justice fist holding scales LegalConsumer.com
Empowering Consumers Since 2006
Obamacare
☰
Obamacare by State
Obamacare Guide
Search
Help
You are viewing information for Knox County, NE

Obamacare 2023 Rates for Knox County

Obamacare > Rates > Nebraska > Knox County

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

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

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

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

Obamacare Providers, 74 Plans and 2023 Rates for Knox County, Nebraska

Below, you’ll find a summary of the 74 plans for Knox County, Nebraska and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

ADVERTISEMENT

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-833-7352
Toc - Plan #1 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Copay ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$474.97
$539.07
$606.99
$848.27
$1,289.03 		$838.31
$902.41
$970.33
$1,211.61 		$1,201.65
$1,265.75
$1,333.67
$1,574.95 		$1,564.99
$1,629.09
$1,697.01
$1,938.29 		$363.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$949.94
$1,078.14
$1,213.98
$1,696.54
$2,578.06 		$1,313.28
$1,441.48
$1,577.32
$2,059.88 		$1,676.62
$1,804.82
$1,940.66
$2,423.22 		$2,039.96
$2,168.16
$2,304.00
$2,786.56 		$363.34
Toc - Plan #2 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Copay + Dental Reimbursement ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$499.19
$566.57
$637.95
$891.53
$1,354.77 		$881.06
$948.44
$1,019.82
$1,273.40 		$1,262.93
$1,330.31
$1,401.69
$1,655.27 		$1,644.80
$1,712.18
$1,783.56
$2,037.14 		$381.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$998.38
$1,133.14
$1,275.90
$1,783.06
$2,709.54 		$1,380.25
$1,515.01
$1,657.77
$2,164.93 		$1,762.12
$1,896.88
$2,039.64
$2,546.80 		$2,143.99
$2,278.75
$2,421.51
$2,928.67 		$381.87
Toc - Plan #3 Medica
Expanded Bronze

(EPO) Medica Insure Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$556.11
$631.17
$710.70
$993.20
$1,509.26 		$981.53
$1,056.59
$1,136.12
$1,418.62 		$1,406.95
$1,482.01
$1,561.54
$1,844.04 		$1,832.37
$1,907.43
$1,986.96
$2,269.46 		$425.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,112.22
$1,262.34
$1,421.40
$1,986.40
$3,018.52 		$1,537.64
$1,687.76
$1,846.82
$2,411.82 		$1,963.06
$2,113.18
$2,272.24
$2,837.24 		$2,388.48
$2,538.60
$2,697.66
$3,262.66 		$425.42
Toc - Plan #4 Medica
Catastrophic

(EPO) Medica Insure Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$353.18
$400.85
$451.36
$630.77
$958.52 		$623.36
$671.03
$721.54
$900.95 		$893.54
$941.21
$991.72
$1,171.13 		$1,163.72
$1,211.39
$1,261.90
$1,441.31 		$270.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.36
$801.70
$902.72
$1,261.54
$1,917.04 		$976.54
$1,071.88
$1,172.90
$1,531.72 		$1,246.72
$1,342.06
$1,443.08
$1,801.90 		$1,516.90
$1,612.24
$1,713.26
$2,072.08 		$270.18
Toc - Plan #5 Medica
Gold

(EPO) Medica Insure Gold Share ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$8,450 $16,900 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 		$638.49
$724.68
$815.98
$1,140.33
$1,732.84 		$1,126.93
$1,213.12
$1,304.42
$1,628.77 		$1,615.37
$1,701.56
$1,792.86
$2,117.21 		$2,103.81
$2,190.00
$2,281.30
$2,605.65 		$488.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,276.98
$1,449.36
$1,631.96
$2,280.66
$3,465.68 		$1,765.42
$1,937.80
$2,120.40
$2,769.10 		$2,253.86
$2,426.24
$2,608.84
$3,257.54 		$2,742.30
$2,914.68
$3,097.28
$3,745.98 		$488.44
Toc - Plan #6 Medica
Silver

(EPO) Medica Insure Silver Share ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$660.96
$750.18
$844.70
$1,180.46
$1,793.82 		$1,166.59
$1,255.81
$1,350.33
$1,686.09 		$1,672.22
$1,761.44
$1,855.96
$2,191.72 		$2,177.85
$2,267.07
$2,361.59
$2,697.35 		$505.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,321.92
$1,500.36
$1,689.40
$2,360.92
$3,587.64 		$1,827.55
$2,005.99
$2,195.03
$2,866.55 		$2,333.18
$2,511.62
$2,700.66
$3,372.18 		$2,838.81
$3,017.25
$3,206.29
$3,877.81 		$505.63
Toc - Plan #7 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$486.36
$552.01
$621.56
$868.62
$1,319.96 		$858.42
$924.07
$993.62
$1,240.68 		$1,230.48
$1,296.13
$1,365.68
$1,612.74 		$1,602.54
$1,668.19
$1,737.74
$1,984.80 		$372.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$972.72
$1,104.02
$1,243.12
$1,737.24
$2,639.92 		$1,344.78
$1,476.08
$1,615.18
$2,109.30 		$1,716.84
$1,848.14
$1,987.24
$2,481.36 		$2,088.90
$2,220.20
$2,359.30
$2,853.42 		$372.06
Toc - Plan #8 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Copay $0 PCP Office Visits ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$483.76
$549.05
$618.23
$863.97
$1,312.89 		$853.83
$919.12
$988.30
$1,234.04 		$1,223.90
$1,289.19
$1,358.37
$1,604.11 		$1,593.97
$1,659.26
$1,728.44
$1,974.18 		$370.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$967.52
$1,098.10
$1,236.46
$1,727.94
$2,625.78 		$1,337.59
$1,468.17
$1,606.53
$2,098.01 		$1,707.66
$1,838.24
$1,976.60
$2,468.08 		$2,077.73
$2,208.31
$2,346.67
$2,838.15 		$370.07
Toc - Plan #9 Medica
Gold

(EPO) Medica Insure Gold Copay $0 PCP Office Visits ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,450 $16,900 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 		$663.63
$753.21
$848.11
$1,185.23
$1,801.07 		$1,171.30
$1,260.88
$1,355.78
$1,692.90 		$1,678.97
$1,768.55
$1,863.45
$2,200.57 		$2,186.64
$2,276.22
$2,371.12
$2,708.24 		$507.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,327.26
$1,506.42
$1,696.22
$2,370.46
$3,602.14 		$1,834.93
$2,014.09
$2,203.89
$2,878.13 		$2,342.60
$2,521.76
$2,711.56
$3,385.80 		$2,850.27
$3,029.43
$3,219.23
$3,893.47 		$507.67
Toc - Plan #10 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Premier ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$480.96
$545.87
$614.65
$858.97
$1,305.29 		$848.88
$913.79
$982.57
$1,226.89 		$1,216.80
$1,281.71
$1,350.49
$1,594.81 		$1,584.72
$1,649.63
$1,718.41
$1,962.73 		$367.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$961.92
$1,091.74
$1,229.30
$1,717.94
$2,610.58 		$1,329.84
$1,459.66
$1,597.22
$2,085.86 		$1,697.76
$1,827.58
$1,965.14
$2,453.78 		$2,065.68
$2,195.50
$2,333.06
$2,821.70 		$367.92
Toc - Plan #11 Medica
Gold

(EPO) Medica Insure Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$658.62
$747.52
$841.70
$1,176.27
$1,787.46 		$1,162.45
$1,251.35
$1,345.53
$1,680.10 		$1,666.28
$1,755.18
$1,849.36
$2,183.93 		$2,170.11
$2,259.01
$2,353.19
$2,687.76 		$503.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,317.24
$1,495.04
$1,683.40
$2,352.54
$3,574.92 		$1,821.07
$1,998.87
$2,187.23
$2,856.37 		$2,324.90
$2,502.70
$2,691.06
$3,360.20 		$2,828.73
$3,006.53
$3,194.89
$3,864.03 		$503.83
Toc - Plan #12 Medica
Silver

(EPO) Medica Insure Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$633.28
$718.77
$809.32
$1,131.03
$1,718.70 		$1,117.73
$1,203.22
$1,293.77
$1,615.48 		$1,602.18
$1,687.67
$1,778.22
$2,099.93 		$2,086.63
$2,172.12
$2,262.67
$2,584.38 		$484.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,266.56
$1,437.54
$1,618.64
$2,262.06
$3,437.40 		$1,751.01
$1,921.99
$2,103.09
$2,746.51 		$2,235.46
$2,406.44
$2,587.54
$3,230.96 		$2,719.91
$2,890.89
$3,071.99
$3,715.41 		$484.45
Toc - Plan #13 Medica
Bronze

(EPO) Medica Insure Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$468.19
$531.39
$598.34
$836.17
$1,270.65 		$826.35
$889.55
$956.50
$1,194.33 		$1,184.51
$1,247.71
$1,314.66
$1,552.49 		$1,542.67
$1,605.87
$1,672.82
$1,910.65 		$358.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$936.38
$1,062.78
$1,196.68
$1,672.34
$2,541.30 		$1,294.54
$1,420.94
$1,554.84
$2,030.50 		$1,652.70
$1,779.10
$1,913.00
$2,388.66 		$2,010.86
$2,137.26
$2,271.16
$2,746.82 		$358.16
Toc - Plan #14 Medica
Gold

(EPO) Medica Insure Gold HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$6,000 $12,000 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 		$784.31
$890.18
$1,002.33
$1,400.76
$2,128.58 		$1,384.30
$1,490.17
$1,602.32
$2,000.75 		$1,984.29
$2,090.16
$2,202.31
$2,600.74 		$2,584.28
$2,690.15
$2,802.30
$3,200.73 		$599.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,568.62
$1,780.36
$2,004.66
$2,801.52
$4,257.16 		$2,168.61
$2,380.35
$2,604.65
$3,401.51 		$2,768.60
$2,980.34
$3,204.64
$4,001.50 		$3,368.59
$3,580.33
$3,804.63
$4,601.49 		$599.99

ADVERTISEMENT

Ambetter from Nebraska Total Care

Local: 1-833-890-0329 | Toll Free: 1-833-890-0329 | TTY: 1-833-890-0329
Toc - Plan #15 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.93
$409.65
$461.26
$644.61
$979.54 		$637.04
$685.76
$737.37
$920.72 		$913.15
$961.87
$1,013.48
$1,196.83 		$1,189.26
$1,237.98
$1,289.59
$1,472.94 		$276.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.86
$819.30
$922.52
$1,289.22
$1,959.08 		$997.97
$1,095.41
$1,198.63
$1,565.33 		$1,274.08
$1,371.52
$1,474.74
$1,841.44 		$1,550.19
$1,647.63
$1,750.85
$2,117.55 		$276.11
Toc - Plan #16 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.22
$399.75
$450.12
$629.04
$955.89 		$621.66
$669.19
$719.56
$898.48 		$891.10
$938.63
$989.00
$1,167.92 		$1,160.54
$1,208.07
$1,258.44
$1,437.36 		$269.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.44
$799.50
$900.24
$1,258.08
$1,911.78 		$973.88
$1,068.94
$1,169.68
$1,527.52 		$1,243.32
$1,338.38
$1,439.12
$1,796.96 		$1,512.76
$1,607.82
$1,708.56
$2,066.40 		$269.44
Toc - Plan #17 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$394.81
$448.10
$504.56
$705.11
$1,071.49 		$696.83
$750.12
$806.58
$1,007.13 		$998.85
$1,052.14
$1,108.60
$1,309.15 		$1,300.87
$1,354.16
$1,410.62
$1,611.17 		$302.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.62
$896.20
$1,009.12
$1,410.22
$2,142.98 		$1,091.64
$1,198.22
$1,311.14
$1,712.24 		$1,393.66
$1,500.24
$1,613.16
$2,014.26 		$1,695.68
$1,802.26
$1,915.18
$2,316.28 		$302.02
Toc - Plan #18 Ambetter from Nebraska Total Care
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$427.24
$484.90
$546.00
$763.03
$1,159.49 		$754.07
$811.73
$872.83
$1,089.86 		$1,080.90
$1,138.56
$1,199.66
$1,416.69 		$1,407.73
$1,465.39
$1,526.49
$1,743.52 		$326.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.48
$969.80
$1,092.00
$1,526.06
$2,318.98 		$1,181.31
$1,296.63
$1,418.83
$1,852.89 		$1,508.14
$1,623.46
$1,745.66
$2,179.72 		$1,834.97
$1,950.29
$2,072.49
$2,506.55 		$326.83
Toc - Plan #19 Ambetter from Nebraska Total Care
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$423.22
$480.34
$540.86
$755.86
$1,148.60 		$746.98
$804.10
$864.62
$1,079.62 		$1,070.74
$1,127.86
$1,188.38
$1,403.38 		$1,394.50
$1,451.62
$1,512.14
$1,727.14 		$323.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.44
$960.68
$1,081.72
$1,511.72
$2,297.20 		$1,170.20
$1,284.44
$1,405.48
$1,835.48 		$1,493.96
$1,608.20
$1,729.24
$2,159.24 		$1,817.72
$1,931.96
$2,053.00
$2,483.00 		$323.76
Toc - Plan #20 Ambetter from Nebraska Total Care
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$463.72
$526.31
$592.62
$828.19
$1,258.52 		$818.46
$881.05
$947.36
$1,182.93 		$1,173.20
$1,235.79
$1,302.10
$1,537.67 		$1,527.94
$1,590.53
$1,656.84
$1,892.41 		$354.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.44
$1,052.62
$1,185.24
$1,656.38
$2,517.04 		$1,282.18
$1,407.36
$1,539.98
$2,011.12 		$1,636.92
$1,762.10
$1,894.72
$2,365.86 		$1,991.66
$2,116.84
$2,249.46
$2,720.60 		$354.74
Toc - Plan #21 Ambetter from Nebraska Total Care
Bronze

(HMO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$314.96
$357.47
$402.51
$562.50
$854.78 		$555.90
$598.41
$643.45
$803.44 		$796.84
$839.35
$884.39
$1,044.38 		$1,037.78
$1,080.29
$1,125.33
$1,285.32 		$240.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.92
$714.94
$805.02
$1,125.00
$1,709.56 		$870.86
$955.88
$1,045.96
$1,365.94 		$1,111.80
$1,196.82
$1,286.90
$1,606.88 		$1,352.74
$1,437.76
$1,527.84
$1,847.82 		$240.94
Toc - Plan #22 Ambetter from Nebraska Total Care
Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$510.55
$579.46
$652.47
$911.82
$1,385.60 		$901.11
$970.02
$1,043.03
$1,302.38 		$1,291.67
$1,360.58
$1,433.59
$1,692.94 		$1,682.23
$1,751.14
$1,824.15
$2,083.50 		$390.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,021.10
$1,158.92
$1,304.94
$1,823.64
$2,771.20 		$1,411.66
$1,549.48
$1,695.50
$2,214.20 		$1,802.22
$1,940.04
$2,086.06
$2,604.76 		$2,192.78
$2,330.60
$2,476.62
$2,995.32 		$390.56
Toc - Plan #23 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345.04
$391.61
$440.95
$616.22
$936.41 		$608.99
$655.56
$704.90
$880.17 		$872.94
$919.51
$968.85
$1,144.12 		$1,136.89
$1,183.46
$1,232.80
$1,408.07 		$263.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.08
$783.22
$881.90
$1,232.44
$1,872.82 		$954.03
$1,047.17
$1,145.85
$1,496.39 		$1,217.98
$1,311.12
$1,409.80
$1,760.34 		$1,481.93
$1,575.07
$1,673.75
$2,024.29 		$263.95
Toc - Plan #24 Ambetter from Nebraska Total Care
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.41
$473.75
$533.44
$745.48
$1,132.83 		$736.72
$793.06
$852.75
$1,064.79 		$1,056.03
$1,112.37
$1,172.06
$1,384.10 		$1,375.34
$1,431.68
$1,491.37
$1,703.41 		$319.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.82
$947.50
$1,066.88
$1,490.96
$2,265.66 		$1,154.13
$1,266.81
$1,386.19
$1,810.27 		$1,473.44
$1,586.12
$1,705.50
$2,129.58 		$1,792.75
$1,905.43
$2,024.81
$2,448.89 		$319.31
Toc - Plan #25 Ambetter from Nebraska Total Care
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$439.41
$498.72
$561.56
$784.77
$1,192.54 		$775.55
$834.86
$897.70
$1,120.91 		$1,111.69
$1,171.00
$1,233.84
$1,457.05 		$1,447.83
$1,507.14
$1,569.98
$1,793.19 		$336.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.82
$997.44
$1,123.12
$1,569.54
$2,385.08 		$1,214.96
$1,333.58
$1,459.26
$1,905.68 		$1,551.10
$1,669.72
$1,795.40
$2,241.82 		$1,887.24
$2,005.86
$2,131.54
$2,577.96 		$336.14
Toc - Plan #26 Ambetter from Nebraska Total Care
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$329.53
$374.01
$421.13
$588.52
$894.32 		$581.61
$626.09
$673.21
$840.60 		$833.69
$878.17
$925.29
$1,092.68 		$1,085.77
$1,130.25
$1,177.37
$1,344.76 		$252.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.06
$748.02
$842.26
$1,177.04
$1,788.64 		$911.14
$1,000.10
$1,094.34
$1,429.12 		$1,163.22
$1,252.18
$1,346.42
$1,681.20 		$1,415.30
$1,504.26
$1,598.50
$1,933.28 		$252.08
Toc - Plan #27 Ambetter from Nebraska Total Care
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$419.72
$476.37
$536.39
$749.60
$1,139.09 		$740.80
$797.45
$857.47
$1,070.68 		$1,061.88
$1,118.53
$1,178.55
$1,391.76 		$1,382.96
$1,439.61
$1,499.63
$1,712.84 		$321.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.44
$952.74
$1,072.78
$1,499.20
$2,278.18 		$1,160.52
$1,273.82
$1,393.86
$1,820.28 		$1,481.60
$1,594.90
$1,714.94
$2,141.36 		$1,802.68
$1,915.98
$2,036.02
$2,462.44 		$321.08
Toc - Plan #28 Ambetter from Nebraska Total Care
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$421.73
$478.65
$538.95
$753.18
$1,144.54 		$744.34
$801.26
$861.56
$1,075.79 		$1,066.95
$1,123.87
$1,184.17
$1,398.40 		$1,389.56
$1,446.48
$1,506.78
$1,721.01 		$322.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.46
$957.30
$1,077.90
$1,506.36
$2,289.08 		$1,166.07
$1,279.91
$1,400.51
$1,828.97 		$1,488.68
$1,602.52
$1,723.12
$2,151.58 		$1,811.29
$1,925.13
$2,045.73
$2,474.19 		$322.61
Toc - Plan #29 Ambetter from Nebraska Total Care
Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$444.58
$504.59
$568.16
$794.01
$1,206.57 		$784.68
$844.69
$908.26
$1,134.11 		$1,124.78
$1,184.79
$1,248.36
$1,474.21 		$1,464.88
$1,524.89
$1,588.46
$1,814.31 		$340.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.16
$1,009.18
$1,136.32
$1,588.02
$2,413.14 		$1,229.26
$1,349.28
$1,476.42
$1,928.12 		$1,569.36
$1,689.38
$1,816.52
$2,268.22 		$1,909.46
$2,029.48
$2,156.62
$2,608.32 		$340.10
Toc - Plan #30 Ambetter from Nebraska Total Care
Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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 		$439.07
$498.33
$561.12
$784.16
$1,191.61 		$774.95
$834.21
$897.00
$1,120.04 		$1,110.83
$1,170.09
$1,232.88
$1,455.92 		$1,446.71
$1,505.97
$1,568.76
$1,791.80 		$335.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.14
$996.66
$1,122.24
$1,568.32
$2,383.22 		$1,214.02
$1,332.54
$1,458.12
$1,904.20 		$1,549.90
$1,668.42
$1,794.00
$2,240.08 		$1,885.78
$2,004.30
$2,129.88
$2,575.96 		$335.88
Toc - Plan #31 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375.75
$426.46
$480.19
$671.07
$1,019.75 		$663.19
$713.90
$767.63
$958.51 		$950.63
$1,001.34
$1,055.07
$1,245.95 		$1,238.07
$1,288.78
$1,342.51
$1,533.39 		$287.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.50
$852.92
$960.38
$1,342.14
$2,039.50 		$1,038.94
$1,140.36
$1,247.82
$1,629.58 		$1,326.38
$1,427.80
$1,535.26
$1,917.02 		$1,613.82
$1,715.24
$1,822.70
$2,204.46 		$287.44
Toc - Plan #32 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.67
$416.16
$468.60
$654.86
$995.12 		$647.17
$696.66
$749.10
$935.36 		$927.67
$977.16
$1,029.60
$1,215.86 		$1,208.17
$1,257.66
$1,310.10
$1,496.36 		$280.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.34
$832.32
$937.20
$1,309.72
$1,990.24 		$1,013.84
$1,112.82
$1,217.70
$1,590.22 		$1,294.34
$1,393.32
$1,498.20
$1,870.72 		$1,574.84
$1,673.82
$1,778.70
$2,151.22 		$280.50
Toc - Plan #33 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$411.02
$466.49
$525.27
$734.06
$1,115.47 		$725.44
$780.91
$839.69
$1,048.48 		$1,039.86
$1,095.33
$1,154.11
$1,362.90 		$1,354.28
$1,409.75
$1,468.53
$1,677.32 		$314.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.04
$932.98
$1,050.54
$1,468.12
$2,230.94 		$1,136.46
$1,247.40
$1,364.96
$1,782.54 		$1,450.88
$1,561.82
$1,679.38
$2,096.96 		$1,765.30
$1,876.24
$1,993.80
$2,411.38 		$314.42
Toc - Plan #34 Ambetter from Nebraska Total Care
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$444.77
$504.81
$568.41
$794.35
$1,207.09 		$785.01
$845.05
$908.65
$1,134.59 		$1,125.25
$1,185.29
$1,248.89
$1,474.83 		$1,465.49
$1,525.53
$1,589.13
$1,815.07 		$340.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.54
$1,009.62
$1,136.82
$1,588.70
$2,414.18 		$1,229.78
$1,349.86
$1,477.06
$1,928.94 		$1,570.02
$1,690.10
$1,817.30
$2,269.18 		$1,910.26
$2,030.34
$2,157.54
$2,609.42 		$340.24
Toc - Plan #35 Ambetter from Nebraska Total Care
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$482.76
$547.92
$616.95
$862.19
$1,310.17 		$852.06
$917.22
$986.25
$1,231.49 		$1,221.36
$1,286.52
$1,355.55
$1,600.79 		$1,590.66
$1,655.82
$1,724.85
$1,970.09 		$369.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$965.52
$1,095.84
$1,233.90
$1,724.38
$2,620.34 		$1,334.82
$1,465.14
$1,603.20
$2,093.68 		$1,704.12
$1,834.44
$1,972.50
$2,462.98 		$2,073.42
$2,203.74
$2,341.80
$2,832.28 		$369.30
Toc - Plan #36 Ambetter from Nebraska Total Care
Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$531.50
$603.24
$679.25
$949.25
$1,442.47 		$938.09
$1,009.83
$1,085.84
$1,355.84 		$1,344.68
$1,416.42
$1,492.43
$1,762.43 		$1,751.27
$1,823.01
$1,899.02
$2,169.02 		$406.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,063.00
$1,206.48
$1,358.50
$1,898.50
$2,884.94 		$1,469.59
$1,613.07
$1,765.09
$2,305.09 		$1,876.18
$2,019.66
$2,171.68
$2,711.68 		$2,282.77
$2,426.25
$2,578.27
$3,118.27 		$406.59
Toc - Plan #37 Ambetter from Nebraska Total Care
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$440.59
$500.06
$563.07
$786.88
$1,195.74 		$777.64
$837.11
$900.12
$1,123.93 		$1,114.69
$1,174.16
$1,237.17
$1,460.98 		$1,451.74
$1,511.21
$1,574.22
$1,798.03 		$337.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.18
$1,000.12
$1,126.14
$1,573.76
$2,391.48 		$1,218.23
$1,337.17
$1,463.19
$1,910.81 		$1,555.28
$1,674.22
$1,800.24
$2,247.86 		$1,892.33
$2,011.27
$2,137.29
$2,584.91 		$337.05
Toc - Plan #38 Ambetter from Nebraska Total Care
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$343.06
$389.36
$438.41
$612.68
$931.03 		$605.49
$651.79
$700.84
$875.11 		$867.92
$914.22
$963.27
$1,137.54 		$1,130.35
$1,176.65
$1,225.70
$1,399.97 		$262.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.12
$778.72
$876.82
$1,225.36
$1,862.06 		$948.55
$1,041.15
$1,139.25
$1,487.79 		$1,210.98
$1,303.58
$1,401.68
$1,750.22 		$1,473.41
$1,566.01
$1,664.11
$2,012.65 		$262.43
Toc - Plan #39 Ambetter from Nebraska Total Care
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$436.95
$495.92
$558.40
$780.37
$1,185.84 		$771.21
$830.18
$892.66
$1,114.63 		$1,105.47
$1,164.44
$1,226.92
$1,448.89 		$1,439.73
$1,498.70
$1,561.18
$1,783.15 		$334.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$873.90
$991.84
$1,116.80
$1,560.74
$2,371.68 		$1,208.16
$1,326.10
$1,451.06
$1,895.00 		$1,542.42
$1,660.36
$1,785.32
$2,229.26 		$1,876.68
$1,994.62
$2,119.58
$2,563.52 		$334.26
Toc - Plan #40 Ambetter from Nebraska Total Care
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$439.04
$498.30
$561.08
$784.10
$1,191.52 		$774.90
$834.16
$896.94
$1,119.96 		$1,110.76
$1,170.02
$1,232.80
$1,455.82 		$1,446.62
$1,505.88
$1,568.66
$1,791.68 		$335.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.08
$996.60
$1,122.16
$1,568.20
$2,383.04 		$1,213.94
$1,332.46
$1,458.02
$1,904.06 		$1,549.80
$1,668.32
$1,793.88
$2,239.92 		$1,885.66
$2,004.18
$2,129.74
$2,575.78 		$335.86
Toc - Plan #41 Ambetter from Nebraska Total Care
Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

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 		$462.83
$525.30
$591.49
$826.60
$1,256.10 		$816.89
$879.36
$945.55
$1,180.66 		$1,170.95
$1,233.42
$1,299.61
$1,534.72 		$1,525.01
$1,587.48
$1,653.67
$1,888.78 		$354.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.66
$1,050.60
$1,182.98
$1,653.20
$2,512.20 		$1,279.72
$1,404.66
$1,537.04
$2,007.26 		$1,633.78
$1,758.72
$1,891.10
$2,361.32 		$1,987.84
$2,112.78
$2,245.16
$2,715.38 		$354.06
Toc - Plan #42 Ambetter from Nebraska Total Care
Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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 		$457.09
$518.79
$584.15
$816.35
$1,240.53 		$806.76
$868.46
$933.82
$1,166.02 		$1,156.43
$1,218.13
$1,283.49
$1,515.69 		$1,506.10
$1,567.80
$1,633.16
$1,865.36 		$349.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$914.18
$1,037.58
$1,168.30
$1,632.70
$2,481.06 		$1,263.85
$1,387.25
$1,517.97
$1,982.37 		$1,613.52
$1,736.92
$1,867.64
$2,332.04 		$1,963.19
$2,086.59
$2,217.31
$2,681.71 		$349.67
Toc - Plan #43 Ambetter from Nebraska Total Care
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$348.03
$395.00
$444.77
$621.56
$944.52 		$614.26
$661.23
$711.00
$887.79 		$880.49
$927.46
$977.23
$1,154.02 		$1,146.72
$1,193.69
$1,243.46
$1,420.25 		$266.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.06
$790.00
$889.54
$1,243.12
$1,889.04 		$962.29
$1,056.23
$1,155.77
$1,509.35 		$1,228.52
$1,322.46
$1,422.00
$1,775.58 		$1,494.75
$1,588.69
$1,688.23
$2,041.81 		$266.23
Toc - Plan #44 Ambetter from Nebraska Total Care
Silver

(HMO) Ambetter Virtual Access Silver - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$7,400 $14,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.84
$474.24
$533.98
$746.24
$1,133.99 		$737.48
$793.88
$853.62
$1,065.88 		$1,057.12
$1,113.52
$1,173.26
$1,385.52 		$1,376.76
$1,433.16
$1,492.90
$1,705.16 		$319.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.68
$948.48
$1,067.96
$1,492.48
$2,267.98 		$1,155.32
$1,268.12
$1,387.60
$1,812.12 		$1,474.96
$1,587.76
$1,707.24
$2,131.76 		$1,794.60
$1,907.40
$2,026.88
$2,451.40 		$319.64
Toc - Plan #45 Ambetter from Nebraska Total Care
Gold

(HMO) Ambetter Virtual Access Gold - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-890-0329

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 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 		$456.63
$518.26
$583.56
$815.52
$1,239.27 		$805.94
$867.57
$932.87
$1,164.83 		$1,155.25
$1,216.88
$1,282.18
$1,514.14 		$1,504.56
$1,566.19
$1,631.49
$1,863.45 		$349.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$913.26
$1,036.52
$1,167.12
$1,631.04
$2,478.54 		$1,262.57
$1,385.83
$1,516.43
$1,980.35 		$1,611.88
$1,735.14
$1,865.74
$2,329.66 		$1,961.19
$2,084.45
$2,215.05
$2,678.97 		$349.31

ADVERTISEMENT

Blue Cross and Blue Shield of Nebraska

Local: 1-888-592-8960 | Toll Free: 1-888-592-8960 | TTY: 1-800-821-4791
Toc - Plan #46 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze HSA 6000 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$486.62
$552.31
$621.90
$869.10
$1,320.68 		$858.88
$924.57
$994.16
$1,241.36 		$1,231.14
$1,296.83
$1,366.42
$1,613.62 		$1,603.40
$1,669.09
$1,738.68
$1,985.88 		$372.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$973.24
$1,104.62
$1,243.80
$1,738.20
$2,641.36 		$1,345.50
$1,476.88
$1,616.06
$2,110.46 		$1,717.76
$1,849.14
$1,988.32
$2,482.72 		$2,090.02
$2,221.40
$2,360.58
$2,854.98 		$372.26
Toc - Plan #47 Blue Cross and Blue Shield of Nebraska
Bronze

(EPO) Nebraska HeartlandBlue Bronze 0% Coinsurance 9100 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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 		$443.44
$503.31
$566.72
$791.99
$1,203.50 		$782.67
$842.54
$905.95
$1,131.22 		$1,121.90
$1,181.77
$1,245.18
$1,470.45 		$1,461.13
$1,521.00
$1,584.41
$1,809.68 		$339.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.88
$1,006.62
$1,133.44
$1,583.98
$2,407.00 		$1,226.11
$1,345.85
$1,472.67
$1,923.21 		$1,565.34
$1,685.08
$1,811.90
$2,262.44 		$1,904.57
$2,024.31
$2,151.13
$2,601.67 		$339.23
Toc - Plan #48 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze $0 PCP Visit 8100 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 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 		$468.50
$531.75
$598.74
$836.74
$1,271.50 		$826.90
$890.15
$957.14
$1,195.14 		$1,185.30
$1,248.55
$1,315.54
$1,553.54 		$1,543.70
$1,606.95
$1,673.94
$1,911.94 		$358.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$937.00
$1,063.50
$1,197.48
$1,673.48
$2,543.00 		$1,295.40
$1,421.90
$1,555.88
$2,031.88 		$1,653.80
$1,780.30
$1,914.28
$2,390.28 		$2,012.20
$2,138.70
$2,272.68
$2,748.68 		$358.40
Toc - Plan #49 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze $0 Mental Health Visit 7750 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$461.24
$523.51
$589.46
$823.77
$1,251.80 		$814.09
$876.36
$942.31
$1,176.62 		$1,166.94
$1,229.21
$1,295.16
$1,529.47 		$1,519.79
$1,582.06
$1,648.01
$1,882.32 		$352.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.48
$1,047.02
$1,178.92
$1,647.54
$2,503.60 		$1,275.33
$1,399.87
$1,531.77
$2,000.39 		$1,628.18
$1,752.72
$1,884.62
$2,353.24 		$1,981.03
$2,105.57
$2,237.47
$2,706.09 		$352.85
Toc - Plan #50 Blue Cross and Blue Shield of Nebraska
Bronze

(EPO) Nebraska HeartlandBlue Bronze Standard Deductible 9100 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

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 		$443.44
$503.31
$566.72
$791.99
$1,203.50 		$782.67
$842.54
$905.95
$1,131.22 		$1,121.90
$1,181.77
$1,245.18
$1,470.45 		$1,461.13
$1,521.00
$1,584.41
$1,809.68 		$339.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.88
$1,006.62
$1,133.44
$1,583.98
$2,407.00 		$1,226.11
$1,345.85
$1,472.67
$1,923.21 		$1,565.34
$1,685.08
$1,811.90
$2,262.44 		$1,904.57
$2,024.31
$2,151.13
$2,601.67 		$339.23
Toc - Plan #51 Blue Cross and Blue Shield of Nebraska
Expanded Bronze

(EPO) Nebraska HeartlandBlue Bronze Standard Copay 7500 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$454.56
$515.92
$580.92
$811.84
$1,233.67 		$802.30
$863.66
$928.66
$1,159.58 		$1,150.04
$1,211.40
$1,276.40
$1,507.32 		$1,497.78
$1,559.14
$1,624.14
$1,855.06 		$347.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.12
$1,031.84
$1,161.84
$1,623.68
$2,467.34 		$1,256.86
$1,379.58
$1,509.58
$1,971.42 		$1,604.60
$1,727.32
$1,857.32
$2,319.16 		$1,952.34
$2,075.06
$2,205.06
$2,666.90 		$347.74
Toc - Plan #52 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver $0 Deductible 9100 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$645.12
$732.21
$824.46
$1,152.18
$1,750.85 		$1,138.63
$1,225.72
$1,317.97
$1,645.69 		$1,632.14
$1,719.23
$1,811.48
$2,139.20 		$2,125.65
$2,212.74
$2,304.99
$2,632.71 		$493.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,290.24
$1,464.42
$1,648.92
$2,304.36
$3,501.70 		$1,783.75
$1,957.93
$2,142.43
$2,797.87 		$2,277.26
$2,451.44
$2,635.94
$3,291.38 		$2,770.77
$2,944.95
$3,129.45
$3,784.89 		$493.51
Toc - Plan #53 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver $0 PCP Visit 5000 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,950 $17,900 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 		$579.84
$658.12
$741.04
$1,035.60
$1,573.69 		$1,023.42
$1,101.70
$1,184.62
$1,479.18 		$1,467.00
$1,545.28
$1,628.20
$1,922.76 		$1,910.58
$1,988.86
$2,071.78
$2,366.34 		$443.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,159.68
$1,316.24
$1,482.08
$2,071.20
$3,147.38 		$1,603.26
$1,759.82
$1,925.66
$2,514.78 		$2,046.84
$2,203.40
$2,369.24
$2,958.36 		$2,490.42
$2,646.98
$2,812.82
$3,401.94 		$443.58
Toc - Plan #54 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$585.37
$664.39
$748.10
$1,045.46
$1,588.68 		$1,033.17
$1,112.19
$1,195.90
$1,493.26 		$1,480.97
$1,559.99
$1,643.70
$1,941.06 		$1,928.77
$2,007.79
$2,091.50
$2,388.86 		$447.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,170.74
$1,328.78
$1,496.20
$2,090.92
$3,177.36 		$1,618.54
$1,776.58
$1,944.00
$2,538.72 		$2,066.34
$2,224.38
$2,391.80
$2,986.52 		$2,514.14
$2,672.18
$2,839.60
$3,434.32 		$447.80
Toc - Plan #55 Blue Cross and Blue Shield of Nebraska
Silver

(EPO) Nebraska HeartlandBlue Silver Standard 5800 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$579.78
$658.05
$740.95
$1,035.48
$1,573.51 		$1,023.31
$1,101.58
$1,184.48
$1,479.01 		$1,466.84
$1,545.11
$1,628.01
$1,922.54 		$1,910.37
$1,988.64
$2,071.54
$2,366.07 		$443.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,159.56
$1,316.10
$1,481.90
$2,070.96
$3,147.02 		$1,603.09
$1,759.63
$1,925.43
$2,514.49 		$2,046.62
$2,203.16
$2,368.96
$2,958.02 		$2,490.15
$2,646.69
$2,812.49
$3,401.55 		$443.53
Toc - Plan #56 Blue Cross and Blue Shield of Nebraska
Gold

(EPO) Nebraska HeartlandBlue Gold $0 PCP Visit 1500 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$622.82
$706.90
$795.97
$1,112.36
$1,690.34 		$1,099.28
$1,183.36
$1,272.43
$1,588.82 		$1,575.74
$1,659.82
$1,748.89
$2,065.28 		$2,052.20
$2,136.28
$2,225.35
$2,541.74 		$476.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,245.64
$1,413.80
$1,591.94
$2,224.72
$3,380.68 		$1,722.10
$1,890.26
$2,068.40
$2,701.18 		$2,198.56
$2,366.72
$2,544.86
$3,177.64 		$2,675.02
$2,843.18
$3,021.32
$3,654.10 		$476.46
Toc - Plan #57 Blue Cross and Blue Shield of Nebraska
Gold

(EPO) Nebraska HeartlandBlue Gold $0 Deductible NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$676.53
$767.87
$864.61
$1,208.29
$1,836.11 		$1,194.08
$1,285.42
$1,382.16
$1,725.84 		$1,711.63
$1,802.97
$1,899.71
$2,243.39 		$2,229.18
$2,320.52
$2,417.26
$2,760.94 		$517.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,353.06
$1,535.74
$1,729.22
$2,416.58
$3,672.22 		$1,870.61
$2,053.29
$2,246.77
$2,934.13 		$2,388.16
$2,570.84
$2,764.32
$3,451.68 		$2,905.71
$3,088.39
$3,281.87
$3,969.23 		$517.55
Toc - Plan #58 Blue Cross and Blue Shield of Nebraska
Gold

(EPO) Nebraska HeartlandBlue Gold Standard 2000 NB

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8960

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$615.43
$698.52
$786.52
$1,099.17
$1,670.29 		$1,086.24
$1,169.33
$1,257.33
$1,569.98 		$1,557.05
$1,640.14
$1,728.14
$2,040.79 		$2,027.86
$2,110.95
$2,198.95
$2,511.60 		$470.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,230.86
$1,397.04
$1,573.04
$2,198.34
$3,340.58 		$1,701.67
$1,867.85
$2,043.85
$2,669.15 		$2,172.48
$2,338.66
$2,514.66
$3,139.96 		$2,643.29
$2,809.47
$2,985.47
$3,610.77 		$470.81

ADVERTISEMENT

Oscar Insurance Company

Local:  | Toll Free: 

Toc - Plan #59 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$498.76
$566.08
$637.40
$890.77
$1,353.61 		$880.30
$947.62
$1,018.94
$1,272.31 		$1,261.84
$1,329.16
$1,400.48
$1,653.85 		$1,643.38
$1,710.70
$1,782.02
$2,035.39 		$381.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$997.52
$1,132.16
$1,274.80
$1,781.54
$2,707.22 		$1,379.06
$1,513.70
$1,656.34
$2,163.08 		$1,760.60
$1,895.24
$2,037.88
$2,544.62 		$2,142.14
$2,276.78
$2,419.42
$2,926.16 		$381.54
Toc - Plan #60 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$590.27
$669.95
$754.35
$1,054.21
$1,601.97 		$1,041.82
$1,121.50
$1,205.90
$1,505.76 		$1,493.37
$1,573.05
$1,657.45
$1,957.31 		$1,944.92
$2,024.60
$2,109.00
$2,408.86 		$451.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,180.54
$1,339.90
$1,508.70
$2,108.42
$3,203.94 		$1,632.09
$1,791.45
$1,960.25
$2,559.97 		$2,083.64
$2,243.00
$2,411.80
$3,011.52 		$2,535.19
$2,694.55
$2,863.35
$3,463.07 		$451.55
Toc - Plan #61 Oscar Insurance Company
Silver

(EPO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$645.88
$733.06
$825.42
$1,153.52
$1,752.89 		$1,139.97
$1,227.15
$1,319.51
$1,647.61 		$1,634.06
$1,721.24
$1,813.60
$2,141.70 		$2,128.15
$2,215.33
$2,307.69
$2,635.79 		$494.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,291.76
$1,466.12
$1,650.84
$2,307.04
$3,505.78 		$1,785.85
$1,960.21
$2,144.93
$2,801.13 		$2,279.94
$2,454.30
$2,639.02
$3,295.22 		$2,774.03
$2,948.39
$3,133.11
$3,789.31 		$494.09
Toc - Plan #62 Oscar Insurance Company
Catastrophic

(EPO) Secure

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$431.44
$489.67
$551.37
$770.53
$1,170.90 		$761.48
$819.71
$881.41
$1,100.57 		$1,091.52
$1,149.75
$1,211.45
$1,430.61 		$1,421.56
$1,479.79
$1,541.49
$1,760.65 		$330.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.88
$979.34
$1,102.74
$1,541.06
$2,341.80 		$1,192.92
$1,309.38
$1,432.78
$1,871.10 		$1,522.96
$1,639.42
$1,762.82
$2,201.14 		$1,853.00
$1,969.46
$2,092.86
$2,531.18 		$330.04
Toc - Plan #63 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$529.85
$601.37
$677.14
$946.30
$1,437.99 		$935.18
$1,006.70
$1,082.47
$1,351.63 		$1,340.51
$1,412.03
$1,487.80
$1,756.96 		$1,745.84
$1,817.36
$1,893.13
$2,162.29 		$405.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,059.70
$1,202.74
$1,354.28
$1,892.60
$2,875.98 		$1,465.03
$1,608.07
$1,759.61
$2,297.93 		$1,870.36
$2,013.40
$2,164.94
$2,703.26 		$2,275.69
$2,418.73
$2,570.27
$3,108.59 		$405.33
Toc - Plan #64 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$636.43
$722.34
$813.35
$1,136.65
$1,727.25 		$1,123.29
$1,209.20
$1,300.21
$1,623.51 		$1,610.15
$1,696.06
$1,787.07
$2,110.37 		$2,097.01
$2,182.92
$2,273.93
$2,597.23 		$486.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,272.86
$1,444.68
$1,626.70
$2,273.30
$3,454.50 		$1,759.72
$1,931.54
$2,113.56
$2,760.16 		$2,246.58
$2,418.40
$2,600.42
$3,247.02 		$2,733.44
$2,905.26
$3,087.28
$3,733.88 		$486.86
Toc - Plan #65 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$528.63
$599.98
$675.58
$944.11
$1,434.67 		$933.02
$1,004.37
$1,079.97
$1,348.50 		$1,337.41
$1,408.76
$1,484.36
$1,752.89 		$1,741.80
$1,813.15
$1,888.75
$2,157.28 		$404.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,057.26
$1,199.96
$1,351.16
$1,888.22
$2,869.34 		$1,461.65
$1,604.35
$1,755.55
$2,292.61 		$1,866.04
$2,008.74
$2,159.94
$2,697.00 		$2,270.43
$2,413.13
$2,564.33
$3,101.39 		$404.39
Toc - Plan #66 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$539.31
$612.11
$689.23
$963.19
$1,463.66 		$951.87
$1,024.67
$1,101.79
$1,375.75 		$1,364.43
$1,437.23
$1,514.35
$1,788.31 		$1,776.99
$1,849.79
$1,926.91
$2,200.87 		$412.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,078.62
$1,224.22
$1,378.46
$1,926.38
$2,927.32 		$1,491.18
$1,636.78
$1,791.02
$2,338.94 		$1,903.74
$2,049.34
$2,203.58
$2,751.50 		$2,316.30
$2,461.90
$2,616.14
$3,164.06 		$412.56
Toc - Plan #67 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$621.16
$705.00
$793.83
$1,109.37
$1,685.80 		$1,096.34
$1,180.18
$1,269.01
$1,584.55 		$1,571.52
$1,655.36
$1,744.19
$2,059.73 		$2,046.70
$2,130.54
$2,219.37
$2,534.91 		$475.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,242.32
$1,410.00
$1,587.66
$2,218.74
$3,371.60 		$1,717.50
$1,885.18
$2,062.84
$2,693.92 		$2,192.68
$2,360.36
$2,538.02
$3,169.10 		$2,667.86
$2,835.54
$3,013.20
$3,644.28 		$475.18
Toc - Plan #68 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$649.20
$736.83
$829.66
$1,159.45
$1,761.90 		$1,145.83
$1,233.46
$1,326.29
$1,656.08 		$1,642.46
$1,730.09
$1,822.92
$2,152.71 		$2,139.09
$2,226.72
$2,319.55
$2,649.34 		$496.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,298.40
$1,473.66
$1,659.32
$2,318.90
$3,523.80 		$1,795.03
$1,970.29
$2,155.95
$2,815.53 		$2,291.66
$2,466.92
$2,652.58
$3,312.16 		$2,788.29
$2,963.55
$3,149.21
$3,808.79 		$496.63
Toc - Plan #69 Oscar Insurance Company
Gold

(EPO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$655.63
$744.13
$837.89
$1,170.94
$1,779.36 		$1,157.18
$1,245.68
$1,339.44
$1,672.49 		$1,658.73
$1,747.23
$1,840.99
$2,174.04 		$2,160.28
$2,248.78
$2,342.54
$2,675.59 		$501.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,311.26
$1,488.26
$1,675.78
$2,341.88
$3,558.72 		$1,812.81
$1,989.81
$2,177.33
$2,843.43 		$2,314.36
$2,491.36
$2,678.88
$3,344.98 		$2,815.91
$2,992.91
$3,180.43
$3,846.53 		$501.55
Toc - Plan #70 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$638.75
$724.97
$816.31
$1,140.79
$1,733.53 		$1,127.38
$1,213.60
$1,304.94
$1,629.42 		$1,616.01
$1,702.23
$1,793.57
$2,118.05 		$2,104.64
$2,190.86
$2,282.20
$2,606.68 		$488.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,277.50
$1,449.94
$1,632.62
$2,281.58
$3,467.06 		$1,766.13
$1,938.57
$2,121.25
$2,770.21 		$2,254.76
$2,427.20
$2,609.88
$3,258.84 		$2,743.39
$2,915.83
$3,098.51
$3,747.47 		$488.63
Toc - Plan #71 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$526.50
$597.57
$672.85
$940.31
$1,428.89 		$929.26
$1,000.33
$1,075.61
$1,343.07 		$1,332.02
$1,403.09
$1,478.37
$1,745.83 		$1,734.78
$1,805.85
$1,881.13
$2,148.59 		$402.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,053.00
$1,195.14
$1,345.70
$1,880.62
$2,857.78 		$1,455.76
$1,597.90
$1,748.46
$2,283.38 		$1,858.52
$2,000.66
$2,151.22
$2,686.14 		$2,261.28
$2,403.42
$2,553.98
$3,088.90 		$402.76
Toc - Plan #72 Oscar Insurance Company
Bronze

(EPO) Bronze Simple- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$476.10
$540.36
$608.44
$850.29
$1,292.10 		$840.31
$904.57
$972.65
$1,214.50 		$1,204.52
$1,268.78
$1,336.86
$1,578.71 		$1,568.73
$1,632.99
$1,701.07
$1,942.92 		$364.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952.20
$1,080.72
$1,216.88
$1,700.58
$2,584.20 		$1,316.41
$1,444.93
$1,581.09
$2,064.79 		$1,680.62
$1,809.14
$1,945.30
$2,429.00 		$2,044.83
$2,173.35
$2,309.51
$2,793.21 		$364.21
Toc - Plan #73 Oscar Insurance Company
Silver

(EPO) Silver Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$627.36
$712.04
$801.75
$1,120.44
$1,702.62 		$1,107.28
$1,191.96
$1,281.67
$1,600.36 		$1,587.20
$1,671.88
$1,761.59
$2,080.28 		$2,067.12
$2,151.80
$2,241.51
$2,560.20 		$479.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,254.72
$1,424.08
$1,603.50
$2,240.88
$3,405.24 		$1,734.64
$1,904.00
$2,083.42
$2,720.80 		$2,214.56
$2,383.92
$2,563.34
$3,200.72 		$2,694.48
$2,863.84
$3,043.26
$3,680.64 		$479.92
Toc - Plan #74 Oscar Insurance Company
Gold

(EPO) Gold Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$605.30
$687.01
$773.56
$1,081.05
$1,642.76 		$1,068.35
$1,150.06
$1,236.61
$1,544.10 		$1,531.40
$1,613.11
$1,699.66
$2,007.15 		$1,994.45
$2,076.16
$2,162.71
$2,470.20 		$463.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,210.60
$1,374.02
$1,547.12
$2,162.10
$3,285.52 		$1,673.65
$1,837.07
$2,010.17
$2,625.15 		$2,136.70
$2,300.12
$2,473.22
$3,088.20 		$2,599.75
$2,763.17
$2,936.27
$3,551.25 		$463.05

‡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 Knox County here.

Knox County is in “Rating Area 3” of Nebraska.

Currently, there are 74 plans offered in Rating Area 3.

Top

2023 Obamacare Plans for Knox County, NE

Plan Browser: 74 Plans
scroll down for more