Orange County, Florida Obamacare 2024 Rates

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

The health insurance rates listed below are for calendar year 2024.

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, 185 Plans and 2024 Rates for Orange County, Florida

Below, you’ll find a summary of the 185 plans for Orange County, Florida and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

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Florida Blue (BlueCross BlueShield FL)

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

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

(EPO) BlueSelect Bronze 24L01-01 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$9,450 $18,900 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
$401.81
$456.05
$513.51
$717.63
$1,090.51
$709.19
$763.43
$820.89
$1,025.01
$1,016.57
$1,070.81
$1,128.27
$1,332.39
$1,323.95
$1,378.19
$1,435.65
$1,639.77
$307.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.62
$912.10
$1,027.02
$1,435.26
$2,181.02
$1,111.00
$1,219.48
$1,334.40
$1,742.64
$1,418.38
$1,526.86
$1,641.78
$2,050.02
$1,725.76
$1,834.24
$1,949.16
$2,357.40
$307.38
Toc - Plan #2 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
$2,800 $5,600 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
$545.18
$618.78
$696.74
$973.69
$1,479.62
$962.24
$1,035.84
$1,113.80
$1,390.75
$1,379.30
$1,452.90
$1,530.86
$1,807.81
$1,796.36
$1,869.96
$1,947.92
$2,224.87
$417.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,090.36
$1,237.56
$1,393.48
$1,947.38
$2,959.24
$1,507.42
$1,654.62
$1,810.54
$2,364.44
$1,924.48
$2,071.68
$2,227.60
$2,781.50
$2,341.54
$2,488.74
$2,644.66
$3,198.56
$417.06
Toc - Plan #3 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
$715.61
$812.22
$914.55
$1,278.08
$1,942.17
$1,263.05
$1,359.66
$1,461.99
$1,825.52
$1,810.49
$1,907.10
$2,009.43
$2,372.96
$2,357.93
$2,454.54
$2,556.87
$2,920.40
$547.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,431.22
$1,624.44
$1,829.10
$2,556.16
$3,884.34
$1,978.66
$2,171.88
$2,376.54
$3,103.60
$2,526.10
$2,719.32
$2,923.98
$3,651.04
$3,073.54
$3,266.76
$3,471.42
$4,198.48
$547.44
Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.41
$487.38
$548.79
$766.93
$1,165.42
$757.91
$815.88
$877.29
$1,095.43
$1,086.41
$1,144.38
$1,205.79
$1,423.93
$1,414.91
$1,472.88
$1,534.29
$1,752.43
$328.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.82
$974.76
$1,097.58
$1,533.86
$2,330.84
$1,187.32
$1,303.26
$1,426.08
$1,862.36
$1,515.82
$1,631.76
$1,754.58
$2,190.86
$1,844.32
$1,960.26
$2,083.08
$2,519.36
$328.50
Toc - Plan #5 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
$743.56
$843.94
$950.27
$1,328.00
$2,018.02
$1,312.38
$1,412.76
$1,519.09
$1,896.82
$1,881.20
$1,981.58
$2,087.91
$2,465.64
$2,450.02
$2,550.40
$2,656.73
$3,034.46
$568.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,487.12
$1,687.88
$1,900.54
$2,656.00
$4,036.04
$2,055.94
$2,256.70
$2,469.36
$3,224.82
$2,624.76
$2,825.52
$3,038.18
$3,793.64
$3,193.58
$3,394.34
$3,607.00
$4,362.46
$568.82
Toc - Plan #6 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
$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
$510.31
$579.20
$652.18
$911.41
$1,384.98
$900.70
$969.59
$1,042.57
$1,301.80
$1,291.09
$1,359.98
$1,432.96
$1,692.19
$1,681.48
$1,750.37
$1,823.35
$2,082.58
$390.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,020.62
$1,158.40
$1,304.36
$1,822.82
$2,769.96
$1,411.01
$1,548.79
$1,694.75
$2,213.21
$1,801.40
$1,939.18
$2,085.14
$2,603.60
$2,191.79
$2,329.57
$2,475.53
$2,993.99
$390.39
Toc - Plan #7 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
$6,250 $12,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$614.93
$697.95
$785.88
$1,098.26
$1,668.92
$1,085.35
$1,168.37
$1,256.30
$1,568.68
$1,555.77
$1,638.79
$1,726.72
$2,039.10
$2,026.19
$2,109.21
$2,197.14
$2,509.52
$470.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,229.86
$1,395.90
$1,571.76
$2,196.52
$3,337.84
$1,700.28
$1,866.32
$2,042.18
$2,666.94
$2,170.70
$2,336.74
$2,512.60
$3,137.36
$2,641.12
$2,807.16
$2,983.02
$3,607.78
$470.42
Toc - Plan #8 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
$7,050 $14,100 Annual Deductible
$7,050 $14,100 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
$418.15
$474.60
$534.40
$746.82
$1,134.86
$738.03
$794.48
$854.28
$1,066.70
$1,057.91
$1,114.36
$1,174.16
$1,386.58
$1,377.79
$1,434.24
$1,494.04
$1,706.46
$319.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.30
$949.20
$1,068.80
$1,493.64
$2,269.72
$1,156.18
$1,269.08
$1,388.68
$1,813.52
$1,476.06
$1,588.96
$1,708.56
$2,133.40
$1,795.94
$1,908.84
$2,028.44
$2,453.28
$319.88
Toc - Plan #9 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
$5,900 $11,800 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
$597.14
$677.75
$763.14
$1,066.49
$1,620.64
$1,053.95
$1,134.56
$1,219.95
$1,523.30
$1,510.76
$1,591.37
$1,676.76
$1,980.11
$1,967.57
$2,048.18
$2,133.57
$2,436.92
$456.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,194.28
$1,355.50
$1,526.28
$2,132.98
$3,241.28
$1,651.09
$1,812.31
$1,983.09
$2,589.79
$2,107.90
$2,269.12
$2,439.90
$3,046.60
$2,564.71
$2,725.93
$2,896.71
$3,503.41
$456.81
Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2139 ($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
$9,450 $18,900 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
$449.71
$510.42
$574.73
$803.18
$1,220.51
$793.74
$854.45
$918.76
$1,147.21
$1,137.77
$1,198.48
$1,262.79
$1,491.24
$1,481.80
$1,542.51
$1,606.82
$1,835.27
$344.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$899.42
$1,020.84
$1,149.46
$1,606.36
$2,441.02
$1,243.45
$1,364.87
$1,493.49
$1,950.39
$1,587.48
$1,708.90
$1,837.52
$2,294.42
$1,931.51
$2,052.93
$2,181.55
$2,638.45
$344.03
Toc - Plan #11 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
$9,400 $18,800 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
$421.54
$478.45
$538.73
$752.87
$1,144.06
$744.02
$800.93
$861.21
$1,075.35
$1,066.50
$1,123.41
$1,183.69
$1,397.83
$1,388.98
$1,445.89
$1,506.17
$1,720.31
$322.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$843.08
$956.90
$1,077.46
$1,505.74
$2,288.12
$1,165.56
$1,279.38
$1,399.94
$1,828.22
$1,488.04
$1,601.86
$1,722.42
$2,150.70
$1,810.52
$1,924.34
$2,044.90
$2,473.18
$322.48
Toc - Plan #12 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
$5,900 $11,800 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
$530.10
$601.66
$677.47
$946.76
$1,438.69
$935.63
$1,007.19
$1,083.00
$1,352.29
$1,341.16
$1,412.72
$1,488.53
$1,757.82
$1,746.69
$1,818.25
$1,894.06
$2,163.35
$405.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,060.20
$1,203.32
$1,354.94
$1,893.52
$2,877.38
$1,465.73
$1,608.85
$1,760.47
$2,299.05
$1,871.26
$2,014.38
$2,166.00
$2,704.58
$2,276.79
$2,419.91
$2,571.53
$3,110.11
$405.53
Toc - Plan #13 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
$1,500 $3,000 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
$582.16
$660.75
$744.00
$1,039.74
$1,579.98
$1,027.51
$1,106.10
$1,189.35
$1,485.09
$1,472.86
$1,551.45
$1,634.70
$1,930.44
$1,918.21
$1,996.80
$2,080.05
$2,375.79
$445.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,164.32
$1,321.50
$1,488.00
$2,079.48
$3,159.96
$1,609.67
$1,766.85
$1,933.35
$2,524.83
$2,055.02
$2,212.20
$2,378.70
$2,970.18
$2,500.37
$2,657.55
$2,824.05
$3,415.53
$445.35
Toc - Plan #14 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
$3,200 $6,400 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
$739.46
$839.29
$945.03
$1,320.68
$2,006.89
$1,305.15
$1,404.98
$1,510.72
$1,886.37
$1,870.84
$1,970.67
$2,076.41
$2,452.06
$2,436.53
$2,536.36
$2,642.10
$3,017.75
$565.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,478.92
$1,678.58
$1,890.06
$2,641.36
$4,013.78
$2,044.61
$2,244.27
$2,455.75
$3,207.05
$2,610.30
$2,809.96
$3,021.44
$3,772.74
$3,175.99
$3,375.65
$3,587.13
$4,338.43
$565.69
Toc - Plan #15 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-03 ($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
$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
$800.76
$908.86
$1,023.37
$1,430.16
$2,173.26
$1,413.34
$1,521.44
$1,635.95
$2,042.74
$2,025.92
$2,134.02
$2,248.53
$2,655.32
$2,638.50
$2,746.60
$2,861.11
$3,267.90
$612.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,601.52
$1,817.72
$2,046.74
$2,860.32
$4,346.52
$2,214.10
$2,430.30
$2,659.32
$3,472.90
$2,826.68
$3,042.88
$3,271.90
$4,085.48
$3,439.26
$3,655.46
$3,884.48
$4,698.06
$612.58
Toc - Plan #16 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-04 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / 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
$9,450 $18,900 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
$572.34
$649.61
$731.45
$1,022.20
$1,553.33
$1,010.18
$1,087.45
$1,169.29
$1,460.04
$1,448.02
$1,525.29
$1,607.13
$1,897.88
$1,885.86
$1,963.13
$2,044.97
$2,335.72
$437.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,144.68
$1,299.22
$1,462.90
$2,044.40
$3,106.66
$1,582.52
$1,737.06
$1,900.74
$2,482.24
$2,020.36
$2,174.90
$2,338.58
$2,920.08
$2,458.20
$2,612.74
$2,776.42
$3,357.92
$437.84
Toc - Plan #17 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-05 ($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
$1,080.49
$1,226.36
$1,380.87
$1,929.76
$2,932.45
$1,907.06
$2,052.93
$2,207.44
$2,756.33
$2,733.63
$2,879.50
$3,034.01
$3,582.90
$3,560.20
$3,706.07
$3,860.58
$4,409.47
$826.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,160.98
$2,452.72
$2,761.74
$3,859.52
$5,864.90
$2,987.55
$3,279.29
$3,588.31
$4,686.09
$3,814.12
$4,105.86
$4,414.88
$5,512.66
$4,640.69
$4,932.43
$5,241.45
$6,339.23
$826.57
Toc - Plan #18 Florida Blue (BlueCross BlueShield FL)
Bronze

(PPO) BlueOptions Bronze 24J01-06 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$9,450 $18,900 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
$535.47
$607.76
$684.33
$956.35
$1,453.27
$945.10
$1,017.39
$1,093.96
$1,365.98
$1,354.73
$1,427.02
$1,503.59
$1,775.61
$1,764.36
$1,836.65
$1,913.22
$2,185.24
$409.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,070.94
$1,215.52
$1,368.66
$1,912.70
$2,906.54
$1,480.57
$1,625.15
$1,778.29
$2,322.33
$1,890.20
$2,034.78
$2,187.92
$2,731.96
$2,299.83
$2,444.41
$2,597.55
$3,141.59
$409.63
Toc - Plan #19 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-07 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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
$856.59
$972.23
$1,094.72
$1,529.87
$2,324.79
$1,511.88
$1,627.52
$1,750.01
$2,185.16
$2,167.17
$2,282.81
$2,405.30
$2,840.45
$2,822.46
$2,938.10
$3,060.59
$3,495.74
$655.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,713.18
$1,944.46
$2,189.44
$3,059.74
$4,649.58
$2,368.47
$2,599.75
$2,844.73
$3,715.03
$3,023.76
$3,255.04
$3,500.02
$4,370.32
$3,679.05
$3,910.33
$4,155.31
$5,025.61
$655.29
Toc - Plan #20 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-08 ($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
$1,123.82
$1,275.54
$1,436.24
$2,007.14
$3,050.05
$1,983.54
$2,135.26
$2,295.96
$2,866.86
$2,843.26
$2,994.98
$3,155.68
$3,726.58
$3,702.98
$3,854.70
$4,015.40
$4,586.30
$859.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,247.64
$2,551.08
$2,872.48
$4,014.28
$6,100.10
$3,107.36
$3,410.80
$3,732.20
$4,874.00
$3,967.08
$4,270.52
$4,591.92
$5,733.72
$4,826.80
$5,130.24
$5,451.64
$6,593.44
$859.72
Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-09 ($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
$6,250 $12,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$922.11
$1,046.59
$1,178.46
$1,646.89
$2,502.61
$1,627.52
$1,752.00
$1,883.87
$2,352.30
$2,332.93
$2,457.41
$2,589.28
$3,057.71
$3,038.34
$3,162.82
$3,294.69
$3,763.12
$705.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,844.22
$2,093.18
$2,356.92
$3,293.78
$5,005.22
$2,549.63
$2,798.59
$3,062.33
$3,999.19
$3,255.04
$3,504.00
$3,767.74
$4,704.60
$3,960.45
$4,209.41
$4,473.15
$5,410.01
$705.41
Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze (HSA) 24J01-10 (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
$7,050 $14,100 Annual Deductible
$7,050 $14,100 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
$556.72
$631.88
$711.49
$994.30
$1,510.94
$982.61
$1,057.77
$1,137.38
$1,420.19
$1,408.50
$1,483.66
$1,563.27
$1,846.08
$1,834.39
$1,909.55
$1,989.16
$2,271.97
$425.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,113.44
$1,263.76
$1,422.98
$1,988.60
$3,021.88
$1,539.33
$1,689.65
$1,848.87
$2,414.49
$1,965.22
$2,115.54
$2,274.76
$2,840.38
$2,391.11
$2,541.43
$2,700.65
$3,266.27
$425.89
Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-12 ($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
$5,900 $11,800 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
$894.86
$1,015.67
$1,143.63
$1,598.22
$2,428.65
$1,579.43
$1,700.24
$1,828.20
$2,282.79
$2,264.00
$2,384.81
$2,512.77
$2,967.36
$2,948.57
$3,069.38
$3,197.34
$3,651.93
$684.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,789.72
$2,031.34
$2,287.26
$3,196.44
$4,857.30
$2,474.29
$2,715.91
$2,971.83
$3,881.01
$3,158.86
$3,400.48
$3,656.40
$4,565.58
$3,843.43
$4,085.05
$4,340.97
$5,250.15
$684.57
Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-17 ($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
$9,450 $18,900 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
$599.28
$680.18
$765.88
$1,070.31
$1,626.45
$1,057.73
$1,138.63
$1,224.33
$1,528.76
$1,516.18
$1,597.08
$1,682.78
$1,987.21
$1,974.63
$2,055.53
$2,141.23
$2,445.66
$458.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,198.56
$1,360.36
$1,531.76
$2,140.62
$3,252.90
$1,657.01
$1,818.81
$1,990.21
$2,599.07
$2,115.46
$2,277.26
$2,448.66
$3,057.52
$2,573.91
$2,735.71
$2,907.11
$3,515.97
$458.45
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-18S (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
$9,400 $18,800 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
$561.01
$636.75
$716.97
$1,001.96
$1,522.58
$990.18
$1,065.92
$1,146.14
$1,431.13
$1,419.35
$1,495.09
$1,575.31
$1,860.30
$1,848.52
$1,924.26
$2,004.48
$2,289.47
$429.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,122.02
$1,273.50
$1,433.94
$2,003.92
$3,045.16
$1,551.19
$1,702.67
$1,863.11
$2,433.09
$1,980.36
$2,131.84
$2,292.28
$2,862.26
$2,409.53
$2,561.01
$2,721.45
$3,291.43
$429.17
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-19S ($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
$5,900 $11,800 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
$832.22
$944.57
$1,063.58
$1,486.34
$2,258.65
$1,468.87
$1,581.22
$1,700.23
$2,122.99
$2,105.52
$2,217.87
$2,336.88
$2,759.64
$2,742.17
$2,854.52
$2,973.53
$3,396.29
$636.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,664.44
$1,889.14
$2,127.16
$2,972.68
$4,517.30
$2,301.09
$2,525.79
$2,763.81
$3,609.33
$2,937.74
$3,162.44
$3,400.46
$4,245.98
$3,574.39
$3,799.09
$4,037.11
$4,882.63
$636.65
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-20S ($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
$1,500 $3,000 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
$872.76
$990.58
$1,115.39
$1,558.75
$2,368.67
$1,540.42
$1,658.24
$1,783.05
$2,226.41
$2,208.08
$2,325.90
$2,450.71
$2,894.07
$2,875.74
$2,993.56
$3,118.37
$3,561.73
$667.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,745.52
$1,981.16
$2,230.78
$3,117.50
$4,737.34
$2,413.18
$2,648.82
$2,898.44
$3,785.16
$3,080.84
$3,316.48
$3,566.10
$4,452.82
$3,748.50
$3,984.14
$4,233.76
$5,120.48
$667.66
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-21S ($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
$3,200 $6,400 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
$1,116.80
$1,267.57
$1,427.27
$1,994.60
$3,031.00
$1,971.15
$2,121.92
$2,281.62
$2,848.95
$2,825.50
$2,976.27
$3,135.97
$3,703.30
$3,679.85
$3,830.62
$3,990.32
$4,557.65
$854.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,233.60
$2,535.14
$2,854.54
$3,989.20
$6,062.00
$3,087.95
$3,389.49
$3,708.89
$4,843.55
$3,942.30
$4,243.84
$4,563.24
$5,697.90
$4,796.65
$5,098.19
$5,417.59
$6,552.25
$854.35

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #29 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$400.76
$454.86
$512.17
$715.76
$1,087.66
$707.34
$761.44
$818.75
$1,022.34
$1,013.92
$1,068.02
$1,125.33
$1,328.92
$1,320.50
$1,374.60
$1,431.91
$1,635.50
$306.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$801.52
$909.72
$1,024.34
$1,431.52
$2,175.32
$1,108.10
$1,216.30
$1,330.92
$1,738.10
$1,414.68
$1,522.88
$1,637.50
$2,044.68
$1,721.26
$1,829.46
$1,944.08
$2,351.26
$306.58
Toc - Plan #30 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$320.03
$363.23
$408.99
$571.56
$868.54
$564.85
$608.05
$653.81
$816.38
$809.67
$852.87
$898.63
$1,061.20
$1,054.49
$1,097.69
$1,143.45
$1,306.02
$244.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.06
$726.46
$817.98
$1,143.12
$1,737.08
$884.88
$971.28
$1,062.80
$1,387.94
$1,129.70
$1,216.10
$1,307.62
$1,632.76
$1,374.52
$1,460.92
$1,552.44
$1,877.58
$244.82
Toc - Plan #31 Aetna CVS Health
Silver

(HMO) Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$8,395 $16,790 Annual Deductible
$8,885 $17,770 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$400.50
$454.57
$511.84
$715.29
$1,086.95
$706.88
$760.95
$818.22
$1,021.67
$1,013.26
$1,067.33
$1,124.60
$1,328.05
$1,319.64
$1,373.71
$1,430.98
$1,634.43
$306.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$801.00
$909.14
$1,023.68
$1,430.58
$2,173.90
$1,107.38
$1,215.52
$1,330.06
$1,736.96
$1,413.76
$1,521.90
$1,636.44
$2,043.34
$1,720.14
$1,828.28
$1,942.82
$2,349.72
$306.38
Toc - Plan #32 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$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
$428.34
$486.16
$547.41
$765.01
$1,162.50
$756.02
$813.84
$875.09
$1,092.69
$1,083.70
$1,141.52
$1,202.77
$1,420.37
$1,411.38
$1,469.20
$1,530.45
$1,748.05
$327.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.68
$972.32
$1,094.82
$1,530.02
$2,325.00
$1,184.36
$1,300.00
$1,422.50
$1,857.70
$1,512.04
$1,627.68
$1,750.18
$2,185.38
$1,839.72
$1,955.36
$2,077.86
$2,513.06
$327.68
Toc - Plan #33 Aetna CVS Health
Silver

(HMO) Silver 6: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,445 $16,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.94
$464.15
$522.63
$730.37
$1,109.87
$721.78
$776.99
$835.47
$1,043.21
$1,034.62
$1,089.83
$1,148.31
$1,356.05
$1,347.46
$1,402.67
$1,461.15
$1,668.89
$312.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$817.88
$928.30
$1,045.26
$1,460.74
$2,219.74
$1,130.72
$1,241.14
$1,358.10
$1,773.58
$1,443.56
$1,553.98
$1,670.94
$2,086.42
$1,756.40
$1,866.82
$1,983.78
$2,399.26
$312.84
Toc - Plan #34 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 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
$352.43
$400.01
$450.41
$629.44
$956.50
$622.04
$669.62
$720.02
$899.05
$891.65
$939.23
$989.63
$1,168.66
$1,161.26
$1,208.84
$1,259.24
$1,438.27
$269.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704.86
$800.02
$900.82
$1,258.88
$1,913.00
$974.47
$1,069.63
$1,170.43
$1,528.49
$1,244.08
$1,339.24
$1,440.04
$1,798.10
$1,513.69
$1,608.85
$1,709.65
$2,067.71
$269.61
Toc - Plan #35 Aetna CVS Health
Gold

(HMO) Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$795 $1,590 Annual Deductible
$9,195 $18,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.62
$484.21
$545.21
$761.93
$1,157.83
$752.98
$810.57
$871.57
$1,088.29
$1,079.34
$1,136.93
$1,197.93
$1,414.65
$1,405.70
$1,463.29
$1,524.29
$1,741.01
$326.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.24
$968.42
$1,090.42
$1,523.86
$2,315.66
$1,179.60
$1,294.78
$1,416.78
$1,850.22
$1,505.96
$1,621.14
$1,743.14
$2,176.58
$1,832.32
$1,947.50
$2,069.50
$2,502.94
$326.36
Toc - Plan #36 Aetna CVS Health
Gold

(HMO) Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$432.30
$490.66
$552.48
$772.08
$1,173.25
$763.01
$821.37
$883.19
$1,102.79
$1,093.72
$1,152.08
$1,213.90
$1,433.50
$1,424.43
$1,482.79
$1,544.61
$1,764.21
$330.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$864.60
$981.32
$1,104.96
$1,544.16
$2,346.50
$1,195.31
$1,312.03
$1,435.67
$1,874.87
$1,526.02
$1,642.74
$1,766.38
$2,205.58
$1,856.73
$1,973.45
$2,097.09
$2,536.29
$330.71
Toc - Plan #37 Aetna CVS Health
Silver

(HMO) Silver 7: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,845 $17,690 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.13
$464.37
$522.87
$730.71
$1,110.38
$722.12
$777.36
$835.86
$1,043.70
$1,035.11
$1,090.35
$1,148.85
$1,356.69
$1,348.10
$1,403.34
$1,461.84
$1,669.68
$312.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.26
$928.74
$1,045.74
$1,461.42
$2,220.76
$1,131.25
$1,241.73
$1,358.73
$1,774.41
$1,444.24
$1,554.72
$1,671.72
$2,087.40
$1,757.23
$1,867.71
$1,984.71
$2,400.39
$312.99

ADVERTISEMENT

AvMed

Local: 1-800-477-8768 | Toll Free: 

Toc - Plan #38 AvMed
Platinum

(HMO) AvMed Entrust Platinum 25 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,100 $6,200 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
$800.23
$908.26
$1,022.69
$1,429.20
$2,171.81
$1,412.40
$1,520.43
$1,634.86
$2,041.37
$2,024.57
$2,132.60
$2,247.03
$2,653.54
$2,636.74
$2,744.77
$2,859.20
$3,265.71
$612.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,600.46
$1,816.52
$2,045.38
$2,858.40
$4,343.62
$2,212.63
$2,428.69
$2,657.55
$3,470.57
$2,824.80
$3,040.86
$3,269.72
$4,082.74
$3,436.97
$3,653.03
$3,881.89
$4,694.91
$612.17
Toc - Plan #39 AvMed
Gold

(HMO) AvMed Entrust Gold 125 (2024)

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
$541.14
$614.20
$691.58
$966.48
$1,468.66
$955.11
$1,028.17
$1,105.55
$1,380.45
$1,369.08
$1,442.14
$1,519.52
$1,794.42
$1,783.05
$1,856.11
$1,933.49
$2,208.39
$413.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,082.28
$1,228.40
$1,383.16
$1,932.96
$2,937.32
$1,496.25
$1,642.37
$1,797.13
$2,346.93
$1,910.22
$2,056.34
$2,211.10
$2,760.90
$2,324.19
$2,470.31
$2,625.07
$3,174.87
$413.97
Toc - Plan #40 AvMed
Silver

(HMO) AvMed Entrust Silver 300 (2024)

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
$519.85
$590.03
$664.37
$928.46
$1,410.88
$917.54
$987.72
$1,062.06
$1,326.15
$1,315.23
$1,385.41
$1,459.75
$1,723.84
$1,712.92
$1,783.10
$1,857.44
$2,121.53
$397.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,039.70
$1,180.06
$1,328.74
$1,856.92
$2,821.76
$1,437.39
$1,577.75
$1,726.43
$2,254.61
$1,835.08
$1,975.44
$2,124.12
$2,652.30
$2,232.77
$2,373.13
$2,521.81
$3,049.99
$397.69
Toc - Plan #41 AvMed
Silver

(HMO) AvMed Entrust Silver 350 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$501.92
$569.68
$641.45
$896.42
$1,362.20
$885.89
$953.65
$1,025.42
$1,280.39
$1,269.86
$1,337.62
$1,409.39
$1,664.36
$1,653.83
$1,721.59
$1,793.36
$2,048.33
$383.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,003.84
$1,139.36
$1,282.90
$1,792.84
$2,724.40
$1,387.81
$1,523.33
$1,666.87
$2,176.81
$1,771.78
$1,907.30
$2,050.84
$2,560.78
$2,155.75
$2,291.27
$2,434.81
$2,944.75
$383.97
Toc - Plan #42 AvMed
Silver

(HMO) AvMed Entrust Silver 500 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$496.70
$563.76
$634.79
$887.11
$1,348.06
$876.68
$943.74
$1,014.77
$1,267.09
$1,256.66
$1,323.72
$1,394.75
$1,647.07
$1,636.64
$1,703.70
$1,774.73
$2,027.05
$379.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$993.40
$1,127.52
$1,269.58
$1,774.22
$2,696.12
$1,373.38
$1,507.50
$1,649.56
$2,154.20
$1,753.36
$1,887.48
$2,029.54
$2,534.18
$2,133.34
$2,267.46
$2,409.52
$2,914.16
$379.98
Toc - Plan #43 AvMed
Silver

(HMO) AvMed Entrust Silver 550 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$492.07
$558.50
$628.87
$878.84
$1,335.48
$868.51
$934.94
$1,005.31
$1,255.28
$1,244.95
$1,311.38
$1,381.75
$1,631.72
$1,621.39
$1,687.82
$1,758.19
$2,008.16
$376.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$984.14
$1,117.00
$1,257.74
$1,757.68
$2,670.96
$1,360.58
$1,493.44
$1,634.18
$2,134.12
$1,737.02
$1,869.88
$2,010.62
$2,510.56
$2,113.46
$2,246.32
$2,387.06
$2,887.00
$376.44
Toc - Plan #44 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 600 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.08
$466.58
$525.36
$734.19
$1,115.67
$725.56
$781.06
$839.84
$1,048.67
$1,040.04
$1,095.54
$1,154.32
$1,363.15
$1,354.52
$1,410.02
$1,468.80
$1,677.63
$314.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.16
$933.16
$1,050.72
$1,468.38
$2,231.34
$1,136.64
$1,247.64
$1,365.20
$1,782.86
$1,451.12
$1,562.12
$1,679.68
$2,097.34
$1,765.60
$1,876.60
$1,994.16
$2,411.82
$314.48
Toc - Plan #45 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 650 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,750 $17,500 Annual Deductible
$8,750 $17,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386.90
$439.14
$494.46
$691.01
$1,050.06
$682.88
$735.12
$790.44
$986.99
$978.86
$1,031.10
$1,086.42
$1,282.97
$1,274.84
$1,327.08
$1,382.40
$1,578.95
$295.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$773.80
$878.28
$988.92
$1,382.02
$2,100.12
$1,069.78
$1,174.26
$1,284.90
$1,678.00
$1,365.76
$1,470.24
$1,580.88
$1,973.98
$1,661.74
$1,766.22
$1,876.86
$2,269.96
$295.98
Toc - Plan #46 AvMed
Platinum

(HMO) AvMed Entrust Platinum Standard (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 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
$812.04
$921.67
$1,037.79
$1,450.31
$2,203.89
$1,433.25
$1,542.88
$1,659.00
$2,071.52
$2,054.46
$2,164.09
$2,280.21
$2,692.73
$2,675.67
$2,785.30
$2,901.42
$3,313.94
$621.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,624.08
$1,843.34
$2,075.58
$2,900.62
$4,407.78
$2,245.29
$2,464.55
$2,696.79
$3,521.83
$2,866.50
$3,085.76
$3,318.00
$4,143.04
$3,487.71
$3,706.97
$3,939.21
$4,764.25
$621.21
Toc - Plan #47 AvMed
Gold

(HMO) AvMed Entrust Gold Standard (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$565.15
$641.45
$722.26
$1,009.36
$1,533.82
$997.49
$1,073.79
$1,154.60
$1,441.70
$1,429.83
$1,506.13
$1,586.94
$1,874.04
$1,862.17
$1,938.47
$2,019.28
$2,306.38
$432.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,130.30
$1,282.90
$1,444.52
$2,018.72
$3,067.64
$1,562.64
$1,715.24
$1,876.86
$2,451.06
$1,994.98
$2,147.58
$2,309.20
$2,883.40
$2,427.32
$2,579.92
$2,741.54
$3,315.74
$432.34
Toc - Plan #48 AvMed
Silver

(HMO) AvMed Entrust Silver Standard (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$481.77
$546.81
$615.70
$860.44
$1,307.53
$850.32
$915.36
$984.25
$1,228.99
$1,218.87
$1,283.91
$1,352.80
$1,597.54
$1,587.42
$1,652.46
$1,721.35
$1,966.09
$368.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$963.54
$1,093.62
$1,231.40
$1,720.88
$2,615.06
$1,332.09
$1,462.17
$1,599.95
$2,089.43
$1,700.64
$1,830.72
$1,968.50
$2,457.98
$2,069.19
$2,199.27
$2,337.05
$2,826.53
$368.55
Toc - Plan #49 AvMed
Expanded Bronze

(HMO) AvMed Entrust Expanded Bronze Standard (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$394.94
$448.26
$504.74
$705.37
$1,071.87
$697.07
$750.39
$806.87
$1,007.50
$999.20
$1,052.52
$1,109.00
$1,309.63
$1,301.33
$1,354.65
$1,411.13
$1,611.76
$302.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$789.88
$896.52
$1,009.48
$1,410.74
$2,143.74
$1,092.01
$1,198.65
$1,311.61
$1,712.87
$1,394.14
$1,500.78
$1,613.74
$2,015.00
$1,696.27
$1,802.91
$1,915.87
$2,317.13
$302.13
Toc - Plan #50 AvMed
Platinum

(HMO) AvMed Entrust Platinum 25 Dental+Vision (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,100 $6,200 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
$805.43
$914.16
$1,029.34
$1,438.50
$2,185.94
$1,421.58
$1,530.31
$1,645.49
$2,054.65
$2,037.73
$2,146.46
$2,261.64
$2,670.80
$2,653.88
$2,762.61
$2,877.79
$3,286.95
$616.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,610.86
$1,828.32
$2,058.68
$2,877.00
$4,371.88
$2,227.01
$2,444.47
$2,674.83
$3,493.15
$2,843.16
$3,060.62
$3,290.98
$4,109.30
$3,459.31
$3,676.77
$3,907.13
$4,725.45
$616.15
Toc - Plan #51 AvMed
Gold

(HMO) AvMed Entrust Gold 125 Dental+Vision (2024)

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
$546.33
$620.09
$698.21
$975.75
$1,482.75
$964.28
$1,038.04
$1,116.16
$1,393.70
$1,382.23
$1,455.99
$1,534.11
$1,811.65
$1,800.18
$1,873.94
$1,952.06
$2,229.60
$417.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,092.66
$1,240.18
$1,396.42
$1,951.50
$2,965.50
$1,510.61
$1,658.13
$1,814.37
$2,369.45
$1,928.56
$2,076.08
$2,232.32
$2,787.40
$2,346.51
$2,494.03
$2,650.27
$3,205.35
$417.95
Toc - Plan #52 AvMed
Silver

(HMO) AvMed Entrust Silver 300 Dental+Vision (2024)

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
$525.04
$595.93
$671.01
$937.73
$1,424.97
$926.70
$997.59
$1,072.67
$1,339.39
$1,328.36
$1,399.25
$1,474.33
$1,741.05
$1,730.02
$1,800.91
$1,875.99
$2,142.71
$401.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,050.08
$1,191.86
$1,342.02
$1,875.46
$2,849.94
$1,451.74
$1,593.52
$1,743.68
$2,277.12
$1,853.40
$1,995.18
$2,145.34
$2,678.78
$2,255.06
$2,396.84
$2,547.00
$3,080.44
$401.66
Toc - Plan #53 AvMed
Silver

(HMO) AvMed Entrust Silver 350 Dental+Vision (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$507.11
$575.57
$648.09
$905.70
$1,376.30
$895.05
$963.51
$1,036.03
$1,293.64
$1,282.99
$1,351.45
$1,423.97
$1,681.58
$1,670.93
$1,739.39
$1,811.91
$2,069.52
$387.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,014.22
$1,151.14
$1,296.18
$1,811.40
$2,752.60
$1,402.16
$1,539.08
$1,684.12
$2,199.34
$1,790.10
$1,927.02
$2,072.06
$2,587.28
$2,178.04
$2,314.96
$2,460.00
$2,975.22
$387.94
Toc - Plan #54 AvMed
Silver

(HMO) AvMed Entrust Silver 500 Dental+Vision (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$501.90
$569.65
$641.42
$896.39
$1,362.15
$885.85
$953.60
$1,025.37
$1,280.34
$1,269.80
$1,337.55
$1,409.32
$1,664.29
$1,653.75
$1,721.50
$1,793.27
$2,048.24
$383.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,003.80
$1,139.30
$1,282.84
$1,792.78
$2,724.30
$1,387.75
$1,523.25
$1,666.79
$2,176.73
$1,771.70
$1,907.20
$2,050.74
$2,560.68
$2,155.65
$2,291.15
$2,434.69
$2,944.63
$383.95
Toc - Plan #55 AvMed
Silver

(HMO) AvMed Entrust Silver 550 Dental+Vision (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$497.26
$564.40
$635.50
$888.12
$1,349.58
$877.67
$944.81
$1,015.91
$1,268.53
$1,258.08
$1,325.22
$1,396.32
$1,648.94
$1,638.49
$1,705.63
$1,776.73
$2,029.35
$380.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$994.52
$1,128.80
$1,271.00
$1,776.24
$2,699.16
$1,374.93
$1,509.21
$1,651.41
$2,156.65
$1,755.34
$1,889.62
$2,031.82
$2,537.06
$2,135.75
$2,270.03
$2,412.23
$2,917.47
$380.41
Toc - Plan #56 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 625 Dental+Vision (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$493.67
$560.32
$630.91
$881.70
$1,339.83
$871.33
$937.98
$1,008.57
$1,259.36
$1,248.99
$1,315.64
$1,386.23
$1,637.02
$1,626.65
$1,693.30
$1,763.89
$2,014.68
$377.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$987.34
$1,120.64
$1,261.82
$1,763.40
$2,679.66
$1,365.00
$1,498.30
$1,639.48
$2,141.06
$1,742.66
$1,875.96
$2,017.14
$2,518.72
$2,120.32
$2,253.62
$2,394.80
$2,896.38
$377.66

ADVERTISEMENT

Ambetter from Sunshine Health

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

Toc - Plan #57 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
$387.90
$440.25
$495.72
$692.77
$1,052.73
$684.63
$736.98
$792.45
$989.50
$981.36
$1,033.71
$1,089.18
$1,286.23
$1,278.09
$1,330.44
$1,385.91
$1,582.96
$296.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.80
$880.50
$991.44
$1,385.54
$2,105.46
$1,072.53
$1,177.23
$1,288.17
$1,682.27
$1,369.26
$1,473.96
$1,584.90
$1,979.00
$1,665.99
$1,770.69
$1,881.63
$2,275.73
$296.73
Toc - Plan #58 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
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$320.42
$363.67
$409.49
$572.26
$869.60
$565.54
$608.79
$654.61
$817.38
$810.66
$853.91
$899.73
$1,062.50
$1,055.78
$1,099.03
$1,144.85
$1,307.62
$245.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.84
$727.34
$818.98
$1,144.52
$1,739.20
$885.96
$972.46
$1,064.10
$1,389.64
$1,131.08
$1,217.58
$1,309.22
$1,634.76
$1,376.20
$1,462.70
$1,554.34
$1,879.88
$245.12
Toc - Plan #59 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
$404.42
$459.01
$516.84
$722.28
$1,097.58
$713.80
$768.39
$826.22
$1,031.66
$1,023.18
$1,077.77
$1,135.60
$1,341.04
$1,332.56
$1,387.15
$1,444.98
$1,650.42
$309.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.84
$918.02
$1,033.68
$1,444.56
$2,195.16
$1,118.22
$1,227.40
$1,343.06
$1,753.94
$1,427.60
$1,536.78
$1,652.44
$2,063.32
$1,736.98
$1,846.16
$1,961.82
$2,372.70
$309.38
Toc - Plan #60 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.07
$358.72
$403.92
$564.48
$857.78
$557.85
$600.50
$645.70
$806.26
$799.63
$842.28
$887.48
$1,048.04
$1,041.41
$1,084.06
$1,129.26
$1,289.82
$241.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.14
$717.44
$807.84
$1,128.96
$1,715.56
$873.92
$959.22
$1,049.62
$1,370.74
$1,115.70
$1,201.00
$1,291.40
$1,612.52
$1,357.48
$1,442.78
$1,533.18
$1,854.30
$241.78
Toc - Plan #61 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
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$362.89
$411.87
$463.77
$648.11
$984.87
$640.50
$689.48
$741.38
$925.72
$918.11
$967.09
$1,018.99
$1,203.33
$1,195.72
$1,244.70
$1,296.60
$1,480.94
$277.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$725.78
$823.74
$927.54
$1,296.22
$1,969.74
$1,003.39
$1,101.35
$1,205.15
$1,573.83
$1,281.00
$1,378.96
$1,482.76
$1,851.44
$1,558.61
$1,656.57
$1,760.37
$2,129.05
$277.61
Toc - Plan #62 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
$393.86
$447.02
$503.35
$703.42
$1,068.92
$695.16
$748.32
$804.65
$1,004.72
$996.46
$1,049.62
$1,105.95
$1,306.02
$1,297.76
$1,350.92
$1,407.25
$1,607.32
$301.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.72
$894.04
$1,006.70
$1,406.84
$2,137.84
$1,089.02
$1,195.34
$1,308.00
$1,708.14
$1,390.32
$1,496.64
$1,609.30
$2,009.44
$1,691.62
$1,797.94
$1,910.60
$2,310.74
$301.30
Toc - Plan #63 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
$6,300 $12,600 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
$400.89
$455.00
$512.32
$715.97
$1,087.99
$707.56
$761.67
$818.99
$1,022.64
$1,014.23
$1,068.34
$1,125.66
$1,329.31
$1,320.90
$1,375.01
$1,432.33
$1,635.98
$306.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$801.78
$910.00
$1,024.64
$1,431.94
$2,175.98
$1,108.45
$1,216.67
$1,331.31
$1,738.61
$1,415.12
$1,523.34
$1,637.98
$2,045.28
$1,721.79
$1,830.01
$1,944.65
$2,351.95
$306.67
Toc - Plan #64 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
$370.78
$420.83
$473.85
$662.20
$1,006.28
$654.42
$704.47
$757.49
$945.84
$938.06
$988.11
$1,041.13
$1,229.48
$1,221.70
$1,271.75
$1,324.77
$1,513.12
$283.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$741.56
$841.66
$947.70
$1,324.40
$2,012.56
$1,025.20
$1,125.30
$1,231.34
$1,608.04
$1,308.84
$1,408.94
$1,514.98
$1,891.68
$1,592.48
$1,692.58
$1,798.62
$2,175.32
$283.64
Toc - Plan #65 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
$5,500 $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
$426.52
$484.09
$545.08
$761.75
$1,157.55
$752.80
$810.37
$871.36
$1,088.03
$1,079.08
$1,136.65
$1,197.64
$1,414.31
$1,405.36
$1,462.93
$1,523.92
$1,740.59
$326.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.04
$968.18
$1,090.16
$1,523.50
$2,315.10
$1,179.32
$1,294.46
$1,416.44
$1,849.78
$1,505.60
$1,620.74
$1,742.72
$2,176.06
$1,831.88
$1,947.02
$2,069.00
$2,502.34
$326.28
Toc - Plan #66 Ambetter from Sunshine Health
Expanded Bronze

(EPO) 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
$9,400 $18,800 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
$309.94
$351.77
$396.09
$553.54
$841.16
$547.04
$588.87
$633.19
$790.64
$784.14
$825.97
$870.29
$1,027.74
$1,021.24
$1,063.07
$1,107.39
$1,264.84
$237.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619.88
$703.54
$792.18
$1,107.08
$1,682.32
$856.98
$940.64
$1,029.28
$1,344.18
$1,094.08
$1,177.74
$1,266.38
$1,581.28
$1,331.18
$1,414.84
$1,503.48
$1,818.38
$237.10
Toc - Plan #67 Ambetter from Sunshine Health
Silver

(EPO) Standard Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$392.53
$445.51
$501.64
$701.04
$1,065.30
$692.81
$745.79
$801.92
$1,001.32
$993.09
$1,046.07
$1,102.20
$1,301.60
$1,293.37
$1,346.35
$1,402.48
$1,601.88
$300.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$785.06
$891.02
$1,003.28
$1,402.08
$2,130.60
$1,085.34
$1,191.30
$1,303.56
$1,702.36
$1,385.62
$1,491.58
$1,603.84
$2,002.64
$1,685.90
$1,791.86
$1,904.12
$2,302.92
$300.28
Toc - Plan #68 Ambetter from Sunshine Health
Gold

(EPO) Standard Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$368.55
$418.29
$470.99
$658.21
$1,000.21
$650.48
$700.22
$752.92
$940.14
$932.41
$982.15
$1,034.85
$1,222.07
$1,214.34
$1,264.08
$1,316.78
$1,504.00
$281.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737.10
$836.58
$941.98
$1,316.42
$2,000.42
$1,019.03
$1,118.51
$1,223.91
$1,598.35
$1,300.96
$1,400.44
$1,505.84
$1,880.28
$1,582.89
$1,682.37
$1,787.77
$2,162.21
$281.93
Toc - Plan #69 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
$418.34
$474.81
$534.63
$747.14
$1,135.35
$738.36
$794.83
$854.65
$1,067.16
$1,058.38
$1,114.85
$1,174.67
$1,387.18
$1,378.40
$1,434.87
$1,494.69
$1,707.20
$320.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.68
$949.62
$1,069.26
$1,494.28
$2,270.70
$1,156.70
$1,269.64
$1,389.28
$1,814.30
$1,476.72
$1,589.66
$1,709.30
$2,134.32
$1,796.74
$1,909.68
$2,029.32
$2,454.34
$320.02
Toc - Plan #70 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
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$331.45
$376.19
$423.58
$591.95
$899.53
$585.00
$629.74
$677.13
$845.50
$838.55
$883.29
$930.68
$1,099.05
$1,092.10
$1,136.84
$1,184.23
$1,352.60
$253.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$662.90
$752.38
$847.16
$1,183.90
$1,799.06
$916.45
$1,005.93
$1,100.71
$1,437.45
$1,170.00
$1,259.48
$1,354.26
$1,691.00
$1,423.55
$1,513.03
$1,607.81
$1,944.55
$253.55
Toc - Plan #71 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
$401.25
$455.40
$512.78
$716.61
$1,088.96
$708.20
$762.35
$819.73
$1,023.56
$1,015.15
$1,069.30
$1,126.68
$1,330.51
$1,322.10
$1,376.25
$1,433.63
$1,637.46
$306.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802.50
$910.80
$1,025.56
$1,433.22
$2,177.92
$1,109.45
$1,217.75
$1,332.51
$1,740.17
$1,416.40
$1,524.70
$1,639.46
$2,047.12
$1,723.35
$1,831.65
$1,946.41
$2,354.07
$306.95
Toc - Plan #72 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
$407.42
$462.41
$520.67
$727.63
$1,105.71
$719.09
$774.08
$832.34
$1,039.30
$1,030.76
$1,085.75
$1,144.01
$1,350.97
$1,342.43
$1,397.42
$1,455.68
$1,662.64
$311.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.84
$924.82
$1,041.34
$1,455.26
$2,211.42
$1,126.51
$1,236.49
$1,353.01
$1,766.93
$1,438.18
$1,548.16
$1,664.68
$2,078.60
$1,749.85
$1,859.83
$1,976.35
$2,390.27
$311.67
Toc - Plan #73 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
$5,500 $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
$441.20
$500.75
$563.84
$787.97
$1,197.39
$778.71
$838.26
$901.35
$1,125.48
$1,116.22
$1,175.77
$1,238.86
$1,462.99
$1,453.73
$1,513.28
$1,576.37
$1,800.50
$337.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.40
$1,001.50
$1,127.68
$1,575.94
$2,394.78
$1,219.91
$1,339.01
$1,465.19
$1,913.45
$1,557.42
$1,676.52
$1,802.70
$2,250.96
$1,894.93
$2,014.03
$2,140.21
$2,588.47
$337.51
Toc - Plan #74 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Standard Expanded Bronze + Vision + Adult Dental

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
$9,400 $18,800 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
$320.61
$363.88
$409.73
$572.59
$870.11
$565.87
$609.14
$654.99
$817.85
$811.13
$854.40
$900.25
$1,063.11
$1,056.39
$1,099.66
$1,145.51
$1,308.37
$245.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.22
$727.76
$819.46
$1,145.18
$1,740.22
$886.48
$973.02
$1,064.72
$1,390.44
$1,131.74
$1,218.28
$1,309.98
$1,635.70
$1,377.00
$1,463.54
$1,555.24
$1,880.96
$245.26
Toc - Plan #75 Ambetter from Sunshine Health
Silver

(EPO) Standard Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$406.04
$460.84
$518.90
$725.17
$1,101.96
$716.65
$771.45
$829.51
$1,035.78
$1,027.26
$1,082.06
$1,140.12
$1,346.39
$1,337.87
$1,392.67
$1,450.73
$1,657.00
$310.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$812.08
$921.68
$1,037.80
$1,450.34
$2,203.92
$1,122.69
$1,232.29
$1,348.41
$1,760.95
$1,433.30
$1,542.90
$1,659.02
$2,071.56
$1,743.91
$1,853.51
$1,969.63
$2,382.17
$310.61
Toc - Plan #76 Ambetter from Sunshine Health
Gold

(EPO) Standard Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.23
$432.69
$487.20
$680.86
$1,034.63
$672.86
$724.32
$778.83
$972.49
$964.49
$1,015.95
$1,070.46
$1,264.12
$1,256.12
$1,307.58
$1,362.09
$1,555.75
$291.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.46
$865.38
$974.40
$1,361.72
$2,069.26
$1,054.09
$1,157.01
$1,266.03
$1,653.35
$1,345.72
$1,448.64
$1,557.66
$1,944.98
$1,637.35
$1,740.27
$1,849.29
$2,236.61
$291.63
Toc - Plan #77 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$326.94
$371.07
$417.82
$583.90
$887.30
$577.04
$621.17
$667.92
$834.00
$827.14
$871.27
$918.02
$1,084.10
$1,077.24
$1,121.37
$1,168.12
$1,334.20
$250.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$653.88
$742.14
$835.64
$1,167.80
$1,774.60
$903.98
$992.24
$1,085.74
$1,417.90
$1,154.08
$1,242.34
$1,335.84
$1,668.00
$1,404.18
$1,492.44
$1,585.94
$1,918.10
$250.10
Toc - Plan #78 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
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.38
$426.05
$479.73
$670.42
$1,018.76
$662.54
$713.21
$766.89
$957.58
$949.70
$1,000.37
$1,054.05
$1,244.74
$1,236.86
$1,287.53
$1,341.21
$1,531.90
$287.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.76
$852.10
$959.46
$1,340.84
$2,037.52
$1,037.92
$1,139.26
$1,246.62
$1,628.00
$1,325.08
$1,426.42
$1,533.78
$1,915.16
$1,612.24
$1,713.58
$1,820.94
$2,202.32
$287.16
Toc - Plan #79 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
$6,300 $12,600 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
$414.69
$470.66
$529.96
$740.61
$1,125.43
$731.92
$787.89
$847.19
$1,057.84
$1,049.15
$1,105.12
$1,164.42
$1,375.07
$1,366.38
$1,422.35
$1,481.65
$1,692.30
$317.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$829.38
$941.32
$1,059.92
$1,481.22
$2,250.86
$1,146.61
$1,258.55
$1,377.15
$1,798.45
$1,463.84
$1,575.78
$1,694.38
$2,115.68
$1,781.07
$1,893.01
$2,011.61
$2,432.91
$317.23
Toc - Plan #80 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
$383.54
$435.31
$490.16
$684.99
$1,040.91
$676.94
$728.71
$783.56
$978.39
$970.34
$1,022.11
$1,076.96
$1,271.79
$1,263.74
$1,315.51
$1,370.36
$1,565.19
$293.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.08
$870.62
$980.32
$1,369.98
$2,081.82
$1,060.48
$1,164.02
$1,273.72
$1,663.38
$1,353.88
$1,457.42
$1,567.12
$1,956.78
$1,647.28
$1,750.82
$1,860.52
$2,250.18
$293.40

ADVERTISEMENT

Florida Blue HMO (a BlueCross BlueShield FL company)

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

Toc - Plan #81 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 then $45 / 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
$9,450 $18,900 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
$380.50
$431.87
$486.28
$679.57
$1,032.68
$671.58
$722.95
$777.36
$970.65
$962.66
$1,014.03
$1,068.44
$1,261.73
$1,253.74
$1,305.11
$1,359.52
$1,552.81
$291.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$761.00
$863.74
$972.56
$1,359.14
$2,065.36
$1,052.08
$1,154.82
$1,263.64
$1,650.22
$1,343.16
$1,445.90
$1,554.72
$1,941.30
$1,634.24
$1,736.98
$1,845.80
$2,232.38
$291.08
Toc - Plan #82 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
$515.67
$585.29
$659.03
$920.99
$1,399.53
$910.16
$979.78
$1,053.52
$1,315.48
$1,304.65
$1,374.27
$1,448.01
$1,709.97
$1,699.14
$1,768.76
$1,842.50
$2,104.46
$394.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,031.34
$1,170.58
$1,318.06
$1,841.98
$2,799.06
$1,425.83
$1,565.07
$1,712.55
$2,236.47
$1,820.32
$1,959.56
$2,107.04
$2,630.96
$2,214.81
$2,354.05
$2,501.53
$3,025.45
$394.49
Toc - Plan #83 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2017 ($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
$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
$441.05
$500.59
$563.66
$787.72
$1,197.01
$778.45
$837.99
$901.06
$1,125.12
$1,115.85
$1,175.39
$1,238.46
$1,462.52
$1,453.25
$1,512.79
$1,575.86
$1,799.92
$337.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.10
$1,001.18
$1,127.32
$1,575.44
$2,394.02
$1,219.50
$1,338.58
$1,464.72
$1,912.84
$1,556.90
$1,675.98
$1,802.12
$2,250.24
$1,894.30
$2,013.38
$2,139.52
$2,587.64
$337.40
Toc - Plan #84 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Virtual Visits / $35 PCP Visit / $75 Specialist Visits / $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
$9,450 $18,900 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
$400.48
$454.54
$511.81
$715.26
$1,086.90
$706.85
$760.91
$818.18
$1,021.63
$1,013.22
$1,067.28
$1,124.55
$1,328.00
$1,319.59
$1,373.65
$1,430.92
$1,634.37
$306.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$800.96
$909.08
$1,023.62
$1,430.52
$2,173.80
$1,107.33
$1,215.45
$1,329.99
$1,736.89
$1,413.70
$1,521.82
$1,636.36
$2,043.26
$1,720.07
$1,828.19
$1,942.73
$2,349.63
$306.37
Toc - Plan #85 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237 ($0 Virtual Visits / $60 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
$9,450 $18,900 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
$418.35
$474.83
$534.65
$747.17
$1,135.40
$738.39
$794.87
$854.69
$1,067.21
$1,058.43
$1,114.91
$1,174.73
$1,387.25
$1,378.47
$1,434.95
$1,494.77
$1,707.29
$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
$1,494.34
$2,270.80
$1,156.74
$1,269.70
$1,389.34
$1,814.38
$1,476.78
$1,589.74
$1,709.38
$2,134.42
$1,796.82
$1,909.78
$2,029.42
$2,454.46
$320.04
Toc - Plan #86 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
$1,650 $3,300 Annual Deductible
$9,450 $18,900 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
$372.52
$422.81
$476.08
$665.32
$1,011.02
$657.50
$707.79
$761.06
$950.30
$942.48
$992.77
$1,046.04
$1,235.28
$1,227.46
$1,277.75
$1,331.02
$1,520.26
$284.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$745.04
$845.62
$952.16
$1,330.64
$2,022.04
$1,030.02
$1,130.60
$1,237.14
$1,615.62
$1,315.00
$1,415.58
$1,522.12
$1,900.60
$1,599.98
$1,700.56
$1,807.10
$2,185.58
$284.98
Toc - Plan #87 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.73
$409.43
$461.01
$644.26
$979.02
$636.69
$685.39
$736.97
$920.22
$912.65
$961.35
$1,012.93
$1,196.18
$1,188.61
$1,237.31
$1,288.89
$1,472.14
$275.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.46
$818.86
$922.02
$1,288.52
$1,958.04
$997.42
$1,094.82
$1,197.98
$1,564.48
$1,273.38
$1,370.78
$1,473.94
$1,840.44
$1,549.34
$1,646.74
$1,749.90
$2,116.40
$275.96
Toc - Plan #88 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2329 ($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
$9,450 $18,900 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
$391.14
$443.94
$499.88
$698.58
$1,061.55
$690.36
$743.16
$799.10
$997.80
$989.58
$1,042.38
$1,098.32
$1,297.02
$1,288.80
$1,341.60
$1,397.54
$1,596.24
$299.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782.28
$887.88
$999.76
$1,397.16
$2,123.10
$1,081.50
$1,187.10
$1,298.98
$1,696.38
$1,380.72
$1,486.32
$1,598.20
$1,995.60
$1,679.94
$1,785.54
$1,897.42
$2,294.82
$299.22
Toc - Plan #89 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 / 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
$413.23
$469.02
$528.11
$738.03
$1,121.51
$729.35
$785.14
$844.23
$1,054.15
$1,045.47
$1,101.26
$1,160.35
$1,370.27
$1,361.59
$1,417.38
$1,476.47
$1,686.39
$316.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.46
$938.04
$1,056.22
$1,476.06
$2,243.02
$1,142.58
$1,254.16
$1,372.34
$1,792.18
$1,458.70
$1,570.28
$1,688.46
$2,108.30
$1,774.82
$1,886.40
$2,004.58
$2,424.42
$316.12
Toc - Plan #90 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
$5,900 $11,800 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
$441.48
$501.08
$564.21
$788.48
$1,198.18
$779.21
$838.81
$901.94
$1,126.21
$1,116.94
$1,176.54
$1,239.67
$1,463.94
$1,454.67
$1,514.27
$1,577.40
$1,801.67
$337.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.96
$1,002.16
$1,128.42
$1,576.96
$2,396.36
$1,220.69
$1,339.89
$1,466.15
$1,914.69
$1,558.42
$1,677.62
$1,803.88
$2,252.42
$1,896.15
$2,015.35
$2,141.61
$2,590.15
$337.73
Toc - Plan #91 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
$1,500 $3,000 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
$508.43
$577.07
$649.77
$908.06
$1,379.88
$897.38
$966.02
$1,038.72
$1,297.01
$1,286.33
$1,354.97
$1,427.67
$1,685.96
$1,675.28
$1,743.92
$1,816.62
$2,074.91
$388.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,016.86
$1,154.14
$1,299.54
$1,816.12
$2,759.76
$1,405.81
$1,543.09
$1,688.49
$2,205.07
$1,794.76
$1,932.04
$2,077.44
$2,594.02
$2,183.71
$2,320.99
$2,466.39
$2,982.97
$388.95
Toc - Plan #92 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Connected Care Silver 24M03-70 ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,450 $18,900 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
$404.02
$458.56
$516.34
$721.58
$1,096.51
$713.10
$767.64
$825.42
$1,030.66
$1,022.18
$1,076.72
$1,134.50
$1,339.74
$1,331.26
$1,385.80
$1,443.58
$1,648.82
$309.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.04
$917.12
$1,032.68
$1,443.16
$2,193.02
$1,117.12
$1,226.20
$1,341.76
$1,752.24
$1,426.20
$1,535.28
$1,650.84
$2,061.32
$1,735.28
$1,844.36
$1,959.92
$2,370.40
$309.08
Toc - Plan #93 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 24M05-74 ($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
$5,950 $11,900 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
$534.44
$606.59
$683.01
$954.51
$1,450.47
$943.29
$1,015.44
$1,091.86
$1,363.36
$1,352.14
$1,424.29
$1,500.71
$1,772.21
$1,760.99
$1,833.14
$1,909.56
$2,181.06
$408.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,068.88
$1,213.18
$1,366.02
$1,909.02
$2,900.94
$1,477.73
$1,622.03
$1,774.87
$2,317.87
$1,886.58
$2,030.88
$2,183.72
$2,726.72
$2,295.43
$2,439.73
$2,592.57
$3,135.57
$408.85
Toc - Plan #94 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) myBlue Platinum 24M05-75 ($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
$655.40
$743.88
$837.60
$1,170.54
$1,778.76
$1,156.78
$1,245.26
$1,338.98
$1,671.92
$1,658.16
$1,746.64
$1,840.36
$2,173.30
$2,159.54
$2,248.02
$2,341.74
$2,674.68
$501.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,310.80
$1,487.76
$1,675.20
$2,341.08
$3,557.52
$1,812.18
$1,989.14
$2,176.58
$2,842.46
$2,313.56
$2,490.52
$2,677.96
$3,343.84
$2,814.94
$2,991.90
$3,179.34
$3,845.22
$501.38
Toc - Plan #95 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) myBlue Platinum 24M05-00S ($0 Deductible / $10 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
$0 $0 Annual Deductible
$3,200 $6,400 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
$652.67
$740.78
$834.11
$1,165.67
$1,771.35
$1,151.96
$1,240.07
$1,333.40
$1,664.96
$1,651.25
$1,739.36
$1,832.69
$2,164.25
$2,150.54
$2,238.65
$2,331.98
$2,663.54
$499.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,305.34
$1,481.56
$1,668.22
$2,331.34
$3,542.70
$1,804.63
$1,980.85
$2,167.51
$2,830.63
$2,303.92
$2,480.14
$2,666.80
$3,329.92
$2,803.21
$2,979.43
$3,166.09
$3,829.21
$499.29
Toc - Plan #96 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237D ($0 Virtual Visits / $60 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
$9,450 $18,900 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
$426.72
$484.33
$545.35
$762.12
$1,158.12
$753.16
$810.77
$871.79
$1,088.56
$1,079.60
$1,137.21
$1,198.23
$1,415.00
$1,406.04
$1,463.65
$1,524.67
$1,741.44
$326.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.44
$968.66
$1,090.70
$1,524.24
$2,316.24
$1,179.88
$1,295.10
$1,417.14
$1,850.68
$1,506.32
$1,621.54
$1,743.58
$2,177.12
$1,832.76
$1,947.98
$2,070.02
$2,503.56
$326.44
Toc - Plan #97 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 / 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
$421.61
$478.53
$538.82
$753.00
$1,144.25
$744.14
$801.06
$861.35
$1,075.53
$1,066.67
$1,123.59
$1,183.88
$1,398.06
$1,389.20
$1,446.12
$1,506.41
$1,720.59
$322.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$843.22
$957.06
$1,077.64
$1,506.00
$2,288.50
$1,165.75
$1,279.59
$1,400.17
$1,828.53
$1,488.28
$1,602.12
$1,722.70
$2,151.06
$1,810.81
$1,924.65
$2,045.23
$2,473.59
$322.53
Toc - Plan #98 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Connected Care Silver 24M03-70D ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / Adult Dental / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,450 $18,900 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
$412.44
$468.12
$527.10
$736.62
$1,119.36
$727.96
$783.64
$842.62
$1,052.14
$1,043.48
$1,099.16
$1,158.14
$1,367.66
$1,359.00
$1,414.68
$1,473.66
$1,683.18
$315.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$824.88
$936.24
$1,054.20
$1,473.24
$2,238.72
$1,140.40
$1,251.76
$1,369.72
$1,788.76
$1,455.92
$1,567.28
$1,685.24
$2,104.28
$1,771.44
$1,882.80
$2,000.76
$2,419.80
$315.52
Toc - Plan #99 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K02-15 ($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
$953.88
$1,082.65
$1,219.06
$1,703.63
$2,588.83
$1,683.60
$1,812.37
$1,948.78
$2,433.35
$2,413.32
$2,542.09
$2,678.50
$3,163.07
$3,143.04
$3,271.81
$3,408.22
$3,892.79
$729.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,907.76
$2,165.30
$2,438.12
$3,407.26
$5,177.66
$2,637.48
$2,895.02
$3,167.84
$4,136.98
$3,367.20
$3,624.74
$3,897.56
$4,866.70
$4,096.92
$4,354.46
$4,627.28
$5,596.42
$729.72
Toc - Plan #100 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K02-17 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / 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
$9,450 $18,900 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
$560.00
$635.60
$715.68
$1,000.16
$1,519.84
$988.40
$1,064.00
$1,144.08
$1,428.56
$1,416.80
$1,492.40
$1,572.48
$1,856.96
$1,845.20
$1,920.80
$2,000.88
$2,285.36
$428.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,120.00
$1,271.20
$1,431.36
$2,000.32
$3,039.68
$1,548.40
$1,699.60
$1,859.76
$2,428.72
$1,976.80
$2,128.00
$2,288.16
$2,857.12
$2,405.20
$2,556.40
$2,716.56
$3,285.52
$428.40
Toc - Plan #101 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(POS) BlueCare Bronze 24K02-18 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$9,450 $18,900 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
$510.25
$579.13
$652.10
$911.31
$1,384.82
$900.59
$969.47
$1,042.44
$1,301.65
$1,290.93
$1,359.81
$1,432.78
$1,691.99
$1,681.27
$1,750.15
$1,823.12
$2,082.33
$390.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,020.50
$1,158.26
$1,304.20
$1,822.62
$2,769.64
$1,410.84
$1,548.60
$1,694.54
$2,212.96
$1,801.18
$1,938.94
$2,084.88
$2,603.30
$2,191.52
$2,329.28
$2,475.22
$2,993.64
$390.34
Toc - Plan #102 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K02-20 ($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
$6,250 $12,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$825.19
$936.59
$1,054.59
$1,473.79
$2,239.57
$1,456.46
$1,567.86
$1,685.86
$2,105.06
$2,087.73
$2,199.13
$2,317.13
$2,736.33
$2,719.00
$2,830.40
$2,948.40
$3,367.60
$631.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,650.38
$1,873.18
$2,109.18
$2,947.58
$4,479.14
$2,281.65
$2,504.45
$2,740.45
$3,578.85
$2,912.92
$3,135.72
$3,371.72
$4,210.12
$3,544.19
$3,766.99
$4,002.99
$4,841.39
$631.27
Toc - Plan #103 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K02-21 ($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
$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
$655.05
$743.48
$837.15
$1,169.92
$1,777.81
$1,156.16
$1,244.59
$1,338.26
$1,671.03
$1,657.27
$1,745.70
$1,839.37
$2,172.14
$2,158.38
$2,246.81
$2,340.48
$2,673.25
$501.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,310.10
$1,486.96
$1,674.30
$2,339.84
$3,555.62
$1,811.21
$1,988.07
$2,175.41
$2,840.95
$2,312.32
$2,489.18
$2,676.52
$3,342.06
$2,813.43
$2,990.29
$3,177.63
$3,843.17
$501.11
Toc - Plan #104 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K02-23 ($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
$9,450 $18,900 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
$597.50
$678.16
$763.61
$1,067.14
$1,621.62
$1,054.59
$1,135.25
$1,220.70
$1,524.23
$1,511.68
$1,592.34
$1,677.79
$1,981.32
$1,968.77
$2,049.43
$2,134.88
$2,438.41
$457.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,195.00
$1,356.32
$1,527.22
$2,134.28
$3,243.24
$1,652.09
$1,813.41
$1,984.31
$2,591.37
$2,109.18
$2,270.50
$2,441.40
$3,048.46
$2,566.27
$2,727.59
$2,898.49
$3,505.55
$457.09
Toc - Plan #105 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K02-26S (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
$9,400 $18,800 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
$545.57
$619.22
$697.24
$974.39
$1,480.68
$962.93
$1,036.58
$1,114.60
$1,391.75
$1,380.29
$1,453.94
$1,531.96
$1,809.11
$1,797.65
$1,871.30
$1,949.32
$2,226.47
$417.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,091.14
$1,238.44
$1,394.48
$1,948.78
$2,961.36
$1,508.50
$1,655.80
$1,811.84
$2,366.14
$1,925.86
$2,073.16
$2,229.20
$2,783.50
$2,343.22
$2,490.52
$2,646.56
$3,200.86
$417.36
Toc - Plan #106 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K02-27S ($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
$5,900 $11,800 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
$693.73
$787.38
$886.59
$1,239.00
$1,882.78
$1,224.43
$1,318.08
$1,417.29
$1,769.70
$1,755.13
$1,848.78
$1,947.99
$2,300.40
$2,285.83
$2,379.48
$2,478.69
$2,831.10
$530.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,387.46
$1,574.76
$1,773.18
$2,478.00
$3,765.56
$1,918.16
$2,105.46
$2,303.88
$3,008.70
$2,448.86
$2,636.16
$2,834.58
$3,539.40
$2,979.56
$3,166.86
$3,365.28
$4,070.10
$530.70
Toc - Plan #107 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K02-28S ($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
$1,500 $3,000 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
$767.22
$870.79
$980.51
$1,370.25
$2,082.24
$1,354.14
$1,457.71
$1,567.43
$1,957.17
$1,941.06
$2,044.63
$2,154.35
$2,544.09
$2,527.98
$2,631.55
$2,741.27
$3,131.01
$586.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,534.44
$1,741.58
$1,961.02
$2,740.50
$4,164.48
$2,121.36
$2,328.50
$2,547.94
$3,327.42
$2,708.28
$2,915.42
$3,134.86
$3,914.34
$3,295.20
$3,502.34
$3,721.78
$4,501.26
$586.92
Toc - Plan #108 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K02-29S ($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
$3,200 $6,400 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
$950.86
$1,079.23
$1,215.20
$1,698.24
$2,580.63
$1,678.27
$1,806.64
$1,942.61
$2,425.65
$2,405.68
$2,534.05
$2,670.02
$3,153.06
$3,133.09
$3,261.46
$3,397.43
$3,880.47
$727.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,901.72
$2,158.46
$2,430.40
$3,396.48
$5,161.26
$2,629.13
$2,885.87
$3,157.81
$4,123.89
$3,356.54
$3,613.28
$3,885.22
$4,851.30
$4,083.95
$4,340.69
$4,612.63
$5,578.71
$727.41

ADVERTISEMENT

Health First Commercial Plans, Inc.

Local: 1-855-443-4735 | Toll Free: 1-855-443-4735 | TTY: 1-800-955-8771

Toc - Plan #109 Health First Commercial Plans, Inc.
Silver

(HMO) Silver Gym Access 1664 (Primary Care & Specialist Copays, Open Access, Fitness Center Included)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 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
$421.02
$477.86
$538.07
$751.95
$1,142.66
$743.10
$799.94
$860.15
$1,074.03
$1,065.18
$1,122.02
$1,182.23
$1,396.11
$1,387.26
$1,444.10
$1,504.31
$1,718.19
$322.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$842.04
$955.72
$1,076.14
$1,503.90
$2,285.32
$1,164.12
$1,277.80
$1,398.22
$1,825.98
$1,486.20
$1,599.88
$1,720.30
$2,148.06
$1,808.28
$1,921.96
$2,042.38
$2,470.14
$322.08
Toc - Plan #110 Health First Commercial Plans, Inc.
Silver

(HMO) Silver Gym Access 1688 (Open Access, Fitness Center Included)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 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
$414.67
$470.66
$529.95
$740.61
$1,125.43
$731.90
$787.89
$847.18
$1,057.84
$1,049.13
$1,105.12
$1,164.41
$1,375.07
$1,366.36
$1,422.35
$1,481.64
$1,692.30
$317.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$829.34
$941.32
$1,059.90
$1,481.22
$2,250.86
$1,146.57
$1,258.55
$1,377.13
$1,798.45
$1,463.80
$1,575.78
$1,694.36
$2,115.68
$1,781.03
$1,893.01
$2,011.59
$2,432.91
$317.23
Toc - Plan #111 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$2,650 $5,300 Annual Deductible
$8,150 $16,300 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
$438.64
$497.86
$560.59
$783.42
$1,190.48
$774.20
$833.42
$896.15
$1,118.98
$1,109.76
$1,168.98
$1,231.71
$1,454.54
$1,445.32
$1,504.54
$1,567.27
$1,790.10
$335.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$877.28
$995.72
$1,121.18
$1,566.84
$2,380.96
$1,212.84
$1,331.28
$1,456.74
$1,902.40
$1,548.40
$1,666.84
$1,792.30
$2,237.96
$1,883.96
$2,002.40
$2,127.86
$2,573.52
$335.56
Toc - Plan #112 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Gym Access 1742 (Emergency Room & Inpatient Hospitalization Copay, $0 Outpatient Labs, $0 MRI, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$446.69
$507.00
$570.87
$797.80
$1,212.33
$788.41
$848.72
$912.59
$1,139.52
$1,130.13
$1,190.44
$1,254.31
$1,481.24
$1,471.85
$1,532.16
$1,596.03
$1,822.96
$341.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$893.38
$1,014.00
$1,141.74
$1,595.60
$2,424.66
$1,235.10
$1,355.72
$1,483.46
$1,937.32
$1,576.82
$1,697.44
$1,825.18
$2,279.04
$1,918.54
$2,039.16
$2,166.90
$2,620.76
$341.72
Toc - Plan #113 Health First Commercial Plans, Inc.
Catastrophic

(HMO) Catastrophic Gym Access 1746 (Primary Care Copay Visits 1-3, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$196.36
$222.87
$250.95
$350.71
$532.93
$346.58
$373.09
$401.17
$500.93
$496.80
$523.31
$551.39
$651.15
$647.02
$673.53
$701.61
$801.37
$150.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$392.72
$445.74
$501.90
$701.42
$1,065.86
$542.94
$595.96
$652.12
$851.64
$693.16
$746.18
$802.34
$1,001.86
$843.38
$896.40
$952.56
$1,152.08
$150.22
Toc - Plan #114 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze 1750 (Unlimited Primary Care, Specialist & Urgent Care Copay Visits, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,350 $18,700 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
$343.71
$390.12
$439.27
$613.87
$932.84
$606.65
$653.06
$702.21
$876.81
$869.59
$916.00
$965.15
$1,139.75
$1,132.53
$1,178.94
$1,228.09
$1,402.69
$262.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.42
$780.24
$878.54
$1,227.74
$1,865.68
$950.36
$1,043.18
$1,141.48
$1,490.68
$1,213.30
$1,306.12
$1,404.42
$1,753.62
$1,476.24
$1,569.06
$1,667.36
$2,016.56
$262.94
Toc - Plan #115 Health First Commercial Plans, Inc.
Gold

(HMO) Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 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
$424.92
$482.29
$543.05
$758.91
$1,153.24
$749.99
$807.36
$868.12
$1,083.98
$1,075.06
$1,132.43
$1,193.19
$1,409.05
$1,400.13
$1,457.50
$1,518.26
$1,734.12
$325.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.84
$964.58
$1,086.10
$1,517.82
$2,306.48
$1,174.91
$1,289.65
$1,411.17
$1,842.89
$1,499.98
$1,614.72
$1,736.24
$2,167.96
$1,825.05
$1,939.79
$2,061.31
$2,493.03
$325.07
Toc - Plan #116 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze HSA 1794 (HSA Qualified, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 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
$352.50
$400.08
$450.49
$629.56
$956.68
$622.16
$669.74
$720.15
$899.22
$891.82
$939.40
$989.81
$1,168.88
$1,161.48
$1,209.06
$1,259.47
$1,438.54
$269.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$705.00
$800.16
$900.98
$1,259.12
$1,913.36
$974.66
$1,069.82
$1,170.64
$1,528.78
$1,244.32
$1,339.48
$1,440.30
$1,798.44
$1,513.98
$1,609.14
$1,709.96
$2,068.10
$269.66
Toc - Plan #117 Health First Commercial Plans, Inc.
Silver

(HMO) Silver 1806 ($2,100 Deductible, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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
$404.32
$458.91
$516.73
$722.12
$1,097.34
$713.63
$768.22
$826.04
$1,031.43
$1,022.94
$1,077.53
$1,135.35
$1,340.74
$1,332.25
$1,386.84
$1,444.66
$1,650.05
$309.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.64
$917.82
$1,033.46
$1,444.24
$2,194.68
$1,117.95
$1,227.13
$1,342.77
$1,753.55
$1,427.26
$1,536.44
$1,652.08
$2,062.86
$1,736.57
$1,845.75
$1,961.39
$2,372.17
$309.31
Toc - Plan #118 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze 1826 ($0 Medical Deductible, $0 Primary Care Copay- Visits 1 & 2, Specialist & Urgent Care Copay, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$379.39
$430.61
$484.87
$677.60
$1,029.68
$669.63
$720.85
$775.11
$967.84
$959.87
$1,011.09
$1,065.35
$1,258.08
$1,250.11
$1,301.33
$1,355.59
$1,548.32
$290.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.78
$861.22
$969.74
$1,355.20
$2,059.36
$1,049.02
$1,151.46
$1,259.98
$1,645.44
$1,339.26
$1,441.70
$1,550.22
$1,935.68
$1,629.50
$1,731.94
$1,840.46
$2,225.92
$290.24
Toc - Plan #119 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze Standard 1828

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$343.32
$389.66
$438.76
$613.16
$931.76
$605.96
$652.30
$701.40
$875.80
$868.60
$914.94
$964.04
$1,138.44
$1,131.24
$1,177.58
$1,226.68
$1,401.08
$262.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.64
$779.32
$877.52
$1,226.32
$1,863.52
$949.28
$1,041.96
$1,140.16
$1,488.96
$1,211.92
$1,304.60
$1,402.80
$1,751.60
$1,474.56
$1,567.24
$1,665.44
$2,014.24
$262.64
Toc - Plan #120 Health First Commercial Plans, Inc.
Silver

(HMO) Silver Standard 1829

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$402.93
$457.32
$514.94
$719.63
$1,093.55
$711.17
$765.56
$823.18
$1,027.87
$1,019.41
$1,073.80
$1,131.42
$1,336.11
$1,327.65
$1,382.04
$1,439.66
$1,644.35
$308.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.86
$914.64
$1,029.88
$1,439.26
$2,187.10
$1,114.10
$1,222.88
$1,338.12
$1,747.50
$1,422.34
$1,531.12
$1,646.36
$2,055.74
$1,730.58
$1,839.36
$1,954.60
$2,363.98
$308.24
Toc - Plan #121 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Standard 1833

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$422.67
$479.73
$540.18
$754.89
$1,147.13
$746.01
$803.07
$863.52
$1,078.23
$1,069.35
$1,126.41
$1,186.86
$1,401.57
$1,392.69
$1,449.75
$1,510.20
$1,724.91
$323.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.34
$959.46
$1,080.36
$1,509.78
$2,294.26
$1,168.68
$1,282.80
$1,403.70
$1,833.12
$1,492.02
$1,606.14
$1,727.04
$2,156.46
$1,815.36
$1,929.48
$2,050.38
$2,479.80
$323.34
Toc - Plan #122 Health First Commercial Plans, Inc.
Expanded Bronze

(HMO) Bronze Savings 1820 (Primary Care Copay Visits 1-5, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$9,450 $18,900 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
$320.57
$363.84
$409.68
$572.53
$870.02
$565.80
$609.07
$654.91
$817.76
$811.03
$854.30
$900.14
$1,062.99
$1,056.26
$1,099.53
$1,145.37
$1,308.22
$245.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.14
$727.68
$819.36
$1,145.06
$1,740.04
$886.37
$972.91
$1,064.59
$1,390.29
$1,131.60
$1,218.14
$1,309.82
$1,635.52
$1,376.83
$1,463.37
$1,555.05
$1,880.75
$245.23
Toc - Plan #123 Health First Commercial Plans, Inc.
Silver

(HMO) Silver Savings 1821 (Primary Care Copay, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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
$392.36
$445.33
$501.44
$700.76
$1,064.87
$692.52
$745.49
$801.60
$1,000.92
$992.68
$1,045.65
$1,101.76
$1,301.08
$1,292.84
$1,345.81
$1,401.92
$1,601.24
$300.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.72
$890.66
$1,002.88
$1,401.52
$2,129.74
$1,084.88
$1,190.82
$1,303.04
$1,701.68
$1,385.04
$1,490.98
$1,603.20
$2,001.84
$1,685.20
$1,791.14
$1,903.36
$2,302.00
$300.16
Toc - Plan #124 Health First Commercial Plans, Inc.
Gold

(HMO) Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-443-4735

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 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
$395.87
$449.31
$505.92
$707.02
$1,074.39
$698.71
$752.15
$808.76
$1,009.86
$1,001.55
$1,054.99
$1,111.60
$1,312.70
$1,304.39
$1,357.83
$1,414.44
$1,615.54
$302.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.74
$898.62
$1,011.84
$1,414.04
$2,148.78
$1,094.58
$1,201.46
$1,314.68
$1,716.88
$1,397.42
$1,504.30
$1,617.52
$2,019.72
$1,700.26
$1,807.14
$1,920.36
$2,322.56
$302.84

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #125 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite + 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
$9,450 $18,900 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
$371.18
$421.28
$474.35
$662.91
$1,007.35
$655.12
$705.22
$758.29
$946.85
$939.06
$989.16
$1,042.23
$1,230.79
$1,223.00
$1,273.10
$1,326.17
$1,514.73
$283.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.36
$842.56
$948.70
$1,325.82
$2,014.70
$1,026.30
$1,126.50
$1,232.64
$1,609.76
$1,310.24
$1,410.44
$1,516.58
$1,893.70
$1,594.18
$1,694.38
$1,800.52
$2,177.64
$283.94
Toc - Plan #126 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
$409.04
$464.25
$522.74
$730.52
$1,110.10
$721.95
$777.16
$835.65
$1,043.43
$1,034.86
$1,090.07
$1,148.56
$1,356.34
$1,347.77
$1,402.98
$1,461.47
$1,669.25
$312.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.08
$928.50
$1,045.48
$1,461.04
$2,220.20
$1,130.99
$1,241.41
$1,358.39
$1,773.95
$1,443.90
$1,554.32
$1,671.30
$2,086.86
$1,756.81
$1,867.23
$1,984.21
$2,399.77
$312.91
Toc - Plan #127 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
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$247.32
$280.70
$316.07
$441.70
$671.21
$436.51
$469.89
$505.26
$630.89
$625.70
$659.08
$694.45
$820.08
$814.89
$848.27
$883.64
$1,009.27
$189.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$494.64
$561.40
$632.14
$883.40
$1,342.42
$683.83
$750.59
$821.33
$1,072.59
$873.02
$939.78
$1,010.52
$1,261.78
$1,062.21
$1,128.97
$1,199.71
$1,450.97
$189.19
Toc - Plan #128 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite + 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
$9,450 $18,900 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
$373.42
$423.83
$477.22
$666.92
$1,013.45
$659.08
$709.49
$762.88
$952.58
$944.74
$995.15
$1,048.54
$1,238.24
$1,230.40
$1,280.81
$1,334.20
$1,523.90
$285.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.84
$847.66
$954.44
$1,333.84
$2,026.90
$1,032.50
$1,133.32
$1,240.10
$1,619.50
$1,318.16
$1,418.98
$1,525.76
$1,905.16
$1,603.82
$1,704.64
$1,811.42
$2,190.82
$285.66
Toc - Plan #129 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
$434.15
$492.75
$554.83
$775.37
$1,178.25
$766.27
$824.87
$886.95
$1,107.49
$1,098.39
$1,156.99
$1,219.07
$1,439.61
$1,430.51
$1,489.11
$1,551.19
$1,771.73
$332.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.30
$985.50
$1,109.66
$1,550.74
$2,356.50
$1,200.42
$1,317.62
$1,441.78
$1,882.86
$1,532.54
$1,649.74
$1,773.90
$2,214.98
$1,864.66
$1,981.86
$2,106.02
$2,547.10
$332.12
Toc - Plan #130 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
$407.98
$463.05
$521.39
$728.64
$1,107.24
$720.08
$775.15
$833.49
$1,040.74
$1,032.18
$1,087.25
$1,145.59
$1,352.84
$1,344.28
$1,399.35
$1,457.69
$1,664.94
$312.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$815.96
$926.10
$1,042.78
$1,457.28
$2,214.48
$1,128.06
$1,238.20
$1,354.88
$1,769.38
$1,440.16
$1,550.30
$1,666.98
$2,081.48
$1,752.26
$1,862.40
$1,979.08
$2,393.58
$312.10
Toc - Plan #131 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
$8,000 $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
$416.36
$472.56
$532.10
$743.61
$1,129.98
$734.87
$791.07
$850.61
$1,062.12
$1,053.38
$1,109.58
$1,169.12
$1,380.63
$1,371.89
$1,428.09
$1,487.63
$1,699.14
$318.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.72
$945.12
$1,064.20
$1,487.22
$2,259.96
$1,151.23
$1,263.63
$1,382.71
$1,805.73
$1,469.74
$1,582.14
$1,701.22
$2,124.24
$1,788.25
$1,900.65
$2,019.73
$2,442.75
$318.51
Toc - Plan #132 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic 4700

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
$336.00
$381.35
$429.39
$600.07
$911.87
$593.03
$638.38
$686.42
$857.10
$850.06
$895.41
$943.45
$1,114.13
$1,107.09
$1,152.44
$1,200.48
$1,371.16
$257.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.00
$762.70
$858.78
$1,200.14
$1,823.74
$929.03
$1,019.73
$1,115.81
$1,457.17
$1,186.06
$1,276.76
$1,372.84
$1,714.20
$1,443.09
$1,533.79
$1,629.87
$1,971.23
$257.03
Toc - Plan #133 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
$405.01
$459.67
$517.59
$723.33
$1,099.17
$714.83
$769.49
$827.41
$1,033.15
$1,024.65
$1,079.31
$1,137.23
$1,342.97
$1,334.47
$1,389.13
$1,447.05
$1,652.79
$309.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.02
$919.34
$1,035.18
$1,446.66
$2,198.34
$1,119.84
$1,229.16
$1,345.00
$1,756.48
$1,429.66
$1,538.98
$1,654.82
$2,066.30
$1,739.48
$1,848.80
$1,964.64
$2,376.12
$309.82
Toc - Plan #134 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite 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
$474.03
$538.01
$605.80
$846.60
$1,286.49
$836.65
$900.63
$968.42
$1,209.22
$1,199.27
$1,263.25
$1,331.04
$1,571.84
$1,561.89
$1,625.87
$1,693.66
$1,934.46
$362.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$948.06
$1,076.02
$1,211.60
$1,693.20
$2,572.98
$1,310.68
$1,438.64
$1,574.22
$2,055.82
$1,673.30
$1,801.26
$1,936.84
$2,418.44
$2,035.92
$2,163.88
$2,299.46
$2,781.06
$362.62
Toc - Plan #135 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
$450.11
$510.86
$575.23
$803.88
$1,221.57
$794.44
$855.19
$919.56
$1,148.21
$1,138.77
$1,199.52
$1,263.89
$1,492.54
$1,483.10
$1,543.85
$1,608.22
$1,836.87
$344.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$900.22
$1,021.72
$1,150.46
$1,607.76
$2,443.14
$1,244.55
$1,366.05
$1,494.79
$1,952.09
$1,588.88
$1,710.38
$1,839.12
$2,296.42
$1,933.21
$2,054.71
$2,183.45
$2,640.75
$344.33
Toc - Plan #136 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite 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
$9,450 $18,900 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
$364.54
$413.74
$465.87
$651.05
$989.33
$643.40
$692.60
$744.73
$929.91
$922.26
$971.46
$1,023.59
$1,208.77
$1,201.12
$1,250.32
$1,302.45
$1,487.63
$278.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.08
$827.48
$931.74
$1,302.10
$1,978.66
$1,007.94
$1,106.34
$1,210.60
$1,580.96
$1,286.80
$1,385.20
$1,489.46
$1,859.82
$1,565.66
$1,664.06
$1,768.32
$2,138.68
$278.86
Toc - Plan #137 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
$9,400 $18,800 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
$333.02
$377.97
$425.59
$594.76
$903.79
$587.77
$632.72
$680.34
$849.51
$842.52
$887.47
$935.09
$1,104.26
$1,097.27
$1,142.22
$1,189.84
$1,359.01
$254.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.04
$755.94
$851.18
$1,189.52
$1,807.58
$920.79
$1,010.69
$1,105.93
$1,444.27
$1,175.54
$1,265.44
$1,360.68
$1,699.02
$1,430.29
$1,520.19
$1,615.43
$1,953.77
$254.75
Toc - Plan #138 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
$5,900 $11,800 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
$405.85
$460.62
$518.66
$724.82
$1,101.44
$716.31
$771.08
$829.12
$1,035.28
$1,026.77
$1,081.54
$1,139.58
$1,345.74
$1,337.23
$1,392.00
$1,450.04
$1,656.20
$310.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.70
$921.24
$1,037.32
$1,449.64
$2,202.88
$1,122.16
$1,231.70
$1,347.78
$1,760.10
$1,432.62
$1,542.16
$1,658.24
$2,070.56
$1,743.08
$1,852.62
$1,968.70
$2,381.02
$310.46
Toc - Plan #139 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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419.63
$476.27
$536.27
$749.44
$1,138.84
$740.64
$797.28
$857.28
$1,070.45
$1,061.65
$1,118.29
$1,178.29
$1,391.46
$1,382.66
$1,439.30
$1,499.30
$1,712.47
$321.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839.26
$952.54
$1,072.54
$1,498.88
$2,277.68
$1,160.27
$1,273.55
$1,393.55
$1,819.89
$1,481.28
$1,594.56
$1,714.56
$2,140.90
$1,802.29
$1,915.57
$2,035.57
$2,461.91
$321.01

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

Toc - Plan #140 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 8500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,450 $18,900 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
$340.99
$387.03
$435.79
$609.01
$925.45
$601.85
$647.89
$696.65
$869.87
$862.71
$908.75
$957.51
$1,130.73
$1,123.57
$1,169.61
$1,218.37
$1,391.59
$260.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$681.98
$774.06
$871.58
$1,218.02
$1,850.90
$942.84
$1,034.92
$1,132.44
$1,478.88
$1,203.70
$1,295.78
$1,393.30
$1,739.74
$1,464.56
$1,556.64
$1,654.16
$2,000.60
$260.86
Toc - Plan #141 Cigna Healthcare
Silver

(EPO) Connect Silver 4000 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,200 $18,400 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
$459.68
$521.73
$587.47
$820.98
$1,247.56
$811.33
$873.38
$939.12
$1,172.63
$1,162.98
$1,225.03
$1,290.77
$1,524.28
$1,514.63
$1,576.68
$1,642.42
$1,875.93
$351.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$919.36
$1,043.46
$1,174.94
$1,641.96
$2,495.12
$1,271.01
$1,395.11
$1,526.59
$1,993.61
$1,622.66
$1,746.76
$1,878.24
$2,345.26
$1,974.31
$2,098.41
$2,229.89
$2,696.91
$351.65
Toc - Plan #142 Cigna Healthcare
Silver

(EPO) Connect Silver 5000 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$456.01
$517.57
$582.78
$814.44
$1,237.62
$804.86
$866.42
$931.63
$1,163.29
$1,153.71
$1,215.27
$1,280.48
$1,512.14
$1,502.56
$1,564.12
$1,629.33
$1,860.99
$348.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$912.02
$1,035.14
$1,165.56
$1,628.88
$2,475.24
$1,260.87
$1,383.99
$1,514.41
$1,977.73
$1,609.72
$1,732.84
$1,863.26
$2,326.58
$1,958.57
$2,081.69
$2,212.11
$2,675.43
$348.85
Toc - Plan #143 Cigna Healthcare
Silver

(EPO) Connect Silver 9100 Indiv Med Deductible

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
$465.05
$527.83
$594.33
$830.58
$1,262.14
$820.81
$883.59
$950.09
$1,186.34
$1,176.57
$1,239.35
$1,305.85
$1,542.10
$1,532.33
$1,595.11
$1,661.61
$1,897.86
$355.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$930.10
$1,055.66
$1,188.66
$1,661.16
$2,524.28
$1,285.86
$1,411.42
$1,544.42
$2,016.92
$1,641.62
$1,767.18
$1,900.18
$2,372.68
$1,997.38
$2,122.94
$2,255.94
$2,728.44
$355.76
Toc - Plan #144 Cigna Healthcare
Gold

(EPO) Connect Gold 2500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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
$473.53
$537.46
$605.18
$845.73
$1,285.17
$835.78
$899.71
$967.43
$1,207.98
$1,198.03
$1,261.96
$1,329.68
$1,570.23
$1,560.28
$1,624.21
$1,691.93
$1,932.48
$362.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$947.06
$1,074.92
$1,210.36
$1,691.46
$2,570.34
$1,309.31
$1,437.17
$1,572.61
$2,053.71
$1,671.56
$1,799.42
$1,934.86
$2,415.96
$2,033.81
$2,161.67
$2,297.11
$2,778.21
$362.25
Toc - Plan #145 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 6500 Indiv Med Deductible Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,450 $18,900 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
$341.04
$387.08
$435.85
$609.10
$925.59
$601.94
$647.98
$696.75
$870.00
$862.84
$908.88
$957.65
$1,130.90
$1,123.74
$1,169.78
$1,218.55
$1,391.80
$260.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.08
$774.16
$871.70
$1,218.20
$1,851.18
$942.98
$1,035.06
$1,132.60
$1,479.10
$1,203.88
$1,295.96
$1,393.50
$1,740.00
$1,464.78
$1,556.86
$1,654.40
$2,000.90
$260.90
Toc - Plan #146 Cigna Healthcare
Silver

(EPO) Connect Silver 3000 Indiv Med Deductible

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
$9,400 $18,800 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
$455.01
$516.43
$581.50
$812.64
$1,234.89
$803.09
$864.51
$929.58
$1,160.72
$1,151.17
$1,212.59
$1,277.66
$1,508.80
$1,499.25
$1,560.67
$1,625.74
$1,856.88
$348.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$910.02
$1,032.86
$1,163.00
$1,625.28
$2,469.78
$1,258.10
$1,380.94
$1,511.08
$1,973.36
$1,606.18
$1,729.02
$1,859.16
$2,321.44
$1,954.26
$2,077.10
$2,207.24
$2,669.52
$348.08
Toc - Plan #147 Cigna Healthcare
Gold

(EPO) Connect Gold 500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$9,450 $18,900 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
$493.52
$560.14
$630.71
$881.42
$1,339.40
$871.06
$937.68
$1,008.25
$1,258.96
$1,248.60
$1,315.22
$1,385.79
$1,636.50
$1,626.14
$1,692.76
$1,763.33
$2,014.04
$377.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$987.04
$1,120.28
$1,261.42
$1,762.84
$2,678.80
$1,364.58
$1,497.82
$1,638.96
$2,140.38
$1,742.12
$1,875.36
$2,016.50
$2,517.92
$2,119.66
$2,252.90
$2,394.04
$2,895.46
$377.54
Toc - Plan #148 Cigna Healthcare
Gold

(EPO) Connect Gold CMS Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$478.76
$543.39
$611.85
$855.06
$1,299.34
$845.01
$909.64
$978.10
$1,221.31
$1,211.26
$1,275.89
$1,344.35
$1,587.56
$1,577.51
$1,642.14
$1,710.60
$1,953.81
$366.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$957.52
$1,086.78
$1,223.70
$1,710.12
$2,598.68
$1,323.77
$1,453.03
$1,589.95
$2,076.37
$1,690.02
$1,819.28
$1,956.20
$2,442.62
$2,056.27
$2,185.53
$2,322.45
$2,808.87
$366.25
Toc - Plan #149 Cigna Healthcare
Silver

(EPO) Connect Silver CMS Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$458.82
$520.76
$586.38
$819.46
$1,245.25
$809.82
$871.76
$937.38
$1,170.46
$1,160.82
$1,222.76
$1,288.38
$1,521.46
$1,511.82
$1,573.76
$1,639.38
$1,872.46
$351.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.64
$1,041.52
$1,172.76
$1,638.92
$2,490.50
$1,268.64
$1,392.52
$1,523.76
$1,989.92
$1,619.64
$1,743.52
$1,874.76
$2,340.92
$1,970.64
$2,094.52
$2,225.76
$2,691.92
$351.00
Toc - Plan #150 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze CMS Standard

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
$9,400 $18,800 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
$342.70
$388.96
$437.97
$612.06
$930.09
$604.87
$651.13
$700.14
$874.23
$867.04
$913.30
$962.31
$1,136.40
$1,129.21
$1,175.47
$1,224.48
$1,398.57
$262.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.40
$777.92
$875.94
$1,224.12
$1,860.18
$947.57
$1,040.09
$1,138.11
$1,486.29
$1,209.74
$1,302.26
$1,400.28
$1,748.46
$1,471.91
$1,564.43
$1,662.45
$2,010.63
$262.17
Toc - Plan #151 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 0 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$374.93
$425.55
$479.16
$669.63
$1,017.56
$661.75
$712.37
$765.98
$956.45
$948.57
$999.19
$1,052.80
$1,243.27
$1,235.39
$1,286.01
$1,339.62
$1,530.09
$286.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.86
$851.10
$958.32
$1,339.26
$2,035.12
$1,036.68
$1,137.92
$1,245.14
$1,626.08
$1,323.50
$1,424.74
$1,531.96
$1,912.90
$1,610.32
$1,711.56
$1,818.78
$2,199.72
$286.82
Toc - Plan #152 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 5500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,400 $18,800 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
$346.36
$393.12
$442.65
$618.61
$940.03
$611.33
$658.09
$707.62
$883.58
$876.30
$923.06
$972.59
$1,148.55
$1,141.27
$1,188.03
$1,237.56
$1,413.52
$264.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$692.72
$786.24
$885.30
$1,237.22
$1,880.06
$957.69
$1,051.21
$1,150.27
$1,502.19
$1,222.66
$1,316.18
$1,415.24
$1,767.16
$1,487.63
$1,581.15
$1,680.21
$2,032.13
$264.97

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #153 Molina Healthcare
Gold

(HMO) Gold 1

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

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 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
$480.69
$545.58
$614.32
$858.51
$1,304.59
$848.42
$913.31
$982.05
$1,226.24
$1,216.15
$1,281.04
$1,349.78
$1,593.97
$1,583.88
$1,648.77
$1,717.51
$1,961.70
$367.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$961.38
$1,091.16
$1,228.64
$1,717.02
$2,609.18
$1,329.11
$1,458.89
$1,596.37
$2,084.75
$1,696.84
$1,826.62
$1,964.10
$2,452.48
$2,064.57
$2,194.35
$2,331.83
$2,820.21
$367.73
Toc - Plan #154 Molina Healthcare
Silver

(HMO) Silver 1

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.78
$463.97
$522.42
$730.09
$1,109.44
$721.50
$776.69
$835.14
$1,042.81
$1,034.22
$1,089.41
$1,147.86
$1,355.53
$1,346.94
$1,402.13
$1,460.58
$1,668.25
$312.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$817.56
$927.94
$1,044.84
$1,460.18
$2,218.88
$1,130.28
$1,240.66
$1,357.56
$1,772.90
$1,443.00
$1,553.38
$1,670.28
$2,085.62
$1,755.72
$1,866.10
$1,983.00
$2,398.34
$312.72
Toc - Plan #155 Molina Healthcare
Expanded Bronze

(HMO) Bronze 4

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 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
$378.68
$429.80
$483.95
$676.31
$1,027.73
$668.37
$719.49
$773.64
$966.00
$958.06
$1,009.18
$1,063.33
$1,255.69
$1,247.75
$1,298.87
$1,353.02
$1,545.38
$289.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.36
$859.60
$967.90
$1,352.62
$2,055.46
$1,047.05
$1,149.29
$1,257.59
$1,642.31
$1,336.74
$1,438.98
$1,547.28
$1,932.00
$1,626.43
$1,728.67
$1,836.97
$2,221.69
$289.69
Toc - Plan #156 Molina Healthcare
Gold

(HMO) Gold 8

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$491.54
$557.90
$628.19
$877.90
$1,334.05
$867.57
$933.93
$1,004.22
$1,253.93
$1,243.60
$1,309.96
$1,380.25
$1,629.96
$1,619.63
$1,685.99
$1,756.28
$2,005.99
$376.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$983.08
$1,115.80
$1,256.38
$1,755.80
$2,668.10
$1,359.11
$1,491.83
$1,632.41
$2,131.83
$1,735.14
$1,867.86
$2,008.44
$2,507.86
$2,111.17
$2,243.89
$2,384.47
$2,883.89
$376.03
Toc - Plan #157 Molina Healthcare
Silver

(HMO) Silver 8

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$416.31
$472.51
$532.05
$743.53
$1,129.87
$734.79
$790.99
$850.53
$1,062.01
$1,053.27
$1,109.47
$1,169.01
$1,380.49
$1,371.75
$1,427.95
$1,487.49
$1,698.97
$318.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.62
$945.02
$1,064.10
$1,487.06
$2,259.74
$1,151.10
$1,263.50
$1,382.58
$1,805.54
$1,469.58
$1,581.98
$1,701.06
$2,124.02
$1,788.06
$1,900.46
$2,019.54
$2,442.50
$318.48
Toc - Plan #158 Molina Healthcare
Expanded Bronze

(HMO) Bronze 8

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$325.58
$369.53
$416.09
$581.48
$883.62
$574.65
$618.60
$665.16
$830.55
$823.72
$867.67
$914.23
$1,079.62
$1,072.79
$1,116.74
$1,163.30
$1,328.69
$249.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$651.16
$739.06
$832.18
$1,162.96
$1,767.24
$900.23
$988.13
$1,081.25
$1,412.03
$1,149.30
$1,237.20
$1,330.32
$1,661.10
$1,398.37
$1,486.27
$1,579.39
$1,910.17
$249.07
Toc - Plan #159 Molina Healthcare
Silver

(HMO) Silver 12 with First 4 Primary Care Visits Free

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,450 $18,900 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
$407.15
$462.11
$520.34
$727.17
$1,105.00
$718.62
$773.58
$831.81
$1,038.64
$1,030.09
$1,085.05
$1,143.28
$1,350.11
$1,341.56
$1,396.52
$1,454.75
$1,661.58
$311.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.30
$924.22
$1,040.68
$1,454.34
$2,210.00
$1,125.77
$1,235.69
$1,352.15
$1,765.81
$1,437.24
$1,547.16
$1,663.62
$2,077.28
$1,748.71
$1,858.63
$1,975.09
$2,388.75
$311.47
Toc - Plan #160 Molina Healthcare
Gold

(HMO) Gold 1 with Adult Vision Services

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

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 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
$483.86
$549.18
$618.38
$864.18
$1,313.20
$854.02
$919.34
$988.54
$1,234.34
$1,224.18
$1,289.50
$1,358.70
$1,604.50
$1,594.34
$1,659.66
$1,728.86
$1,974.66
$370.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$967.72
$1,098.36
$1,236.76
$1,728.36
$2,626.40
$1,337.88
$1,468.52
$1,606.92
$2,098.52
$1,708.04
$1,838.68
$1,977.08
$2,468.68
$2,078.20
$2,208.84
$2,347.24
$2,838.84
$370.16
Toc - Plan #161 Molina Healthcare
Silver

(HMO) Silver 1 with Adult Vision Services

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.84
$467.43
$526.33
$735.54
$1,117.72
$726.89
$782.48
$841.38
$1,050.59
$1,041.94
$1,097.53
$1,156.43
$1,365.64
$1,356.99
$1,412.58
$1,471.48
$1,680.69
$315.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$823.68
$934.86
$1,052.66
$1,471.08
$2,235.44
$1,138.73
$1,249.91
$1,367.71
$1,786.13
$1,453.78
$1,564.96
$1,682.76
$2,101.18
$1,768.83
$1,880.01
$1,997.81
$2,416.23
$315.05

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0405 | Toll Free: 1-888-200-0405 | TTY: 1-888-200-0405

Toc - Plan #162 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,900 $7,800 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
$441.82
$501.46
$564.64
$789.08
$1,199.09
$779.81
$839.45
$902.63
$1,127.07
$1,117.80
$1,177.44
$1,240.62
$1,465.06
$1,455.79
$1,515.43
$1,578.61
$1,803.05
$337.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$883.64
$1,002.92
$1,129.28
$1,578.16
$2,398.18
$1,221.63
$1,340.91
$1,467.27
$1,916.15
$1,559.62
$1,678.90
$1,805.26
$2,254.14
$1,897.61
$2,016.89
$2,143.25
$2,592.13
$337.99
Toc - Plan #163 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$9,450 $18,900 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
$354.09
$401.89
$452.52
$632.40
$960.99
$624.97
$672.77
$723.40
$903.28
$895.85
$943.65
$994.28
$1,174.16
$1,166.73
$1,214.53
$1,265.16
$1,445.04
$270.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.18
$803.78
$905.04
$1,264.80
$1,921.98
$979.06
$1,074.66
$1,175.92
$1,535.68
$1,249.94
$1,345.54
$1,446.80
$1,806.56
$1,520.82
$1,616.42
$1,717.68
$2,077.44
$270.88
Toc - Plan #164 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,450 $18,900 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
$354.63
$402.50
$453.22
$633.37
$962.46
$625.92
$673.79
$724.51
$904.66
$897.21
$945.08
$995.80
$1,175.95
$1,168.50
$1,216.37
$1,267.09
$1,447.24
$271.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.26
$805.00
$906.44
$1,266.74
$1,924.92
$980.55
$1,076.29
$1,177.73
$1,538.03
$1,251.84
$1,347.58
$1,449.02
$1,809.32
$1,523.13
$1,618.87
$1,720.31
$2,080.61
$271.29
Toc - Plan #165 UnitedHealthcare
Gold

(HMO) UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$507.81
$576.37
$648.98
$906.95
$1,378.20
$896.29
$964.85
$1,037.46
$1,295.43
$1,284.77
$1,353.33
$1,425.94
$1,683.91
$1,673.25
$1,741.81
$1,814.42
$2,072.39
$388.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,015.62
$1,152.74
$1,297.96
$1,813.90
$2,756.40
$1,404.10
$1,541.22
$1,686.44
$2,202.38
$1,792.58
$1,929.70
$2,074.92
$2,590.86
$2,181.06
$2,318.18
$2,463.40
$2,979.34
$388.48
Toc - Plan #166 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$499.17
$566.56
$637.94
$891.52
$1,354.76
$881.04
$948.43
$1,019.81
$1,273.39
$1,262.91
$1,330.30
$1,401.68
$1,655.26
$1,644.78
$1,712.17
$1,783.55
$2,037.13
$381.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$998.34
$1,133.12
$1,275.88
$1,783.04
$2,709.52
$1,380.21
$1,514.99
$1,657.75
$2,164.91
$1,762.08
$1,896.86
$2,039.62
$2,546.78
$2,143.95
$2,278.73
$2,421.49
$2,928.65
$381.87
Toc - Plan #167 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$459.59
$521.63
$587.35
$820.82
$1,247.32
$811.18
$873.22
$938.94
$1,172.41
$1,162.77
$1,224.81
$1,290.53
$1,524.00
$1,514.36
$1,576.40
$1,642.12
$1,875.59
$351.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$919.18
$1,043.26
$1,174.70
$1,641.64
$2,494.64
$1,270.77
$1,394.85
$1,526.29
$1,993.23
$1,622.36
$1,746.44
$1,877.88
$2,344.82
$1,973.95
$2,098.03
$2,229.47
$2,696.41
$351.59
Toc - Plan #168 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$436.91
$495.90
$558.37
$780.33
$1,185.78
$771.15
$830.14
$892.61
$1,114.57
$1,105.39
$1,164.38
$1,226.85
$1,448.81
$1,439.63
$1,498.62
$1,561.09
$1,783.05
$334.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.82
$991.80
$1,116.74
$1,560.66
$2,371.56
$1,208.06
$1,326.04
$1,450.98
$1,894.90
$1,542.30
$1,660.28
$1,785.22
$2,229.14
$1,876.54
$1,994.52
$2,119.46
$2,563.38
$334.24
Toc - Plan #169 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($0 Virtual Urgent Care, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,450 $18,900 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
$348.89
$395.99
$445.89
$623.12
$946.90
$615.79
$662.89
$712.79
$890.02
$882.69
$929.79
$979.69
$1,156.92
$1,149.59
$1,196.69
$1,246.59
$1,423.82
$266.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$697.78
$791.98
$891.78
$1,246.24
$1,893.80
$964.68
$1,058.88
$1,158.68
$1,513.14
$1,231.58
$1,325.78
$1,425.58
$1,780.04
$1,498.48
$1,592.68
$1,692.48
$2,046.94
$266.90
Toc - Plan #170 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.15
$403.09
$453.88
$634.30
$963.87
$626.84
$674.78
$725.57
$905.99
$898.53
$946.47
$997.26
$1,177.68
$1,170.22
$1,218.16
$1,268.95
$1,449.37
$271.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.30
$806.18
$907.76
$1,268.60
$1,927.74
$981.99
$1,077.87
$1,179.45
$1,540.29
$1,253.68
$1,349.56
$1,451.14
$1,811.98
$1,525.37
$1,621.25
$1,722.83
$2,083.67
$271.69
Toc - Plan #171 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus $0 Indiv Med Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$372.42
$422.70
$475.96
$665.15
$1,010.76
$657.32
$707.60
$760.86
$950.05
$942.22
$992.50
$1,045.76
$1,234.95
$1,227.12
$1,277.40
$1,330.66
$1,519.85
$284.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.84
$845.40
$951.92
$1,330.30
$2,021.52
$1,029.74
$1,130.30
$1,236.82
$1,615.20
$1,314.64
$1,415.20
$1,521.72
$1,900.10
$1,599.54
$1,700.10
$1,806.62
$2,185.00
$284.90
Toc - Plan #172 UnitedHealthcare
Silver

(HMO) UHC Silver Value ($0 Virtual Urgent Care, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 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
$440.84
$500.36
$563.40
$787.35
$1,196.45
$778.09
$837.61
$900.65
$1,124.60
$1,115.34
$1,174.86
$1,237.90
$1,461.85
$1,452.59
$1,512.11
$1,575.15
$1,799.10
$337.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$881.68
$1,000.72
$1,126.80
$1,574.70
$2,392.90
$1,218.93
$1,337.97
$1,464.05
$1,911.95
$1,556.18
$1,675.22
$1,801.30
$2,249.20
$1,893.43
$2,012.47
$2,138.55
$2,586.45
$337.25
Toc - Plan #173 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 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
$445.82
$506.01
$569.76
$796.24
$1,209.96
$786.87
$847.06
$910.81
$1,137.29
$1,127.92
$1,188.11
$1,251.86
$1,478.34
$1,468.97
$1,529.16
$1,592.91
$1,819.39
$341.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$891.64
$1,012.02
$1,139.52
$1,592.48
$2,419.92
$1,232.69
$1,353.07
$1,480.57
$1,933.53
$1,573.74
$1,694.12
$1,821.62
$2,274.58
$1,914.79
$2,035.17
$2,162.67
$2,615.63
$341.05
Toc - Plan #174 UnitedHealthcare
Gold

(HMO) UHC Gold Value ($0 Virtual Urgent Care, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$496.38
$563.39
$634.38
$886.54
$1,347.18
$876.11
$943.12
$1,014.11
$1,266.27
$1,255.84
$1,322.85
$1,393.84
$1,646.00
$1,635.57
$1,702.58
$1,773.57
$2,025.73
$379.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$992.76
$1,126.78
$1,268.76
$1,773.08
$2,694.36
$1,372.49
$1,506.51
$1,648.49
$2,152.81
$1,752.22
$1,886.24
$2,028.22
$2,532.54
$2,131.95
$2,265.97
$2,407.95
$2,912.27
$379.73
Toc - Plan #175 UnitedHealthcare
Gold

(HMO) UHC Gold Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$497.72
$564.91
$636.09
$888.93
$1,350.81
$878.48
$945.67
$1,016.85
$1,269.69
$1,259.24
$1,326.43
$1,397.61
$1,650.45
$1,640.00
$1,707.19
$1,778.37
$2,031.21
$380.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$995.44
$1,129.82
$1,272.18
$1,777.86
$2,701.62
$1,376.20
$1,510.58
$1,652.94
$2,158.62
$1,756.96
$1,891.34
$2,033.70
$2,539.38
$2,137.72
$2,272.10
$2,414.46
$2,920.14
$380.76
Toc - Plan #176 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$526.24
$597.28
$672.53
$939.86
$1,428.20
$928.81
$999.85
$1,075.10
$1,342.43
$1,331.38
$1,402.42
$1,477.67
$1,745.00
$1,733.95
$1,804.99
$1,880.24
$2,147.57
$402.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,052.48
$1,194.56
$1,345.06
$1,879.72
$2,856.40
$1,455.05
$1,597.13
$1,747.63
$2,282.29
$1,857.62
$1,999.70
$2,150.20
$2,684.86
$2,260.19
$2,402.27
$2,552.77
$3,087.43
$402.57
Toc - Plan #177 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 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
$465.41
$528.24
$594.80
$831.23
$1,263.13
$821.45
$884.28
$950.84
$1,187.27
$1,177.49
$1,240.32
$1,306.88
$1,543.31
$1,533.53
$1,596.36
$1,662.92
$1,899.35
$356.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$930.82
$1,056.48
$1,189.60
$1,662.46
$2,526.26
$1,286.86
$1,412.52
$1,545.64
$2,018.50
$1,642.90
$1,768.56
$1,901.68
$2,374.54
$1,998.94
$2,124.60
$2,257.72
$2,730.58
$356.04

ADVERTISEMENT

Ambetter from Sunshine Health

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

Toc - Plan #178 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Elite VALUE Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.44
$415.90
$468.30
$654.44
$994.49
$646.76
$696.22
$748.62
$934.76
$927.08
$976.54
$1,028.94
$1,215.08
$1,207.40
$1,256.86
$1,309.26
$1,495.40
$280.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732.88
$831.80
$936.60
$1,308.88
$1,988.98
$1,013.20
$1,112.12
$1,216.92
$1,589.20
$1,293.52
$1,392.44
$1,497.24
$1,869.52
$1,573.84
$1,672.76
$1,777.56
$2,149.84
$280.32
Toc - Plan #179 Ambetter from Sunshine Health
Silver

(HMO) Complete VALUE Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412.64
$468.34
$527.35
$736.97
$1,119.89
$728.31
$784.01
$843.02
$1,052.64
$1,043.98
$1,099.68
$1,158.69
$1,368.31
$1,359.65
$1,415.35
$1,474.36
$1,683.98
$315.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$825.28
$936.68
$1,054.70
$1,473.94
$2,239.78
$1,140.95
$1,252.35
$1,370.37
$1,789.61
$1,456.62
$1,568.02
$1,686.04
$2,105.28
$1,772.29
$1,883.69
$2,001.71
$2,420.95
$315.67
Toc - Plan #180 Ambetter from Sunshine Health
Silver

(HMO) Clear VALUE Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$397.74
$451.42
$508.30
$710.34
$1,079.43
$702.00
$755.68
$812.56
$1,014.60
$1,006.26
$1,059.94
$1,116.82
$1,318.86
$1,310.52
$1,364.20
$1,421.08
$1,623.12
$304.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.48
$902.84
$1,016.60
$1,420.68
$2,158.86
$1,099.74
$1,207.10
$1,320.86
$1,724.94
$1,404.00
$1,511.36
$1,625.12
$2,029.20
$1,708.26
$1,815.62
$1,929.38
$2,333.46
$304.26
Toc - Plan #181 Ambetter from Sunshine Health
Silver

(HMO) Focused VALUE Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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
$404.81
$459.45
$517.33
$722.97
$1,098.63
$714.48
$769.12
$827.00
$1,032.64
$1,024.15
$1,078.79
$1,136.67
$1,342.31
$1,333.82
$1,388.46
$1,446.34
$1,651.98
$309.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$809.62
$918.90
$1,034.66
$1,445.94
$2,197.26
$1,119.29
$1,228.57
$1,344.33
$1,755.61
$1,428.96
$1,538.24
$1,654.00
$2,065.28
$1,738.63
$1,847.91
$1,963.67
$2,374.95
$309.67
Toc - Plan #182 Ambetter from Sunshine Health
Gold

(HMO) Complete VALUE Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.67
$444.54
$500.54
$699.51
$1,062.97
$691.29
$744.16
$800.16
$999.13
$990.91
$1,043.78
$1,099.78
$1,298.75
$1,290.53
$1,343.40
$1,399.40
$1,598.37
$299.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.34
$889.08
$1,001.08
$1,399.02
$2,125.94
$1,082.96
$1,188.70
$1,300.70
$1,698.64
$1,382.58
$1,488.32
$1,600.32
$1,998.26
$1,682.20
$1,787.94
$1,899.94
$2,297.88
$299.62
Toc - Plan #183 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Standard Expanded Bronze VALUE

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$312.96
$355.20
$399.95
$558.93
$849.35
$552.37
$594.61
$639.36
$798.34
$791.78
$834.02
$878.77
$1,037.75
$1,031.19
$1,073.43
$1,118.18
$1,277.16
$239.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625.92
$710.40
$799.90
$1,117.86
$1,698.70
$865.33
$949.81
$1,039.31
$1,357.27
$1,104.74
$1,189.22
$1,278.72
$1,596.68
$1,344.15
$1,428.63
$1,518.13
$1,836.09
$239.41
Toc - Plan #184 Ambetter from Sunshine Health
Silver

(HMO) Standard Silver VALUE

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$396.37
$449.87
$506.55
$707.90
$1,075.73
$699.59
$753.09
$809.77
$1,011.12
$1,002.81
$1,056.31
$1,112.99
$1,314.34
$1,306.03
$1,359.53
$1,416.21
$1,617.56
$303.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.74
$899.74
$1,013.10
$1,415.80
$2,151.46
$1,095.96
$1,202.96
$1,316.32
$1,719.02
$1,399.18
$1,506.18
$1,619.54
$2,022.24
$1,702.40
$1,809.40
$1,922.76
$2,325.46
$303.22
Toc - Plan #185 Ambetter from Sunshine Health
Gold

(HMO) Standard Gold VALUE

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$372.14
$422.37
$475.59
$664.63
$1,009.97
$656.82
$707.05
$760.27
$949.31
$941.50
$991.73
$1,044.95
$1,233.99
$1,226.18
$1,276.41
$1,329.63
$1,518.67
$284.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.28
$844.74
$951.18
$1,329.26
$2,019.94
$1,028.96
$1,129.42
$1,235.86
$1,613.94
$1,313.64
$1,414.10
$1,520.54
$1,898.62
$1,598.32
$1,698.78
$1,805.22
$2,183.30
$284.68

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Orange County here.

Orange County is in “Rating Area 48” of Florida.

Currently, there are 185 plans offered in Rating Area 48.

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2024 Obamacare Plans for Orange County, FL

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