$2,906.48

$544.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,424.40
$1,616.70
$1,820.38
$2,543.98
$3,865.82

$1,969.23
$2,161.53
$2,365.21
$3,088.81

$2,514.06
$2,706.36
$2,910.04
$3,633.64

$3,058.89
$3,251.19
$3,454.87
$4,178.47

$544.83

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

$586.55
$665.73
$749.61
$1,047.58
$1,591.90

$1,035.26
$1,114.44
$1,198.32
$1,496.29

$1,483.97
$1,563.15
$1,647.03
$1,945.00

$1,932.68
$2,011.86
$2,095.74
$2,393.71

$448.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,173.10
$1,331.46
$1,499.22
$2,095.16
$3,183.80

$1,621.81
$1,780.17
$1,947.93
$2,543.87

$2,070.52
$2,228.88
$2,396.64
$2,992.58

$2,519.23
$2,677.59
$2,845.35
$3,441.29

$448.71

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

$514.98
$584.50
$658.14
$919.75
$1,397.66

$908.94
$978.46
$1,052.10
$1,313.71

$1,302.90
$1,372.42
$1,446.06
$1,707.67

$1,696.86
$1,766.38
$1,840.02
$2,101.63

$393.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,029.96
$1,169.00
$1,316.28
$1,839.50
$2,795.32

$1,423.92
$1,562.96
$1,710.24
$2,233.46

$1,817.88
$1,956.92
$2,104.20
$2,627.42

$2,211.84
$2,350.88
$2,498.16
$3,021.38

$393.96

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

$422.74
$479.81
$540.26
$755.01
$1,147.32

$746.14
$803.21
$863.66
$1,078.41

$1,069.54
$1,126.61
$1,187.06
$1,401.81

$1,392.94
$1,450.01
$1,510.46
$1,725.21

$323.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$845.48
$959.62
$1,080.52
$1,510.02
$2,294.64

$1,168.88
$1,283.02
$1,403.92
$1,833.42

$1,492.28
$1,606.42
$1,727.32
$2,156.82

$1,815.68
$1,929.82
$2,050.72
$2,480.22

$323.40

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

$465.74
$528.61
$595.22
$831.81
$1,264.02

$822.03
$884.90
$951.51
$1,188.10

$1,178.32
$1,241.19
$1,307.80
$1,544.39

$1,534.61
$1,597.48
$1,664.09
$1,900.68

$356.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$931.48
$1,057.22
$1,190.44
$1,663.62
$2,528.04

$1,287.77
$1,413.51
$1,546.73
$2,019.91

$1,644.06
$1,769.80
$1,903.02
$2,376.20

$2,000.35
$2,126.09
$2,259.31
$2,732.49

$356.29

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

$626.13
$710.66
$800.19
$1,118.27
$1,699.32

$1,105.12
$1,189.65
$1,279.18
$1,597.26

$1,584.11
$1,668.64
$1,758.17
$2,076.25

$2,063.10
$2,147.63
$2,237.16
$2,555.24

$478.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,252.26
$1,421.32
$1,600.38
$2,236.54
$3,398.64

$1,731.25
$1,900.31
$2,079.37
$2,715.53

$2,210.24
$2,379.30
$2,558.36
$3,194.52

$2,689.23
$2,858.29
$3,037.35
$3,673.51

$478.99

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

$645.51
$732.65
$824.96
$1,152.88
$1,751.91

$1,139.33
$1,226.47
$1,318.78
$1,646.70

$1,633.15
$1,720.29
$1,812.60
$2,140.52

$2,126.97
$2,214.11
$2,306.42
$2,634.34

$493.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,291.02
$1,465.30
$1,649.92
$2,305.76
$3,503.82

$1,784.84
$1,959.12
$2,143.74
$2,799.58

$2,278.66
$2,452.94
$2,637.56
$3,293.40

$2,772.48
$2,946.76
$3,131.38
$3,787.22

$493.82

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

$804.96
$913.63
$1,028.74
$1,437.66
$2,184.66

$1,420.75
$1,529.42
$1,644.53
$2,053.45

$2,036.54
$2,145.21
$2,260.32
$2,669.24

$2,652.33
$2,761.00
$2,876.11
$3,285.03

$615.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,609.92
$1,827.26
$2,057.48
$2,875.32
$4,369.32

$2,225.71
$2,443.05
$2,673.27
$3,491.11

$2,841.50
$3,058.84
$3,289.06
$4,106.90

$3,457.29
$3,674.63
$3,904.85
$4,722.69

$615.79

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

$498.00
$565.23
$636.44
$889.43
$1,351.57

$878.97
$946.20
$1,017.41
$1,270.40

$1,259.94
$1,327.17
$1,398.38
$1,651.37

$1,640.91
$1,708.14
$1,779.35
$2,032.34

$380.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$996.00
$1,130.46
$1,272.88
$1,778.86
$2,703.14

$1,376.97
$1,511.43
$1,653.85
$2,159.83

$1,757.94
$1,892.40
$2,034.82
$2,540.80

$2,138.91
$2,273.37
$2,415.79
$2,921.77

$380.97

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

$330.50
$375.12
$422.38
$590.27
$896.98

$583.33
$627.95
$675.21
$843.10

$836.16
$880.78
$928.04
$1,095.93

$1,088.99
$1,133.61
$1,180.87
$1,348.76

$252.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$661.00
$750.24
$844.76
$1,180.54
$1,793.96

$913.83
$1,003.07
$1,097.59
$1,433.37

$1,166.66
$1,255.90
$1,350.42
$1,686.20

$1,419.49
$1,508.73
$1,603.25
$1,939.03

$252.83

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

$311.13
$353.13
$397.62
$555.68
$844.41

$549.14
$591.14
$635.63
$793.69

$787.15
$829.15
$873.64
$1,031.70

$1,025.16
$1,067.16
$1,111.65
$1,269.71

$238.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$622.26
$706.26
$795.24
$1,111.36
$1,688.82

$860.27
$944.27
$1,033.25
$1,349.37

$1,098.28
$1,182.28
$1,271.26
$1,587.38

$1,336.29
$1,420.29
$1,509.27
$1,825.39

$238.01

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

$407.03
$461.98
$520.18
$726.96
$1,104.68

$718.41
$773.36
$831.56
$1,038.34

$1,029.79
$1,084.74
$1,142.94
$1,349.72

$1,341.17
$1,396.12
$1,454.32
$1,661.10

$311.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$814.06
$923.96
$1,040.36
$1,453.92
$2,209.36

$1,125.44
$1,235.34
$1,351.74
$1,765.30

$1,436.82
$1,546.72
$1,663.12
$2,076.68

$1,748.20
$1,858.10
$1,974.50
$2,388.06

$311.38

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

$387.99
$440.37
$495.85
$692.95
$1,053.00

$684.80
$737.18
$792.66
$989.76

$981.61
$1,033.99
$1,089.47
$1,286.57

$1,278.42
$1,330.80
$1,386.28
$1,583.38

$296.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$775.98
$880.74
$991.70
$1,385.90
$2,106.00

$1,072.79
$1,177.55
$1,288.51
$1,682.71

$1,369.60
$1,474.36
$1,585.32
$1,979.52

$1,666.41
$1,771.17
$1,882.13
$2,276.33

$296.81

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

$460.79
$523.00
$588.89
$822.97
$1,250.58

$813.29
$875.50
$941.39
$1,175.47

$1,165.79
$1,228.00
$1,293.89
$1,527.97

$1,518.29
$1,580.50
$1,646.39
$1,880.47

$352.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$921.58
$1,046.00
$1,177.78
$1,645.94
$2,501.16

$1,274.08
$1,398.50
$1,530.28
$1,998.44

$1,626.58
$1,751.00
$1,882.78
$2,350.94

$1,979.08
$2,103.50
$2,235.28
$2,703.44

$352.50

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

$413.53
$469.36
$528.49
$738.56
$1,122.32

$729.88
$785.71
$844.84
$1,054.91

$1,046.23
$1,102.06
$1,161.19
$1,371.26

$1,362.58
$1,418.41
$1,477.54
$1,687.61

$316.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$827.06
$938.72
$1,056.98
$1,477.12
$2,244.64

$1,143.41
$1,255.07
$1,373.33
$1,793.47

$1,459.76
$1,571.42
$1,689.68
$2,109.82

$1,776.11
$1,887.77
$2,006.03
$2,426.17

$316.35

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

$384.87
$436.83
$491.86
$687.38
$1,044.54

$679.30
$731.26
$786.29
$981.81

$973.73
$1,025.69
$1,080.72
$1,276.24

$1,268.16
$1,320.12
$1,375.15
$1,570.67

$294.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$769.74
$873.66
$983.72
$1,374.76
$2,089.08

$1,064.17
$1,168.09
$1,278.15
$1,669.19

$1,358.60
$1,462.52
$1,572.58
$1,963.62

$1,653.03
$1,756.95
$1,867.01
$2,258.05

$294.43

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

$383.41
$435.17
$490.00
$684.77
$1,040.57

$676.72
$728.48
$783.31
$978.08

$970.03
$1,021.79
$1,076.62
$1,271.39

$1,263.34
$1,315.10
$1,369.93
$1,564.70

$293.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$766.82
$870.34
$980.00
$1,369.54
$2,081.14

$1,060.13
$1,163.65
$1,273.31
$1,662.85

$1,353.44
$1,456.96
$1,566.62
$1,956.16

$1,646.75
$1,750.27
$1,859.93
$2,249.47

$293.31

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

$357.54
$405.81
$456.94
$638.57
$970.36

$631.06
$679.33
$730.46
$912.09

$904.58
$952.85
$1,003.98
$1,185.61

$1,178.10
$1,226.37
$1,277.50
$1,459.13

$273.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.08
$811.62
$913.88
$1,277.14
$1,940.72

$988.60
$1,085.14
$1,187.40
$1,550.66

$1,262.12
$1,358.66
$1,460.92
$1,824.18

$1,535.64
$1,632.18
$1,734.44
$2,097.70

$273.52

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

$330.89
$375.56
$422.88
$590.97
$898.04

$584.02
$628.69
$676.01
$844.10

$837.15
$881.82
$929.14
$1,097.23

$1,090.28
$1,134.95
$1,182.27
$1,350.36

$253.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$661.78
$751.12
$845.76
$1,181.94
$1,796.08

$914.91
$1,004.25
$1,098.89
$1,435.07

$1,168.04
$1,257.38
$1,352.02
$1,688.20

$1,421.17
$1,510.51
$1,605.15
$1,941.33

$253.13

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

$376.70
$427.55
$481.42
$672.79
$1,022.36

$664.88
$715.73
$769.60
$960.97

$953.06
$1,003.91
$1,057.78
$1,249.15

$1,241.24
$1,292.09
$1,345.96
$1,537.33

$288.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$753.40
$855.10
$962.84
$1,345.58
$2,044.72

$1,041.58
$1,143.28
$1,251.02
$1,633.76

$1,329.76
$1,431.46
$1,539.20
$1,921.94

$1,617.94
$1,719.64
$1,827.38
$2,210.12

$288.18

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

$323.40
$367.06
$413.31
$577.59
$877.71

$570.80
$614.46
$660.71
$824.99

$818.20
$861.86
$908.11
$1,072.39

$1,065.60
$1,109.26
$1,155.51
$1,319.79

$247.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$646.80
$734.12
$826.62
$1,155.18
$1,755.42

$894.20
$981.52
$1,074.02
$1,402.58

$1,141.60
$1,228.92
$1,321.42
$1,649.98

$1,389.00
$1,476.32
$1,568.82
$1,897.38

$247.40

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

$324.09
$367.84
$414.19
$578.82
$879.58

$572.02
$615.77
$662.12
$826.75

$819.95
$863.70
$910.05
$1,074.68

$1,067.88
$1,111.63
$1,157.98
$1,322.61

$247.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$648.18
$735.68
$828.38
$1,157.64
$1,759.16

$896.11
$983.61
$1,076.31
$1,405.57

$1,144.04
$1,231.54
$1,324.24
$1,653.50

$1,391.97
$1,479.47
$1,572.17
$1,901.43

$247.93

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

$294.45
$334.20
$376.31
$525.89
$799.14

$519.70
$559.45
$601.56
$751.14

$744.95
$784.70
$826.81
$976.39

$970.20
$1,009.95
$1,052.06
$1,201.64

$225.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$588.90
$668.40
$752.62
$1,051.78
$1,598.28

$814.15
$893.65
$977.87
$1,277.03

$1,039.40
$1,118.90
$1,203.12
$1,502.28

$1,264.65
$1,344.15
$1,428.37
$1,727.53

$225.25

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

$315.88
$358.52
$403.69
$564.16
$857.30

$557.53
$600.17
$645.34
$805.81

$799.18
$841.82
$886.99
$1,047.46

$1,040.83
$1,083.47
$1,128.64
$1,289.11

$241.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$631.76
$717.04
$807.38
$1,128.32
$1,714.60

$873.41
$958.69
$1,049.03
$1,369.97

$1,115.06
$1,200.34
$1,290.68
$1,611.62

$1,356.71
$1,441.99
$1,532.33
$1,853.27

$241.65

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

$346.20
$392.94
$442.44
$618.31
$939.59

$611.04
$657.78
$707.28
$883.15

$875.88
$922.62
$972.12
$1,147.99

$1,140.72
$1,187.46
$1,236.96
$1,412.83

$264.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$692.40
$785.88
$884.88
$1,236.62
$1,879.18

$957.24
$1,050.72
$1,149.72
$1,501.46

$1,222.08
$1,315.56
$1,414.56
$1,766.30

$1,486.92
$1,580.40
$1,679.40
$2,031.14

$264.84

Toc - Plan #112 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Connected Care Silver 2230 ($0 Primary Care Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Disponible en Espa�ol / 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

$7,400 $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

$373.34
$423.74
$477.13
$666.79
$1,013.24

$658.95
$709.35
$762.74
$952.40

$944.56
$994.96
$1,048.35
$1,238.01

$1,230.17
$1,280.57
$1,333.96
$1,523.62

$285.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$746.68
$847.48
$954.26
$1,333.58
$2,026.48

$1,032.29
$1,133.09
$1,239.87
$1,619.19

$1,317.90
$1,418.70
$1,525.48
$1,904.80

$1,603.51
$1,704.31
$1,811.09
$2,190.41

$285.61

Toc - Plan #113 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Connected Care Bronze 2231 ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Disponible en Espa�ol / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$306.24
$347.58
$391.37
$546.94
$831.14

$540.51
$581.85
$625.64
$781.21

$774.78
$816.12
$859.91
$1,015.48

$1,009.05
$1,050.39
$1,094.18
$1,249.75

$234.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$612.48
$695.16
$782.74
$1,093.88
$1,662.28

$846.75
$929.43
$1,017.01
$1,328.15

$1,081.02
$1,163.70
$1,251.28
$1,562.42

$1,315.29
$1,397.97
$1,485.55
$1,796.69

$234.27

Toc - Plan #114 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Connected Care Silver 2332 ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Disponible en Espa�ol / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$361.56
$410.37
$462.07
$645.75
$981.27

$638.15
$686.96
$738.66
$922.34

$914.74
$963.55
$1,015.25
$1,198.93

$1,191.33
$1,240.14
$1,291.84
$1,475.52

$276.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$723.12
$820.74
$924.14
$1,291.50
$1,962.54

$999.71
$1,097.33
$1,200.73
$1,568.09

$1,276.30
$1,373.92
$1,477.32
$1,844.68

$1,552.89
$1,650.51
$1,753.91
$2,121.27

$276.59

Toc - Plan #115 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

$364.64
$413.87
$466.01
$651.25
$989.63

$643.59
$692.82
$744.96
$930.20

$922.54
$971.77
$1,023.91
$1,209.15

$1,201.49
$1,250.72
$1,302.86
$1,488.10

$278.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$729.28
$827.74
$932.02
$1,302.50
$1,979.26

$1,008.23
$1,106.69
$1,210.97
$1,581.45

$1,287.18
$1,385.64
$1,489.92
$1,860.40

$1,566.13
$1,664.59
$1,768.87
$2,139.35

$278.95

Toc - Plan #116 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

$379.18
$430.37
$484.59
$677.22
$1,029.09

$669.25
$720.44
$774.66
$967.29

$959.32
$1,010.51
$1,064.73
$1,257.36

$1,249.39
$1,300.58
$1,354.80
$1,547.43

$290.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$758.36
$860.74
$969.18
$1,354.44
$2,058.18

$1,048.43
$1,150.81
$1,259.25
$1,644.51

$1,338.50
$1,440.88
$1,549.32
$1,934.58

$1,628.57
$1,730.95
$1,839.39
$2,224.65

$290.07

Toc - Plan #117 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

$436.16
$495.04
$557.41
$778.98
$1,183.74

$769.82
$828.70
$891.07
$1,112.64

$1,103.48
$1,162.36
$1,224.73
$1,446.30

$1,437.14
$1,496.02
$1,558.39
$1,779.96

$333.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$872.32
$990.08
$1,114.82
$1,557.96
$2,367.48

$1,205.98
$1,323.74
$1,448.48
$1,891.62

$1,539.64
$1,657.40
$1,782.14
$2,225.28

$1,873.30
$1,991.06
$2,115.80
$2,558.94

$333.66

Toc - Plan #118 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

$384.36
$436.25
$491.21
$686.47
$1,043.15

$678.40
$730.29
$785.25
$980.51

$972.44
$1,024.33
$1,079.29
$1,274.55

$1,266.48
$1,318.37
$1,373.33
$1,568.59

$294.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$768.72
$872.50
$982.42
$1,372.94
$2,086.30

$1,062.76
$1,166.54
$1,276.46
$1,666.98

$1,356.80
$1,460.58
$1,570.50
$1,961.02

$1,650.84
$1,754.62
$1,864.54
$2,255.06

$294.04

Toc - Plan #119 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Connected Care Silver 2332D ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / Adult Dental / 24x7 Provider Access / Disponible en Espa�ol / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$369.20
$419.04
$471.84
$659.39
$1,002.01

$651.64
$701.48
$754.28
$941.83

$934.08
$983.92
$1,036.72
$1,224.27

$1,216.52
$1,266.36
$1,319.16
$1,506.71

$282.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$738.40
$838.08
$943.68
$1,318.78
$2,004.02

$1,020.84
$1,120.52
$1,226.12
$1,601.22

$1,303.28
$1,402.96
$1,508.56
$1,883.66

$1,585.72
$1,685.40
$1,791.00
$2,166.10

$282.44

Toc - Plan #120 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

$372.27
$422.53
$475.76
$664.87
$1,010.34

$657.06
$707.32
$760.55
$949.66

$941.85
$992.11
$1,045.34
$1,234.45

$1,226.64
$1,276.90
$1,330.13
$1,519.24

$284.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$744.54
$845.06
$951.52
$1,329.74
$2,020.68

$1,029.33
$1,129.85
$1,236.31
$1,614.53

$1,314.12
$1,414.64
$1,521.10
$1,899.32

$1,598.91
$1,699.43
$1,805.89
$2,184.11

$284.79

Oscar Insurance Company of Florida

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

Toc - Plan #121 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

$374.38
$424.91
$478.44
$668.62
$1,016.04

$660.77
$711.30
$764.83
$955.01

$947.16
$997.69
$1,051.22
$1,241.40

$1,233.55
$1,284.08
$1,337.61
$1,527.79

$286.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$748.76
$849.82
$956.88
$1,337.24
$2,032.08

$1,035.15
$1,136.21
$1,243.27
$1,623.63

$1,321.54
$1,422.60
$1,529.66
$1,910.02

$1,607.93
$1,708.99
$1,816.05
$2,196.41

$286.39

Toc - Plan #122 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

$292.03
$331.44
$373.20
$521.54
$792.53

$515.42
$554.83
$596.59
$744.93

$738.81
$778.22
$819.98
$968.32

$962.20
$1,001.61
$1,043.37
$1,191.71

$223.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$584.06
$662.88
$746.40
$1,043.08
$1,585.06

$807.45
$886.27
$969.79
$1,266.47

$1,030.84
$1,109.66
$1,193.18
$1,489.86

$1,254.23
$1,333.05
$1,416.57
$1,713.25

$223.39

Toc - Plan #123 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

$284.14
$322.49
$363.12
$507.45
$771.12

$501.50
$539.85
$580.48
$724.81

$718.86
$757.21
$797.84
$942.17

$936.22
$974.57
$1,015.20
$1,159.53

$217.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$568.28
$644.98
$726.24
$1,014.90
$1,542.24

$785.64
$862.34
$943.60
$1,232.26

$1,003.00
$1,079.70
$1,160.96
$1,449.62

$1,220.36
$1,297.06
$1,378.32
$1,666.98

$217.36

Toc - Plan #124 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

$344.84
$391.38
$440.69
$615.86
$935.86

$608.63
$655.17
$704.48
$879.65

$872.42
$918.96
$968.27
$1,143.44

$1,136.21
$1,182.75
$1,232.06
$1,407.23

$263.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$689.68
$782.76
$881.38
$1,231.72
$1,871.72

$953.47
$1,046.55
$1,145.17
$1,495.51

$1,217.26
$1,310.34
$1,408.96
$1,759.30

$1,481.05
$1,574.13
$1,672.75
$2,023.09

$263.79

Toc - Plan #125 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

$382.86
$434.53
$489.28
$683.77
$1,039.05

$675.74
$727.41
$782.16
$976.65

$968.62
$1,020.29
$1,075.04
$1,269.53

$1,261.50
$1,313.17
$1,367.92
$1,562.41

$292.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.72
$869.06
$978.56
$1,367.54
$2,078.10

$1,058.60
$1,161.94
$1,271.44
$1,660.42

$1,351.48
$1,454.82
$1,564.32
$1,953.30

$1,644.36
$1,747.70
$1,857.20
$2,246.18

$292.88

Toc - Plan #126 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

$380.64
$432.01
$486.44
$679.80
$1,033.02

$671.82
$723.19
$777.62
$970.98

$963.00
$1,014.37
$1,068.80
$1,262.16

$1,254.18
$1,305.55
$1,359.98
$1,553.34

$291.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$761.28
$864.02
$972.88
$1,359.60
$2,066.04

$1,052.46
$1,155.20
$1,264.06
$1,650.78

$1,343.64
$1,446.38
$1,555.24
$1,941.96

$1,634.82
$1,737.56
$1,846.42
$2,233.14

$291.18

Toc - Plan #127 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

$383.42
$435.17
$489.99
$684.76
$1,040.56

$676.73
$728.48
$783.30
$978.07

$970.04
$1,021.79
$1,076.61
$1,271.38

$1,263.35
$1,315.10
$1,369.92
$1,564.69

$293.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$766.84
$870.34
$979.98
$1,369.52
$2,081.12

$1,060.15
$1,163.65
$1,273.29
$1,662.83

$1,353.46
$1,456.96
$1,566.60
$1,956.14

$1,646.77
$1,750.27
$1,859.91
$2,249.45

$293.31

Toc - Plan #128 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

$218.35
$247.81
$279.04
$389.95
$592.57

$385.38
$414.84
$446.07
$556.98

$552.41
$581.87
$613.10
$724.01

$719.44
$748.90
$780.13
$891.04

$167.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$436.70
$495.62
$558.08
$779.90
$1,185.14

$603.73
$662.65
$725.11
$946.93

$770.76
$829.68
$892.14
$1,113.96

$937.79
$996.71
$1,059.17
$1,280.99

$167.03

Toc - Plan #129 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

$344.39
$390.87
$440.11
$615.06
$934.64

$607.84
$654.32
$703.56
$878.51

$871.29
$917.77
$967.01
$1,141.96

$1,134.74
$1,181.22
$1,230.46
$1,405.41

$263.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$688.78
$781.74
$880.22
$1,230.12
$1,869.28

$952.23
$1,045.19
$1,143.67
$1,493.57

$1,215.68
$1,308.64
$1,407.12
$1,757.02

$1,479.13
$1,572.09
$1,670.57
$2,020.47

$263.45

Toc - Plan #130 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

$405.86
$460.64
$518.68
$724.85
$1,101.48

$716.34
$771.12
$829.16
$1,035.33

$1,026.82
$1,081.60
$1,139.64
$1,345.81

$1,337.30
$1,392.08
$1,450.12
$1,656.29

$310.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$811.72
$921.28
$1,037.36
$1,449.70
$2,202.96

$1,122.20
$1,231.76
$1,347.84
$1,760.18

$1,432.68
$1,542.24
$1,658.32
$2,070.66

$1,743.16
$1,852.72
$1,968.80
$2,381.14

$310.48

Toc - Plan #131 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

$302.45
$343.27
$386.52
$540.16
$820.83

$533.82
$574.64
$617.89
$771.53

$765.19
$806.01
$849.26
$1,002.90

$996.56
$1,037.38
$1,080.63
$1,234.27

$231.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$604.90
$686.54
$773.04
$1,080.32
$1,641.66

$836.27
$917.91
$1,004.41
$1,311.69

$1,067.64
$1,149.28
$1,235.78
$1,543.06

$1,299.01
$1,380.65
$1,467.15
$1,774.43

$231.37

Toc - Plan #132 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

$387.87
$440.22
$495.68
$692.72
$1,052.65

$684.58
$736.93
$792.39
$989.43

$981.29
$1,033.64
$1,089.10
$1,286.14

$1,278.00
$1,330.35
$1,385.81
$1,582.85

$296.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$775.74
$880.44
$991.36
$1,385.44
$2,105.30

$1,072.45
$1,177.15
$1,288.07
$1,682.15

$1,369.16
$1,473.86
$1,584.78
$1,978.86

$1,665.87
$1,770.57
$1,881.49
$2,275.57

$296.71

Toc - Plan #133 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

$390.66
$443.38
$499.25
$697.69
$1,060.21

$689.50
$742.22
$798.09
$996.53

$988.34
$1,041.06
$1,096.93
$1,295.37

$1,287.18
$1,339.90
$1,395.77
$1,594.21

$298.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$781.32
$886.76
$998.50
$1,395.38
$2,120.42

$1,080.16
$1,185.60
$1,297.34
$1,694.22

$1,379.00
$1,484.44
$1,596.18
$1,993.06

$1,677.84
$1,783.28
$1,895.02
$2,291.90

$298.84

Toc - Plan #134 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

$300.82
$341.42
$384.43
$537.25
$816.40

$530.94
$571.54
$614.55
$767.37

$761.06
$801.66
$844.67
$997.49

$991.18
$1,031.78
$1,074.79
$1,227.61

$230.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$601.64
$682.84
$768.86
$1,074.50
$1,632.80

$831.76
$912.96
$998.98
$1,304.62

$1,061.88
$1,143.08
$1,229.10
$1,534.74

$1,292.00
$1,373.20
$1,459.22
$1,764.86

$230.12

Toc - Plan #135 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

$310.53
$352.44
$396.85
$554.59
$842.75

$548.08
$589.99
$634.40
$792.14

$785.63
$827.54
$871.95
$1,029.69

$1,023.18
$1,065.09
$1,109.50
$1,267.24

$237.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$621.06
$704.88
$793.70
$1,109.18
$1,685.50

$858.61
$942.43
$1,031.25
$1,346.73

$1,096.16
$1,179.98
$1,268.80
$1,584.28

$1,333.71
$1,417.53
$1,506.35
$1,821.83

$237.55

Toc - Plan #136 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

$367.87
$417.52
$470.13
$657.00
$998.38

$649.28
$698.93
$751.54
$938.41

$930.69
$980.34
$1,032.95
$1,219.82

$1,212.10
$1,261.75
$1,314.36
$1,501.23

$281.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$735.74
$835.04
$940.26
$1,314.00
$1,996.76

$1,017.15
$1,116.45
$1,221.67
$1,595.41

$1,298.56
$1,397.86
$1,503.08
$1,876.82

$1,579.97
$1,679.27
$1,784.49
$2,158.23

$281.41

Toc - Plan #137 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

$392.33
$445.28
$501.38
$700.68
$1,064.75

$692.45
$745.40
$801.50
$1,000.80

$992.57
$1,045.52
$1,101.62
$1,300.92

$1,292.69
$1,345.64
$1,401.74
$1,601.04

$300.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$784.66
$890.56
$1,002.76
$1,401.36
$2,129.50

$1,084.78
$1,190.68
$1,302.88
$1,701.48

$1,384.90
$1,490.80
$1,603.00
$2,001.60

$1,685.02
$1,790.92
$1,903.12
$2,301.72

$300.12

Toc - Plan #138 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

$383.42
$435.17
$489.99
$684.76
$1,040.56

$676.73
$728.48
$783.30
$978.07

$970.04
$1,021.79
$1,076.61
$1,271.38

$1,263.35
$1,315.10
$1,369.92
$1,564.69

$293.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$766.84
$870.34
$979.98
$1,369.52
$2,081.12

$1,060.15
$1,163.65
$1,273.29
$1,662.83

$1,353.46
$1,456.96
$1,566.60
$1,956.14

$1,646.77
$1,750.27
$1,859.91
$2,249.45

$293.31

Toc - Plan #139 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

$444.38
$504.36
$567.91
$793.65
$1,206.03

$784.33
$844.31
$907.86
$1,133.60

$1,124.28
$1,184.26
$1,247.81
$1,473.55

$1,464.23
$1,524.21
$1,587.76
$1,813.50

$339.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$888.76
$1,008.72
$1,135.82
$1,587.30
$2,412.06

$1,228.71
$1,348.67
$1,475.77
$1,927.25

$1,568.66
$1,688.62
$1,815.72
$2,267.20

$1,908.61
$2,028.57
$2,155.67
$2,607.15

$339.95

Toc - Plan #140 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

$416.08
$472.24
$531.74
$743.10
$1,129.22

$734.38
$790.54
$850.04
$1,061.40

$1,052.68
$1,108.84
$1,168.34
$1,379.70

$1,370.98
$1,427.14
$1,486.64
$1,698.00

$318.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$832.16
$944.48
$1,063.48
$1,486.20
$2,258.44

$1,150.46
$1,262.78
$1,381.78
$1,804.50

$1,468.76
$1,581.08
$1,700.08
$2,122.80

$1,787.06
$1,899.38
$2,018.38
$2,441.10

$318.30

Toc - Plan #141 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

$335.88
$381.21
$429.24
$599.86
$911.55

$592.82
$638.15
$686.18
$856.80

$849.76
$895.09
$943.12
$1,113.74

$1,106.70
$1,152.03
$1,200.06
$1,370.68

$256.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$671.76
$762.42
$858.48
$1,199.72
$1,823.10

$928.70
$1,019.36
$1,115.42
$1,456.66

$1,185.64
$1,276.30
$1,372.36
$1,713.60

$1,442.58
$1,533.24
$1,629.30
$1,970.54

$256.94

Toc - Plan #142 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

$381.75
$433.27
$487.86
$681.78
$1,036.04

$673.78
$725.30
$779.89
$973.81

$965.81
$1,017.33
$1,071.92
$1,265.84

$1,257.84
$1,309.36
$1,363.95
$1,557.87

$292.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$763.50
$866.54
$975.72
$1,363.56
$2,072.08

$1,055.53
$1,158.57
$1,267.75
$1,655.59

$1,347.56
$1,450.60
$1,559.78
$1,947.62

$1,639.59
$1,742.63
$1,851.81
$2,239.65

$292.03

Toc - Plan #143 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

$307.00
$348.43
$392.33
$548.28
$833.16

$541.84
$583.27
$627.17
$783.12

$776.68
$818.11
$862.01
$1,017.96

$1,011.52
$1,052.95
$1,096.85
$1,252.80

$234.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$614.00
$696.86
$784.66
$1,096.56
$1,666.32

$848.84
$931.70
$1,019.50
$1,331.40

$1,083.68
$1,166.54
$1,254.34
$1,566.24

$1,318.52
$1,401.38
$1,489.18
$1,801.08

$234.84

Toc - Plan #144 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

$271.05
$307.63
$346.39
$484.08
$735.61

$478.40
$514.98
$553.74
$691.43

$685.75
$722.33
$761.09
$898.78

$893.10
$929.68
$968.44
$1,106.13

$207.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$542.10
$615.26
$692.78
$968.16
$1,471.22

$749.45
$822.61
$900.13
$1,175.51

$956.80
$1,029.96
$1,107.48
$1,382.86

$1,164.15
$1,237.31
$1,314.83
$1,590.21

$207.35

Toc - Plan #145 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

$377.86
$428.86
$482.89
$674.84
$1,025.48

$666.91
$717.91
$771.94
$963.89

$955.96
$1,006.96
$1,060.99
$1,252.94

$1,245.01
$1,296.01
$1,350.04
$1,541.99

$289.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$755.72
$857.72
$965.78
$1,349.68
$2,050.96

$1,044.77
$1,146.77
$1,254.83
$1,638.73

$1,333.82
$1,435.82
$1,543.88
$1,927.78

$1,622.87
$1,724.87
$1,832.93
$2,216.83

$289.05

Toc - Plan #146 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

$387.05
$439.29
$494.63
$691.25
$1,050.42

$683.13
$735.37
$790.71
$987.33

$979.21
$1,031.45
$1,086.79
$1,283.41

$1,275.29
$1,327.53
$1,382.87
$1,579.49

$296.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$774.10
$878.58
$989.26
$1,382.50
$2,100.84

$1,070.18
$1,174.66
$1,285.34
$1,678.58

$1,366.26
$1,470.74
$1,581.42
$1,974.66

$1,662.34
$1,766.82
$1,877.50
$2,270.74

$296.08

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

Toc - Plan #147 Cigna Healthcare

Bronze

(EPO) Cigna Connect 8700

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$319.77
$362.93
$408.66
$571.10
$867.84

$564.39
$607.55
$653.28
$815.72

$809.01
$852.17
$897.90
$1,060.34

$1,053.63
$1,096.79
$1,142.52
$1,304.96

$244.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$639.54
$725.86
$817.32
$1,142.20
$1,735.68

$884.16
$970.48
$1,061.94
$1,386.82

$1,128.78
$1,215.10
$1,306.56
$1,631.44

$1,373.40
$1,459.72
$1,551.18
$1,876.06

$244.62

Toc - Plan #148 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 7300

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,300 $14,600 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$332.12
$376.95
$424.45
$593.16
$901.37

$586.19
$631.02
$678.52
$847.23

$840.26
$885.09
$932.59
$1,101.30

$1,094.33
$1,139.16
$1,186.66
$1,355.37

$254.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$664.24
$753.90
$848.90
$1,186.32
$1,802.74

$918.31
$1,007.97
$1,102.97
$1,440.39

$1,172.38
$1,262.04
$1,357.04
$1,694.46

$1,426.45
$1,516.11
$1,611.11
$1,948.53

$254.07

Toc - Plan #149 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 8200

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$8,200 $16,400 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$332.25
$377.10
$424.61
$593.40
$901.72

$586.42
$631.27
$678.78
$847.57

$840.59
$885.44
$932.95
$1,101.74

$1,094.76
$1,139.61
$1,187.12
$1,355.91

$254.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$664.50
$754.20
$849.22
$1,186.80
$1,803.44

$918.67
$1,008.37
$1,103.39
$1,440.97

$1,172.84
$1,262.54
$1,357.56
$1,695.14

$1,427.01
$1,516.71
$1,611.73
$1,949.31

$254.17

Toc - Plan #150 Cigna Healthcare

Silver

(EPO) Cigna Connect 4400

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$4,400 $8,800 Annual Deductible

$9,050 $18,100 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

$381.74
$433.28
$487.86
$681.79
$1,036.05

$673.77
$725.31
$779.89
$973.82

$965.80
$1,017.34
$1,071.92
$1,265.85

$1,257.83
$1,309.37
$1,363.95
$1,557.88

$292.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$763.48
$866.56
$975.72
$1,363.58
$2,072.10

$1,055.51
$1,158.59
$1,267.75
$1,655.61

$1,347.54
$1,450.62
$1,559.78
$1,947.64

$1,639.57
$1,742.65
$1,851.81
$2,239.67

$292.03

Toc - Plan #151 Cigna Healthcare

Silver

(EPO) Cigna Connect 4500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 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

$385.70
$437.77
$492.92
$688.85
$1,046.78

$680.76
$732.83
$787.98
$983.91

$975.82
$1,027.89
$1,083.04
$1,278.97

$1,270.88
$1,322.95
$1,378.10
$1,574.03

$295.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$771.40
$875.54
$985.84
$1,377.70
$2,093.56

$1,066.46
$1,170.60
$1,280.90
$1,672.76

$1,361.52
$1,465.66
$1,575.96
$1,967.82

$1,656.58
$1,760.72
$1,871.02
$2,262.88

$295.06

Toc - Plan #152 Cigna Healthcare

Silver

(EPO) Cigna Connect 8900

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$8,900 $17,800 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$388.73
$441.21
$496.80
$694.27
$1,055.01

$686.11
$738.59
$794.18
$991.65

$983.49
$1,035.97
$1,091.56
$1,289.03

$1,280.87
$1,333.35
$1,388.94
$1,586.41

$297.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$777.46
$882.42
$993.60
$1,388.54
$2,110.02

$1,074.84
$1,179.80
$1,290.98
$1,685.92

$1,372.22
$1,477.18
$1,588.36
$1,983.30

$1,669.60
$1,774.56
$1,885.74
$2,280.68

$297.38

Toc - Plan #153 Cigna Healthcare

Silver

(EPO) Cigna Connect 3500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 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

$389.35
$441.91
$497.58
$695.37
$1,056.68

$687.20
$739.76
$795.43
$993.22

$985.05
$1,037.61
$1,093.28
$1,291.07

$1,282.90
$1,335.46
$1,391.13
$1,588.92

$297.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$778.70
$883.82
$995.16
$1,390.74
$2,113.36

$1,076.55
$1,181.67
$1,293.01
$1,688.59

$1,374.40
$1,479.52
$1,590.86
$1,986.44

$1,672.25
$1,777.37
$1,888.71
$2,284.29

$297.85

Toc - Plan #154 Cigna Healthcare

Gold

(EPO) Cigna Connect 1950

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$1,950 $3,900 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$463.41
$525.97
$592.23
$827.65
$1,257.69

$817.92
$880.48
$946.74
$1,182.16

$1,172.43
$1,234.99
$1,301.25
$1,536.67

$1,526.94
$1,589.50
$1,655.76
$1,891.18

$354.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$926.82
$1,051.94
$1,184.46
$1,655.30
$2,515.38

$1,281.33
$1,406.45
$1,538.97
$2,009.81

$1,635.84
$1,760.96
$1,893.48
$2,364.32

$1,990.35
$2,115.47
$2,247.99
$2,718.83

$354.51

Toc - Plan #155 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 8000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$331.37
$376.10
$423.49
$591.83
$899.34

$584.87
$629.60
$676.99
$845.33

$838.37
$883.10
$930.49
$1,098.83

$1,091.87
$1,136.60
$1,183.99
$1,352.33

$253.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$662.74
$752.20
$846.98
$1,183.66
$1,798.68

$916.24
$1,005.70
$1,100.48
$1,437.16

$1,169.74
$1,259.20
$1,353.98
$1,690.66

$1,423.24
$1,512.70
$1,607.48
$1,944.16

$253.50

Toc - Plan #156 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 6800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$6,800 $13,600 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$331.15
$375.86
$423.21
$591.43
$898.74

$584.48
$629.19
$676.54
$844.76

$837.81
$882.52
$929.87
$1,098.09

$1,091.14
$1,135.85
$1,183.20
$1,351.42

$253.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$662.30
$751.72
$846.42
$1,182.86
$1,797.48

$915.63
$1,005.05
$1,099.75
$1,436.19

$1,168.96
$1,258.38
$1,353.08
$1,689.52

$1,422.29
$1,511.71
$1,606.41
$1,942.85

$253.33

Toc - Plan #157 Cigna Healthcare

Silver

(EPO) Cigna Connect 3000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$382.97
$434.67
$489.44
$683.99
$1,039.39

$675.94
$727.64
$782.41
$976.96

$968.91
$1,020.61
$1,075.38
$1,269.93

$1,261.88
$1,313.58
$1,368.35
$1,562.90

$292.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.94
$869.34
$978.88
$1,367.98
$2,078.78

$1,058.91
$1,162.31
$1,271.85
$1,660.95

$1,351.88
$1,455.28
$1,564.82
$1,953.92

$1,644.85
$1,748.25
$1,857.79
$2,246.89

$292.97

Toc - Plan #158 Cigna Healthcare

Silver

(EPO) Cigna Connect 0B

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$399.67
$453.63
$510.78
$713.82
$1,084.72

$705.42
$759.38
$816.53
$1,019.57

$1,011.17
$1,065.13
$1,122.28
$1,325.32

$1,316.92
$1,370.88
$1,428.03
$1,631.07

$305.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$799.34
$907.26
$1,021.56
$1,427.64
$2,169.44

$1,105.09
$1,213.01
$1,327.31
$1,733.39

$1,410.84
$1,518.76
$1,633.06
$2,039.14

$1,716.59
$1,824.51
$1,938.81
$2,344.89

$305.75

Toc - Plan #159 Cigna Healthcare

Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$4,200 $8,400 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$386.36
$438.51
$493.76
$690.03
$1,048.57

$681.92
$734.07
$789.32
$985.59

$977.48
$1,029.63
$1,084.88
$1,281.15

$1,273.04
$1,325.19
$1,380.44
$1,576.71

$295.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$772.72
$877.02
$987.52
$1,380.06
$2,097.14

$1,068.28
$1,172.58
$1,283.08
$1,675.62

$1,363.84
$1,468.14
$1,578.64
$1,971.18

$1,659.40
$1,763.70
$1,874.20
$2,266.74

$295.56

Toc - Plan #160 Cigna Healthcare

Gold

(EPO) Cigna Connect 900

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$900 $1,800 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

$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 #161 Cigna Healthcare

Gold

(EPO) Cigna Connect 1900 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$466.18
$529.11
$595.77
$832.59
$1,265.20

$822.81
$885.74
$952.40
$1,189.22

$1,179.44
$1,242.37
$1,309.03
$1,545.85

$1,536.07
$1,599.00
$1,665.66
$1,902.48

$356.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$932.36
$1,058.22
$1,191.54
$1,665.18
$2,530.40

$1,288.99
$1,414.85
$1,548.17
$2,021.81

$1,645.62
$1,771.48
$1,904.80
$2,378.44

$2,002.25
$2,128.11
$2,261.43
$2,735.07

$356.63

Toc - Plan #162 Cigna Healthcare

Gold

(EPO) Cigna Simple Choice 2000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$464.02
$526.67
$593.02
$828.75
$1,259.36

$819.00
$881.65
$948.00
$1,183.73

$1,173.98
$1,236.63
$1,302.98
$1,538.71

$1,528.96
$1,591.61
$1,657.96
$1,893.69

$354.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$928.04
$1,053.34
$1,186.04
$1,657.50
$2,518.72

$1,283.02
$1,408.32
$1,541.02
$2,012.48

$1,638.00
$1,763.30
$1,896.00
$2,367.46

$1,992.98
$2,118.28
$2,250.98
$2,722.44

$354.98

Toc - Plan #163 Cigna Healthcare

Silver

(EPO) Cigna Simple Choice 5800

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$382.14
$433.72
$488.37
$682.50
$1,037.12

$674.47
$726.05
$780.70
$974.83

$966.80
$1,018.38
$1,073.03
$1,267.16

$1,259.13
$1,310.71
$1,365.36
$1,559.49

$292.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$764.28
$867.44
$976.74
$1,365.00
$2,074.24

$1,056.61
$1,159.77
$1,269.07
$1,657.33

$1,348.94
$1,452.10
$1,561.40
$1,949.66

$1,641.27
$1,744.43
$1,853.73
$2,241.99

$292.33

Toc - Plan #164 Cigna Healthcare

Bronze

(EPO) Cigna Simple Choice 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$316.69
$359.44
$404.73
$565.61
$859.49

$558.96
$601.71
$647.00
$807.88

$801.23
$843.98
$889.27
$1,050.15

$1,043.50
$1,086.25
$1,131.54
$1,292.42

$242.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$633.38
$718.88
$809.46
$1,131.22
$1,718.98

$875.65
$961.15
$1,051.73
$1,373.49

$1,117.92
$1,203.42
$1,294.00
$1,615.76

$1,360.19
$1,445.69
$1,536.27
$1,858.03

$242.27

Toc - Plan #165 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Simple Choice 7500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$330.01
$374.56
$421.75
$589.39
$895.64

$582.47
$627.02
$674.21
$841.85

$834.93
$879.48
$926.67
$1,094.31

$1,087.39
$1,131.94
$1,179.13
$1,346.77

$252.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$660.02
$749.12
$843.50
$1,178.78
$1,791.28

$912.48
$1,001.58
$1,095.96
$1,431.24

$1,164.94
$1,254.04
$1,348.42
$1,683.70

$1,417.40
$1,506.50
$1,600.88
$1,936.16

$252.46

Toc - Plan #166 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 0A

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$355.59
$403.59
$454.44
$635.08
$965.07

$627.62
$675.62
$726.47
$907.11

$899.65
$947.65
$998.50
$1,179.14

$1,171.68
$1,219.68
$1,270.53
$1,451.17

$272.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$711.18
$807.18
$908.88
$1,270.16
$1,930.14

$983.21
$1,079.21
$1,180.91
$1,542.19

$1,255.24
$1,351.24
$1,452.94
$1,814.22

$1,527.27
$1,623.27
$1,724.97
$2,086.25

$272.03

Toc - Plan #167 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 7600 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,600 $15,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$331.06
$375.76
$423.10
$591.28
$898.50

$584.32
$629.02
$676.36
$844.54

$837.58
$882.28
$929.62
$1,097.80

$1,090.84
$1,135.54
$1,182.88
$1,351.06

$253.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$662.12
$751.52
$846.20
$1,182.56
$1,797.00

$915.38
$1,004.78
$1,099.46
$1,435.82

$1,168.64
$1,258.04
$1,352.72
$1,689.08

$1,421.90
$1,511.30
$1,605.98
$1,942.34

$253.26

Toc - Plan #168 Cigna Healthcare

Gold

(EPO) Cigna Connect 2100 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$2,100 $4,200 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

$463.45
$526.02
$592.29
$827.72
$

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

Obamacare Providers, 226 Plans and 2023 Rates for Miami-Dade County, Florida

You may also be interested in:

Do I Qualify For a Tax Credit to Pay My Premiums?

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Using a Broker to Help You Sign Up

Obamacare Rates and Providers for Other Years

How To Sign Up for Obamacare in Florida for 2023

Where's the Florida Health Care Exchange?

Florida Medicaid Expansion: Do I Qualify for Medicaid Under the ACA?

Florida Has Not Expanded Medicaid

The Medicaid Coverage Gap

Get Help Finding a Health Insurance Plan in Florida

Get Help From Florida's Health Insurance Exchange

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More Information

Florida Blue (BlueCross BlueShield FL)

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

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:

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

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:

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

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:

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

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:

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

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:

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

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

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:

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

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

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:

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

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:

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

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

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:

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

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:

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

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:

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

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:

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

Annual Out of Pocket Expenses:

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

Individual Family

$5,950 $11,900 Annual Deductible

$7,150 $14,300 Maximum Out of Pocket Per Year

Individual Family

$6,900 $13,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$1,000 $2,000 Annual Deductible

$4,000 $8,000 Maximum Out of Pocket Per Year

Individual Family

$7,400 $14,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$2,000 $4,000 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$7,900 $15,800 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$3,000 $6,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,950 $11,900 Annual Deductible

$7,150 $14,300 Maximum Out of Pocket Per Year

Individual Family

$6,900 $13,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$1,000 $2,000 Annual Deductible

$4,000 $8,000 Maximum Out of Pocket Per Year

Individual Family

$7,400 $14,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$2,000 $4,000 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$7,900 $15,800 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year