Obamacare 2022 Rates and Health Insurance Providers for Dallas County , Texas

Obamacare > Rates > Texas > Dallas County

Obamacare Rates and Providers for Other Years

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

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 Dallas County, TX.

The health insurance rates listed below are for calendar year 2022.

For detailed information on available 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

The table below shows premiums for the following profiles at various ages:

  • Individuals
  • Couples
  • Couples with 1, 2, or 3 children
  • Individuals with 1, 2, or 3 children
  • A child alone

Each plan links to the insurance provider's website. You can find the following:

  • Summary of plan benefits and costs
  • Plan brochure
  • Provider Directory where you can find out which doctors and hospitals in the Dallas, TX area accept this insurance coverage as within the plan's network.

Obamacare Providers, Plans and 2022 Rates for Dallas County, Texas

Below, you’ll find a summary of the 86 plans for Dallas County, Texas 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

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

You may also be interested in:

How To Sign Up for Obamacare in Texas

For 2022 health plans, Texas open enrollment has ended. However, you may still be able to purchase health insurance for this year if you qualify for a special enrollment period. For example, if you’ve recently lost your job or income due to the COVID-19 crisis or for any other reason, you might qualify for a 60-day special enrollment period that will allow you to sign up for a new health insurance plan. (See What Happens If I Missed the Enrollment Deadline for 2022?)

To get covered, you can go directly to the online health insurance marketplace for Texas. If you need personalized help, you can reach out to an enrollment assistant. Most enrollment helpers are working remotely during the COVID crisis.

Where's the Texas Health Care Exchange?

You can find the health insurance exchange for Texas at Healthcare.gov. This is where you can learn about the various health insurance options available to you under the Affordable Care Act. If you see a plan you like, you'll be guided through the enrollment process online.

more...  

Texas Medicaid Expansion: Do I Qualify for Medicaid Under the ACA?

The Affordable Care Act (Obamacare) expanded Medicaid eligibility to include more people who couldn’t otherwise obtain health insurance. As written, the ACA would extend Medicaid to all adults with incomes at or below 138% of the federal poverty level. (For a single person in Texas in 2021, that’s $17,609. For a family of four, it’s $36,156.)

However, the U.S. Supreme Court later ruled that it was up to individual states to decide whether to expand Medicaid. As of October 2021, 12 states have not expanded their programs.

Texas Has Not Expanded Medicaid

Because Texas has not yet expanded Medicaid eligibility, you may have fewer options for health coverage than people in states where Medicaid is more inclusive.

The Medicaid Coverage Gap

The Affordable Care Act assumed that Medicaid would be expanded to cover all Americans with incomes at or below 138% of the federal poverty level. And it created health plan subsidies for people with incomes between 100% - 400% of the poverty level.

That means Texas residents with incomes below the poverty level may fall into a coverage gap where they can get neither Medicaid nor ACA subsidies.

more...  

Get Help Finding a Health Insurance Plan in Texas

Get Help From Texas's Health Insurance Exchange

The following links and telephone numbers take you to the official help resources for Healthcare.gov, the health insurance marketplace for Texas.

Help by phone: 800-318-2596 (TTY: 855-889-4325)

In-person help: Go to Find Local Help, where you can enter your city and state or zip code to find an application assister, insurance agent, or health insurance broker in your area.

Get Help From a Licensed Insurance Broker

To directly connect with a Texas insurance broker who can help you evaluate insurance plans and choose a plan that's appropriate for your situation, call 800-943-6832. (We receive advertising income from the licensed brokers who offer their services through this telephone number.)

More Information

For more detailed information, see How Do I Sign Up for Obamacare in Texas?

  • Dallas County, TX Obamacare Rates
  • General Info
  • Rates

ADVERTISEMENT

Oscar Insurance Company

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

Toc - Plan #1 Oscar Insurance Company
Expanded Bronze

(EPO) Oscar Bronze Simple

Annual Out of Pocket Expenses
Individual Family
$7,300 $14,600 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$264,18
$299,83
$337,61
$471,80
$716,95
$466,27
$501,92
$539,70
$673,89
$668,36
$704,01
$741,79
$875,98
$870,45
$906,10
$943,88
$1 078,07
$202,09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$528,36
$599,66
$675,22
$943,60
$1 433,90
$730,45
$801,75
$877,31
$1 145,69
$932,54
$1 003,84
$1 079,40
$1 347,78
$1 134,63
$1 205,93
$1 281,49
$1 549,87
$202,09
Toc - Plan #2 Oscar Insurance Company
Expanded Bronze

(EPO) Oscar Bronze Classic PCP Copay

Annual Out of Pocket Expenses
Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$272,81
$309,63
$348,64
$487,22
$740,38
$481,50
$518,32
$557,33
$695,91
$690,19
$727,01
$766,02
$904,60
$898,88
$935,70
$974,71
$1 113,29
$208,69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$545,62
$619,26
$697,28
$974,44
$1 480,76
$754,31
$827,95
$905,97
$1 183,13
$963,00
$1 036,64
$1 114,66
$1 391,82
$1 171,69
$1 245,33
$1 323,35
$1 600,51
$208,69
Toc - Plan #3 Oscar Insurance Company
Expanded Bronze

(EPO) Oscar Bronze Classic

Annual Out of Pocket Expenses
Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$265,79
$301,66
$339,66
$474,68
$721,31
$469,11
$504,98
$542,98
$678,00
$672,43
$708,30
$746,30
$881,32
$875,75
$911,62
$949,62
$1 084,64
$203,32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$531,58
$603,32
$679,32
$949,36
$1 442,62
$734,90
$806,64
$882,64
$1 152,68
$938,22
$1 009,96
$1 085,96
$1 356,00
$1 141,54
$1 213,28
$1 289,28
$1 559,32
$203,32
Toc - Plan #4 Oscar Insurance Company
Expanded Bronze

(EPO) Oscar Bronze Classic Next

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323,10
$366,71
$412,92
$577,05
$876,88
$570,27
$613,88
$660,09
$824,22
$817,44
$861,05
$907,26
$1 071,39
$1 064,61
$1 108,22
$1 154,43
$1 318,56
$247,17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646,20
$733,42
$825,84
$1 154,10
$1 753,76
$893,37
$980,59
$1 073,01
$1 401,27
$1 140,54
$1 227,76
$1 320,18
$1 648,44
$1 387,71
$1 474,93
$1 567,35
$1 895,61
$247,17
Toc - Plan #5 Oscar Insurance Company
Silver

(EPO) Oscar Silver Classic

Annual Out of Pocket Expenses
Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364,44
$413,63
$465,74
$650,87
$989,06
$643,23
$692,42
$744,53
$929,66
$922,02
$971,21
$1 023,32
$1 208,45
$1 200,81
$1 250,00
$1 302,11
$1 487,24
$278,79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728,88
$827,26
$931,48
$1 301,74
$1 978,12
$1 007,67
$1 106,05
$1 210,27
$1 580,53
$1 286,46
$1 384,84
$1 489,06
$1 859,32
$1 565,25
$1 663,63
$1 767,85
$2 138,11
$278,79
Toc - Plan #6 Oscar Insurance Company
Silver

(EPO) Oscar Silver Saver 2

Annual Out of Pocket Expenses
Individual Family
$6,200 $12,400 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357,77
$406,06
$457,22
$638,96
$970,96
$631,46
$679,75
$730,91
$912,65
$905,15
$953,44
$1 004,60
$1 186,34
$1 178,84
$1 227,13
$1 278,29
$1 460,03
$273,69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715,54
$812,12
$914,44
$1 277,92
$1 941,92
$989,23
$1 085,81
$1 188,13
$1 551,61
$1 262,92
$1 359,50
$1 461,82
$1 825,30
$1 536,61
$1 633,19
$1 735,51
$2 098,99
$273,69
Toc - Plan #7 Oscar Insurance Company
Silver

(EPO) Oscar Silver Classic Next

Annual Out of Pocket Expenses
Individual Family
$6,000 $12,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366,35
$415,80
$468,18
$654,28
$994,25
$646,60
$696,05
$748,43
$934,53
$926,85
$976,30
$1 028,68
$1 214,78
$1 207,10
$1 256,55
$1 308,93
$1 495,03
$280,25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732,70
$831,60
$936,36
$1 308,56
$1 988,50
$1 012,95
$1 111,85
$1 216,61
$1 588,81
$1 293,20
$1 392,10
$1 496,86
$1 869,06
$1 573,45
$1 672,35
$1 777,11
$2 149,31
$280,25
Toc - Plan #8 Oscar Insurance Company
Catastrophic

(EPO) Oscar Secure

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$218,47
$247,95
$279,19
$390,16
$592,89
$385,59
$415,07
$446,31
$557,28
$552,71
$582,19
$613,43
$724,40
$719,83
$749,31
$780,55
$891,52
$167,12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$436,94
$495,90
$558,38
$780,32
$1 185,78
$604,06
$663,02
$725,50
$947,44
$771,18
$830,14
$892,62
$1 114,56
$938,30
$997,26
$1 059,74
$1 281,68
$167,12
Toc - Plan #9 Oscar Insurance Company
Expanded Bronze

(EPO) Oscar Bronze Classic Next 2

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322,81
$366,37
$412,53
$576,51
$876,07
$569,75
$613,31
$659,47
$823,45
$816,69
$860,25
$906,41
$1 070,39
$1 063,63
$1 107,19
$1 153,35
$1 317,33
$246,94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$645,62
$732,74
$825,06
$1 153,02
$1 752,14
$892,56
$979,68
$1 072,00
$1 399,96
$1 139,50
$1 226,62
$1 318,94
$1 646,90
$1 386,44
$1 473,56
$1 565,88
$1 893,84
$246,94
Toc - Plan #10 Oscar Insurance Company
Gold

(EPO) Oscar Gold Classic

Annual Out of Pocket Expenses
Individual Family
$2,500 $5,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386,95
$439,17
$494,51
$691,07
$1 050,15
$682,96
$735,18
$790,52
$987,08
$978,97
$1 031,19
$1 086,53
$1 283,09
$1 274,98
$1 327,20
$1 382,54
$1 579,10
$296,01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$773,90
$878,34
$989,02
$1 382,14
$2 100,30
$1 069,91
$1 174,35
$1 285,03
$1 678,15
$1 365,92
$1 470,36
$1 581,04
$1 974,16
$1 661,93
$1 766,37
$1 877,05
$2 270,17
$296,01
Toc - Plan #11 Oscar Insurance Company
Expanded Bronze

(EPO) Oscar Bronze HDHP

Annual Out of Pocket Expenses
Individual Family
$5,200 $10,400 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$283,95
$322,27
$362,88
$507,12
$770,62
$501,16
$539,48
$580,09
$724,33
$718,37
$756,69
$797,30
$941,54
$935,58
$973,90
$1 014,51
$1 158,75
$217,21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$567,90
$644,54
$725,76
$1 014,24
$1 541,24
$785,11
$861,75
$942,97
$1 231,45
$1 002,32
$1 078,96
$1 160,18
$1 448,66
$1 219,53
$1 296,17
$1 377,39
$1 665,87
$217,21
Toc - Plan #12 Oscar Insurance Company
Silver

(EPO) Oscar Silver Classic Copay

Annual Out of Pocket Expenses
Individual Family
$7,000 $14,000 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372,83
$423,16
$476,47
$665,87
$1 011,85
$658,04
$708,37
$761,68
$951,08
$943,25
$993,58
$1 046,89
$1 236,29
$1 228,46
$1 278,79
$1 332,10
$1 521,50
$285,21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$745,66
$846,32
$952,94
$1 331,74
$2 023,70
$1 030,87
$1 131,53
$1 238,15
$1 616,95
$1 316,08
$1 416,74
$1 523,36
$1 902,16
$1 601,29
$1 701,95
$1 808,57
$2 187,37
$285,21
Toc - Plan #13 Oscar Insurance Company
Silver

(EPO) Oscar Silver Classic $0 Ded

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386,09
$438,20
$493,41
$689,53
$1 047,81
$681,44
$733,55
$788,76
$984,88
$976,79
$1 028,90
$1 084,11
$1 280,23
$1 272,14
$1 324,25
$1 379,46
$1 575,58
$295,35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$772,18
$876,40
$986,82
$1 379,06
$2 095,62
$1 067,53
$1 171,75
$1 282,17
$1 674,41
$1 362,88
$1 467,10
$1 577,52
$1 969,76
$1 658,23
$1 762,45
$1 872,87
$2 265,11
$295,35

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989

Toc - Plan #14 Ambetter from Superior HealthPlan
Bronze

(EPO) Ambetter Essential Care 1 (2021)

Annual Out of Pocket Expenses
Individual Family
$8,300 $16,600 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303,56
$344,53
$387,94
$542,14
$823,84
$535,78
$576,75
$620,16
$774,36
$768,00
$808,97
$852,38
$1 006,58
$1 000,22
$1 041,19
$1 084,60
$1 238,80
$232,22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$607,12
$689,06
$775,88
$1 084,28
$1 647,68
$839,34
$921,28
$1 008,10
$1 316,50
$1 071,56
$1 153,50
$1 240,32
$1 548,72
$1 303,78
$1 385,72
$1 472,54
$1 780,94
$232,22
Toc - Plan #15 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 11 (2021)

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360,57
$409,23
$460,79
$643,95
$978,55
$636,40
$685,06
$736,62
$919,78
$912,23
$960,89
$1 012,45
$1 195,61
$1 188,06
$1 236,72
$1 288,28
$1 471,44
$275,83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721,14
$818,46
$921,58
$1 287,90
$1 957,10
$996,97
$1 094,29
$1 197,41
$1 563,73
$1 272,80
$1 370,12
$1 473,24
$1 839,56
$1 548,63
$1 645,95
$1 749,07
$2 115,39
$275,83
Toc - Plan #16 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 5 (2021)

Annual Out of Pocket Expenses
Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$359,59
$408,13
$459,55
$642,21
$975,91
$634,67
$683,21
$734,63
$917,29
$909,75
$958,29
$1 009,71
$1 192,37
$1 184,83
$1 233,37
$1 284,79
$1 467,45
$275,08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$719,18
$816,26
$919,10
$1 284,42
$1 951,82
$994,26
$1 091,34
$1 194,18
$1 559,50
$1 269,34
$1 366,42
$1 469,26
$1 834,58
$1 544,42
$1 641,50
$1 744,34
$2 109,66
$275,08
Toc - Plan #17 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 10 (2021)

Annual Out of Pocket Expenses
Individual Family
$7,200 $14,400 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$314,63
$357,10
$402,09
$561,91
$853,88
$555,32
$597,79
$642,78
$802,60
$796,01
$838,48
$883,47
$1 043,29
$1 036,70
$1 079,17
$1 124,16
$1 283,98
$240,69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$629,26
$714,20
$804,18
$1 123,82
$1 707,76
$869,95
$954,89
$1 044,87
$1 364,51
$1 110,64
$1 195,58
$1 285,56
$1 605,20
$1 351,33
$1 436,27
$1 526,25
$1 845,89
$240,69
Toc - Plan #18 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 5 (2021)

Annual Out of Pocket Expenses
Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$480,09
$544,89
$613,54
$857,42
$1 302,94
$847,35
$912,15
$980,80
$1 224,68
$1 214,61
$1 279,41
$1 348,06
$1 591,94
$1 581,87
$1 646,67
$1 715,32
$1 959,20
$367,26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$960,18
$1 089,78
$1 227,08
$1 714,84
$2 605,88
$1 327,44
$1 457,04
$1 594,34
$2 082,10
$1 694,70
$1 824,30
$1 961,60
$2 449,36
$2 061,96
$2 191,56
$2 328,86
$2 816,62
$367,26
Toc - Plan #19 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021)

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328,12
$372,40
$419,32
$586,00
$890,48
$579,12
$623,40
$670,32
$837,00
$830,12
$874,40
$921,32
$1 088,00
$1 081,12
$1 125,40
$1 172,32
$1 339,00
$251,00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656,24
$744,80
$838,64
$1 172,00
$1 780,96
$907,24
$995,80
$1 089,64
$1 423,00
$1 158,24
$1 246,80
$1 340,64
$1 674,00
$1 409,24
$1 497,80
$1 591,64
$1 925,00
$251,00
Toc - Plan #20 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 12 (2021)

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353,14
$400,80
$451,30
$630,69
$958,39
$623,28
$670,94
$721,44
$900,83
$893,42
$941,08
$991,58
$1 170,97
$1 163,56
$1 211,22
$1 261,72
$1 441,11
$270,14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706,28
$801,60
$902,60
$1 261,38
$1 916,78
$976,42
$1 071,74
$1 172,74
$1 531,52
$1 246,56
$1 341,88
$1 442,88
$1 801,66
$1 516,70
$1 612,02
$1 713,02
$2 071,80
$270,14
Toc - Plan #21 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 29 (2021)

Annual Out of Pocket Expenses
Individual Family
$5,450 $10,900 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$350,04
$397,28
$447,34
$625,15
$949,98
$617,81
$665,05
$715,11
$892,92
$885,58
$932,82
$982,88
$1 160,69
$1 153,35
$1 200,59
$1 250,65
$1 428,46
$267,77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700,08
$794,56
$894,68
$1 250,30
$1 899,96
$967,85
$1 062,33
$1 162,45
$1 518,07
$1 235,62
$1 330,10
$1 430,22
$1 785,84
$1 503,39
$1 597,87
$1 697,99
$2 053,61
$267,77
Toc - Plan #22 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 25 HSA (2021)

Annual Out of Pocket Expenses
Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364,64
$413,86
$466,00
$651,23
$989,61
$643,58
$692,80
$744,94
$930,17
$922,52
$971,74
$1 023,88
$1 209,11
$1 201,46
$1 250,68
$1 302,82
$1 488,05
$278,94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729,28
$827,72
$932,00
$1 302,46
$1 979,22
$1 008,22
$1 106,66
$1 210,94
$1 581,40
$1 287,16
$1 385,60
$1 489,88
$1 860,34
$1 566,10
$1 664,54
$1 768,82
$2 139,28
$278,94
Toc - Plan #23 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 27 (2021)

Annual Out of Pocket Expenses
Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385,41
$437,43
$492,54
$688,32
$1 045,97
$680,24
$732,26
$787,37
$983,15
$975,07
$1 027,09
$1 082,20
$1 277,98
$1 269,90
$1 321,92
$1 377,03
$1 572,81
$294,83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770,82
$874,86
$985,08
$1 376,64
$2 091,94
$1 065,65
$1 169,69
$1 279,91
$1 671,47
$1 360,48
$1 464,52
$1 574,74
$1 966,30
$1 655,31
$1 759,35
$1 869,57
$2 261,13
$294,83
Toc - Plan #24 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 28 (2021)

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388,55
$440,99
$496,55
$693,92
$1 054,48
$685,78
$738,22
$793,78
$991,15
$983,01
$1 035,45
$1 091,01
$1 288,38
$1 280,24
$1 332,68
$1 388,24
$1 585,61
$297,23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777,10
$881,98
$993,10
$1 387,84
$2 108,96
$1 074,33
$1 179,21
$1 290,33
$1 685,07
$1 371,56
$1 476,44
$1 587,56
$1 982,30
$1 668,79
$1 773,67
$1 884,79
$2 279,53
$297,23
Toc - Plan #25 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 15 (2021)

Annual Out of Pocket Expenses
Individual Family
$1,150 $2,300 Annual Deductible
$4,450 $8,900 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$490,37
$556,55
$626,68
$875,78
$1 330,83
$865,49
$931,67
$1 001,80
$1 250,90
$1 240,61
$1 306,79
$1 376,92
$1 626,02
$1 615,73
$1 681,91
$1 752,04
$2 001,14
$375,12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$980,74
$1 113,10
$1 253,36
$1 751,56
$2 661,66
$1 355,86
$1 488,22
$1 628,48
$2 126,68
$1 730,98
$1 863,34
$2 003,60
$2 501,80
$2 106,10
$2 238,46
$2 378,72
$2 876,92
$375,12
Toc - Plan #26 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 5 (2021) + Vision

Annual Out of Pocket Expenses
Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$485,60
$551,15
$620,59
$867,27
$1 317,90
$857,08
$922,63
$992,07
$1 238,75
$1 228,56
$1 294,11
$1 363,55
$1 610,23
$1 600,04
$1 665,59
$1 735,03
$1 981,71
$371,48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$971,20
$1 102,30
$1 241,18
$1 734,54
$2 635,80
$1 342,68
$1 473,78
$1 612,66
$2 106,02
$1 714,16
$1 845,26
$1 984,14
$2 477,50
$2 085,64
$2 216,74
$2 355,62
$2 848,98
$371,48
Toc - Plan #27 Ambetter from Superior HealthPlan
Bronze

(EPO) Ambetter Essential Care 1 (2021) + Vision

Annual Out of Pocket Expenses
Individual Family
$8,300 $16,600 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$307,05
$348,49
$392,39
$548,37
$833,30
$541,93
$583,37
$627,27
$783,25
$776,81
$818,25
$862,15
$1 018,13
$1 011,69
$1 053,13
$1 097,03
$1 253,01
$234,88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$614,10
$696,98
$784,78
$1 096,74
$1 666,60
$848,98
$931,86
$1 019,66
$1 331,62
$1 083,86
$1 166,74
$1 254,54
$1 566,50
$1 318,74
$1 401,62
$1 489,42
$1 801,38
$234,88
Toc - Plan #28 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 10 (2021) + Vision

Annual Out of Pocket Expenses
Individual Family
$7,200 $14,400 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$318,24
$361,19
$406,70
$568,36
$863,69
$561,69
$604,64
$650,15
$811,81
$805,14
$848,09
$893,60
$1 055,26
$1 048,59
$1 091,54
$1 137,05
$1 298,71
$243,45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636,48
$722,38
$813,40
$1 136,72
$1 727,38
$879,93
$965,83
$1 056,85
$1 380,17
$1 123,38
$1 209,28
$1 300,30
$1 623,62
$1 366,83
$1 452,73
$1 543,75
$1 867,07
$243,45
Toc - Plan #29 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 11 (2021) + Vision

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364,71
$413,93
$466,08
$651,35
$989,78
$643,70
$692,92
$745,07
$930,34
$922,69
$971,91
$1 024,06
$1 209,33
$1 201,68
$1 250,90
$1 303,05
$1 488,32
$278,99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729,42
$827,86
$932,16
$1 302,70
$1 979,56
$1 008,41
$1 106,85
$1 211,15
$1 581,69
$1 287,40
$1 385,84
$1 490,14
$1 860,68
$1 566,39
$1 664,83
$1 769,13
$2 139,67
$278,99
Toc - Plan #30 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 5 (2021) + Vision

Annual Out of Pocket Expenses
Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363,72
$412,81
$464,82
$649,59
$987,11
$641,96
$691,05
$743,06
$927,83
$920,20
$969,29
$1 021,30
$1 206,07
$1 198,44
$1 247,53
$1 299,54
$1 484,31
$278,24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727,44
$825,62
$929,64
$1 299,18
$1 974,22
$1 005,68
$1 103,86
$1 207,88
$1 577,42
$1 283,92
$1 382,10
$1 486,12
$1 855,66
$1 562,16
$1 660,34
$1 764,36
$2 133,90
$278,24
Toc - Plan #31 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021) + Vision

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$331,88
$376,68
$424,13
$592,73
$900,70
$585,76
$630,56
$678,01
$846,61
$839,64
$884,44
$931,89
$1 100,49
$1 093,52
$1 138,32
$1 185,77
$1 354,37
$253,88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$663,76
$753,36
$848,26
$1 185,46
$1 801,40
$917,64
$1 007,24
$1 102,14
$1 439,34
$1 171,52
$1 261,12
$1 356,02
$1 693,22
$1 425,40
$1 515,00
$1 609,90
$1 947,10
$253,88
Toc - Plan #32 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 12 (2021) + Vision

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357,19
$405,40
$456,48
$637,93
$969,39
$630,43
$678,64
$729,72
$911,17
$903,67
$951,88
$1 002,96
$1 184,41
$1 176,91
$1 225,12
$1 276,20
$1 457,65
$273,24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714,38
$810,80
$912,96
$1 275,86
$1 938,78
$987,62
$1 084,04
$1 186,20
$1 549,10
$1 260,86
$1 357,28
$1 459,44
$1 822,34
$1 534,10
$1 630,52
$1 732,68
$2 095,58
$273,24
Toc - Plan #33 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 25 HSA (2021) + Vision

Annual Out of Pocket Expenses
Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$368,83
$418,61
$471,35
$658,71
$1 000,97
$650,97
$700,75
$753,49
$940,85
$933,11
$982,89
$1 035,63
$1 222,99
$1 215,25
$1 265,03
$1 317,77
$1 505,13
$282,14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737,66
$837,22
$942,70
$1 317,42
$2 001,94
$1 019,80
$1 119,36
$1 224,84
$1 599,56
$1 301,94
$1 401,50
$1 506,98
$1 881,70
$1 584,08
$1 683,64
$1 789,12
$2 163,84
$282,14
Toc - Plan #34 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 27 (2021) + Vision

Annual Out of Pocket Expenses
Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389,83
$442,45
$498,19
$696,22
$1 057,98
$688,04
$740,66
$796,40
$994,43
$986,25
$1 038,87
$1 094,61
$1 292,64
$1 284,46
$1 337,08
$1 392,82
$1 590,85
$298,21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$779,66
$884,90
$996,38
$1 392,44
$2 115,96
$1 077,87
$1 183,11
$1 294,59
$1 690,65
$1 376,08
$1 481,32
$1 592,80
$1 988,86
$1 674,29
$1 779,53
$1 891,01
$2 287,07
$298,21
Toc - Plan #35 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 28 (2021) + Vision

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393,01
$446,05
$502,25
$701,89
$1 066,59
$693,65
$746,69
$802,89
$1 002,53
$994,29
$1 047,33
$1 103,53
$1 303,17
$1 294,93
$1 347,97
$1 404,17
$1 603,81
$300,64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786,02
$892,10
$1 004,50
$1 403,78
$2 133,18
$1 086,66
$1 192,74
$1 305,14
$1 704,42
$1 387,30
$1 493,38
$1 605,78
$2 005,06
$1 687,94
$1 794,02
$1 906,42
$2 305,70
$300,64
Toc - Plan #36 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 15 (2021) + Vision

Annual Out of Pocket Expenses
Individual Family
$1,150 $2,300 Annual Deductible
$4,450 $8,900 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$496,00
$562,94
$633,87
$885,83
$1 346,11
$875,43
$942,37
$1 013,30
$1 265,26
$1 254,86
$1 321,80
$1 392,73
$1 644,69
$1 634,29
$1 701,23
$1 772,16
$2 024,12
$379,43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$992,00
$1 125,88
$1 267,74
$1 771,66
$2 692,22
$1 371,43
$1 505,31
$1 647,17
$2 151,09
$1 750,86
$1 884,74
$2 026,60
$2 530,52
$2 130,29
$2 264,17
$2 406,03
$2 909,95
$379,43
Toc - Plan #37 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 5 (2021) + Vision + Adult Dental

Annual Out of Pocket Expenses
Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$503,01
$570,90
$642,83
$898,35
$1 365,14
$887,80
$955,69
$1 027,62
$1 283,14
$1 272,59
$1 340,48
$1 412,41
$1 667,93
$1 657,38
$1 725,27
$1 797,20
$2 052,72
$384,79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 006,02
$1 141,80
$1 285,66
$1 796,70
$2 730,28
$1 390,81
$1 526,59
$1 670,45
$2 181,49
$1 775,60
$1 911,38
$2 055,24
$2 566,28
$2 160,39
$2 296,17
$2 440,03
$2 951,07
$384,79
Toc - Plan #38 Ambetter from Superior HealthPlan
Bronze

(EPO) Ambetter Essential Care 1 (2021) + Vision + Adult Dental

Annual Out of Pocket Expenses
Individual Family
$8,300 $16,600 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$318,05
$360,98
$406,46
$568,02
$863,17
$561,35
$604,28
$649,76
$811,32
$804,65
$847,58
$893,06
$1 054,62
$1 047,95
$1 090,88
$1 136,36
$1 297,92
$243,30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636,10
$721,96
$812,92
$1 136,04
$1 726,34
$879,40
$965,26
$1 056,22
$1 379,34
$1 122,70
$1 208,56
$1 299,52
$1 622,64
$1 366,00
$1 451,86
$1 542,82
$1 865,94
$243,30
Toc - Plan #39 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 10 (2021) + Vision + Adult Dental

Annual Out of Pocket Expenses
Individual Family
$7,200 $14,400 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$329,65
$374,14
$421,28
$588,74
$894,64
$581,82
$626,31
$673,45
$840,91
$833,99
$878,48
$925,62
$1 093,08
$1 086,16
$1 130,65
$1 177,79
$1 345,25
$252,17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$659,30
$748,28
$842,56
$1 177,48
$1 789,28
$911,47
$1 000,45
$1 094,73
$1 429,65
$1 163,64
$1 252,62
$1 346,90
$1 681,82
$1 415,81
$1 504,79
$1 599,07
$1 933,99
$252,17
Toc - Plan #40 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 11 (2021) + Vision + Adult Dental

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$377,78
$428,77
$482,79
$674,69
$1 025,26
$666,77
$717,76
$771,78
$963,68
$955,76
$1 006,75
$1 060,77
$1 252,67
$1 244,75
$1 295,74
$1 349,76
$1 541,66
$288,99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$755,56
$857,54
$965,58
$1 349,38
$2 050,52
$1 044,55
$1 146,53
$1 254,57
$1 638,37
$1 333,54
$1 435,52
$1 543,56
$1 927,36
$1 622,53
$1 724,51
$1 832,55
$2 216,35
$288,99
Toc - Plan #41 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 5 (2021) + Vision + Adult Dental

Annual Out of Pocket Expenses
Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376,76
$427,61
$481,48
$672,87
$1 022,49
$664,97
$715,82
$769,69
$961,08
$953,18
$1 004,03
$1 057,90
$1 249,29
$1 241,39
$1 292,24
$1 346,11
$1 537,50
$288,21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753,52
$855,22
$962,96
$1 345,74
$2 044,98
$1 041,73
$1 143,43
$1 251,17
$1 633,95
$1 329,94
$1 431,64
$1 539,38
$1 922,16
$1 618,15
$1 719,85
$1 827,59
$2 210,37
$288,21
Toc - Plan #42 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021) + Vision + Adult Dental

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343,78
$390,18
$439,34
$613,97
$932,99
$606,76
$653,16
$702,32
$876,95
$869,74
$916,14
$965,30
$1 139,93
$1 132,72
$1 179,12
$1 228,28
$1 402,91
$262,98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687,56
$780,36
$878,68
$1 227,94
$1 865,98
$950,54
$1 043,34
$1 141,66
$1 490,92
$1 213,52
$1 306,32
$1 404,64
$1 753,90
$1 476,50
$1 569,30
$1 667,62
$2 016,88
$262,98
Toc - Plan #43 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 12 (2021) + Vision + Adult Dental

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370,00
$419,93
$472,84
$660,80
$1 004,14
$653,04
$702,97
$755,88
$943,84
$936,08
$986,01
$1 038,92
$1 226,88
$1 219,12
$1 269,05
$1 321,96
$1 509,92
$283,04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740,00
$839,86
$945,68
$1 321,60
$2 008,28
$1 023,04
$1 122,90
$1 228,72
$1 604,64
$1 306,08
$1 405,94
$1 511,76
$1 887,68
$1 589,12
$1 688,98
$1 794,80
$2 170,72
$283,04
Toc - Plan #44 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 25 HSA (2021) + Vision + Adult Dental

Annual Out of Pocket Expenses
Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382,05
$433,61
$488,24
$682,32
$1 036,85
$674,31
$725,87
$780,50
$974,58
$966,57
$1 018,13
$1 072,76
$1 266,84
$1 258,83
$1 310,39
$1 365,02
$1 559,10
$292,26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764,10
$867,22
$976,48
$1 364,64
$2 073,70
$1 056,36
$1 159,48
$1 268,74
$1 656,90
$1 348,62
$1 451,74
$1 561,00
$1 949,16
$1 640,88
$1 744,00
$1 853,26
$2 241,42
$292,26
Toc - Plan #45 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 27 (2021) + Vision + Adult Dental

Annual Out of Pocket Expenses
Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403,81
$458,31
$516,05
$721,18
$1 095,90
$712,71
$767,21
$824,95
$1 030,08
$1 021,61
$1 076,11
$1 133,85
$1 338,98
$1 330,51
$1 385,01
$1 442,75
$1 647,88
$308,90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$807,62
$916,62
$1 032,10
$1 442,36
$2 191,80
$1 116,52
$1 225,52
$1 341,00
$1 751,26
$1 425,42
$1 534,42
$1 649,90
$2 060,16
$1 734,32
$1 843,32
$1 958,80
$2 369,06
$308,90
Toc - Plan #46 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 28 (2021) + Vision + Adult Dental

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407,09
$462,04
$520,25
$727,05
$1 104,82
$718,51
$773,46
$831,67
$1 038,47
$1 029,93
$1 084,88
$1 143,09
$1 349,89
$1 341,35
$1 396,30
$1 454,51
$1 661,31
$311,42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814,18
$924,08
$1 040,50
$1 454,10
$2 209,64
$1 125,60
$1 235,50
$1 351,92
$1 765,52
$1 437,02
$1 546,92
$1 663,34
$2 076,94
$1 748,44
$1 858,34
$1 974,76
$2 388,36
$311,42
Toc - Plan #47 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 15 (2021) + Vision + Adult Dental

Annual Out of Pocket Expenses
Individual Family
$1,150 $2,300 Annual Deductible
$4,450 $8,900 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$513,77
$583,12
$656,59
$917,58
$1 394,36
$906,80
$976,15
$1 049,62
$1 310,61
$1 299,83
$1 369,18
$1 442,65
$1 703,64
$1 692,86
$1 762,21
$1 835,68
$2 096,67
$393,03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1 027,54
$1 166,24
$1 313,18
$1 835,16
$2 788,72
$1 420,57
$1 559,27
$1 706,21
$2 228,19
$1 813,60
$1 952,30
$2 099,24
$2 621,22
$2 206,63
$2 345,33
$2 492,27
$3 014,25
$393,03

ADVERTISEMENT

Blue Cross and Blue Shield of Texas

Local: 1-888-697-0683 | Toll Free: 1-888-697-0683 | TTY: 1-800-735-2989

Toc - Plan #48 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO_ 206

Annual Out of Pocket Expenses
Individual Family
$750 $2,250 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415,20
$471,25
$530,62
$741,54
$1 126,85
$732,83
$788,88
$848,25
$1 059,17
$1 050,46
$1 106,51
$1 165,88
$1 376,80
$1 368,09
$1 424,14
$1 483,51
$1 694,43
$317,63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$830,40
$942,50
$1 061,24
$1 483,08
$2 253,70
$1 148,03
$1 260,13
$1 378,87
$1 800,71
$1 465,66
$1 577,76
$1 696,50
$2 118,34
$1 783,29
$1 895,39
$2 014,13
$2 435,97
$317,63
Toc - Plan #49 Blue Cross and Blue Shield of Texas
Catastrophic

(HMO) Blue Advantage Security HMO_ 200

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$283,98
$322,32
$362,93
$507,19
$770,72
$501,22
$539,56
$580,17
$724,43
$718,46
$756,80
$797,41
$941,67
$935,70
$974,04
$1 014,65
$1 158,91
$217,24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$567,96
$644,64
$725,86
$1 014,38
$1 541,44
$785,20
$861,88
$943,10
$1 231,62
$1 002,44
$1 079,12
$1 160,34
$1 448,86
$1 219,68
$1 296,36
$1 377,58
$1 666,10
$217,24
Toc - Plan #50 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO_ 205

Annual Out of Pocket Expenses
Individual Family
$1,900 $5,700 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414,91
$470,92
$530,25
$741,02
$1 126,06
$732,31
$788,32
$847,65
$1 058,42
$1 049,71
$1 105,72
$1 165,05
$1 375,82
$1 367,11
$1 423,12
$1 482,45
$1 693,22
$317,40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$829,82
$941,84
$1 060,50
$1 482,04
$2 252,12
$1 147,22
$1 259,24
$1 377,90
$1 799,44
$1 464,62
$1 576,64
$1 695,30
$2 116,84
$1 782,02
$1 894,04
$2 012,70
$2 434,24
$317,40
Toc - Plan #51 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO_ 204

Annual Out of Pocket Expenses
Individual Family
$6,000 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312,53
$354,72
$399,41
$558,18
$848,20
$551,61
$593,80
$638,49
$797,26
$790,69
$832,88
$877,57
$1 036,34
$1 029,77
$1 071,96
$1 116,65
$1 275,42
$239,08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625,06
$709,44
$798,82
$1 116,36
$1 696,40
$864,14
$948,52
$1 037,90
$1 355,44
$1 103,22
$1 187,60
$1 276,98
$1 594,52
$1 342,30
$1 426,68
$1 516,06
$1 833,60
$239,08
Toc - Plan #52 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO_ 301

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$309,83
$351,66
$395,97
$553,36
$840,89
$546,85
$588,68
$632,99
$790,38
$783,87
$825,70
$870,01
$1 027,40
$1 020,89
$1 062,72
$1 107,03
$1 264,42
$237,02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619,66
$703,32
$791,94
$1 106,72
$1 681,78
$856,68
$940,34
$1 028,96
$1 343,74
$1 093,70
$1 177,36
$1 265,98
$1 580,76
$1 330,72
$1 414,38
$1 503,00
$1 817,78
$237,02
Toc - Plan #53 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Plus Gold_ 203

Annual Out of Pocket Expenses
Individual Family
$750 $2,250 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$459,02
$520,99
$586,63
$819,81
$1 245,78
$810,17
$872,14
$937,78
$1 170,96
$1 161,32
$1 223,29
$1 288,93
$1 522,11
$1 512,47
$1 574,44
$1 640,08
$1 873,26
$351,15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$918,04
$1 041,98
$1 173,26
$1 639,62
$2 491,56
$1 269,19
$1 393,13
$1 524,41
$1 990,77
$1 620,34
$1 744,28
$1 875,56
$2 341,92
$1 971,49
$2 095,43
$2 226,71
$2 693,07
$351,15
Toc - Plan #54 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver_ 202

Annual Out of Pocket Expenses
Individual Family
$1,250 $3,750 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$456,07
$517,64
$582,86
$814,54
$1 237,77
$804,96
$866,53
$931,75
$1 163,43
$1 153,85
$1 215,42
$1 280,64
$1 512,32
$1 502,74
$1 564,31
$1 629,53
$1 861,21
$348,89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$912,14
$1 035,28
$1 165,72
$1 629,08
$2 475,54
$1 261,03
$1 384,17
$1 514,61
$1 977,97
$1 609,92
$1 733,06
$1 863,50
$2 326,86
$1 958,81
$2 081,95
$2 212,39
$2 675,75
$348,89
Toc - Plan #55 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Plus Bronze_ 303

Annual Out of Pocket Expenses
Individual Family
$4,900 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$345,70
$392,37
$441,81
$617,42
$938,23
$610,16
$656,83
$706,27
$881,88
$874,62
$921,29
$970,73
$1 146,34
$1 139,08
$1 185,75
$1 235,19
$1 410,80
$264,46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$691,40
$784,74
$883,62
$1 234,84
$1 876,46
$955,86
$1 049,20
$1 148,08
$1 499,30
$1 220,32
$1 313,66
$1 412,54
$1 763,76
$1 484,78
$1 578,12
$1 677,00
$2 028,22
$264,46
Toc - Plan #56 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Plus Bronze_ 305

Annual Out of Pocket Expenses
Individual Family
$5,000 $15,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322,98
$366,59
$412,77
$576,85
$876,58
$570,06
$613,67
$659,85
$823,93
$817,14
$860,75
$906,93
$1 071,01
$1 064,22
$1 107,83
$1 154,01
$1 318,09
$247,08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$645,96
$733,18
$825,54
$1 153,70
$1 753,16
$893,04
$980,26
$1 072,62
$1 400,78
$1 140,12
$1 227,34
$1 319,70
$1 647,86
$1 387,20
$1 474,42
$1 566,78
$1 894,94
$247,08
Toc - Plan #57 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) MyBlue Health Bronze_ 402

Annual Out of Pocket Expenses
Individual Family
$7,400 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$237,63
$269,71
$303,69
$424,41
$644,93
$419,42
$451,50
$485,48
$606,20
$601,21
$633,29
$667,27
$787,99
$783,00
$815,08
$849,06
$969,78
$181,79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$475,26
$539,42
$607,38
$848,82
$1 289,86
$657,05
$721,21
$789,17
$1 030,61
$838,84
$903,00
$970,96
$1 212,40
$1 020,63
$1 084,79
$1 152,75
$1 394,19
$181,79
Toc - Plan #58 Blue Cross and Blue Shield of Texas
Gold

(HMO) MyBlue Health Gold_ 403

Annual Out of Pocket Expenses
Individual Family
$1,100 $3,300 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316,51
$359,23
$404,49
$565,28
$859,00
$558,64
$601,36
$646,62
$807,41
$800,77
$843,49
$888,75
$1 049,54
$1 042,90
$1 085,62
$1 130,88
$1 291,67
$242,13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$633,02
$718,46
$808,98
$1 130,56
$1 718,00
$875,15
$960,59
$1 051,11
$1 372,69
$1 117,28
$1 202,72
$1 293,24
$1 614,82
$1 359,41
$1 444,85
$1 535,37
$1 856,95
$242,13
Toc - Plan #59 Blue Cross and Blue Shield of Texas
Silver

(HMO) MyBlue Health Silver_ 405

Annual Out of Pocket Expenses
Individual Family
$3,300 $9,900 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312,52
$354,71
$399,40
$558,16
$848,18
$551,60
$593,79
$638,48
$797,24
$790,68
$832,87
$877,56
$1 036,32
$1 029,76
$1 071,95
$1 116,64
$1 275,40
$239,08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625,04
$709,42
$798,80
$1 116,32
$1 696,36
$864,12
$948,50
$1 037,88
$1 355,40
$1 103,20
$1 187,58
$1 276,96
$1 594,48
$1 342,28
$1 426,66
$1 516,04
$1 833,56
$239,08

ADVERTISEMENT

Scott and White Health Plan

Local: 1-254-298-3000x20300 | Toll Free: 1-800-321-7947 | TTY: 1-800-735-2989

Toc - Plan #60 Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs)

Annual Out of Pocket Expenses
Individual Family
$2,000 $4,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384,94
$436,91
$491,96
$687,51
$1 044,73
$679,42
$731,39
$786,44
$981,99
$973,90
$1 025,87
$1 080,92
$1 276,47
$1 268,38
$1 320,35
$1 375,40
$1 570,95
$294,48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$769,88
$873,82
$983,92
$1 375,02
$2 089,46
$1 064,36
$1 168,30
$1 278,40
$1 669,50
$1 358,84
$1 462,78
$1 572,88
$1 963,98
$1 653,32
$1 757,26
$1 867,36
$2 258,46
$294,48
Toc - Plan #61 Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 003 ($0 Preventive Care and Preventive Rx Drugs)

Annual Out of Pocket Expenses
Individual Family
$3,000 $6,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373,90
$424,37
$477,84
$667,78
$1 014,76
$659,93
$710,40
$763,87
$953,81
$945,96
$996,43
$1 049,90
$1 239,84
$1 231,99
$1 282,46
$1 335,93
$1 525,87
$286,03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747,80
$848,74
$955,68
$1 335,56
$2 029,52
$1 033,83
$1 134,77
$1 241,71
$1 621,59
$1 319,86
$1 420,80
$1 527,74
$1 907,62
$1 605,89
$1 706,83
$1 813,77
$2 193,65
$286,03
Toc - Plan #62 Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 004 ($0 deductible, $15 PCP visit, $0 Preventive Care and Preventive Rx Drugs)

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414,23
$470,15
$529,38
$739,81
$1 124,22
$731,12
$787,04
$846,27
$1 056,70
$1 048,01
$1 103,93
$1 163,16
$1 373,59
$1 364,90
$1 420,82
$1 480,05
$1 690,48
$316,89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$828,46
$940,30
$1 058,76
$1 479,62
$2 248,44
$1 145,35
$1 257,19
$1 375,65
$1 796,51
$1 462,24
$1 574,08
$1 692,54
$2 113,40
$1 779,13
$1 890,97
$2 009,43
$2 430,29
$316,89
Toc - Plan #63 Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 005 ($0 deductible copay only, $0 Preventive Care and Preventive Rx Drugs)

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398,59
$452,40
$509,40
$711,88
$1 081,77
$703,51
$757,32
$814,32
$1 016,80
$1 008,43
$1 062,24
$1 119,24
$1 321,72
$1 313,35
$1 367,16
$1 424,16
$1 626,64
$304,92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$797,18
$904,80
$1 018,80
$1 423,76
$2 163,54
$1 102,10
$1 209,72
$1 323,72
$1 728,68
$1 407,02
$1 514,64
$1 628,64
$2 033,60
$1 711,94
$1 819,56
$1 933,56
$2 338,52
$304,92
Toc - Plan #64 Scott and White Health Plan
Expanded Bronze

(HMO) BSW Savers Bronze HMO H S A 006 ($0 Preventive Care and Preventive Rx Drugs)

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312,45
$354,63
$399,31
$558,03
$847,98
$551,47
$593,65
$638,33
$797,05
$790,49
$832,67
$877,35
$1 036,07
$1 029,51
$1 071,69
$1 116,37
$1 275,09
$239,02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$624,90
$709,26
$798,62
$1 116,06
$1 695,96
$863,92
$948,28
$1 037,64
$1 355,08
$1 102,94
$1 187,30
$1 276,66
$1 594,10
$1 341,96
$1 426,32
$1 515,68
$1 833,12
$239,02
Toc - Plan #65 Scott and White Health Plan
Expanded Bronze

(HMO) BSW Vital Bronze HMO 007 ($20 Generic Rx Drugs, $0 Preventive Care and Preventive Rx Drugs)

Annual Out of Pocket Expenses
Individual Family
$4,000 $8,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$318,76
$361,79
$407,37
$569,30
$865,11
$562,61
$605,64
$651,22
$813,15
$806,46
$849,49
$895,07
$1 057,00
$1 050,31
$1 093,34
$1 138,92
$1 300,85
$243,85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$637,52
$723,58
$814,74
$1 138,60
$1 730,22
$881,37
$967,43
$1 058,59
$1 382,45
$1 125,22
$1 211,28
$1 302,44
$1 626,30
$1 369,07
$1 455,13
$1 546,29
$1 870,15
$243,85
Toc - Plan #66 Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 008 ($25 PCP visit, $0 Preventive Care and Preventive Rx Drugs)

Annual Out of Pocket Expenses
Individual Family
$7,800 $15,600 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364,20
$413,36
$465,44
$650,45
$988,43
$642,81
$691,97
$744,05
$929,06
$921,42
$970,58
$1 022,66
$1 207,67
$1 200,03
$1 249,19
$1 301,27
$1 486,28
$278,61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728,40
$826,72
$930,88
$1 300,90
$1 976,86
$1 007,01
$1 105,33
$1 209,49
$1 579,51
$1 285,62
$1 383,94
$1 488,10
$1 858,12
$1 564,23
$1 662,55
$1 766,71
$2 136,73
$278,61
Toc - Plan #67 Scott and White Health Plan
Expanded Bronze

(HMO) BSW Vital Bronze HMO 009 (No limit on PCP visit copay, $0 Preventive Care and Preventive Rx Drugs)

Annual Out of Pocket Expenses
Individual Family
$7,600 $15,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310,36
$352,26
$396,64
$554,30
$842,31
$547,78
$589,68
$634,06
$791,72
$785,20
$827,10
$871,48
$1 029,14
$1 022,62
$1 064,52
$1 108,90
$1 266,56
$237,42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620,72
$704,52
$793,28
$1 108,60
$1 684,62
$858,14
$941,94
$1 030,70
$1 346,02
$1 095,56
$1 179,36
$1 268,12
$1 583,44
$1 332,98
$1 416,78
$1 505,54
$1 820,86
$237,42

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-2025 | Toll Free: 1-888-560-2025

Toc - Plan #68 Molina Healthcare
Gold

(HMO) Molina Gold 3

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354,37
$402,21
$452,89
$632,91
$961,77
$625,47
$673,31
$723,99
$904,01
$896,57
$944,41
$995,09
$1 175,11
$1 167,67
$1 215,51
$1 266,19
$1 446,21
$271,10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708,74
$804,42
$905,78
$1 265,82
$1 923,54
$979,84
$1 075,52
$1 176,88
$1 536,92
$1 250,94
$1 346,62
$1 447,98
$1 808,02
$1 522,04
$1 617,72
$1 719,08
$2 079,12
$271,10
Toc - Plan #69 Molina Healthcare
Silver

(HMO) Molina Silver 3 250

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333,41
$378,42
$426,09
$595,47
$904,87
$588,47
$633,48
$681,15
$850,53
$843,53
$888,54
$936,21
$1 105,59
$1 098,59
$1 143,60
$1 191,27
$1 360,65
$255,06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666,82
$756,84
$852,18
$1 190,94
$1 809,74
$921,88
$1 011,90
$1 107,24
$1 446,00
$1 176,94
$1 266,96
$1 362,30
$1 701,06
$1 432,00
$1 522,02
$1 617,36
$1 956,12
$255,06
Toc - Plan #70 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Annual Out of Pocket Expenses
Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356,69
$404,84
$455,85
$637,04
$968,05
$629,56
$677,71
$728,72
$909,91
$902,43
$950,58
$1 001,59
$1 182,78
$1 175,30
$1 223,45
$1 274,46
$1 455,65
$272,87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713,38
$809,68
$911,70
$1 274,08
$1 936,10
$986,25
$1 082,55
$1 184,57
$1 546,95
$1 259,12
$1 355,42
$1 457,44
$1 819,82
$1 531,99
$1 628,29
$1 730,31
$2 092,69
$272,87
Toc - Plan #71 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332,53
$377,43
$424,98
$593,91
$902,50
$586,92
$631,82
$679,37
$848,30
$841,31
$886,21
$933,76
$1 102,69
$1 095,70
$1 140,60
$1 188,15
$1 357,08
$254,39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665,06
$754,86
$849,96
$1 187,82
$1 805,00
$919,45
$1 009,25
$1 104,35
$1 442,21
$1 173,84
$1 263,64
$1 358,74
$1 696,60
$1 428,23
$1 518,03
$1 613,13
$1 950,99
$254,39
Toc - Plan #72 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

Annual Out of Pocket Expenses
Individual Family
$6,100 $12,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$235,40
$267,18
$300,84
$420,43
$638,88
$415,48
$447,26
$480,92
$600,51
$595,56
$627,34
$661,00
$780,59
$775,64
$807,42
$841,08
$960,67
$180,08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$470,80
$534,36
$601,68
$840,86
$1 277,76
$650,88
$714,44
$781,76
$1 020,94
$830,96
$894,52
$961,84
$1 201,02
$1 011,04
$1 074,60
$1 141,92
$1 381,10
$180,08
Toc - Plan #73 Molina Healthcare
Silver

(HMO) Constant Care Silver 2 250

Annual Out of Pocket Expenses
Individual Family
$5,200 $10,400 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332,23
$377,08
$424,59
$593,36
$901,67
$586,39
$631,24
$678,75
$847,52
$840,55
$885,40
$932,91
$1 101,68
$1 094,71
$1 139,56
$1 187,07
$1 355,84
$254,16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664,46
$754,16
$849,18
$1 186,72
$1 803,34
$918,62
$1 008,32
$1 103,34
$1 440,88
$1 172,78
$1 262,48
$1 357,50
$1 695,04
$1 426,94
$1 516,64
$1 611,66
$1 949,20
$254,16
Toc - Plan #74 Molina Healthcare
Bronze

(HMO) Core Care Bronze 2

Annual Out of Pocket Expenses
Individual Family
$8,000 $16,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$233,37
$264,88
$298,25
$416,80
$633,37
$411,90
$443,41
$476,78
$595,33
$590,43
$621,94
$655,31
$773,86
$768,96
$800,47
$833,84
$952,39
$178,53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$466,74
$529,76
$596,50
$833,60
$1 266,74
$645,27
$708,29
$775,03
$1 012,13
$823,80
$886,82
$953,56
$1 190,66
$1 002,33
$1 065,35
$1 132,09
$1 369,19
$178,53
Toc - Plan #75 Molina Healthcare
Silver

(HMO) Constant Care Silver 4 250

Annual Out of Pocket Expenses
Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328,80
$373,19
$420,20
$587,23
$892,36
$580,33
$624,72
$671,73
$838,76
$831,86
$876,25
$923,26
$1 090,29
$1 083,39
$1 127,78
$1 174,79
$1 341,82
$251,53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$657,60
$746,38
$840,40
$1 174,46
$1 784,72
$909,13
$997,91
$1 091,93
$1 425,99
$1 160,66
$1 249,44
$1 343,46
$1 677,52
$1 412,19
$1 500,97
$1 594,99
$1 929,05
$251,53
Toc - Plan #76 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$246,33
$279,58
$314,80
$439,94
$668,53
$434,77
$468,02
$503,24
$628,38
$623,21
$656,46
$691,68
$816,82
$811,65
$844,90
$880,12
$1 005,26
$188,44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$492,66
$559,16
$629,60
$879,88
$1 337,06
$681,10
$747,60
$818,04
$1 068,32
$869,54
$936,04
$1 006,48
$1 256,76
$1 057,98
$1 124,48
$1 194,92
$1 445,20
$188,44
Toc - Plan #77 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 5

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$239,65
$272,00
$306,27
$428,01
$650,41
$422,98
$455,33
$489,60
$611,34
$606,31
$638,66
$672,93
$794,67
$789,64
$821,99
$856,26
$978,00
$183,33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$479,30
$544,00
$612,54
$856,02
$1 300,82
$662,63
$727,33
$795,87
$1 039,35
$845,96
$910,66
$979,20
$1 222,68
$1 029,29
$1 093,99
$1 162,53
$1 406,01
$183,33
Toc - Plan #78 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Annual Out of Pocket Expenses
Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360,15
$408,77
$460,28
$643,23
$977,46
$635,67
$684,29
$735,80
$918,75
$911,19
$959,81
$1 011,32
$1 194,27
$1 186,71
$1 235,33
$1 286,84
$1 469,79
$275,52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720,30
$817,54
$920,56
$1 286,46
$1 954,92
$995,82
$1 093,06
$1 196,08
$1 561,98
$1 271,34
$1 368,58
$1 471,60
$1 837,50
$1 546,86
$1 644,10
$1 747,12
$2 113,02
$275,52
Toc - Plan #79 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250 + Vision

Annual Out of Pocket Expenses
Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$336,00
$381,36
$429,41
$600,10
$911,91
$593,04
$638,40
$686,45
$857,14
$850,08
$895,44
$943,49
$1 114,18
$1 107,12
$1 152,48
$1 200,53
$1 371,22
$257,04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672,00
$762,72
$858,82
$1 200,20
$1 823,82
$929,04
$1 019,76
$1 115,86
$1 457,24
$1 186,08
$1 276,80
$1 372,90
$1 714,28
$1 443,12
$1 533,84
$1 629,94
$1 971,32
$257,04
Toc - Plan #80 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1 + Vision

Annual Out of Pocket Expenses
Individual Family
$6,100 $12,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$238,87
$271,12
$305,27
$426,62
$648,29
$421,60
$453,85
$488,00
$609,35
$604,33
$636,58
$670,73
$792,08
$787,06
$819,31
$853,46
$974,81
$182,73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$477,74
$542,24
$610,54
$853,24
$1 296,58
$660,47
$724,97
$793,27
$1 035,97
$843,20
$907,70
$976,00
$1 218,70
$1 025,93
$1 090,43
$1 158,73
$1 401,43
$182,73

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Friday Health Plans

Local: 1-844-451-4444 | Toll Free: 1-844-451-4444 | TTY: 1-800-659-2656

Toc - Plan #81 Friday Health Plans
Catastrophic

(EPO) Friday Catastrophic

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$197,36
$224,00
$252,23
$352,49
$535,64
$348,34
$374,98
$403,21
$503,47
$499,32
$525,96
$554,19
$654,45
$650,30
$676,94
$705,17
$805,43
$150,98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$394,72
$448,00
$504,46
$704,98
$1 071,28
$545,70
$598,98
$655,44
$855,96
$696,68
$749,96
$806,42
$1 006,94
$847,66
$900,94
$957,40
$1 157,92
$150,98
Toc - Plan #82 Friday Health Plans
Bronze

(EPO) Friday Bronze

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$213,70
$242,55
$273,11
$381,67
$579,98
$377,18
$406,03
$436,59
$545,15
$540,66
$569,51
$600,07
$708,63
$704,14
$732,99
$763,55
$872,11
$163,48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$427,40
$485,10
$546,22
$763,34
$1 159,96
$590,88
$648,58
$709,70
$926,82
$754,36
$812,06
$873,18
$1 090,30
$917,84
$975,54
$1 036,66
$1 253,78
$163,48
Toc - Plan #83 Friday Health Plans
Expanded Bronze

(EPO) Friday Bronze Plus

Annual Out of Pocket Expenses
Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$226,19
$256,73
$289,08
$403,98
$613,89
$399,23
$429,77
$462,12
$577,02
$572,27
$602,81
$635,16
$750,06
$745,31
$775,85
$808,20
$923,10
$173,04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$452,38
$513,46
$578,16
$807,96
$1 227,78
$625,42
$686,50
$751,20
$981,00
$798,46
$859,54
$924,24
$1 154,04
$971,50
$1 032,58
$1 097,28
$1 327,08
$173,04
Toc - Plan #84 Friday Health Plans
Expanded Bronze

(EPO) Friday Bronze HSA

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:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$254,86
$289,26
$325,71
$455,17
$691,68
$449,83
$484,23
$520,68
$650,14
$644,80
$679,20
$715,65
$845,11
$839,77
$874,17
$910,62
$1 040,08
$194,97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$509,72
$578,52
$651,42
$910,34
$1 383,36
$704,69
$773,49
$846,39
$1 105,31
$899,66
$968,46
$1 041,36
$1 300,28
$1 094,63
$1 163,43
$1 236,33
$1 495,25
$194,97
Toc - Plan #85 Friday Health Plans
Silver

(EPO) Friday Silver

Annual Out of Pocket Expenses
Individual Family
$5,500 $11,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$326,31
$370,37
$417,03
$582,80
$885,62
$575,94
$620,00
$666,66
$832,43
$825,57
$869,63
$916,29
$1 082,06
$1 075,20
$1 119,26
$1 165,92
$1 331,69
$249,63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$652,62
$740,74
$834,06
$1 165,60
$1 771,24
$902,25
$990,37
$1 083,69
$1 415,23
$1 151,88
$1 240,00
$1 333,32
$1 664,86
$1 401,51
$1 489,63
$1 582,95
$1 914,49
$249,63
Toc - Plan #86 Friday Health Plans
Gold

(EPO) Friday Gold

Annual Out of Pocket Expenses
Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year
Monthly Premiums:
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$307,51
$349,02
$392,99
$549,21
$834,57
$542,75
$584,26
$628,23
$784,45
$777,99
$819,50
$863,47
$1 019,69
$1 013,23
$1 054,74
$1 098,71
$1 254,93
$235,24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$615,02
$698,04
$785,98
$1 098,42
$1 669,14
$850,26
$933,28
$1 021,22
$1 333,66
$1 085,50
$1 168,52
$1 256,46
$1 568,90
$1 320,74
$1 403,76
$1 491,70
$1 804,14
$235,24

‡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 Dallas County here.

Dallas County is in “Rating Area 8” of Texas.

Currently, there are 86 plans offered in Rating Area 8.

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2022 Obamacare Rates for Dallas County

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