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Providers for Zip Code 32765

Obamacare 2017 Marketplace Rates For Seminole County, Florida

Tuesday, December 6th, 2016

Click for Oviedo, Florida Forecast

Obamacare Providers, Plans and 2017 Rates for Seminole County

The health insurance rates listed below are for calendar year 2017.

2017 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

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

Currently, there are 85 plans offered in Seminole County.

Below, you’ll find a summary of plans and rates for each of these providers. This chart is designed to give you a preview of your health insurance options. For detailed information on available subsidies to make your coverage affordable, you must complete an application at HealthCare.gov or contact the provider directly.

 

The table below shows premiums for the following scenarios:

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

Each scenario is covered for age

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

 

Note: If you are over 65, you qualify for Medicare. Click here to see listings of 2017 Medicare Advantage plans for Seminole County

 

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

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

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

Florida Health Care Plan, Inc.

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

TTY: 1-800-955-8771

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

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

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $1,500 : Family: $3,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$451.81
$512.80
$577.41
$806.93
$1226.20
$903.62
$1025.60
$1154.82
$1613.86
$2452.40
$1190.52
$1312.50
$1441.72
$1900.76
$1477.42
$1599.40
$1728.62
$2187.66
$1764.32
$1886.30
$2015.52
$2474.56
$738.71
$799.70
$864.31
$1093.83
$1025.61
$1086.60
$1151.21
$1380.73
$1312.51
$1373.50
$1438.11
$1667.63
$286.90

Plan: (HMO) Gym Access IND Platinum HMO 91

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$443.02
$502.83
$566.19
$791.24
$1202.37
$886.04
$1005.66
$1132.38
$1582.48
$2404.74
$1167.36
$1286.98
$1413.70
$1863.80
$1448.68
$1568.30
$1695.02
$2145.12
$1730.00
$1849.62
$1976.34
$2426.44
$724.34
$784.15
$847.51
$1072.56
$1005.66
$1065.47
$1128.83
$1353.88
$1286.98
$1346.79
$1410.15
$1635.20
$281.32

Plan: (HMO) Gym Acccess IND Platinum HMO 92

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$440.28
$499.71
$562.67
$786.33
$1194.91
$880.56
$999.42
$1125.34
$1572.66
$2389.82
$1160.14
$1279.00
$1404.92
$1852.24
$1439.72
$1558.58
$1684.50
$2131.82
$1719.30
$1838.16
$1964.08
$2411.40
$719.86
$779.29
$842.25
$1065.91
$999.44
$1058.87
$1121.83
$1345.49
$1279.02
$1338.45
$1401.41
$1625.07
$279.58

Blue Cross and Blue Shield of Florida

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

TTY: 1-800-955-8771

Plan: (EPO) BlueOptions Silver 1423

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$433.23
$491.72
$553.67
$773.75
$1175.79
$866.46
$983.44
$1107.34
$1547.50
$2351.58
$1141.56
$1258.54
$1382.44
$1822.60
$1416.66
$1533.64
$1657.54
$2097.70
$1691.76
$1808.74
$1932.64
$2372.80
$708.33
$766.82
$828.77
$1048.85
$983.43
$1041.92
$1103.87
$1323.95
$1258.53
$1317.02
$1378.97
$1599.05
$275.10

Plan: (EPO) BlueOptions Bronze 1419

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$352.36
$399.93
$450.32
$629.31
$956.31
$704.72
$799.86
$900.64
$1258.62
$1912.62
$928.47
$1023.61
$1124.39
$1482.37
$1152.22
$1247.36
$1348.14
$1706.12
$1375.97
$1471.11
$1571.89
$1929.87
$576.11
$623.68
$674.07
$853.06
$799.86
$847.43
$897.82
$1076.81
$1023.61
$1071.18
$1121.57
$1300.56
$223.75

Plan: (EPO) BlueOptions Silver 1431

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

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$468.56
$531.82
$598.82
$836.85
$1271.67
$937.12
$1063.64
$1197.64
$1673.70
$2543.34
$1234.66
$1361.18
$1495.18
$1971.24
$1532.20
$1658.72
$1792.72
$2268.78
$1829.74
$1956.26
$2090.26
$2566.32
$766.10
$829.36
$896.36
$1134.39
$1063.64
$1126.90
$1193.90
$1431.93
$1361.18
$1424.44
$1491.44
$1729.47
$297.54

Plan: (EPO) BlueOptions Platinum 1418

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$685.51
$778.05
$876.08
$1224.32
$1860.47
$1371.02
$1556.10
$1752.16
$2448.64
$3720.94
$1806.32
$1991.40
$2187.46
$2883.94
$2241.62
$2426.70
$2622.76
$3319.24
$2676.92
$2862.00
$3058.06
$3754.54
$1120.81
$1213.35
$1311.38
$1659.62
$1556.11
$1648.65
$1746.68
$2094.92
$1991.41
$2083.95
$2181.98
$2530.22
$435.30

Plan: (EPO) BlueOptions Platinum Premier 1418V

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$713.00
$809.26
$911.21
$1273.42
$1935.08
$1426.00
$1618.52
$1822.42
$2546.84
$3870.16
$1878.76
$2071.28
$2275.18
$2999.60
$2331.52
$2524.04
$2727.94
$3452.36
$2784.28
$2976.80
$3180.70
$3905.12
$1165.76
$1262.02
$1363.97
$1726.18
$1618.52
$1714.78
$1816.73
$2178.94
$2071.28
$2167.54
$2269.49
$2631.70
$452.76

Plan: (EPO) BlueOptions Bronze 1416

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$381.56
$433.07
$487.63
$681.47
$1035.55
$763.12
$866.14
$975.26
$1362.94
$2071.10
$1005.41
$1108.43
$1217.55
$1605.23
$1247.70
$1350.72
$1459.84
$1847.52
$1489.99
$1593.01
$1702.13
$2089.81
$623.85
$675.36
$729.92
$923.76
$866.14
$917.65
$972.21
$1166.05
$1108.43
$1159.94
$1214.50
$1408.34
$242.29

Plan: (EPO) BlueOptions Platinum 1424

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$706.77
$802.18
$903.25
$1262.29
$1918.17
$1413.54
$1604.36
$1806.50
$2524.58
$3836.34
$1862.34
$2053.16
$2255.30
$2973.38
$2311.14
$2501.96
$2704.10
$3422.18
$2759.94
$2950.76
$3152.90
$3870.98
$1155.57
$1250.98
$1352.05
$1711.09
$1604.37
$1699.78
$1800.85
$2159.89
$2053.17
$2148.58
$2249.65
$2608.69
$448.80

Plan: (EPO) BlueOptions Silver 1410

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

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$410.71
$466.16
$524.89
$733.53
$1114.67
$821.42
$932.32
$1049.78
$1467.06
$2229.34
$1082.22
$1193.12
$1310.58
$1727.86
$1343.02
$1453.92
$1571.38
$1988.66
$1603.82
$1714.72
$1832.18
$2249.46
$671.51
$726.96
$785.69
$994.33
$932.31
$987.76
$1046.49
$1255.13
$1193.11
$1248.56
$1307.29
$1515.93
$260.80

Plan: (EPO) BlueOptions Gold 1505

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$604.95
$686.62
$773.13
$1080.44
$1641.83
$1209.90
$1373.24
$1546.26
$2160.88
$3283.66
$1594.04
$1757.38
$1930.40
$2545.02
$1978.18
$2141.52
$2314.54
$2929.16
$2362.32
$2525.66
$2698.68
$3313.30
$989.09
$1070.76
$1157.27
$1464.58
$1373.23
$1454.90
$1541.41
$1848.72
$1757.37
$1839.04
$1925.55
$2232.86
$384.14

Plan: (EPO) BlueOptions Bronze (HSA) 1705

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$362.76
$411.73
$463.61
$647.89
$984.53
$725.52
$823.46
$927.22
$1295.78
$1969.06
$955.87
$1053.81
$1157.57
$1526.13
$1186.22
$1284.16
$1387.92
$1756.48
$1416.57
$1514.51
$1618.27
$1986.83
$593.11
$642.08
$693.96
$878.24
$823.46
$872.43
$924.31
$1108.59
$1053.81
$1102.78
$1154.66
$1338.94
$230.35

Plan: (EPO) BlueOptions Silver 1706S

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$455.01
$516.44
$581.50
$812.65
$1234.90
$910.02
$1032.88
$1163.00
$1625.30
$2469.80
$1198.95
$1321.81
$1451.93
$1914.23
$1487.88
$1610.74
$1740.86
$2203.16
$1776.81
$1899.67
$2029.79
$2492.09
$743.94
$805.37
$870.43
$1101.58
$1032.87
$1094.30
$1159.36
$1390.51
$1321.80
$1383.23
$1448.29
$1679.44
$288.93

Plan: (EPO) BlueOptions Bronze 1707S

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

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$356.82
$404.99
$456.02
$637.28
$968.41
$713.64
$809.98
$912.04
$1274.56
$1936.82
$940.22
$1036.56
$1138.62
$1501.14
$1166.80
$1263.14
$1365.20
$1727.72
$1393.38
$1489.72
$1591.78
$1954.30
$583.40
$631.57
$682.60
$863.86
$809.98
$858.15
$909.18
$1090.44
$1036.56
$1084.73
$1135.76
$1317.02
$226.58

Plan: (EPO) BlueOptions Gold 1708S

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

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $4,750 : Family: $9,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$588.51
$667.96
$752.12
$1051.08
$1597.22
$1177.02
$1335.92
$1504.24
$2102.16
$3194.44
$1550.72
$1709.62
$1877.94
$2475.86
$1924.42
$2083.32
$2251.64
$2849.56
$2298.12
$2457.02
$2625.34
$3223.26
$962.21
$1041.66
$1125.82
$1424.78
$1335.91
$1415.36
$1499.52
$1798.48
$1709.61
$1789.06
$1873.22
$2172.18
$373.70

Plan: (EPO) BlueSelect Silver 1456

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$324.74
$368.58
$415.02
$579.99
$881.34
$649.48
$737.16
$830.04
$1159.98
$1762.68
$855.69
$943.37
$1036.25
$1366.19
$1061.90
$1149.58
$1242.46
$1572.40
$1268.11
$1355.79
$1448.67
$1778.61
$530.95
$574.79
$621.23
$786.20
$737.16
$781.00
$827.44
$992.41
$943.37
$987.21
$1033.65
$1198.62
$206.21

Plan: (EPO) BlueSelect Bronze 1452

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$257.88
$292.69
$329.57
$460.57
$699.89
$515.76
$585.38
$659.14
$921.14
$1399.78
$679.51
$749.13
$822.89
$1084.89
$843.26
$912.88
$986.64
$1248.64
$1007.01
$1076.63
$1150.39
$1412.39
$421.63
$456.44
$493.32
$624.32
$585.38
$620.19
$657.07
$788.07
$749.13
$783.94
$820.82
$951.82
$163.75

Plan: (EPO) BlueSelect Silver 1464

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

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$356.94
$405.13
$456.17
$637.49
$968.74
$713.88
$810.26
$912.34
$1274.98
$1937.48
$940.54
$1036.92
$1139.00
$1501.64
$1167.20
$1263.58
$1365.66
$1728.30
$1393.86
$1490.24
$1592.32
$1954.96
$583.60
$631.79
$682.83
$864.15
$810.26
$858.45
$909.49
$1090.81
$1036.92
$1085.11
$1136.15
$1317.47
$226.66

Plan: (EPO) BlueSelect Platinum 1451

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$504.21
$572.28
$644.38
$900.52
$1368.43
$1008.42
$1144.56
$1288.76
$1801.04
$2736.86
$1328.59
$1464.73
$1608.93
$2121.21
$1648.76
$1784.90
$1929.10
$2441.38
$1968.93
$2105.07
$2249.27
$2761.55
$824.38
$892.45
$964.55
$1220.69
$1144.55
$1212.62
$1284.72
$1540.86
$1464.72
$1532.79
$1604.89
$1861.03
$320.17

Plan: (EPO) BlueSelect Platinum Premier 1451V

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$524.43
$595.23
$670.22
$936.63
$1423.30
$1048.86
$1190.46
$1340.44
$1873.26
$2846.60
$1381.87
$1523.47
$1673.45
$2206.27
$1714.88
$1856.48
$2006.46
$2539.28
$2047.89
$2189.49
$2339.47
$2872.29
$857.44
$928.24
$1003.23
$1269.64
$1190.45
$1261.25
$1336.24
$1602.65
$1523.46
$1594.26
$1669.25
$1935.66
$333.01

Plan: (EPO) BlueSelect Bronze 1449

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$282.19
$320.29
$360.64
$503.99
$765.86
$564.38
$640.58
$721.28
$1007.98
$1531.72
$743.57
$819.77
$900.47
$1187.17
$922.76
$998.96
$1079.66
$1366.36
$1101.95
$1178.15
$1258.85
$1545.55
$461.38
$499.48
$539.83
$683.18
$640.57
$678.67
$719.02
$862.37
$819.76
$857.86
$898.21
$1041.56
$179.19

Plan: (EPO) BlueSelect Platinum 1457

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$521.05
$591.39
$665.90
$930.60
$1414.13
$1042.10
$1182.78
$1331.80
$1861.20
$2828.26
$1372.97
$1513.65
$1662.67
$2192.07
$1703.84
$1844.52
$1993.54
$2522.94
$2034.71
$2175.39
$2324.41
$2853.81
$851.92
$922.26
$996.77
$1261.47
$1182.79
$1253.13
$1327.64
$1592.34
$1513.66
$1584.00
$1658.51
$1923.21
$330.87

Plan: (EPO) BlueSelect Gold 1738S

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

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $4,750 : Family: $9,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$452.70
$513.81
$578.55
$808.52
$1228.63
$905.40
$1027.62
$1157.10
$1617.04
$2457.26
$1192.86
$1315.08
$1444.56
$1904.50
$1480.32
$1602.54
$1732.02
$2191.96
$1767.78
$1890.00
$2019.48
$2479.42
$740.16
$801.27
$866.01
$1095.98
$1027.62
$1088.73
$1153.47
$1383.44
$1315.08
$1376.19
$1440.93
$1670.90
$287.46

Plan: (EPO) BlueSelect Silver 1443

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

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$307.06
$348.51
$392.42
$548.41
$833.36
$614.12
$697.02
$784.84
$1096.82
$1666.72
$809.10
$892.00
$979.82
$1291.80
$1004.08
$1086.98
$1174.80
$1486.78
$1199.06
$1281.96
$1369.78
$1681.76
$502.04
$543.49
$587.40
$743.39
$697.02
$738.47
$782.38
$938.37
$892.00
$933.45
$977.36
$1133.35
$194.98

Plan: (EPO) BlueSelect Gold 1535

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$464.94
$527.71
$594.19
$830.38
$1261.85
$929.88
$1055.42
$1188.38
$1660.76
$2523.70
$1225.12
$1350.66
$1483.62
$1956.00
$1520.36
$1645.90
$1778.86
$2251.24
$1815.60
$1941.14
$2074.10
$2546.48
$760.18
$822.95
$889.43
$1125.62
$1055.42
$1118.19
$1184.67
$1420.86
$1350.66
$1413.43
$1479.91
$1716.10
$295.24

Plan: (EPO) BlueSelect Bronze (HSA) 1735

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$265.53
$301.38
$339.35
$474.24
$720.65
$531.06
$602.76
$678.70
$948.48
$1441.30
$699.67
$771.37
$847.31
$1117.09
$868.28
$939.98
$1015.92
$1285.70
$1036.89
$1108.59
$1184.53
$1454.31
$434.14
$469.99
$507.96
$642.85
$602.75
$638.60
$676.57
$811.46
$771.36
$807.21
$845.18
$980.07
$168.61

Plan: (EPO) BlueSelect Silver 1736S

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$346.46
$393.23
$442.78
$618.78
$940.29
$692.92
$786.46
$885.56
$1237.56
$1880.58
$912.92
$1006.46
$1105.56
$1457.56
$1132.92
$1226.46
$1325.56
$1677.56
$1352.92
$1446.46
$1545.56
$1897.56
$566.46
$613.23
$662.78
$838.78
$786.46
$833.23
$882.78
$1058.78
$1006.46
$1053.23
$1102.78
$1278.78
$220.00

Plan: (EPO) BlueSelect Bronze 1737S

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

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$263.53
$299.11
$336.79
$470.66
$715.22
$527.06
$598.22
$673.58
$941.32
$1430.44
$694.40
$765.56
$840.92
$1108.66
$861.74
$932.90
$1008.26
$1276.00
$1029.08
$1100.24
$1175.60
$1443.34
$430.87
$466.45
$504.13
$638.00
$598.21
$633.79
$671.47
$805.34
$765.55
$801.13
$838.81
$972.68
$167.34

Celtic Insurance Company

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169

TTY: 1-800-955-8770

Plan: (EPO) Ambetter Secure Care 3 (2017) with 3 Free PCP Visits

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$365.78
$415.15
$467.46
$653.27
$992.70
$731.56
$830.30
$934.92
$1306.54
$1985.40
$963.82
$1062.56
$1167.18
$1538.80
$1196.08
$1294.82
$1399.44
$1771.06
$1428.34
$1527.08
$1631.70
$2003.32
$598.04
$647.41
$699.72
$885.53
$830.30
$879.67
$931.98
$1117.79
$1062.56
$1111.93
$1164.24
$1350.05
$232.26

Plan: (EPO) Ambetter Balanced Care 1 (2017)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$279.85
$317.61
$357.63
$499.79
$759.48
$559.70
$635.22
$715.26
$999.58
$1518.96
$737.40
$812.92
$892.96
$1177.28
$915.10
$990.62
$1070.66
$1354.98
$1092.80
$1168.32
$1248.36
$1532.68
$457.55
$495.31
$535.33
$677.49
$635.25
$673.01
$713.03
$855.19
$812.95
$850.71
$890.73
$1032.89
$177.70

Plan: (EPO) Ambetter Balanced Care 2 (2017)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$275.44
$312.61
$352.00
$491.92
$747.52
$550.88
$625.22
$704.00
$983.84
$1495.04
$725.78
$800.12
$878.90
$1158.74
$900.68
$975.02
$1053.80
$1333.64
$1075.58
$1149.92
$1228.70
$1508.54
$450.34
$487.51
$526.90
$666.82
$625.24
$662.41
$701.80
$841.72
$800.14
$837.31
$876.70
$1016.62
$174.90

Plan: (EPO) Ambetter Balanced Care 10 (2017)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$294.72
$334.50
$376.64
$526.35
$799.84
$589.44
$669.00
$753.28
$1052.70
$1599.68
$776.58
$856.14
$940.42
$1239.84
$963.72
$1043.28
$1127.56
$1426.98
$1150.86
$1230.42
$1314.70
$1614.12
$481.86
$521.64
$563.78
$713.49
$669.00
$708.78
$750.92
$900.63
$856.14
$895.92
$938.06
$1087.77
$187.14

Plan: (EPO) Ambetter Essential Care 1 (2017)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$250.65
$284.48
$320.32
$447.65
$680.24
$501.30
$568.96
$640.64
$895.30
$1360.48
$660.46
$728.12
$799.80
$1054.46
$819.62
$887.28
$958.96
$1213.62
$978.78
$1046.44
$1118.12
$1372.78
$409.81
$443.64
$479.48
$606.81
$568.97
$602.80
$638.64
$765.97
$728.13
$761.96
$797.80
$925.13
$159.16

Plan: (EPO) Ambetter Balanced Care 3 (2017)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$293.89
$333.56
$375.58
$524.88
$797.60
$587.78
$667.12
$751.16
$1049.76
$1595.20
$774.40
$853.74
$937.78
$1236.38
$961.02
$1040.36
$1124.40
$1423.00
$1147.64
$1226.98
$1311.02
$1609.62
$480.51
$520.18
$562.20
$711.50
$667.13
$706.80
$748.82
$898.12
$853.75
$893.42
$935.44
$1084.74
$186.62

Plan: (EPO) Ambetter Balanced Care 4 (2017)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$266.35
$302.30
$340.38
$475.68
$722.85
$532.70
$604.60
$680.76
$951.36
$1445.70
$701.83
$773.73
$849.89
$1120.49
$870.96
$942.86
$1019.02
$1289.62
$1040.09
$1111.99
$1188.15
$1458.75
$435.48
$471.43
$509.51
$644.81
$604.61
$640.56
$678.64
$813.94
$773.74
$809.69
$847.77
$983.07
$169.13

Plan: (EPO) Ambetter Balanced Care 12 (2017)

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$298.85
$339.18
$381.92
$533.73
$811.06
$597.70
$678.36
$763.84
$1067.46
$1622.12
$787.46
$868.12
$953.60
$1257.22
$977.22
$1057.88
$1143.36
$1446.98
$1166.98
$1247.64
$1333.12
$1636.74
$488.61
$528.94
$571.68
$723.49
$678.37
$718.70
$761.44
$913.25
$868.13
$908.46
$951.20
$1103.01
$189.76

Plan: (EPO) Ambetter Balanced Care 1 (2017) + Vision

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$284.98
$323.44
$364.19
$508.95
$773.40
$569.96
$646.88
$728.38
$1017.90
$1546.80
$750.91
$827.83
$909.33
$1198.85
$931.86
$1008.78
$1090.28
$1379.80
$1112.81
$1189.73
$1271.23
$1560.75
$465.93
$504.39
$545.14
$689.90
$646.88
$685.34
$726.09
$870.85
$827.83
$866.29
$907.04
$1051.80
$180.95

Plan: (EPO) Ambetter Balanced Care 2 (2017) + Vision

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$280.49
$318.34
$358.45
$500.93
$761.22
$560.98
$636.68
$716.90
$1001.86
$1522.44
$739.08
$814.78
$895.00
$1179.96
$917.18
$992.88
$1073.10
$1358.06
$1095.28
$1170.98
$1251.20
$1536.16
$458.59
$496.44
$536.55
$679.03
$636.69
$674.54
$714.65
$857.13
$814.79
$852.64
$892.75
$1035.23
$178.10

Plan: (EPO) Ambetter Balanced Care 10 (2017) + Vision

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$300.12
$340.63
$383.54
$536.00
$814.50
$600.24
$681.26
$767.08
$1072.00
$1629.00
$790.81
$871.83
$957.65
$1262.57
$981.38
$1062.40
$1148.22
$1453.14
$1171.95
$1252.97
$1338.79
$1643.71
$490.69
$531.20
$574.11
$726.57
$681.26
$721.77
$764.68
$917.14
$871.83
$912.34
$955.25
$1107.71
$190.57

Plan: (EPO) Ambetter Essential Care 1 (2017) + Vision

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$255.25
$289.69
$326.19
$455.85
$692.71
$510.50
$579.38
$652.38
$911.70
$1385.42
$672.57
$741.45
$814.45
$1073.77
$834.64
$903.52
$976.52
$1235.84
$996.71
$1065.59
$1138.59
$1397.91
$417.32
$451.76
$488.26
$617.92
$579.39
$613.83
$650.33
$779.99
$741.46
$775.90
$812.40
$942.06
$162.07

Plan: (EPO) Ambetter Balanced Care 3 (2017) + Vision

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$299.28
$339.67
$382.47
$534.50
$812.22
$598.56
$679.34
$764.94
$1069.00
$1624.44
$788.60
$869.38
$954.98
$1259.04
$978.64
$1059.42
$1145.02
$1449.08
$1168.68
$1249.46
$1335.06
$1639.12
$489.32
$529.71
$572.51
$724.54
$679.36
$719.75
$762.55
$914.58
$869.40
$909.79
$952.59
$1104.62
$190.04

Plan: (EPO) Ambetter Balanced Care 1 (2017) + Vision + Adult Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$295.13
$334.97
$377.17
$527.09
$800.97
$590.26
$669.94
$754.34
$1054.18
$1601.94
$777.66
$857.34
$941.74
$1241.58
$965.06
$1044.74
$1129.14
$1428.98
$1152.46
$1232.14
$1316.54
$1616.38
$482.53
$522.37
$564.57
$714.49
$669.93
$709.77
$751.97
$901.89
$857.33
$897.17
$939.37
$1089.29
$187.40

Plan: (EPO) Ambetter Balanced Care 2 (2017) + Vision + Adult Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$290.49
$329.69
$371.23
$518.79
$788.35
$580.98
$659.38
$742.46
$1037.58
$1576.70
$765.43
$843.83
$926.91
$1222.03
$949.88
$1028.28
$1111.36
$1406.48
$1134.33
$1212.73
$1295.81
$1590.93
$474.94
$514.14
$555.68
$703.24
$659.39
$698.59
$740.13
$887.69
$843.84
$883.04
$924.58
$1072.14
$184.45

Plan: (EPO) Ambetter Balanced Care 10 (2017) + Vision + Adult Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$310.82
$352.77
$397.21
$555.11
$843.54
$621.64
$705.54
$794.42
$1110.22
$1687.08
$819.00
$902.90
$991.78
$1307.58
$1016.36
$1100.26
$1189.14
$1504.94
$1213.72
$1297.62
$1386.50
$1702.30
$508.18
$550.13
$594.57
$752.47
$705.54
$747.49
$791.93
$949.83
$902.90
$944.85
$989.29
$1147.19
$197.36

Plan: (EPO) Ambetter Essential Care 1 (2017) + Vision + Adult Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$264.34
$300.02
$337.82
$472.10
$717.40
$528.68
$600.04
$675.64
$944.20
$1434.80
$696.53
$767.89
$843.49
$1112.05
$864.38
$935.74
$1011.34
$1279.90
$1032.23
$1103.59
$1179.19
$1447.75
$432.19
$467.87
$505.67
$639.95
$600.04
$635.72
$673.52
$807.80
$767.89
$803.57
$841.37
$975.65
$167.85

Plan: (EPO) Ambetter Balanced Care 3 (2017) + Vision + Adult Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-687-1169 - Provider Directory for This Plan: (Celtic Insurance Company)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$309.95
$351.78
$396.10
$553.55
$841.17
$619.90
$703.56
$792.20
$1107.10
$1682.34
$816.71
$900.37
$989.01
$1303.91
$1013.52
$1097.18
$1185.82
$1500.72
$1210.33
$1293.99
$1382.63
$1697.53
$506.76
$548.59
$592.91
$750.36
$703.57
$745.40
$789.72
$947.17
$900.38
$942.21
$986.53
$1143.98
$196.81

Health Options, Inc.

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

TTY: 1-800-955-8771

Plan: (HMO) myBlue Bronze 1601

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$268.08
$304.27
$342.61
$478.79
$727.57
$536.16
$608.54
$685.22
$957.58
$1455.14
$706.39
$778.77
$855.45
$1127.81
$876.62
$949.00
$1025.68
$1298.04
$1046.85
$1119.23
$1195.91
$1468.27
$438.31
$474.50
$512.84
$649.02
$608.54
$644.73
$683.07
$819.25
$778.77
$814.96
$853.30
$989.48
$170.23

Plan: (HMO) myBlue Bronze 1602

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$243.85
$276.77
$311.64
$435.52
$661.81
$487.70
$553.54
$623.28
$871.04
$1323.62
$642.54
$708.38
$778.12
$1025.88
$797.38
$863.22
$932.96
$1180.72
$952.22
$1018.06
$1087.80
$1335.56
$398.69
$431.61
$466.48
$590.36
$553.53
$586.45
$621.32
$745.20
$708.37
$741.29
$776.16
$900.04
$154.84

Plan: (HMO) myBlue Silver 1603

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$289.04
$328.06
$369.39
$516.23
$784.45
$578.08
$656.12
$738.78
$1032.46
$1568.90
$761.62
$839.66
$922.32
$1216.00
$945.16
$1023.20
$1105.86
$1399.54
$1128.70
$1206.74
$1289.40
$1583.08
$472.58
$511.60
$552.93
$699.77
$656.12
$695.14
$736.47
$883.31
$839.66
$878.68
$920.01
$1066.85
$183.54

Plan: (HMO) myBlue Silver 1604

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

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$271.30
$307.93
$346.72
$484.54
$736.31
$542.60
$615.86
$693.44
$969.08
$1472.62
$714.88
$788.14
$865.72
$1141.36
$887.16
$960.42
$1038.00
$1313.64
$1059.44
$1132.70
$1210.28
$1485.92
$443.58
$480.21
$519.00
$656.82
$615.86
$652.49
$691.28
$829.10
$788.14
$824.77
$863.56
$1001.38
$172.28

Plan: (HMO) myBlue Gold 1605

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

Deductible: Individual: $940 : Family: $1,880
Out of Pocket Maximum per year: Individual: $4,700 : Family: $9,400

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$351.41
$398.85
$449.10
$627.62
$953.73
$702.82
$797.70
$898.20
$1255.24
$1907.46
$925.97
$1020.85
$1121.35
$1478.39
$1149.12
$1244.00
$1344.50
$1701.54
$1372.27
$1467.15
$1567.65
$1924.69
$574.56
$622.00
$672.25
$850.77
$797.71
$845.15
$895.40
$1073.92
$1020.86
$1068.30
$1118.55
$1297.07
$223.15

Plan: (HMO) myBlue Silver 1710

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

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$318.42
$361.41
$406.94
$568.70
$864.19
$636.84
$722.82
$813.88
$1137.40
$1728.38
$839.04
$925.02
$1016.08
$1339.60
$1041.24
$1127.22
$1218.28
$1541.80
$1243.44
$1329.42
$1420.48
$1744.00
$520.62
$563.61
$609.14
$770.90
$722.82
$765.81
$811.34
$973.10
$925.02
$968.01
$1013.54
$1175.30
$202.20

Plan: (HMO) myBlue Bronze 1711S

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

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$247.97
$281.45
$316.91
$442.87
$672.99
$495.94
$562.90
$633.82
$885.74
$1345.98
$653.40
$720.36
$791.28
$1043.20
$810.86
$877.82
$948.74
$1200.66
$968.32
$1035.28
$1106.20
$1358.12
$405.43
$438.91
$474.37
$600.33
$562.89
$596.37
$631.83
$757.79
$720.35
$753.83
$789.29
$915.25
$157.46
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Florida Health Care Plan, Inc.

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

TTY: 1-800-955-8771

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

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

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $4,750 : Family: $9,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$374.34
$424.87
$478.40
$668.56
$1015.95
$748.68
$849.74
$956.80
$1337.12
$2031.90
$986.38
$1087.44
$1194.50
$1574.82
$1224.08
$1325.14
$1432.20
$1812.52
$1461.78
$1562.84
$1669.90
$2050.22
$612.04
$662.57
$716.10
$906.26
$849.74
$900.27
$953.80
$1143.96
$1087.44
$1137.97
$1191.50
$1381.66
$237.70
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Health Options, Inc.

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

TTY: 1-800-955-8771

Plan: (HMO) myBlue Silver 1712S

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$304.40
$345.49
$389.02
$543.66
$826.14
$608.80
$690.98
$778.04
$1087.32
$1652.28
$802.09
$884.27
$971.33
$1280.61
$995.38
$1077.56
$1164.62
$1473.90
$1188.67
$1270.85
$1357.91
$1667.19
$497.69
$538.78
$582.31
$736.95
$690.98
$732.07
$775.60
$930.24
$884.27
$925.36
$968.89
$1123.53
$193.29
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Florida Health Care Plan, Inc.

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

TTY: 1-800-955-8771

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$216.01
$245.17
$276.06
$385.79
$586.25
$432.02
$490.34
$552.12
$771.58
$1172.50
$569.19
$627.51
$689.29
$908.75
$706.36
$764.68
$826.46
$1045.92
$843.53
$901.85
$963.63
$1183.09
$353.18
$382.34
$413.23
$522.96
$490.35
$519.51
$550.40
$660.13
$627.52
$656.68
$687.57
$797.30
$137.17

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$237.61
$269.69
$303.67
$424.38
$644.89
$475.22
$539.38
$607.34
$848.76
$1289.78
$626.11
$690.27
$758.23
$999.65
$777.00
$841.16
$909.12
$1150.54
$927.89
$992.05
$1060.01
$1301.43
$388.50
$420.58
$454.56
$575.27
$539.39
$571.47
$605.45
$726.16
$690.28
$722.36
$756.34
$877.05
$150.89

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$307.08
$348.54
$392.45
$548.45
$833.42
$614.16
$697.08
$784.90
$1096.90
$1666.84
$809.16
$892.08
$979.90
$1291.90
$1004.16
$1087.08
$1174.90
$1486.90
$1199.16
$1282.08
$1369.90
$1681.90
$502.08
$543.54
$587.45
$743.45
$697.08
$738.54
$782.45
$938.45
$892.08
$933.54
$977.45
$1133.45
$195.00

Plan: (HMO) IND Essential Plus Bronze HMO 41

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$231.15
$262.36
$295.41
$412.84
$627.35
$462.30
$524.72
$590.82
$825.68
$1254.70
$609.08
$671.50
$737.60
$972.46
$755.86
$818.28
$884.38
$1119.24
$902.64
$965.06
$1031.16
$1266.02
$377.93
$409.14
$442.19
$559.62
$524.71
$555.92
$588.97
$706.40
$671.49
$702.70
$735.75
$853.18
$146.78

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$337.04
$382.54
$430.73
$601.95
$914.72
$674.08
$765.08
$861.46
$1203.90
$1829.44
$888.10
$979.10
$1075.48
$1417.92
$1102.12
$1193.12
$1289.50
$1631.94
$1316.14
$1407.14
$1503.52
$1845.96
$551.06
$596.56
$644.75
$815.97
$765.08
$810.58
$858.77
$1029.99
$979.10
$1024.60
$1072.79
$1244.01
$214.02

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$260.71
$295.90
$333.19
$465.63
$707.56
$521.42
$591.80
$666.38
$931.26
$1415.12
$686.97
$757.35
$831.93
$1096.81
$852.52
$922.90
$997.48
$1262.36
$1018.07
$1088.45
$1163.03
$1427.91
$426.26
$461.45
$498.74
$631.18
$591.81
$627.00
$664.29
$796.73
$757.36
$792.55
$829.84
$962.28
$165.55

Plan: (HMO) Gym Access IND Platinum HMO 4000

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$443.41
$503.27
$566.68
$791.93
$1203.42
$886.82
$1006.54
$1133.36
$1583.86
$2406.84
$1168.39
$1288.11
$1414.93
$1865.43
$1449.96
$1569.68
$1696.50
$2147.00
$1731.53
$1851.25
$1978.07
$2428.57
$724.98
$784.84
$848.25
$1073.50
$1006.55
$1066.41
$1129.82
$1355.07
$1288.12
$1347.98
$1411.39
$1636.64
$281.57

Plan: (POS) Gym Access Platinum POS 4000

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$489.34
$555.40
$625.38
$873.97
$1328.08
$978.68
$1110.80
$1250.76
$1747.94
$2656.16
$1289.41
$1421.53
$1561.49
$2058.67
$1600.14
$1732.26
$1872.22
$2369.40
$1910.87
$2042.99
$2182.95
$2680.13
$800.07
$866.13
$936.11
$1184.70
$1110.80
$1176.86
$1246.84
$1495.43
$1421.53
$1487.59
$1557.57
$1806.16
$310.73

Plan: (HMO) Gym Access IND Gold HMO 5500

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$382.92
$434.61
$489.37
$683.89
$1039.24
$765.84
$869.22
$978.74
$1367.78
$2078.48
$1008.99
$1112.37
$1221.89
$1610.93
$1252.14
$1355.52
$1465.04
$1854.08
$1495.29
$1598.67
$1708.19
$2097.23
$626.07
$677.76
$732.52
$927.04
$869.22
$920.91
$975.67
$1170.19
$1112.37
$1164.06
$1218.82
$1413.34
$243.15

Plan: (POS) Gym Access IND Gold POS 5500

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$421.67
$478.60
$538.90
$753.11
$1144.42
$843.34
$957.20
$1077.80
$1506.22
$2288.84
$1111.10
$1224.96
$1345.56
$1773.98
$1378.86
$1492.72
$1613.32
$2041.74
$1646.62
$1760.48
$1881.08
$2309.50
$689.43
$746.36
$806.66
$1020.87
$957.19
$1014.12
$1074.42
$1288.63
$1224.95
$1281.88
$1342.18
$1556.39
$267.76

Plan: (HMO) Gym Access IND Silver HMO 6400

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$332.48
$377.37
$424.91
$593.81
$902.36
$664.96
$754.74
$849.82
$1187.62
$1804.72
$876.09
$965.87
$1060.95
$1398.75
$1087.22
$1177.00
$1272.08
$1609.88
$1298.35
$1388.13
$1483.21
$1821.01
$543.61
$588.50
$636.04
$804.94
$754.74
$799.63
$847.17
$1016.07
$965.87
$1010.76
$1058.30
$1227.20
$211.13

Plan: (HMO) Gym Access IND Silver HMO 6600

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$308.42
$350.06
$394.16
$550.84
$837.05
$616.84
$700.12
$788.32
$1101.68
$1674.10
$812.69
$895.97
$984.17
$1297.53
$1008.54
$1091.82
$1180.02
$1493.38
$1204.39
$1287.67
$1375.87
$1689.23
$504.27
$545.91
$590.01
$746.69
$700.12
$741.76
$785.86
$942.54
$895.97
$937.61
$981.71
$1138.39
$195.85

Plan: (HMO) IND Gold HMO 4500

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$343.16
$389.49
$438.56
$612.89
$931.34
$686.32
$778.98
$877.12
$1225.78
$1862.68
$904.23
$996.89
$1095.03
$1443.69
$1122.14
$1214.80
$1312.94
$1661.60
$1340.05
$1432.71
$1530.85
$1879.51
$561.07
$607.40
$656.47
$830.80
$778.98
$825.31
$874.38
$1048.71
$996.89
$1043.22
$1092.29
$1266.62
$217.91

Plan: (HMO) Gym Access IND Bronze HMO HSA 5500/6550

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

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$240.33
$272.78
$307.15
$429.23
$652.26
$480.66
$545.56
$614.30
$858.46
$1304.52
$633.27
$698.17
$766.91
$1011.07
$785.88
$850.78
$919.52
$1163.68
$938.49
$1003.39
$1072.13
$1316.29
$392.94
$425.39
$459.76
$581.84
$545.55
$578.00
$612.37
$734.45
$698.16
$730.61
$764.98
$887.06
$152.61

Plan: (HMO) Gym Access IND Bronze HMO HSA 6000/6550

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

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$240.91
$273.43
$307.88
$430.27
$653.83
$481.82
$546.86
$615.76
$860.54
$1307.66
$634.80
$699.84
$768.74
$1013.52
$787.78
$852.82
$921.72
$1166.50
$940.76
$1005.80
$1074.70
$1319.48
$393.89
$426.41
$460.86
$583.25
$546.87
$579.39
$613.84
$736.23
$699.85
$732.37
$766.82
$889.21
$152.98

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

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

Deductible: Individual: $6,700 : Family: $13,400
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$248.70
$282.28
$317.84
$444.19
$674.98
$497.40
$564.56
$635.68
$888.38
$1349.96
$655.33
$722.49
$793.61
$1046.31
$813.26
$880.42
$951.54
$1204.24
$971.19
$1038.35
$1109.47
$1362.17
$406.63
$440.21
$475.77
$602.12
$564.56
$598.14
$633.70
$760.05
$722.49
$756.07
$791.63
$917.98
$157.93

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

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

Deductible: Individual: $6,700 : Family: $13,400
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$273.58
$310.51
$349.63
$488.61
$742.49
$547.16
$621.02
$699.26
$977.22
$1484.98
$720.88
$794.74
$872.98
$1150.94
$894.60
$968.46
$1046.70
$1324.66
$1068.32
$1142.18
$1220.42
$1498.38
$447.30
$484.23
$523.35
$662.33
$621.02
$657.95
$697.07
$836.05
$794.74
$831.67
$870.79
$1009.77
$173.72

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$300.69
$341.29
$384.29
$537.04
$816.08
$601.38
$682.58
$768.58
$1074.08
$1632.16
$792.32
$873.52
$959.52
$1265.02
$983.26
$1064.46
$1150.46
$1455.96
$1174.20
$1255.40
$1341.40
$1646.90
$491.63
$532.23
$575.23
$727.98
$682.57
$723.17
$766.17
$918.92
$873.51
$914.11
$957.11
$1109.86
$190.94

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$325.36
$369.28
$415.80
$581.08
$883.01
$650.72
$738.56
$831.60
$1162.16
$1766.02
$857.32
$945.16
$1038.20
$1368.76
$1063.92
$1151.76
$1244.80
$1575.36
$1270.52
$1358.36
$1451.40
$1781.96
$531.96
$575.88
$622.40
$787.68
$738.56
$782.48
$829.00
$994.28
$945.16
$989.08
$1035.60
$1200.88
$206.60

Plan: (HMO) IND Silver HMO BC 7741

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

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$272.89
$309.73
$348.75
$487.38
$740.61
$545.78
$619.46
$697.50
$974.76
$1481.22
$719.06
$792.74
$870.78
$1148.04
$892.34
$966.02
$1044.06
$1321.32
$1065.62
$1139.30
$1217.34
$1494.60
$446.17
$483.01
$522.03
$660.66
$619.45
$656.29
$695.31
$833.94
$792.73
$829.57
$868.59
$1007.22
$173.28

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

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

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$303.95
$344.99
$388.45
$542.86
$824.93
$607.90
$689.98
$776.90
$1085.72
$1649.86
$800.91
$882.99
$969.91
$1278.73
$993.92
$1076.00
$1162.92
$1471.74
$1186.93
$1269.01
$1355.93
$1664.75
$496.96
$538.00
$581.46
$735.87
$689.97
$731.01
$774.47
$928.88
$882.98
$924.02
$967.48
$1121.89
$193.01

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

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

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $3,200 : Family: $6,400

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$419.01
$475.58
$535.50
$748.35
$1137.19
$838.02
$951.16
$1071.00
$1496.70
$2274.38
$1104.09
$1217.23
$1337.07
$1762.77
$1370.16
$1483.30
$1603.14
$2028.84
$1636.23
$1749.37
$1869.21
$2294.91
$685.08
$741.65
$801.57
$1014.42
$951.15
$1007.72
$1067.64
$1280.49
$1217.22
$1273.79
$1333.71
$1546.56
$266.07

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

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

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $3,200 : Family: $6,400

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$463.74
$526.35
$592.66
$828.24
$1258.60
$927.48
$1052.70
$1185.32
$1656.48
$2517.20
$1221.96
$1347.18
$1479.80
$1950.96
$1516.44
$1641.66
$1774.28
$2245.44
$1810.92
$1936.14
$2068.76
$2539.92
$758.22
$820.83
$887.14
$1122.72
$1052.70
$1115.31
$1181.62
$1417.20
$1347.18
$1409.79
$1476.10
$1711.68
$294.48

Plan: (HMO) IND Platinum HMO BC 5841

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$424.92
$482.28
$543.05
$758.91
$1153.23
$849.84
$964.56
$1086.10
$1517.82
$2306.46
$1119.66
$1234.38
$1355.92
$1787.64
$1389.48
$1504.20
$1625.74
$2057.46
$1659.30
$1774.02
$1895.56
$2327.28
$694.74
$752.10
$812.87
$1028.73
$964.56
$1021.92
$1082.69
$1298.55
$1234.38
$1291.74
$1352.51
$1568.37
$269.82

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$475.29
$539.45
$607.42
$848.86
$1289.93
$950.58
$1078.90
$1214.84
$1697.72
$2579.86
$1252.39
$1380.71
$1516.65
$1999.53
$1554.20
$1682.52
$1818.46
$2301.34
$1856.01
$1984.33
$2120.27
$2603.15
$777.10
$841.26
$909.23
$1150.67
$1078.91
$1143.07
$1211.04
$1452.48
$1380.72
$1444.88
$1512.85
$1754.29
$301.81

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$451.94
$512.96
$577.58
$807.17
$1226.58
$903.88
$1025.92
$1155.16
$1614.34
$2453.16
$1190.86
$1312.90
$1442.14
$1901.32
$1477.84
$1599.88
$1729.12
$2188.30
$1764.82
$1886.86
$2016.10
$2475.28
$738.92
$799.94
$864.56
$1094.15
$1025.90
$1086.92
$1151.54
$1381.13
$1312.88
$1373.90
$1438.52
$1668.11
$286.98

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

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

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

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$499.52
$566.96
$638.39
$892.15
$1355.71
$999.04
$1133.92
$1276.78
$1784.30
$2711.42
$1316.24
$1451.12
$1593.98
$2101.50
$1633.44
$1768.32
$1911.18
$2418.70
$1950.64
$2085.52
$2228.38
$2735.90
$816.72
$884.16
$955.59
$1209.35
$1133.92
$1201.36
$1272.79
$1526.55
$1451.12
$1518.56
$1589.99
$1843.75
$317.20

Plan: (HMO) IND Bronze Standardized HMO

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

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$231.98
$263.30
$296.47
$414.32
$629.59
$463.96
$526.60
$592.94
$828.64
$1259.18
$611.27
$673.91
$740.25
$975.95
$758.58
$821.22
$887.56
$1123.26
$905.89
$968.53
$1034.87
$1270.57
$379.29
$410.61
$443.78
$561.63
$526.60
$557.92
$591.09
$708.94
$673.91
$705.23
$738.40
$856.25
$147.31

Plan: (HMO) IND Silver Standardized HMO 1

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

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$303.96
$344.99
$388.46
$542.87
$824.95
$607.92
$689.98
$776.92
$1085.74
$1649.90
$800.93
$882.99
$969.93
$1278.75
$993.94
$1076.00
$1162.94
$1471.76
$1186.95
$1269.01
$1355.95
$1664.77
$496.97
$538.00
$581.47
$735.88
$689.98
$731.01
$774.48
$928.89
$882.99
$924.02
$967.49
$1121.90
$193.01