Osage County, Oklahoma Obamacare 2024 Rates

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

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

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

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

Obamacare Providers, 65 Plans and 2024 Rates for Osage County, Oklahoma

Below, you’ll find a summary of the 65 plans for Osage County, Oklahoma and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

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Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-676-3777

Toc - Plan #1 Medica
Catastrophic

(PPO) Harmony by Medica Catastrophic

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$226.17
$256.70
$289.05
$403.94
$613.83
$399.19
$429.72
$462.07
$576.96
$572.21
$602.74
$635.09
$749.98
$745.23
$775.76
$808.11
$923.00
$173.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$452.34
$513.40
$578.10
$807.88
$1,227.66
$625.36
$686.42
$751.12
$980.90
$798.38
$859.44
$924.14
$1,153.92
$971.40
$1,032.46
$1,097.16
$1,326.94
$173.02
Toc - Plan #2 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze Share Plus

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

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.25
$368.02
$414.39
$579.10
$880.00
$572.30
$616.07
$662.44
$827.15
$820.35
$864.12
$910.49
$1,075.20
$1,068.40
$1,112.17
$1,158.54
$1,323.25
$248.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.50
$736.04
$828.78
$1,158.20
$1,760.00
$896.55
$984.09
$1,076.83
$1,406.25
$1,144.60
$1,232.14
$1,324.88
$1,654.30
$1,392.65
$1,480.19
$1,572.93
$1,902.35
$248.05
Toc - Plan #3 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze Copay $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$7,850 $15,700 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.62
$358.22
$403.36
$563.69
$856.58
$557.07
$599.67
$644.81
$805.14
$798.52
$841.12
$886.26
$1,046.59
$1,039.97
$1,082.57
$1,127.71
$1,288.04
$241.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$631.24
$716.44
$806.72
$1,127.38
$1,713.16
$872.69
$957.89
$1,048.17
$1,368.83
$1,114.14
$1,199.34
$1,289.62
$1,610.28
$1,355.59
$1,440.79
$1,531.07
$1,851.73
$241.45
Toc - Plan #4 Medica
Gold

(PPO) Harmony by Medica Gold Copay $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.19
$474.64
$534.44
$746.88
$1,134.96
$738.10
$794.55
$854.35
$1,066.79
$1,058.01
$1,114.46
$1,174.26
$1,386.70
$1,377.92
$1,434.37
$1,494.17
$1,706.61
$319.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.38
$949.28
$1,068.88
$1,493.76
$2,269.92
$1,156.29
$1,269.19
$1,388.79
$1,813.67
$1,476.20
$1,589.10
$1,708.70
$2,133.58
$1,796.11
$1,909.01
$2,028.61
$2,453.49
$319.91
Toc - Plan #5 Medica
Silver

(PPO) Harmony by Medica Silver Copay $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.24
$472.44
$531.96
$743.41
$1,129.68
$734.67
$790.87
$850.39
$1,061.84
$1,053.10
$1,109.30
$1,168.82
$1,380.27
$1,371.53
$1,427.73
$1,487.25
$1,698.70
$318.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.48
$944.88
$1,063.92
$1,486.82
$2,259.36
$1,150.91
$1,263.31
$1,382.35
$1,805.25
$1,469.34
$1,581.74
$1,700.78
$2,123.68
$1,787.77
$1,900.17
$2,019.21
$2,442.11
$318.43
Toc - Plan #6 Medica
Expanded Bronze

(PPO) Harmony by Medica Bronze Premier

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$330.30
$374.89
$422.12
$589.92
$896.44
$582.98
$627.57
$674.80
$842.60
$835.66
$880.25
$927.48
$1,095.28
$1,088.34
$1,132.93
$1,180.16
$1,347.96
$252.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$660.60
$749.78
$844.24
$1,179.84
$1,792.88
$913.28
$1,002.46
$1,096.92
$1,432.52
$1,165.96
$1,255.14
$1,349.60
$1,685.20
$1,418.64
$1,507.82
$1,602.28
$1,937.88
$252.68
Toc - Plan #7 Medica
Gold

(PPO) Harmony by Medica Gold Standard

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
$8,700 $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
$408.43
$463.56
$521.97
$729.45
$1,108.47
$720.88
$776.01
$834.42
$1,041.90
$1,033.33
$1,088.46
$1,146.87
$1,354.35
$1,345.78
$1,400.91
$1,459.32
$1,666.80
$312.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$816.86
$927.12
$1,043.94
$1,458.90
$2,216.94
$1,129.31
$1,239.57
$1,356.39
$1,771.35
$1,441.76
$1,552.02
$1,668.84
$2,083.80
$1,754.21
$1,864.47
$1,981.29
$2,396.25
$312.45
Toc - Plan #8 Medica
Silver

(PPO) Harmony by Medica Silver Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.16
$462.13
$520.35
$727.19
$1,105.03
$718.64
$773.61
$831.83
$1,038.67
$1,030.12
$1,085.09
$1,143.31
$1,350.15
$1,341.60
$1,396.57
$1,454.79
$1,661.63
$311.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.32
$924.26
$1,040.70
$1,454.38
$2,210.06
$1,125.80
$1,235.74
$1,352.18
$1,765.86
$1,437.28
$1,547.22
$1,663.66
$2,077.34
$1,748.76
$1,858.70
$1,975.14
$2,388.82
$311.48
Toc - Plan #9 Medica
Bronze

(PPO) Harmony by Medica Bronze Standard

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$295.37
$335.25
$377.49
$527.54
$801.64
$521.33
$561.21
$603.45
$753.50
$747.29
$787.17
$829.41
$979.46
$973.25
$1,013.13
$1,055.37
$1,205.42
$225.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$590.74
$670.50
$754.98
$1,055.08
$1,603.28
$816.70
$896.46
$980.94
$1,281.04
$1,042.66
$1,122.42
$1,206.90
$1,507.00
$1,268.62
$1,348.38
$1,432.86
$1,732.96
$225.96
Toc - Plan #10 Medica
Expanded Bronze

(PPO) Harmony by Medica Expanded Bronze Standard

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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$300.52
$341.10
$384.07
$536.74
$815.62
$530.42
$571.00
$613.97
$766.64
$760.32
$800.90
$843.87
$996.54
$990.22
$1,030.80
$1,073.77
$1,226.44
$229.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$601.04
$682.20
$768.14
$1,073.48
$1,631.24
$830.94
$912.10
$998.04
$1,303.38
$1,060.84
$1,142.00
$1,227.94
$1,533.28
$1,290.74
$1,371.90
$1,457.84
$1,763.18
$229.90

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Ambetter of Oklahoma

Local: 1-833-492-0679 | Toll Free: 1-833-492-0679

Toc - Plan #11 Ambetter of Oklahoma
Expanded Bronze

(PPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.20
$400.87
$451.37
$630.79
$958.55
$623.39
$671.06
$721.56
$900.98
$893.58
$941.25
$991.75
$1,171.17
$1,163.77
$1,211.44
$1,261.94
$1,441.36
$270.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.40
$801.74
$902.74
$1,261.58
$1,917.10
$976.59
$1,071.93
$1,172.93
$1,531.77
$1,246.78
$1,342.12
$1,443.12
$1,801.96
$1,516.97
$1,612.31
$1,713.31
$2,072.15
$270.19
Toc - Plan #12 Ambetter of Oklahoma
Expanded Bronze

(PPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.30
$466.81
$525.63
$734.56
$1,116.24
$725.94
$781.45
$840.27
$1,049.20
$1,040.58
$1,096.09
$1,154.91
$1,363.84
$1,355.22
$1,410.73
$1,469.55
$1,678.48
$314.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.60
$933.62
$1,051.26
$1,469.12
$2,232.48
$1,137.24
$1,248.26
$1,365.90
$1,783.76
$1,451.88
$1,562.90
$1,680.54
$2,098.40
$1,766.52
$1,877.54
$1,995.18
$2,413.04
$314.64
Toc - Plan #13 Ambetter of Oklahoma
Silver

(PPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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
$414.75
$470.73
$530.04
$740.72
$1,125.60
$732.02
$788.00
$847.31
$1,057.99
$1,049.29
$1,105.27
$1,164.58
$1,375.26
$1,366.56
$1,422.54
$1,481.85
$1,692.53
$317.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$829.50
$941.46
$1,060.08
$1,481.44
$2,251.20
$1,146.77
$1,258.73
$1,377.35
$1,798.71
$1,464.04
$1,576.00
$1,694.62
$2,115.98
$1,781.31
$1,893.27
$2,011.89
$2,433.25
$317.27
Toc - Plan #14 Ambetter of Oklahoma
Silver

(PPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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
$392.47
$445.45
$501.57
$700.94
$1,065.15
$692.70
$745.68
$801.80
$1,001.17
$992.93
$1,045.91
$1,102.03
$1,301.40
$1,293.16
$1,346.14
$1,402.26
$1,601.63
$300.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.94
$890.90
$1,003.14
$1,401.88
$2,130.30
$1,085.17
$1,191.13
$1,303.37
$1,702.11
$1,385.40
$1,491.36
$1,603.60
$2,002.34
$1,685.63
$1,791.59
$1,903.83
$2,302.57
$300.23
Toc - Plan #15 Ambetter of Oklahoma
Silver

(PPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$404.01
$458.54
$516.31
$721.54
$1,096.45
$713.07
$767.60
$825.37
$1,030.60
$1,022.13
$1,076.66
$1,134.43
$1,339.66
$1,331.19
$1,385.72
$1,443.49
$1,648.72
$309.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.02
$917.08
$1,032.62
$1,443.08
$2,192.90
$1,117.08
$1,226.14
$1,341.68
$1,752.14
$1,426.14
$1,535.20
$1,650.74
$2,061.20
$1,735.20
$1,844.26
$1,959.80
$2,370.26
$309.06
Toc - Plan #16 Ambetter of Oklahoma
Gold

(PPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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
$465.60
$528.44
$595.02
$831.54
$1,263.61
$821.78
$884.62
$951.20
$1,187.72
$1,177.96
$1,240.80
$1,307.38
$1,543.90
$1,534.14
$1,596.98
$1,663.56
$1,900.08
$356.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$931.20
$1,056.88
$1,190.04
$1,663.08
$2,527.22
$1,287.38
$1,413.06
$1,546.22
$2,019.26
$1,643.56
$1,769.24
$1,902.40
$2,375.44
$1,999.74
$2,125.42
$2,258.58
$2,731.62
$356.18
Toc - Plan #17 Ambetter of Oklahoma
Gold

(PPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$541.82
$614.95
$692.43
$967.67
$1,470.47
$956.30
$1,029.43
$1,106.91
$1,382.15
$1,370.78
$1,443.91
$1,521.39
$1,796.63
$1,785.26
$1,858.39
$1,935.87
$2,211.11
$414.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,083.64
$1,229.90
$1,384.86
$1,935.34
$2,940.94
$1,498.12
$1,644.38
$1,799.34
$2,349.82
$1,912.60
$2,058.86
$2,213.82
$2,764.30
$2,327.08
$2,473.34
$2,628.30
$3,178.78
$414.48
Toc - Plan #18 Ambetter of Oklahoma
Gold

(PPO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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
$458.66
$520.57
$586.16
$819.16
$1,244.79
$809.53
$871.44
$937.03
$1,170.03
$1,160.40
$1,222.31
$1,287.90
$1,520.90
$1,511.27
$1,573.18
$1,638.77
$1,871.77
$350.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.32
$1,041.14
$1,172.32
$1,638.32
$2,489.58
$1,268.19
$1,392.01
$1,523.19
$1,989.19
$1,619.06
$1,742.88
$1,874.06
$2,340.06
$1,969.93
$2,093.75
$2,224.93
$2,690.93
$350.87
Toc - Plan #19 Ambetter of Oklahoma
Expanded Bronze

(PPO) Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$344.44
$390.92
$440.18
$615.15
$934.77
$607.93
$654.41
$703.67
$878.64
$871.42
$917.90
$967.16
$1,142.13
$1,134.91
$1,181.39
$1,230.65
$1,405.62
$263.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.88
$781.84
$880.36
$1,230.30
$1,869.54
$952.37
$1,045.33
$1,143.85
$1,493.79
$1,215.86
$1,308.82
$1,407.34
$1,757.28
$1,479.35
$1,572.31
$1,670.83
$2,020.77
$263.49
Toc - Plan #20 Ambetter of Oklahoma
Silver

(PPO) Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.36
$449.85
$506.53
$707.88
$1,075.69
$699.57
$753.06
$809.74
$1,011.09
$1,002.78
$1,056.27
$1,112.95
$1,314.30
$1,305.99
$1,359.48
$1,416.16
$1,617.51
$303.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.72
$899.70
$1,013.06
$1,415.76
$2,151.38
$1,095.93
$1,202.91
$1,316.27
$1,718.97
$1,399.14
$1,506.12
$1,619.48
$2,022.18
$1,702.35
$1,809.33
$1,922.69
$2,325.39
$303.21
Toc - Plan #21 Ambetter of Oklahoma
Gold

(PPO) Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$462.87
$525.34
$591.53
$826.66
$1,256.19
$816.95
$879.42
$945.61
$1,180.74
$1,171.03
$1,233.50
$1,299.69
$1,534.82
$1,525.11
$1,587.58
$1,653.77
$1,888.90
$354.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$925.74
$1,050.68
$1,183.06
$1,653.32
$2,512.38
$1,279.82
$1,404.76
$1,537.14
$2,007.40
$1,633.90
$1,758.84
$1,891.22
$2,361.48
$1,987.98
$2,112.92
$2,245.30
$2,715.56
$354.08
Toc - Plan #22 Ambetter of Oklahoma
Expanded Bronze

(PPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.32
$416.90
$469.42
$656.02
$996.88
$648.31
$697.89
$750.41
$937.01
$929.30
$978.88
$1,031.40
$1,218.00
$1,210.29
$1,259.87
$1,312.39
$1,498.99
$280.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.64
$833.80
$938.84
$1,312.04
$1,993.76
$1,015.63
$1,114.79
$1,219.83
$1,593.03
$1,296.62
$1,395.78
$1,500.82
$1,874.02
$1,577.61
$1,676.77
$1,781.81
$2,155.01
$280.99
Toc - Plan #23 Ambetter of Oklahoma
Expanded Bronze

(PPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$427.75
$485.49
$546.65
$763.94
$1,160.89
$754.97
$812.71
$873.87
$1,091.16
$1,082.19
$1,139.93
$1,201.09
$1,418.38
$1,409.41
$1,467.15
$1,528.31
$1,745.60
$327.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$855.50
$970.98
$1,093.30
$1,527.88
$2,321.78
$1,182.72
$1,298.20
$1,420.52
$1,855.10
$1,509.94
$1,625.42
$1,747.74
$2,182.32
$1,837.16
$1,952.64
$2,074.96
$2,509.54
$327.22
Toc - Plan #24 Ambetter of Oklahoma
Silver

(PPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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
$431.34
$489.56
$551.24
$770.35
$1,170.62
$761.30
$819.52
$881.20
$1,100.31
$1,091.26
$1,149.48
$1,211.16
$1,430.27
$1,421.22
$1,479.44
$1,541.12
$1,760.23
$329.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$862.68
$979.12
$1,102.48
$1,540.70
$2,341.24
$1,192.64
$1,309.08
$1,432.44
$1,870.66
$1,522.60
$1,639.04
$1,762.40
$2,200.62
$1,852.56
$1,969.00
$2,092.36
$2,530.58
$329.96
Toc - Plan #25 Ambetter of Oklahoma
Silver

(PPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$420.17
$476.88
$536.96
$750.40
$1,140.30
$741.59
$798.30
$858.38
$1,071.82
$1,063.01
$1,119.72
$1,179.80
$1,393.24
$1,384.43
$1,441.14
$1,501.22
$1,714.66
$321.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$840.34
$953.76
$1,073.92
$1,500.80
$2,280.60
$1,161.76
$1,275.18
$1,395.34
$1,822.22
$1,483.18
$1,596.60
$1,716.76
$2,143.64
$1,804.60
$1,918.02
$2,038.18
$2,465.06
$321.42
Toc - Plan #26 Ambetter of Oklahoma
Gold

(PPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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
$484.22
$549.58
$618.82
$864.80
$1,314.15
$854.64
$920.00
$989.24
$1,235.22
$1,225.06
$1,290.42
$1,359.66
$1,605.64
$1,595.48
$1,660.84
$1,730.08
$1,976.06
$370.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$968.44
$1,099.16
$1,237.64
$1,729.60
$2,628.30
$1,338.86
$1,469.58
$1,608.06
$2,100.02
$1,709.28
$1,840.00
$1,978.48
$2,470.44
$2,079.70
$2,210.42
$2,348.90
$2,840.86
$370.42
Toc - Plan #27 Ambetter of Oklahoma
Silver

(PPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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
$408.17
$463.26
$521.63
$728.98
$1,107.75
$720.41
$775.50
$833.87
$1,041.22
$1,032.65
$1,087.74
$1,146.11
$1,353.46
$1,344.89
$1,399.98
$1,458.35
$1,665.70
$312.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$816.34
$926.52
$1,043.26
$1,457.96
$2,215.50
$1,128.58
$1,238.76
$1,355.50
$1,770.20
$1,440.82
$1,551.00
$1,667.74
$2,082.44
$1,753.06
$1,863.24
$1,979.98
$2,394.68
$312.24
Toc - Plan #28 Ambetter of Oklahoma
Gold

(PPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$563.49
$639.55
$720.13
$1,006.37
$1,529.28
$994.55
$1,070.61
$1,151.19
$1,437.43
$1,425.61
$1,501.67
$1,582.25
$1,868.49
$1,856.67
$1,932.73
$2,013.31
$2,299.55
$431.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,126.98
$1,279.10
$1,440.26
$2,012.74
$3,058.56
$1,558.04
$1,710.16
$1,871.32
$2,443.80
$1,989.10
$2,141.22
$2,302.38
$2,874.86
$2,420.16
$2,572.28
$2,733.44
$3,305.92
$431.06
Toc - Plan #29 Ambetter of Oklahoma
Gold

(PPO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

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
$477.01
$541.39
$609.60
$851.92
$1,294.57
$841.91
$906.29
$974.50
$1,216.82
$1,206.81
$1,271.19
$1,339.40
$1,581.72
$1,571.71
$1,636.09
$1,704.30
$1,946.62
$364.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$954.02
$1,082.78
$1,219.20
$1,703.84
$2,589.14
$1,318.92
$1,447.68
$1,584.10
$2,068.74
$1,683.82
$1,812.58
$1,949.00
$2,433.64
$2,048.72
$2,177.48
$2,313.90
$2,798.54
$364.90
Toc - Plan #30 Ambetter of Oklahoma
Expanded Bronze

(PPO) Standard Expanded Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.21
$406.56
$457.78
$639.75
$972.16
$632.23
$680.58
$731.80
$913.77
$906.25
$954.60
$1,005.82
$1,187.79
$1,180.27
$1,228.62
$1,279.84
$1,461.81
$274.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716.42
$813.12
$915.56
$1,279.50
$1,944.32
$990.44
$1,087.14
$1,189.58
$1,553.52
$1,264.46
$1,361.16
$1,463.60
$1,827.54
$1,538.48
$1,635.18
$1,737.62
$2,101.56
$274.02
Toc - Plan #31 Ambetter of Oklahoma
Silver

(PPO) Standard Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412.21
$467.85
$526.79
$736.19
$1,118.71
$727.54
$783.18
$842.12
$1,051.52
$1,042.87
$1,098.51
$1,157.45
$1,366.85
$1,358.20
$1,413.84
$1,472.78
$1,682.18
$315.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$824.42
$935.70
$1,053.58
$1,472.38
$2,237.42
$1,139.75
$1,251.03
$1,368.91
$1,787.71
$1,455.08
$1,566.36
$1,684.24
$2,103.04
$1,770.41
$1,881.69
$1,999.57
$2,418.37
$315.33
Toc - Plan #32 Ambetter of Oklahoma
Gold

(PPO) Standard Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-492-0679

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$481.38
$546.35
$615.19
$859.72
$1,306.43
$849.63
$914.60
$983.44
$1,227.97
$1,217.88
$1,282.85
$1,351.69
$1,596.22
$1,586.13
$1,651.10
$1,719.94
$1,964.47
$368.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$962.76
$1,092.70
$1,230.38
$1,719.44
$2,612.86
$1,331.01
$1,460.95
$1,598.63
$2,087.69
$1,699.26
$1,829.20
$1,966.88
$2,455.94
$2,067.51
$2,197.45
$2,335.13
$2,824.19
$368.25

ADVERTISEMENT

Blue Cross and Blue Shield of Oklahoma

Local: 1-866-520-2507 | Toll Free: 1-866-520-2507 | TTY: 1-800-722-0353

Toc - Plan #33 Blue Cross and Blue Shield of Oklahoma
Expanded Bronze

(PPO) Blue Advantage Bronze PPO? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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
$428.21
$486.02
$547.26
$764.79
$1,162.17
$755.79
$813.60
$874.84
$1,092.37
$1,083.37
$1,141.18
$1,202.42
$1,419.95
$1,410.95
$1,468.76
$1,530.00
$1,747.53
$327.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.42
$972.04
$1,094.52
$1,529.58
$2,324.34
$1,184.00
$1,299.62
$1,422.10
$1,857.16
$1,511.58
$1,627.20
$1,749.68
$2,184.74
$1,839.16
$1,954.78
$2,077.26
$2,512.32
$327.58
Toc - Plan #34 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Advantage Silver PPO? 204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$503.65
$571.65
$643.67
$899.53
$1,366.92
$888.95
$956.95
$1,028.97
$1,284.83
$1,274.25
$1,342.25
$1,414.27
$1,670.13
$1,659.55
$1,727.55
$1,799.57
$2,055.43
$385.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,007.30
$1,143.30
$1,287.34
$1,799.06
$2,733.84
$1,392.60
$1,528.60
$1,672.64
$2,184.36
$1,777.90
$1,913.90
$2,057.94
$2,569.66
$2,163.20
$2,299.20
$2,443.24
$2,954.96
$385.30
Toc - Plan #35 Blue Cross and Blue Shield of Oklahoma
Bronze

(PPO) Blue Advantage Bronze PPO? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370.33
$420.32
$473.28
$661.40
$1,005.07
$653.63
$703.62
$756.58
$944.70
$936.93
$986.92
$1,039.88
$1,228.00
$1,220.23
$1,270.22
$1,323.18
$1,511.30
$283.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.66
$840.64
$946.56
$1,322.80
$2,010.14
$1,023.96
$1,123.94
$1,229.86
$1,606.10
$1,307.26
$1,407.24
$1,513.16
$1,889.40
$1,590.56
$1,690.54
$1,796.46
$2,172.70
$283.30
Toc - Plan #36 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Advantage Gold PPO? 309

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$480.12
$544.94
$613.59
$857.50
$1,303.05
$847.41
$912.23
$980.88
$1,224.79
$1,214.70
$1,279.52
$1,348.17
$1,592.08
$1,581.99
$1,646.81
$1,715.46
$1,959.37
$367.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$960.24
$1,089.88
$1,227.18
$1,715.00
$2,606.10
$1,327.53
$1,457.17
$1,594.47
$2,082.29
$1,694.82
$1,824.46
$1,961.76
$2,449.58
$2,062.11
$2,191.75
$2,329.05
$2,816.87
$367.29
Toc - Plan #37 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Advantage Silver PPO? 605

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$521.45
$591.84
$666.41
$931.30
$1,415.21
$920.36
$990.75
$1,065.32
$1,330.21
$1,319.27
$1,389.66
$1,464.23
$1,729.12
$1,718.18
$1,788.57
$1,863.14
$2,128.03
$398.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,042.90
$1,183.68
$1,332.82
$1,862.60
$2,830.42
$1,441.81
$1,582.59
$1,731.73
$2,261.51
$1,840.72
$1,981.50
$2,130.64
$2,660.42
$2,239.63
$2,380.41
$2,529.55
$3,059.33
$398.91
Toc - Plan #38 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Advantage Gold PPO? 604

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,150 $2,300 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$485.07
$550.56
$619.92
$866.34
$1,316.48
$856.15
$921.64
$991.00
$1,237.42
$1,227.23
$1,292.72
$1,362.08
$1,608.50
$1,598.31
$1,663.80
$1,733.16
$1,979.58
$371.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$970.14
$1,101.12
$1,239.84
$1,732.68
$2,632.96
$1,341.22
$1,472.20
$1,610.92
$2,103.76
$1,712.30
$1,843.28
$1,982.00
$2,474.84
$2,083.38
$2,214.36
$2,353.08
$2,845.92
$371.08
Toc - Plan #39 Blue Cross and Blue Shield of Oklahoma
Bronze

(PPO) Blue Preferred Bronze PPO? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$452.27
$513.32
$578.00
$807.75
$1,227.45
$798.25
$859.30
$923.98
$1,153.73
$1,144.23
$1,205.28
$1,269.96
$1,499.71
$1,490.21
$1,551.26
$1,615.94
$1,845.69
$345.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$904.54
$1,026.64
$1,156.00
$1,615.50
$2,454.90
$1,250.52
$1,372.62
$1,501.98
$1,961.48
$1,596.50
$1,718.60
$1,847.96
$2,307.46
$1,942.48
$2,064.58
$2,193.94
$2,653.44
$345.98
Toc - Plan #40 Blue Cross and Blue Shield of Oklahoma
Expanded Bronze

(PPO) Blue Preferred Bronze PPO? 707

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$470.39
$533.89
$601.15
$840.11
$1,276.63
$830.24
$893.74
$961.00
$1,199.96
$1,190.09
$1,253.59
$1,320.85
$1,559.81
$1,549.94
$1,613.44
$1,680.70
$1,919.66
$359.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$940.78
$1,067.78
$1,202.30
$1,680.22
$2,553.26
$1,300.63
$1,427.63
$1,562.15
$2,040.07
$1,660.48
$1,787.48
$1,922.00
$2,399.92
$2,020.33
$2,147.33
$2,281.85
$2,759.77
$359.85
Toc - Plan #41 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Preferred Gold PPO? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$700 $1,400 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$571.10
$648.20
$729.86
$1,019.98
$1,549.96
$1,007.99
$1,085.09
$1,166.75
$1,456.87
$1,444.88
$1,521.98
$1,603.64
$1,893.76
$1,881.77
$1,958.87
$2,040.53
$2,330.65
$436.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,142.20
$1,296.40
$1,459.72
$2,039.96
$3,099.92
$1,579.09
$1,733.29
$1,896.61
$2,476.85
$2,015.98
$2,170.18
$2,333.50
$2,913.74
$2,452.87
$2,607.07
$2,770.39
$3,350.63
$436.89
Toc - Plan #42 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Preferred Gold PPO? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$605.15
$686.84
$773.38
$1,080.79
$1,642.37
$1,068.09
$1,149.78
$1,236.32
$1,543.73
$1,531.03
$1,612.72
$1,699.26
$2,006.67
$1,993.97
$2,075.66
$2,162.20
$2,469.61
$462.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,210.30
$1,373.68
$1,546.76
$2,161.58
$3,284.74
$1,673.24
$1,836.62
$2,009.70
$2,624.52
$2,136.18
$2,299.56
$2,472.64
$3,087.46
$2,599.12
$2,762.50
$2,935.58
$3,550.40
$462.94
Toc - Plan #43 Blue Cross and Blue Shield of Oklahoma
Catastrophic

(PPO) Blue Preferred Security PPO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370.21
$420.19
$473.13
$661.19
$1,004.75
$653.42
$703.40
$756.34
$944.40
$936.63
$986.61
$1,039.55
$1,227.61
$1,219.84
$1,269.82
$1,322.76
$1,510.82
$283.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.42
$840.38
$946.26
$1,322.38
$2,009.50
$1,023.63
$1,123.59
$1,229.47
$1,605.59
$1,306.84
$1,406.80
$1,512.68
$1,888.80
$1,590.05
$1,690.01
$1,795.89
$2,172.01
$283.21
Toc - Plan #44 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Preferred Silver PPO? 201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$612.73
$695.44
$783.06
$1,094.33
$1,662.94
$1,081.47
$1,164.18
$1,251.80
$1,563.07
$1,550.21
$1,632.92
$1,720.54
$2,031.81
$2,018.95
$2,101.66
$2,189.28
$2,500.55
$468.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,225.46
$1,390.88
$1,566.12
$2,188.66
$3,325.88
$1,694.20
$1,859.62
$2,034.86
$2,657.40
$2,162.94
$2,328.36
$2,503.60
$3,126.14
$2,631.68
$2,797.10
$2,972.34
$3,594.88
$468.74
Toc - Plan #45 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Preferred Silver PPO? 701

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$591.78
$671.67
$756.30
$1,056.92
$1,606.10
$1,044.49
$1,124.38
$1,209.01
$1,509.63
$1,497.20
$1,577.09
$1,661.72
$1,962.34
$1,949.91
$2,029.80
$2,114.43
$2,415.05
$452.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,183.56
$1,343.34
$1,512.60
$2,113.84
$3,212.20
$1,636.27
$1,796.05
$1,965.31
$2,566.55
$2,088.98
$2,248.76
$2,418.02
$3,019.26
$2,541.69
$2,701.47
$2,870.73
$3,471.97
$452.71
Toc - Plan #46 Blue Cross and Blue Shield of Oklahoma
Expanded Bronze

(PPO) Blue Advantage Bronze PPO? 801

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386.26
$438.40
$493.64
$689.86
$1,048.31
$681.75
$733.89
$789.13
$985.35
$977.24
$1,029.38
$1,084.62
$1,280.84
$1,272.73
$1,324.87
$1,380.11
$1,576.33
$295.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$772.52
$876.80
$987.28
$1,379.72
$2,096.62
$1,068.01
$1,172.29
$1,282.77
$1,675.21
$1,363.50
$1,467.78
$1,578.26
$1,970.70
$1,658.99
$1,763.27
$1,873.75
$2,266.19
$295.49
Toc - Plan #47 Blue Cross and Blue Shield of Oklahoma
Silver

(PPO) Blue Advantage Silver PPO? 802

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$493.92
$560.60
$631.24
$882.15
$1,340.51
$871.77
$938.45
$1,009.09
$1,260.00
$1,249.62
$1,316.30
$1,386.94
$1,637.85
$1,627.47
$1,694.15
$1,764.79
$2,015.70
$377.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$987.84
$1,121.20
$1,262.48
$1,764.30
$2,681.02
$1,365.69
$1,499.05
$1,640.33
$2,142.15
$1,743.54
$1,876.90
$2,018.18
$2,520.00
$2,121.39
$2,254.75
$2,396.03
$2,897.85
$377.85
Toc - Plan #48 Blue Cross and Blue Shield of Oklahoma
Gold

(PPO) Blue Advantage Gold PPO? 803

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$512.54
$581.74
$655.03
$915.40
$1,391.04
$904.64
$973.84
$1,047.13
$1,307.50
$1,296.74
$1,365.94
$1,439.23
$1,699.60
$1,688.84
$1,758.04
$1,831.33
$2,091.70
$392.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,025.08
$1,163.48
$1,310.06
$1,830.80
$2,782.08
$1,417.18
$1,555.58
$1,702.16
$2,222.90
$1,809.28
$1,947.68
$2,094.26
$2,615.00
$2,201.38
$2,339.78
$2,486.36
$3,007.10
$392.10
Toc - Plan #49 Blue Cross and Blue Shield of Oklahoma
Gold

(HMO) MyBlue Gold HMO? 704

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$1,100 $2,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.16
$415.59
$467.96
$653.97
$993.77
$646.27
$695.70
$748.07
$934.08
$926.38
$975.81
$1,028.18
$1,214.19
$1,206.49
$1,255.92
$1,308.29
$1,494.30
$280.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732.32
$831.18
$935.92
$1,307.94
$1,987.54
$1,012.43
$1,111.29
$1,216.03
$1,588.05
$1,292.54
$1,391.40
$1,496.14
$1,868.16
$1,572.65
$1,671.51
$1,776.25
$2,148.27
$280.11
Toc - Plan #50 Blue Cross and Blue Shield of Oklahoma
Silver

(HMO) MyBlue Silver HMO? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.50
$443.21
$499.05
$697.43
$1,059.81
$689.23
$741.94
$797.78
$996.16
$987.96
$1,040.67
$1,096.51
$1,294.89
$1,286.69
$1,339.40
$1,395.24
$1,593.62
$298.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.00
$886.42
$998.10
$1,394.86
$2,119.62
$1,079.73
$1,185.15
$1,296.83
$1,693.59
$1,378.46
$1,483.88
$1,595.56
$1,992.32
$1,677.19
$1,782.61
$1,894.29
$2,291.05
$298.73
Toc - Plan #51 Blue Cross and Blue Shield of Oklahoma
Gold

(HMO) MyBlue Gold HMO? 708

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.35
$460.07
$518.04
$723.96
$1,100.12
$715.44
$770.16
$828.13
$1,034.05
$1,025.53
$1,080.25
$1,138.22
$1,344.14
$1,335.62
$1,390.34
$1,448.31
$1,654.23
$310.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.70
$920.14
$1,036.08
$1,447.92
$2,200.24
$1,120.79
$1,230.23
$1,346.17
$1,758.01
$1,430.88
$1,540.32
$1,656.26
$2,068.10
$1,740.97
$1,850.41
$1,966.35
$2,378.19
$310.09
Toc - Plan #52 Blue Cross and Blue Shield of Oklahoma
Silver

(HMO) MyBlue Silver HMO? 709

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.38
$440.81
$496.35
$693.65
$1,054.06
$685.49
$737.92
$793.46
$990.76
$982.60
$1,035.03
$1,090.57
$1,287.87
$1,279.71
$1,332.14
$1,387.68
$1,584.98
$297.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.76
$881.62
$992.70
$1,387.30
$2,108.12
$1,073.87
$1,178.73
$1,289.81
$1,684.41
$1,370.98
$1,475.84
$1,586.92
$1,981.52
$1,668.09
$1,772.95
$1,884.03
$2,278.63
$297.11
Toc - Plan #53 Blue Cross and Blue Shield of Oklahoma
Silver

(HMO) MyBlue Silver HMO? 803

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384.49
$436.39
$491.38
$686.70
$1,043.50
$678.62
$730.52
$785.51
$980.83
$972.75
$1,024.65
$1,079.64
$1,274.96
$1,266.88
$1,318.78
$1,373.77
$1,569.09
$294.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.98
$872.78
$982.76
$1,373.40
$2,087.00
$1,063.11
$1,166.91
$1,276.89
$1,667.53
$1,357.24
$1,461.04
$1,571.02
$1,961.66
$1,651.37
$1,755.17
$1,865.15
$2,255.79
$294.13
Toc - Plan #54 Blue Cross and Blue Shield of Oklahoma
Gold

(HMO) MyBlue Gold HMO? 804

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-520-2507

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.10
$448.44
$504.94
$705.65
$1,072.30
$697.35
$750.69
$807.19
$1,007.90
$999.60
$1,052.94
$1,109.44
$1,310.15
$1,301.85
$1,355.19
$1,411.69
$1,612.40
$302.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$790.20
$896.88
$1,009.88
$1,411.30
$2,144.60
$1,092.45
$1,199.13
$1,312.13
$1,713.55
$1,394.70
$1,501.38
$1,614.38
$2,015.80
$1,696.95
$1,803.63
$1,916.63
$2,318.05
$302.25

ADVERTISEMENT

CommunityCare

Local: 1-918-594-5242 | Toll Free: 1-800-777-4890 | TTY: 1-800-722-0353

Toc - Plan #55 CommunityCare
Catastrophic

(HMO) CommunityCare Catastrophic Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$185.82
$210.91
$237.48
$331.88
$504.32
$327.97
$353.06
$379.63
$474.03
$470.12
$495.21
$521.78
$616.18
$612.27
$637.36
$663.93
$758.33
$142.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$371.64
$421.82
$474.96
$663.76
$1,008.64
$513.79
$563.97
$617.11
$805.91
$655.94
$706.12
$759.26
$948.06
$798.09
$848.27
$901.41
$1,090.21
$142.15
Toc - Plan #56 CommunityCare
Gold

(HMO) CommunityCare Gold L21 Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$4,000 $12,000 Annual Deductible
$8,300 $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
$429.20
$487.14
$548.52
$766.55
$1,164.85
$757.54
$815.48
$876.86
$1,094.89
$1,085.88
$1,143.82
$1,205.20
$1,423.23
$1,414.22
$1,472.16
$1,533.54
$1,751.57
$328.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.40
$974.28
$1,097.04
$1,533.10
$2,329.70
$1,186.74
$1,302.62
$1,425.38
$1,861.44
$1,515.08
$1,630.96
$1,753.72
$2,189.78
$1,843.42
$1,959.30
$2,082.06
$2,518.12
$328.34
Toc - Plan #57 CommunityCare
Silver

(HMO) CommunityCare Silver L21 Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$7,700 $17,100 Annual Deductible
$8,500 $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
$441.65
$501.27
$564.43
$788.78
$1,198.63
$779.51
$839.13
$902.29
$1,126.64
$1,117.37
$1,176.99
$1,240.15
$1,464.50
$1,455.23
$1,514.85
$1,578.01
$1,802.36
$337.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$883.30
$1,002.54
$1,128.86
$1,577.56
$2,397.26
$1,221.16
$1,340.40
$1,466.72
$1,915.42
$1,559.02
$1,678.26
$1,804.58
$2,253.28
$1,896.88
$2,016.12
$2,142.44
$2,591.14
$337.86
Toc - Plan #58 CommunityCare
Gold

(HMO) CommunityCare Gold IH221

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$1,100 $3,300 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
$433.81
$492.37
$554.41
$774.79
$1,177.36
$765.67
$824.23
$886.27
$1,106.65
$1,097.53
$1,156.09
$1,218.13
$1,438.51
$1,429.39
$1,487.95
$1,549.99
$1,770.37
$331.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.62
$984.74
$1,108.82
$1,549.58
$2,354.72
$1,199.48
$1,316.60
$1,440.68
$1,881.44
$1,531.34
$1,648.46
$1,772.54
$2,213.30
$1,863.20
$1,980.32
$2,104.40
$2,545.16
$331.86
Toc - Plan #59 CommunityCare
Gold

(HMO) CommunityCare Gold IH222

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$2,100 $6,300 Annual Deductible
$8,500 $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
$434.27
$492.90
$555.00
$775.61
$1,178.61
$766.49
$825.12
$887.22
$1,107.83
$1,098.71
$1,157.34
$1,219.44
$1,440.05
$1,430.93
$1,489.56
$1,551.66
$1,772.27
$332.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.54
$985.80
$1,110.00
$1,551.22
$2,357.22
$1,200.76
$1,318.02
$1,442.22
$1,883.44
$1,532.98
$1,650.24
$1,774.44
$2,215.66
$1,865.20
$1,982.46
$2,106.66
$2,547.88
$332.22
Toc - Plan #60 CommunityCare
Expanded Bronze

(HMO) CommunityCare Bronze IH223

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$5,000 $14,100 Annual Deductible
$7,250 $14,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.64
$360.52
$405.94
$567.30
$862.06
$560.63
$603.51
$648.93
$810.29
$803.62
$846.50
$891.92
$1,053.28
$1,046.61
$1,089.49
$1,134.91
$1,296.27
$242.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$635.28
$721.04
$811.88
$1,134.60
$1,724.12
$878.27
$964.03
$1,054.87
$1,377.59
$1,121.26
$1,207.02
$1,297.86
$1,620.58
$1,364.25
$1,450.01
$1,540.85
$1,863.57
$242.99
Toc - Plan #61 CommunityCare
Expanded Bronze

(HMO) CommunityCare Bronze IH224

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328.24
$372.55
$419.49
$586.23
$890.84
$579.34
$623.65
$670.59
$837.33
$830.44
$874.75
$921.69
$1,088.43
$1,081.54
$1,125.85
$1,172.79
$1,339.53
$251.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.48
$745.10
$838.98
$1,172.46
$1,781.68
$907.58
$996.20
$1,090.08
$1,423.56
$1,158.68
$1,247.30
$1,341.18
$1,674.66
$1,409.78
$1,498.40
$1,592.28
$1,925.76
$251.10
Toc - Plan #62 CommunityCare
Gold

(HMO) CommunityCare Gold Standardized Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$430.12
$488.19
$549.70
$768.20
$1,167.35
$759.16
$817.23
$878.74
$1,097.24
$1,088.20
$1,146.27
$1,207.78
$1,426.28
$1,417.24
$1,475.31
$1,536.82
$1,755.32
$329.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$860.24
$976.38
$1,099.40
$1,536.40
$2,334.70
$1,189.28
$1,305.42
$1,428.44
$1,865.44
$1,518.32
$1,634.46
$1,757.48
$2,194.48
$1,847.36
$1,963.50
$2,086.52
$2,523.52
$329.04
Toc - Plan #63 CommunityCare
Silver

(HMO) CommunityCare Silver Standardized Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.76
$466.21
$524.95
$733.62
$1,114.80
$724.99
$780.44
$839.18
$1,047.85
$1,039.22
$1,094.67
$1,153.41
$1,362.08
$1,353.45
$1,408.90
$1,467.64
$1,676.31
$314.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.52
$932.42
$1,049.90
$1,467.24
$2,229.60
$1,135.75
$1,246.65
$1,364.13
$1,781.47
$1,449.98
$1,560.88
$1,678.36
$2,095.70
$1,764.21
$1,875.11
$1,992.59
$2,409.93
$314.23
Toc - Plan #64 CommunityCare
Expanded Bronze

(HMO) CommunityCare Expanded Bronze Standardized Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$306.11
$347.44
$391.21
$546.71
$830.78
$540.28
$581.61
$625.38
$780.88
$774.45
$815.78
$859.55
$1,015.05
$1,008.62
$1,049.95
$1,093.72
$1,249.22
$234.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.22
$694.88
$782.42
$1,093.42
$1,661.56
$846.39
$929.05
$1,016.59
$1,327.59
$1,080.56
$1,163.22
$1,250.76
$1,561.76
$1,314.73
$1,397.39
$1,484.93
$1,795.93
$234.17
Toc - Plan #65 CommunityCare
Silver

(HMO) CommunityCare Silver SLIH223 Select Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-777-4890

Annual Out of Pocket Expenses:

Individual Family
$6,600 $17,900 Annual Deductible
$8,900 $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
$419.06
$475.63
$535.56
$748.44
$1,137.32
$739.64
$796.21
$856.14
$1,069.02
$1,060.22
$1,116.79
$1,176.72
$1,389.60
$1,380.80
$1,437.37
$1,497.30
$1,710.18
$320.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$838.12
$951.26
$1,071.12
$1,496.88
$2,274.64
$1,158.70
$1,271.84
$1,391.70
$1,817.46
$1,479.28
$1,592.42
$1,712.28
$2,138.04
$1,799.86
$1,913.00
$2,032.86
$2,458.62
$320.58

‡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 Osage County here.

Osage County is in “Rating Area 4” of Oklahoma.

Currently, there are 65 plans offered in Rating Area 4.

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2024 Obamacare Plans for Osage County, OK

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