Obamacare 2021 Rates and Health Insurance Providers for Fort Bend County , Texas

Obamacare > Rates > Texas > Fort Bend County

Obamacare Rates and Providers for Other Years

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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 Fort Bend County, TX.

The health insurance rates listed below are for calendar year 2021.

Obamacare Providers, Plans and 2021 Rates for Fort Bend County, Texas

Below, you’ll find a summary of the 78 plans for Fort Bend County, Texas and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Oscar Insurance Company

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

1. Expanded Bronze Oscar Bronze Simple

2. Expanded Bronze Oscar Bronze Classic PCP Copay

3. Expanded Bronze Oscar Bronze Classic

4. Expanded Bronze Oscar Bronze Classic Next

5. Silver Oscar Silver Classic

6. Silver Oscar Silver Saver 2

7. Silver Oscar Silver Classic Next

8. Catastrophic Oscar Secure

9. Expanded Bronze Oscar Bronze Classic Next 2

10. Gold Oscar Gold Classic

11. Expanded Bronze Oscar Bronze HDHP

12. Silver Oscar Silver Classic Copay

13. Silver Oscar Silver Classic $0 Ded

Community Health Choice

Local: 1-713-295-6704 | Toll Free: 1-855-315-5386 | TTY: 1-855-315-5386

14. Expanded Bronze Community Vital Bronze 003 (No Deductible for PCP, Free Preventive Care, 24/7 Telehealth)

15. Silver Community Advance Preferred Silver 004 (No deductible PCP, Specialists, Urgent Care and Generics, Free 24/7 Telehealth)

16. Gold Community Enhanced Gold 005 (No Deductible PCP, Specialists & Generics, Free 24/7 Telehealth)

17. Expanded Bronze Community Essential Bronze 008 HSA(No cost after deductible, No referrals for Specialists)

18. Silver Community Standard Preferred Silver 009 (No deductible PCP, Urgent Care & Generics, Free 24/7 Telehealth)

19. Bronze Community Value Bronze 10 (Free Preventive Care, Free 24/7 Telehealth)

20. Expanded Bronze Community Virtual Now Bronze 11 (Unlimited Free 24/7 Virtual Visits)

21. Silver Community Standard Silver 12 (No deductible PCP, Urgent Care & Generics, Free 24/7 Telehealth)

22. Silver Community Advance Silver 13 (No Deductible PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth)

Ambetter from Superior HealthPlan

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

23. Silver Ambetter Balanced Care 11 (2021)

24. Bronze Ambetter Essential Care 1 (2021)

25. Expanded Bronze Ambetter Essential Care 10 (2021)

26. Gold Ambetter Secure Care 5 (2021)

27. Expanded Bronze Ambetter Essential Care 2 HSA (2021)

28. Silver Ambetter Balanced Care 5 (2021)

29. Silver Ambetter Balanced Care 12 (2021)

30. Silver Ambetter Balanced Care 29 (2021)

31. Silver Ambetter Balanced Care 25 HSA (2021)

32. Silver Ambetter Balanced Care 27 (2021)

33. Silver Ambetter Balanced Care 28 (2021)

34. Gold Ambetter Secure Care 15 (2021)

35. Gold Ambetter Secure Care 5 (2021) + Vision

36. Bronze Ambetter Essential Care 1 (2021) + Vision

37. Expanded Bronze Ambetter Essential Care 10 (2021) + Vision

38. Silver Ambetter Balanced Care 11 (2021) + Vision

39. Expanded Bronze Ambetter Essential Care 2 HSA (2021) + Vision

40. Silver Ambetter Balanced Care 5 (2021) + Vision

41. Silver Ambetter Balanced Care 12 (2021) + Vision

42. Silver Ambetter Balanced Care 25 HSA (2021) + Vision

43. Silver Ambetter Balanced Care 27 (2021) + Vision

44. Silver Ambetter Balanced Care 28 (2021) + Vision

45. Gold Ambetter Secure Care 15 (2021) + Vision

46. Gold Ambetter Secure Care 5 (2021) + Vision + Adult Dental

47. Bronze Ambetter Essential Care 1 (2021) + Vision + Adult Dental

48. Expanded Bronze Ambetter Essential Care 10 (2021) + Vision + Adult Dental

49. Silver Ambetter Balanced Care 11 (2021) + Vision + Adult Dental

50. Expanded Bronze Ambetter Essential Care 2 HSA (2021) + Vision + Adult Dental

51. Silver Ambetter Balanced Care 5 (2021) + Vision + Adult Dental

52. Silver Ambetter Balanced Care 12 (2021) + Vision + Adult Dental

53. Silver Ambetter Balanced Care 25 HSA (2021) + Vision + Adult Dental

54. Silver Ambetter Balanced Care 27 (2021) + Vision + Adult Dental

55. Silver Ambetter Balanced Care 28 (2021) + Vision + Adult Dental

56. Gold Ambetter Secure Care 15 (2021) + Vision + Adult Dental

Blue Cross and Blue Shield of Texas

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

57. Gold Blue Advantage Gold HMO_ 206

58. Catastrophic Blue Advantage Security HMO_ 200

59. Silver Blue Advantage Silver HMO_ 205

60. Expanded Bronze Blue Advantage Bronze HMO_ 204

61. Bronze Blue Advantage Bronze HMO_ 301

62. Gold Blue Advantage Plus Gold_ 203

63. Silver Blue Advantage Plus Silver_ 202

64. Expanded Bronze Blue Advantage Plus Bronze_ 303

65. Bronze Blue Advantage Plus Bronze_ 305

Molina Healthcare

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

66. Gold Molina Gold 3

67. Silver Molina Silver 3 250

68. Gold Confident Care Gold 1

69. Silver Constant Care Silver 1 250

70. Bronze Core Care Bronze 1

71. Silver Constant Care Silver 2 250

72. Bronze Core Care Bronze 2

73. Silver Constant Care Silver 4 250

74. Expanded Bronze Core Care Bronze 4

75. Expanded Bronze Core Care Bronze 5

76. Gold Confident Care Gold 1 + Vision

77. Silver Constant Care Silver 1 250 + Vision

78. Bronze Core Care Bronze 1 + Vision

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 Richmond, TX area accept this insurance coverage as within the plan's network.

Counties in Texas

2021 Obamacare Rates, Providers, and Plans for Fort Bend County

Oscar Insurance Company

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

Toc - Plan #1

Expanded Bronze

(EPO) Oscar Bronze Simple

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$7,300 $14,600 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $7,300 | Family: $14,600
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$264,81
$300,55
$338,41
$472,93
$718,66

$529,62
$601,10
$676,82
$945,86
$1 437,32

$732,19
$803,67
$879,39
$1 148,43

$934,76
$1 006,24
$1 081,96
$1 351,00

$1 137,33
$1 208,81
$1 284,53
$1 553,57

$467,38
$503,12
$540,98
$675,50

$669,95
$705,69
$743,55
$878,07

$872,52
$908,26
$946,12
$1 080,64

$202,57

Toc - Plan #2

Expanded Bronze

(EPO) Oscar Bronze Classic PCP Copay

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$6,000 $12,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$273,46
$310,37
$349,47
$488,39
$742,15

$546,92
$620,74
$698,94
$976,78
$1 484,30

$756,11
$829,93
$908,13
$1 185,97

$965,30
$1 039,12
$1 117,32
$1 395,16

$1 174,49
$1 248,31
$1 326,51
$1 604,35

$482,65
$519,56
$558,66
$697,58

$691,84
$728,75
$767,85
$906,77

$901,03
$937,94
$977,04
$1 115,96

$209,19

Toc - Plan #3

Expanded Bronze

(EPO) Oscar Bronze Classic

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$6,000 $12,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$266,42
$302,38
$340,47
$475,81
$723,04

$532,84
$604,76
$680,94
$951,62
$1 446,08

$736,64
$808,56
$884,74
$1 155,42

$940,44
$1 012,36
$1 088,54
$1 359,22

$1 144,24
$1 216,16
$1 292,34
$1 563,02

$470,22
$506,18
$544,27
$679,61

$674,02
$709,98
$748,07
$883,41

$877,82
$913,78
$951,87
$1 087,21

$203,80

Toc - Plan #4

Expanded Bronze

(EPO) Oscar Bronze Classic Next

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$323,88
$367,59
$413,90
$578,42
$878,97

$647,76
$735,18
$827,80
$1 156,84
$1 757,94

$895,52
$982,94
$1 075,56
$1 404,60

$1 143,28
$1 230,70
$1 323,32
$1 652,36

$1 391,04
$1 478,46
$1 571,08
$1 900,12

$571,64
$615,35
$661,66
$826,18

$819,40
$863,11
$909,42
$1 073,94

$1 067,16
$1 110,87
$1 157,18
$1 321,70

$247,76

Toc - Plan #5

Silver

(EPO) Oscar Silver Classic

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$5,000 $10,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $5,000 | Family: $10,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$365,31
$414,61
$466,85
$652,42
$991,42

$730,62
$829,22
$933,70
$1 304,84
$1 982,84

$1 010,07
$1 108,67
$1 213,15
$1 584,29

$1 289,52
$1 388,12
$1 492,60
$1 863,74

$1 568,97
$1 667,57
$1 772,05
$2 143,19

$644,76
$694,06
$746,30
$931,87

$924,21
$973,51
$1 025,75
$1 211,32

$1 203,66
$1 252,96
$1 305,20
$1 490,77

$279,45

Toc - Plan #6

Silver

(EPO) Oscar Silver Saver 2

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$6,200 $12,400 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,200 | Family: $12,400
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$358,62
$407,03
$458,31
$640,48
$973,28

$717,24
$814,06
$916,62
$1 280,96
$1 946,56

$991,58
$1 088,40
$1 190,96
$1 555,30

$1 265,92
$1 362,74
$1 465,30
$1 829,64

$1 540,26
$1 637,08
$1 739,64
$2 103,98

$632,96
$681,37
$732,65
$914,82

$907,30
$955,71
$1 006,99
$1 189,16

$1 181,64
$1 230,05
$1 281,33
$1 463,50

$274,34

Toc - Plan #7

Silver

(EPO) Oscar Silver Classic Next

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$6,000 $12,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,000 | Family: $16,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$367,23
$416,79
$469,30
$655,85
$996,62

$734,46
$833,58
$938,60
$1 311,70
$1 993,24

$1 015,38
$1 114,50
$1 219,52
$1 592,62

$1 296,30
$1 395,42
$1 500,44
$1 873,54

$1 577,22
$1 676,34
$1 781,36
$2 154,46

$648,15
$697,71
$750,22
$936,77

$929,07
$978,63
$1 031,14
$1 217,69

$1 209,99
$1 259,55
$1 312,06
$1 498,61

$280,92

Toc - Plan #8

Catastrophic

(EPO) Oscar Secure

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$218,99
$248,54
$279,85
$391,10
$594,31

$437,98
$497,08
$559,70
$782,20
$1 188,62

$605,50
$664,60
$727,22
$949,72

$773,02
$832,12
$894,74
$1 117,24

$940,54
$999,64
$1 062,26
$1 284,76

$386,51
$416,06
$447,37
$558,62

$554,03
$583,58
$614,89
$726,14

$721,55
$751,10
$782,41
$893,66

$167,52

Toc - Plan #9

Expanded Bronze

(EPO) Oscar Bronze Classic Next 2

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$323,58
$367,25
$413,52
$577,89
$878,16

$647,16
$734,50
$827,04
$1 155,78
$1 756,32

$894,69
$982,03
$1 074,57
$1 403,31

$1 142,22
$1 229,56
$1 322,10
$1 650,84

$1 389,75
$1 477,09
$1 569,63
$1 898,37

$571,11
$614,78
$661,05
$825,42

$818,64
$862,31
$908,58
$1 072,95

$1 066,17
$1 109,84
$1 156,11
$1 320,48

$247,53

Toc - Plan #10

Gold

(EPO) Oscar Gold Classic

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$2,500 $5,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Deductible: Individual: $2,500 | Family: $5,000
Out of Pocket Maximum per year: Individual: $6,000 | Family: $12,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$387,87
$440,22
$495,69
$692,72
$1 052,65

$775,74
$880,44
$991,38
$1 385,44
$2 105,30

$1 072,45
$1 177,15
$1 288,09
$1 682,15

$1 369,16
$1 473,86
$1 584,80
$1 978,86

$1 665,87
$1 770,57
$1 881,51
$2 275,57

$684,58
$736,93
$792,40
$989,43

$981,29
$1 033,64
$1 089,11
$1 286,14

$1 278,00
$1 330,35
$1 385,82
$1 582,85

$296,71

Toc - Plan #11

Expanded Bronze

(EPO) Oscar Bronze HDHP

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$5,200 $10,400 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Deductible: Individual: $5,200 | Family: $10,400
Out of Pocket Maximum per year: Individual: $7,000 | Family: $14,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$284,63
$323,04
$363,74
$508,33
$772,46

$569,26
$646,08
$727,48
$1 016,66
$1 544,92

$786,99
$863,81
$945,21
$1 234,39

$1 004,72
$1 081,54
$1 162,94
$1 452,12

$1 222,45
$1 299,27
$1 380,67
$1 669,85

$502,36
$540,77
$581,47
$726,06

$720,09
$758,50
$799,20
$943,79

$937,82
$976,23
$1 016,93
$1 161,52

$217,73

Toc - Plan #12

Silver

(EPO) Oscar Silver Classic Copay

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$7,000 $14,000 Annual Deductible

$8,200 $16,400 Maximum Out of Pocket Per Year

Deductible: Individual: $7,000 | Family: $14,000
Out of Pocket Maximum per year: Individual: $8,200 | Family: $16,400

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$373,72
$424,17
$477,61
$667,45
$1 014,26

$747,44
$848,34
$955,22
$1 334,90
$2 028,52

$1 033,33
$1 134,23
$1 241,11
$1 620,79

$1 319,22
$1 420,12
$1 527,00
$1 906,68

$1 605,11
$1 706,01
$1 812,89
$2 192,57

$659,61
$710,06
$763,50
$953,34

$945,50
$995,95
$1 049,39
$1 239,23

$1 231,39
$1 281,84
$1 335,28
$1 525,12

$285,89

Toc - Plan #13

Silver

(EPO) Oscar Silver Classic $0 Ded

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Oscar Insurance Company
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$387,01
$439,24
$494,58
$691,18
$1 050,31

$774,02
$878,48
$989,16
$1 382,36
$2 100,62

$1 070,07
$1 174,53
$1 285,21
$1 678,41

$1 366,12
$1 470,58
$1 581,26
$1 974,46

$1 662,17
$1 766,63
$1 877,31
$2 270,51

$683,06
$735,29
$790,63
$987,23

$979,11
$1 031,34
$1 086,68
$1 283,28

$1 275,16
$1 327,39
$1 382,73
$1 579,33

$296,05

Community Health Choice

Local: 1-713-295-6704 | Toll Free: 1-855-315-5386 | TTY: 1-855-315-5386

Toc - Plan #14

Expanded Bronze

(HMO) Community Vital Bronze 003 (No Deductible for PCP, Free Preventive Care, 24/7 Telehealth)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Community Health Choice
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses

Individual Family

$7,700 $15,400 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $7,700 | Family: $15,400
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$301,94
$342,71
$385,88
$539,27
$819,48

$603,88
$685,42
$771,76
$1 078,54
$1 638,96

$834,87
$916,41
$1 002,75
$1 309,53

$1 065,86
$1 147,40
$1 233,74
$1 540,52

$1 296,85
$1 378,39
$1 464,73
$1 771,51

$532,93
$573,70
$616,87
$770,26

$763,92
$804,69
$847,86
$1 001,25

$994,91
$1 035,68
$1 078,85
$1 232,24

$230,99

Toc - Plan #15

Silver

(HMO) Community Advance Preferred Silver 004 (No deductible PCP, Specialists, Urgent Care and Generics, Free 24/7 Telehealth)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Community Health Choice
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses

Individual Family

$3,000 $6,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $3,000 | Family: $6,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$401,98
$456,25
$513,73
$717,94
$1 090,97

$803,96
$912,50
$1 027,46
$1 435,88
$2 181,94

$1 111,47
$1 220,01
$1 334,97
$1 743,39

$1 418,98
$1 527,52
$1 642,48
$2 050,90

$1 726,49
$1 835,03
$1 949,99
$2 358,41

$709,49
$763,76
$821,24
$1 025,45

$1 017,00
$1 071,27
$1 128,75
$1 332,96

$1 324,51
$1 378,78
$1 436,26
$1 640,47

$307,51

Toc - Plan #16

Gold

(HMO) Community Enhanced Gold 005 (No Deductible PCP, Specialists & Generics, Free 24/7 Telehealth)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Community Health Choice
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses

Individual Family

$2,000 $4,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $2,000 | Family: $4,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$383,95
$435,78
$490,68
$685,73
$1 042,03

$767,90
$871,56
$981,36
$1 371,46
$2 084,06

$1 061,62
$1 165,28
$1 275,08
$1 665,18

$1 355,34
$1 459,00
$1 568,80
$1 958,90

$1 649,06
$1 752,72
$1 862,52
$2 252,62

$677,67
$729,50
$784,40
$979,45

$971,39
$1 023,22
$1 078,12
$1 273,17

$1 265,11
$1 316,94
$1 371,84
$1 566,89

$293,72

Toc - Plan #17

Expanded Bronze

(HMO) Community Essential Bronze 008 HSA(No cost after deductible, No referrals for Specialists)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Community Health Choice
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses

Individual Family

$7,000 $14,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Deductible: Individual: $7,000 | Family: $14,000
Out of Pocket Maximum per year: Individual: $7,000 | Family: $14,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$310,05
$351,90
$396,24
$553,75
$841,47

$620,10
$703,80
$792,48
$1 107,50
$1 682,94

$857,29
$940,99
$1 029,67
$1 344,69

$1 094,48
$1 178,18
$1 266,86
$1 581,88

$1 331,67
$1 415,37
$1 504,05
$1 819,07

$547,24
$589,09
$633,43
$790,94

$784,43
$826,28
$870,62
$1 028,13

$1 021,62
$1 063,47
$1 107,81
$1 265,32

$237,19

Toc - Plan #18

Silver

(HMO) Community Standard Preferred Silver 009 (No deductible PCP, Urgent Care & Generics, Free 24/7 Telehealth)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Community Health Choice
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses

Individual Family

$5,000 $10,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Deductible: Individual: $5,000 | Family: $10,000
Out of Pocket Maximum per year: Individual: $7,000 | Family: $14,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$393,56
$446,69
$502,97
$702,90
$1 068,13

$787,12
$893,38
$1 005,94
$1 405,80
$2 136,26

$1 088,20
$1 194,46
$1 307,02
$1 706,88

$1 389,28
$1 495,54
$1 608,10
$2 007,96

$1 690,36
$1 796,62
$1 909,18
$2 309,04

$694,64
$747,77
$804,05
$1 003,98

$995,72
$1 048,85
$1 105,13
$1 305,06

$1 296,80
$1 349,93
$1 406,21
$1 606,14

$301,08

Toc - Plan #19

Bronze

(HMO) Community Value Bronze 10 (Free Preventive Care, Free 24/7 Telehealth)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Community Health Choice
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$297,91
$338,13
$380,73
$532,07
$808,54

$595,82
$676,26
$761,46
$1 064,14
$1 617,08

$823,72
$904,16
$989,36
$1 292,04

$1 051,62
$1 132,06
$1 217,26
$1 519,94

$1 279,52
$1 359,96
$1 445,16
$1 747,84

$525,81
$566,03
$608,63
$759,97

$753,71
$793,93
$836,53
$987,87

$981,61
$1 021,83
$1 064,43
$1 215,77

$227,90

Toc - Plan #20

Expanded Bronze

(HMO) Community Virtual Now Bronze 11 (Unlimited Free 24/7 Virtual Visits)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Community Health Choice
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$297,31
$337,45
$379,96
$530,99
$806,90

$594,62
$674,90
$759,92
$1 061,98
$1 613,80

$822,06
$902,34
$987,36
$1 289,42

$1 049,50
$1 129,78
$1 214,80
$1 516,86

$1 276,94
$1 357,22
$1 442,24
$1 744,30

$524,75
$564,89
$607,40
$758,43

$752,19
$792,33
$834,84
$985,87

$979,63
$1 019,77
$1 062,28
$1 213,31

$227,44

Toc - Plan #21

Silver

(HMO) Community Standard Silver 12 (No deductible PCP, Urgent Care & Generics, Free 24/7 Telehealth)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Community Health Choice
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses

Individual Family

$6,000 $12,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$384,75
$436,70
$491,71
$687,17
$1 044,22

$769,50
$873,40
$983,42
$1 374,34
$2 088,44

$1 063,84
$1 167,74
$1 277,76
$1 668,68

$1 358,18
$1 462,08
$1 572,10
$1 963,02

$1 652,52
$1 756,42
$1 866,44
$2 257,36

$679,09
$731,04
$786,05
$981,51

$973,43
$1 025,38
$1 080,39
$1 275,85

$1 267,77
$1 319,72
$1 374,73
$1 570,19

$294,34

Toc - Plan #22

Silver

(HMO) Community Advance Silver 13 (No Deductible PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Community Health Choice
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$388,98
$441,49
$497,12
$694,72
$1 055,70

$777,96
$882,98
$994,24
$1 389,44
$2 111,40

$1 075,53
$1 180,55
$1 291,81
$1 687,01

$1 373,10
$1 478,12
$1 589,38
$1 984,58

$1 670,67
$1 775,69
$1 886,95
$2 282,15

$686,55
$739,06
$794,69
$992,29

$984,12
$1 036,63
$1 092,26
$1 289,86

$1 281,69
$1 334,20
$1 389,83
$1 587,43

$297,57

Ambetter from Superior HealthPlan

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

Toc - Plan #23

Silver

(EPO) Ambetter Balanced Care 11 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$6,000 $12,000 Annual Deductible

$8,500 $17,000 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,500 | Family: $17,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$332,52
$377,40
$424,95
$593,87
$902,44

$665,04
$754,80
$849,90
$1 187,74
$1 804,88

$919,41
$1 009,17
$1 104,27
$1 442,11

$1 173,78
$1 263,54
$1 358,64
$1 696,48

$1 428,15
$1 517,91
$1 613,01
$1 950,85

$586,89
$631,77
$679,32
$848,24

$841,26
$886,14
$933,69
$1 102,61

$1 095,63
$1 140,51
$1 188,06
$1 356,98

$254,37

Toc - Plan #24

Bronze

(EPO) Ambetter Essential Care 1 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$8,300 $16,600 Annual Deductible

$8,300 $16,600 Maximum Out of Pocket Per Year

Deductible: Individual: $8,300 | Family: $16,600
Out of Pocket Maximum per year: Individual: $8,300 | Family: $16,600

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$279,95
$317,73
$357,77
$499,98
$759,76

$559,90
$635,46
$715,54
$999,96
$1 519,52

$774,06
$849,62
$929,70
$1 214,12

$988,22
$1 063,78
$1 143,86
$1 428,28

$1 202,38
$1 277,94
$1 358,02
$1 642,44

$494,11
$531,89
$571,93
$714,14

$708,27
$746,05
$786,09
$928,30

$922,43
$960,21
$1 000,25
$1 142,46

$214,16

Toc - Plan #25

Expanded Bronze

(EPO) Ambetter Essential Care 10 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$7,200 $14,400 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Deductible: Individual: $7,200 | Family: $14,400
Out of Pocket Maximum per year: Individual: $8,400 | Family: $16,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$290,16
$329,32
$370,81
$518,21
$787,47

$580,32
$658,64
$741,62
$1 036,42
$1 574,94

$802,28
$880,60
$963,58
$1 258,38

$1 024,24
$1 102,56
$1 185,54
$1 480,34

$1 246,20
$1 324,52
$1 407,50
$1 702,30

$512,12
$551,28
$592,77
$740,17

$734,08
$773,24
$814,73
$962,13

$956,04
$995,20
$1 036,69
$1 184,09

$221,96

Toc - Plan #26

Gold

(EPO) Ambetter Secure Care 5 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$1,450 $2,900 Annual Deductible

$6,300 $12,600 Maximum Out of Pocket Per Year

Deductible: Individual: $1,450 | Family: $2,900
Out of Pocket Maximum per year: Individual: $6,300 | Family: $12,600

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$442,75
$502,51
$565,82
$790,73
$1 201,59

$885,50
$1 005,02
$1 131,64
$1 581,46
$2 403,18

$1 224,20
$1 343,72
$1 470,34
$1 920,16

$1 562,90
$1 682,42
$1 809,04
$2 258,86

$1 901,60
$2 021,12
$2 147,74
$2 597,56

$781,45
$841,21
$904,52
$1 129,43

$1 120,15
$1 179,91
$1 243,22
$1 468,13

$1 458,85
$1 518,61
$1 581,92
$1 806,83

$338,70

Toc - Plan #27

Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Deductible: Individual: $6,900 | Family: $13,800
Out of Pocket Maximum per year: Individual: $6,900 | Family: $13,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$302,60
$343,43
$386,70
$540,42
$821,22

$605,20
$686,86
$773,40
$1 080,84
$1 642,44

$836,68
$918,34
$1 004,88
$1 312,32

$1 068,16
$1 149,82
$1 236,36
$1 543,80

$1 299,64
$1 381,30
$1 467,84
$1 775,28

$534,08
$574,91
$618,18
$771,90

$765,56
$806,39
$849,66
$1 003,38

$997,04
$1 037,87
$1 081,14
$1 234,86

$231,48

Toc - Plan #28

Silver

(EPO) Ambetter Balanced Care 5 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$7,350 $14,700 Annual Deductible

$7,350 $14,700 Maximum Out of Pocket Per Year

Deductible: Individual: $7,350 | Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 | Family: $14,700

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$331,62
$376,38
$423,80
$592,26
$900,00

$663,24
$752,76
$847,60
$1 184,52
$1 800,00

$916,92
$1 006,44
$1 101,28
$1 438,20

$1 170,60
$1 260,12
$1 354,96
$1 691,88

$1 424,28
$1 513,80
$1 608,64
$1 945,56

$585,30
$630,06
$677,48
$845,94

$838,98
$883,74
$931,16
$1 099,62

$1 092,66
$1 137,42
$1 184,84
$1 353,30

$253,68

Toc - Plan #29

Silver

(EPO) Ambetter Balanced Care 12 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$6,500 $13,000 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Deductible: Individual: $6,500 | Family: $13,000
Out of Pocket Maximum per year: Individual: $8,400 | Family: $16,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$325,67
$369,63
$416,20
$581,63
$883,85

$651,34
$739,26
$832,40
$1 163,26
$1 767,70

$900,47
$988,39
$1 081,53
$1 412,39

$1 149,60
$1 237,52
$1 330,66
$1 661,52

$1 398,73
$1 486,65
$1 579,79
$1 910,65

$574,80
$618,76
$665,33
$830,76

$823,93
$867,89
$914,46
$1 079,89

$1 073,06
$1 117,02
$1 163,59
$1 329,02

$249,13

Toc - Plan #30

Silver

(EPO) Ambetter Balanced Care 29 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$5,450 $10,900 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Deductible: Individual: $5,450 | Family: $10,900
Out of Pocket Maximum per year: Individual: $8,400 | Family: $16,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$322,81
$366,38
$412,54
$576,52
$876,09

$645,62
$732,76
$825,08
$1 153,04
$1 752,18

$892,56
$979,70
$1 072,02
$1 399,98

$1 139,50
$1 226,64
$1 318,96
$1 646,92

$1 386,44
$1 473,58
$1 565,90
$1 893,86

$569,75
$613,32
$659,48
$823,46

$816,69
$860,26
$906,42
$1 070,40

$1 063,63
$1 107,20
$1 153,36
$1 317,34

$246,94

Toc - Plan #31

Silver

(EPO) Ambetter Balanced Care 25 HSA (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$4,800 $9,600 Annual Deductible

$4,800 $9,600 Maximum Out of Pocket Per Year

Deductible: Individual: $4,800 | Family: $9,600
Out of Pocket Maximum per year: Individual: $4,800 | Family: $9,600

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$336,28
$381,67
$429,75
$600,58
$912,63

$672,56
$763,34
$859,50
$1 201,16
$1 825,26

$929,81
$1 020,59
$1 116,75
$1 458,41

$1 187,06
$1 277,84
$1 374,00
$1 715,66

$1 444,31
$1 535,09
$1 631,25
$1 972,91

$593,53
$638,92
$687,00
$857,83

$850,78
$896,17
$944,25
$1 115,08

$1 108,03
$1 153,42
$1 201,50
$1 372,33

$257,25

Toc - Plan #32

Silver

(EPO) Ambetter Balanced Care 27 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$2,750 $5,500 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Deductible: Individual: $2,750 | Family: $5,500
Out of Pocket Maximum per year: Individual: $6,500 | Family: $13,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$355,43
$403,40
$454,23
$634,78
$964,61

$710,86
$806,80
$908,46
$1 269,56
$1 929,22

$982,76
$1 078,70
$1 180,36
$1 541,46

$1 254,66
$1 350,60
$1 452,26
$1 813,36

$1 526,56
$1 622,50
$1 724,16
$2 085,26

$627,33
$675,30
$726,13
$906,68

$899,23
$947,20
$998,03
$1 178,58

$1 171,13
$1 219,10
$1 269,93
$1 450,48

$271,90

Toc - Plan #33

Silver

(EPO) Ambetter Balanced Care 28 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,200 $16,400 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,200 | Family: $16,400

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$358,32
$406,69
$457,93
$639,95
$972,47

$716,64
$813,38
$915,86
$1 279,90
$1 944,94

$990,75
$1 087,49
$1 189,97
$1 554,01

$1 264,86
$1 361,60
$1 464,08
$1 828,12

$1 538,97
$1 635,71
$1 738,19
$2 102,23

$632,43
$680,80
$732,04
$914,06

$906,54
$954,91
$1 006,15
$1 188,17

$1 180,65
$1 229,02
$1 280,26
$1 462,28

$274,11

Toc - Plan #34

Gold

(EPO) Ambetter Secure Care 15 (2021)

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$1,150 $2,300 Annual Deductible

$4,450 $8,900 Maximum Out of Pocket Per Year

Deductible: Individual: $1,150 | Family: $2,300
Out of Pocket Maximum per year: Individual: $4,450 | Family: $8,900

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$452,23
$513,26
$577,93
$807,66
$1 227,31

$904,46
$1 026,52
$1 155,86
$1 615,32
$2 454,62

$1 250,41
$1 372,47
$1 501,81
$1 961,27

$1 596,36
$1 718,42
$1 847,76
$2 307,22

$1 942,31
$2 064,37
$2 193,71
$2 653,17

$798,18
$859,21
$923,88
$1 153,61

$1 144,13
$1 205,16
$1 269,83
$1 499,56

$1 490,08
$1 551,11
$1 615,78
$1 845,51

$345,95

Toc - Plan #35

Gold

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$1,450 $2,900 Annual Deductible

$6,300 $12,600 Maximum Out of Pocket Per Year

Deductible: Individual: $1,450 | Family: $2,900
Out of Pocket Maximum per year: Individual: $6,300 | Family: $12,600

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$447,83
$508,28
$572,32
$799,81
$1 215,39

$895,66
$1 016,56
$1 144,64
$1 599,62
$2 430,78

$1 238,24
$1 359,14
$1 487,22
$1 942,20

$1 580,82
$1 701,72
$1 829,80
$2 284,78

$1 923,40
$2 044,30
$2 172,38
$2 627,36

$790,41
$850,86
$914,90
$1 142,39

$1 132,99
$1 193,44
$1 257,48
$1 484,97

$1 475,57
$1 536,02
$1 600,06
$1 827,55

$342,58

Toc - Plan #36

Bronze

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$8,300 $16,600 Annual Deductible

$8,300 $16,600 Maximum Out of Pocket Per Year

Deductible: Individual: $8,300 | Family: $16,600
Out of Pocket Maximum per year: Individual: $8,300 | Family: $16,600

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$283,17
$321,38
$361,87
$505,72
$768,48

$566,34
$642,76
$723,74
$1 011,44
$1 536,96

$782,95
$859,37
$940,35
$1 228,05

$999,56
$1 075,98
$1 156,96
$1 444,66

$1 216,17
$1 292,59
$1 373,57
$1 661,27

$499,78
$537,99
$578,48
$722,33

$716,39
$754,60
$795,09
$938,94

$933,00
$971,21
$1 011,70
$1 155,55

$216,61

Toc - Plan #37

Expanded Bronze

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$7,200 $14,400 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Deductible: Individual: $7,200 | Family: $14,400
Out of Pocket Maximum per year: Individual: $8,400 | Family: $16,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$293,49
$333,10
$375,07
$524,16
$796,51

$586,98
$666,20
$750,14
$1 048,32
$1 593,02

$811,49
$890,71
$974,65
$1 272,83

$1 036,00
$1 115,22
$1 199,16
$1 497,34

$1 260,51
$1 339,73
$1 423,67
$1 721,85

$518,00
$557,61
$599,58
$748,67

$742,51
$782,12
$824,09
$973,18

$967,02
$1 006,63
$1 048,60
$1 197,69

$224,51

Toc - Plan #38

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$6,000 $12,000 Annual Deductible

$8,500 $17,000 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,500 | Family: $17,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$336,34
$381,73
$429,83
$600,68
$912,80

$672,68
$763,46
$859,66
$1 201,36
$1 825,60

$929,97
$1 020,75
$1 116,95
$1 458,65

$1 187,26
$1 278,04
$1 374,24
$1 715,94

$1 444,55
$1 535,33
$1 631,53
$1 973,23

$593,63
$639,02
$687,12
$857,97

$850,92
$896,31
$944,41
$1 115,26

$1 108,21
$1 153,60
$1 201,70
$1 372,55

$257,29

Toc - Plan #39

Expanded Bronze

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Deductible: Individual: $6,900 | Family: $13,800
Out of Pocket Maximum per year: Individual: $6,900 | Family: $13,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$306,07
$347,38
$391,14
$546,62
$830,65

$612,14
$694,76
$782,28
$1 093,24
$1 661,30

$846,28
$928,90
$1 016,42
$1 327,38

$1 080,42
$1 163,04
$1 250,56
$1 561,52

$1 314,56
$1 397,18
$1 484,70
$1 795,66

$540,21
$581,52
$625,28
$780,76

$774,35
$815,66
$859,42
$1 014,90

$1 008,49
$1 049,80
$1 093,56
$1 249,04

$234,14

Toc - Plan #40

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$7,350 $14,700 Annual Deductible

$7,350 $14,700 Maximum Out of Pocket Per Year

Deductible: Individual: $7,350 | Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 | Family: $14,700

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$335,43
$380,70
$428,67
$599,06
$910,33

$670,86
$761,40
$857,34
$1 198,12
$1 820,66

$927,46
$1 018,00
$1 113,94
$1 454,72

$1 184,06
$1 274,60
$1 370,54
$1 711,32

$1 440,66
$1 531,20
$1 627,14
$1 967,92

$592,03
$637,30
$685,27
$855,66

$848,63
$893,90
$941,87
$1 112,26

$1 105,23
$1 150,50
$1 198,47
$1 368,86

$256,60

Toc - Plan #41

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$6,500 $13,000 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Deductible: Individual: $6,500 | Family: $13,000
Out of Pocket Maximum per year: Individual: $8,400 | Family: $16,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$329,41
$373,87
$420,97
$588,31
$893,99

$658,82
$747,74
$841,94
$1 176,62
$1 787,98

$910,81
$999,73
$1 093,93
$1 428,61

$1 162,80
$1 251,72
$1 345,92
$1 680,60

$1 414,79
$1 503,71
$1 597,91
$1 932,59

$581,40
$625,86
$672,96
$840,30

$833,39
$877,85
$924,95
$1 092,29

$1 085,38
$1 129,84
$1 176,94
$1 344,28

$251,99

Toc - Plan #42

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$4,800 $9,600 Annual Deductible

$4,800 $9,600 Maximum Out of Pocket Per Year

Deductible: Individual: $4,800 | Family: $9,600
Out of Pocket Maximum per year: Individual: $4,800 | Family: $9,600

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$340,14
$386,05
$434,69
$607,47
$923,11

$680,28
$772,10
$869,38
$1 214,94
$1 846,22

$940,48
$1 032,30
$1 129,58
$1 475,14

$1 200,68
$1 292,50
$1 389,78
$1 735,34

$1 460,88
$1 552,70
$1 649,98
$1 995,54

$600,34
$646,25
$694,89
$867,67

$860,54
$906,45
$955,09
$1 127,87

$1 120,74
$1 166,65
$1 215,29
$1 388,07

$260,20

Toc - Plan #43

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$2,750 $5,500 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Deductible: Individual: $2,750 | Family: $5,500
Out of Pocket Maximum per year: Individual: $6,500 | Family: $13,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$359,51
$408,03
$459,44
$642,07
$975,69

$719,02
$816,06
$918,88
$1 284,14
$1 951,38

$994,04
$1 091,08
$1 193,90
$1 559,16

$1 269,06
$1 366,10
$1 468,92
$1 834,18

$1 544,08
$1 641,12
$1 743,94
$2 109,20

$634,53
$683,05
$734,46
$917,09

$909,55
$958,07
$1 009,48
$1 192,11

$1 184,57
$1 233,09
$1 284,50
$1 467,13

$275,02

Toc - Plan #44

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,200 $16,400 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,200 | Family: $16,400

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$362,44
$411,36
$463,18
$647,30
$983,63

$724,88
$822,72
$926,36
$1 294,60
$1 967,26

$1 002,14
$1 099,98
$1 203,62
$1 571,86

$1 279,40
$1 377,24
$1 480,88
$1 849,12

$1 556,66
$1 654,50
$1 758,14
$2 126,38

$639,70
$688,62
$740,44
$924,56

$916,96
$965,88
$1 017,70
$1 201,82

$1 194,22
$1 243,14
$1 294,96
$1 479,08

$277,26

Toc - Plan #45

Gold

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$1,150 $2,300 Annual Deductible

$4,450 $8,900 Maximum Out of Pocket Per Year

Deductible: Individual: $1,150 | Family: $2,300
Out of Pocket Maximum per year: Individual: $4,450 | Family: $8,900

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$457,42
$519,16
$584,57
$816,93
$1 241,40

$914,84
$1 038,32
$1 169,14
$1 633,86
$2 482,80

$1 264,76
$1 388,24
$1 519,06
$1 983,78

$1 614,68
$1 738,16
$1 868,98
$2 333,70

$1 964,60
$2 088,08
$2 218,90
$2 683,62

$807,34
$869,08
$934,49
$1 166,85

$1 157,26
$1 219,00
$1 284,41
$1 516,77

$1 507,18
$1 568,92
$1 634,33
$1 866,69

$349,92

Toc - Plan #46

Gold

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$1,450 $2,900 Annual Deductible

$6,300 $12,600 Maximum Out of Pocket Per Year

Deductible: Individual: $1,450 | Family: $2,900
Out of Pocket Maximum per year: Individual: $6,300 | Family: $12,600

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$463,88
$526,50
$592,83
$828,48
$1 258,96

$927,76
$1 053,00
$1 185,66
$1 656,96
$2 517,92

$1 282,62
$1 407,86
$1 540,52
$2 011,82

$1 637,48
$1 762,72
$1 895,38
$2 366,68

$1 992,34
$2 117,58
$2 250,24
$2 721,54

$818,74
$881,36
$947,69
$1 183,34

$1 173,60
$1 236,22
$1 302,55
$1 538,20

$1 528,46
$1 591,08
$1 657,41
$1 893,06

$354,86

Toc - Plan #47

Bronze

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$8,300 $16,600 Annual Deductible

$8,300 $16,600 Maximum Out of Pocket Per Year

Deductible: Individual: $8,300 | Family: $16,600
Out of Pocket Maximum per year: Individual: $8,300 | Family: $16,600

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$293,32
$332,90
$374,84
$523,84
$796,03

$586,64
$665,80
$749,68
$1 047,68
$1 592,06

$811,02
$890,18
$974,06
$1 272,06

$1 035,40
$1 114,56
$1 198,44
$1 496,44

$1 259,78
$1 338,94
$1 422,82
$1 720,82

$517,70
$557,28
$599,22
$748,22

$742,08
$781,66
$823,60
$972,60

$966,46
$1 006,04
$1 047,98
$1 196,98

$224,38

Toc - Plan #48

Expanded Bronze

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$7,200 $14,400 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Deductible: Individual: $7,200 | Family: $14,400
Out of Pocket Maximum per year: Individual: $8,400 | Family: $16,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$304,01
$345,04
$388,51
$542,95
$825,06

$608,02
$690,08
$777,02
$1 085,90
$1 650,12

$840,58
$922,64
$1 009,58
$1 318,46

$1 073,14
$1 155,20
$1 242,14
$1 551,02

$1 305,70
$1 387,76
$1 474,70
$1 783,58

$536,57
$577,60
$621,07
$775,51

$769,13
$810,16
$853,63
$1 008,07

$1 001,69
$1 042,72
$1 086,19
$1 240,63

$232,56

Toc - Plan #49

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$6,000 $12,000 Annual Deductible

$8,500 $17,000 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,500 | Family: $17,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$348,39
$395,42
$445,24
$622,22
$945,52

$696,78
$790,84
$890,48
$1 244,44
$1 891,04

$963,29
$1 057,35
$1 156,99
$1 510,95

$1 229,80
$1 323,86
$1 423,50
$1 777,46

$1 496,31
$1 590,37
$1 690,01
$2 043,97

$614,90
$661,93
$711,75
$888,73

$881,41
$928,44
$978,26
$1 155,24

$1 147,92
$1 194,95
$1 244,77
$1 421,75

$266,51

Toc - Plan #50

Expanded Bronze

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Deductible: Individual: $6,900 | Family: $13,800
Out of Pocket Maximum per year: Individual: $6,900 | Family: $13,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$317,04
$359,83
$405,16
$566,22
$860,42

$634,08
$719,66
$810,32
$1 132,44
$1 720,84

$876,61
$962,19
$1 052,85
$1 374,97

$1 119,14
$1 204,72
$1 295,38
$1 617,50

$1 361,67
$1 447,25
$1 537,91
$1 860,03

$559,57
$602,36
$647,69
$808,75

$802,10
$844,89
$890,22
$1 051,28

$1 044,63
$1 087,42
$1 132,75
$1 293,81

$242,53

Toc - Plan #51

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$7,350 $14,700 Annual Deductible

$7,350 $14,700 Maximum Out of Pocket Per Year

Deductible: Individual: $7,350 | Family: $14,700
Out of Pocket Maximum per year: Individual: $7,350 | Family: $14,700

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$347,45
$394,35
$444,03
$620,54
$942,96

$694,90
$788,70
$888,06
$1 241,08
$1 885,92

$960,69
$1 054,49
$1 153,85
$1 506,87

$1 226,48
$1 320,28
$1 419,64
$1 772,66

$1 492,27
$1 586,07
$1 685,43
$2 038,45

$613,24
$660,14
$709,82
$886,33

$879,03
$925,93
$975,61
$1 152,12

$1 144,82
$1 191,72
$1 241,40
$1 417,91

$265,79

Toc - Plan #52

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$6,500 $13,000 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Deductible: Individual: $6,500 | Family: $13,000
Out of Pocket Maximum per year: Individual: $8,400 | Family: $16,800

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$341,22
$387,27
$436,06
$609,40
$926,04

$682,44
$774,54
$872,12
$1 218,80
$1 852,08

$943,46
$1 035,56
$1 133,14
$1 479,82

$1 204,48
$1 296,58
$1 394,16
$1 740,84

$1 465,50
$1 557,60
$1 655,18
$2 001,86

$602,24
$648,29
$697,08
$870,42

$863,26
$909,31
$958,10
$1 131,44

$1 124,28
$1 170,33
$1 219,12
$1 392,46

$261,02

Toc - Plan #53

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$4,800 $9,600 Annual Deductible

$4,800 $9,600 Maximum Out of Pocket Per Year

Deductible: Individual: $4,800 | Family: $9,600
Out of Pocket Maximum per year: Individual: $4,800 | Family: $9,600

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$352,33
$399,89
$450,27
$629,25
$956,20

$704,66
$799,78
$900,54
$1 258,50
$1 912,40

$974,19
$1 069,31
$1 170,07
$1 528,03

$1 243,72
$1 338,84
$1 439,60
$1 797,56

$1 513,25
$1 608,37
$1 709,13
$2 067,09

$621,86
$669,42
$719,80
$898,78

$891,39
$938,95
$989,33
$1 168,31

$1 160,92
$1 208,48
$1 258,86
$1 437,84

$269,53

Toc - Plan #54

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$2,750 $5,500 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Deductible: Individual: $2,750 | Family: $5,500
Out of Pocket Maximum per year: Individual: $6,500 | Family: $13,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$372,40
$422,66
$475,91
$665,09
$1 010,66

$744,80
$845,32
$951,82
$1 330,18
$2 021,32

$1 029,68
$1 130,20
$1 236,70
$1 615,06

$1 314,56
$1 415,08
$1 521,58
$1 899,94

$1 599,44
$1 699,96
$1 806,46
$2 184,82

$657,28
$707,54
$760,79
$949,97

$942,16
$992,42
$1 045,67
$1 234,85

$1 227,04
$1 277,30
$1 330,55
$1 519,73

$284,88

Toc - Plan #55

Silver

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,200 $16,400 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,200 | Family: $16,400

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$375,43
$426,10
$479,79
$670,50
$1 018,89

$750,86
$852,20
$959,58
$1 341,00
$2 037,78

$1 038,06
$1 139,40
$1 246,78
$1 628,20

$1 325,26
$1 426,60
$1 533,98
$1 915,40

$1 612,46
$1 713,80
$1 821,18
$2 202,60

$662,63
$713,30
$766,99
$957,70

$949,83
$1 000,50
$1 054,19
$1 244,90

$1 237,03
$1 287,70
$1 341,39
$1 532,10

$287,20

Toc - Plan #56

Gold

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

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Ambetter from Superior HealthPlan
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses

Individual Family

$1,150 $2,300 Annual Deductible

$4,450 $8,900 Maximum Out of Pocket Per Year

Deductible: Individual: $1,150 | Family: $2,300
Out of Pocket Maximum per year: Individual: $4,450 | Family: $8,900

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$473,81
$537,77
$605,52
$846,21
$1 285,90

$947,62
$1 075,54
$1 211,04
$1 692,42
$2 571,80

$1 310,08
$1 438,00
$1 573,50
$2 054,88

$1 672,54
$1 800,46
$1 935,96
$2 417,34

$2 035,00
$2 162,92
$2 298,42
$2 779,80

$836,27
$900,23
$967,98
$1 208,67

$1 198,73
$1 262,69
$1 330,44
$1 571,13

$1 561,19
$1 625,15
$1 692,90
$1 933,59

$362,46

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 #57

Gold

(HMO) Blue Advantage Gold HMO_ 206

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Blue Cross and Blue Shield of Texas
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses

Individual Family

$750 $2,250 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $750 | Family: $2,250
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$387,37
$439,67
$495,06
$691,85
$1 051,33

$774,74
$879,34
$990,12
$1 383,70
$2 102,66

$1 071,08
$1 175,68
$1 286,46
$1 680,04

$1 367,42
$1 472,02
$1 582,80
$1 976,38

$1 663,76
$1 768,36
$1 879,14
$2 272,72

$683,71
$736,01
$791,40
$988,19

$980,05
$1 032,35
$1 087,74
$1 284,53

$1 276,39
$1 328,69
$1 384,08
$1 580,87

$296,34

Toc - Plan #58

Catastrophic

(HMO) Blue Advantage Security HMO_ 200

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Blue Cross and Blue Shield of Texas
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$264,18
$299,84
$337,62
$471,83
$716,99

$528,36
$599,68
$675,24
$943,66
$1 433,98

$730,46
$801,78
$877,34
$1 145,76

$932,56
$1 003,88
$1 079,44
$1 347,86

$1 134,66
$1 205,98
$1 281,54
$1 549,96

$466,28
$501,94
$539,72
$673,93

$668,38
$704,04
$741,82
$876,03

$870,48
$906,14
$943,92
$1 078,13

$202,10

Toc - Plan #59

Silver

(HMO) Blue Advantage Silver HMO_ 205

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Blue Cross and Blue Shield of Texas
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses

Individual Family

$1,900 $5,700 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $1,900 | Family: $5,700
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$386,49
$438,67
$493,94
$690,28
$1 048,94

$772,98
$877,34
$987,88
$1 380,56
$2 097,88

$1 068,65
$1 173,01
$1 283,55
$1 676,23

$1 364,32
$1 468,68
$1 579,22
$1 971,90

$1 659,99
$1 764,35
$1 874,89
$2 267,57

$682,16
$734,34
$789,61
$985,95

$977,83
$1 030,01
$1 085,28
$1 281,62

$1 273,50
$1 325,68
$1 380,95
$1 577,29

$295,67

Toc - Plan #60

Expanded Bronze

(HMO) Blue Advantage Bronze HMO_ 204

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Blue Cross and Blue Shield of Texas
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses

Individual Family

$6,000 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$290,70
$329,95
$371,52
$519,19
$788,96

$581,40
$659,90
$743,04
$1 038,38
$1 577,92

$803,79
$882,29
$965,43
$1 260,77

$1 026,18
$1 104,68
$1 187,82
$1 483,16

$1 248,57
$1 327,07
$1 410,21
$1 705,55

$513,09
$552,34
$593,91
$741,58

$735,48
$774,73
$816,30
$963,97

$957,87
$997,12
$1 038,69
$1 186,36

$222,39

Toc - Plan #61

Bronze

(HMO) Blue Advantage Bronze HMO_ 301

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Blue Cross and Blue Shield of Texas
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$288,28
$327,20
$368,43
$514,87
$782,40

$576,56
$654,40
$736,86
$1 029,74
$1 564,80

$797,10
$874,94
$957,40
$1 250,28

$1 017,64
$1 095,48
$1 177,94
$1 470,82

$1 238,18
$1 316,02
$1 398,48
$1 691,36

$508,82
$547,74
$588,97
$735,41

$729,36
$768,28
$809,51
$955,95

$949,90
$988,82
$1 030,05
$1 176,49

$220,54

Toc - Plan #62

Gold

(HMO) Blue Advantage Plus Gold_ 203

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Blue Cross and Blue Shield of Texas
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses

Individual Family

$750 $2,250 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $750 | Family: $2,250
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$457,69
$519,48
$584,93
$817,43
$1 242,17

$915,38
$1 038,96
$1 169,86
$1 634,86
$2 484,34

$1 265,51
$1 389,09
$1 519,99
$1 984,99

$1 615,64
$1 739,22
$1 870,12
$2 335,12

$1 965,77
$2 089,35
$2 220,25
$2 685,25

$807,82
$869,61
$935,06
$1 167,56

$1 157,95
$1 219,74
$1 285,19
$1 517,69

$1 508,08
$1 569,87
$1 635,32
$1 867,82

$350,13

Toc - Plan #63

Silver

(HMO) Blue Advantage Plus Silver_ 202

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Blue Cross and Blue Shield of Texas
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses

Individual Family

$1,250 $3,750 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $1,250 | Family: $3,750
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$454,07
$515,37
$580,30
$810,96
$1 232,34

$908,14
$1 030,74
$1 160,60
$1 621,92
$2 464,68

$1 255,50
$1 378,10
$1 507,96
$1 969,28

$1 602,86
$1 725,46
$1 855,32
$2 316,64

$1 950,22
$2 072,82
$2 202,68
$2 664,00

$801,43
$862,73
$927,66
$1 158,32

$1 148,79
$1 210,09
$1 275,02
$1 505,68

$1 496,15
$1 557,45
$1 622,38
$1 853,04

$347,36

Toc - Plan #64

Expanded Bronze

(HMO) Blue Advantage Plus Bronze_ 303

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Blue Cross and Blue Shield of Texas
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses

Individual Family

$4,900 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $4,900 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$343,77
$390,18
$439,34
$613,98
$933,00

$687,54
$780,36
$878,68
$1 227,96
$1 866,00

$950,53
$1 043,35
$1 141,67
$1 490,95

$1 213,52
$1 306,34
$1 404,66
$1 753,94

$1 476,51
$1 569,33
$1 667,65
$2 016,93

$606,76
$653,17
$702,33
$876,97

$869,75
$916,16
$965,32
$1 139,96

$1 132,74
$1 179,15
$1 228,31
$1 402,95

$262,99

Toc - Plan #65

Bronze

(HMO) Blue Advantage Plus Bronze_ 305

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Blue Cross and Blue Shield of Texas
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses

Individual Family

$5,000 $15,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $5,000 | Family: $15,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$320,94
$364,27
$410,16
$573,20
$871,03

$641,88
$728,54
$820,32
$1 146,40
$1 742,06

$887,40
$974,06
$1 065,84
$1 391,92

$1 132,92
$1 219,58
$1 311,36
$1 637,44

$1 378,44
$1 465,10
$1 556,88
$1 882,96

$566,46
$609,79
$655,68
$818,72

$811,98
$855,31
$901,20
$1 064,24

$1 057,50
$1 100,83
$1 146,72
$1 309,76

$245,52

Molina Healthcare

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

Toc - Plan #66

Gold

(HMO) Molina Gold 3

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,150 | Family: $16,300

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$343,64
$390,03
$439,17
$613,73
$932,63

$687,28
$780,06
$878,34
$1 227,46
$1 865,26

$950,16
$1 042,94
$1 141,22
$1 490,34

$1 213,04
$1 305,82
$1 404,10
$1 753,22

$1 475,92
$1 568,70
$1 666,98
$2 016,10

$606,52
$652,91
$702,05
$876,61

$869,40
$915,79
$964,93
$1 139,49

$1 132,28
$1 178,67
$1 227,81
$1 402,37

$262,88

Toc - Plan #67

Silver

(HMO) Molina Silver 3 250

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,150 | Family: $16,300

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$323,30
$366,95
$413,18
$577,42
$877,45

$646,60
$733,90
$826,36
$1 154,84
$1 754,90

$893,93
$981,23
$1 073,69
$1 402,17

$1 141,26
$1 228,56
$1 321,02
$1 649,50

$1 388,59
$1 475,89
$1 568,35
$1 896,83

$570,63
$614,28
$660,51
$824,75

$817,96
$861,61
$907,84
$1 072,08

$1 065,29
$1 108,94
$1 155,17
$1 319,41

$247,33

Toc - Plan #68

Gold

(HMO) Confident Care Gold 1

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$2,925 $5,850 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Deductible: Individual: $2,925 | Family: $5,850
Out of Pocket Maximum per year: Individual: $6,500 | Family: $13,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$345,88
$392,57
$442,03
$617,74
$938,71

$691,76
$785,14
$884,06
$1 235,48
$1 877,42

$956,36
$1 049,74
$1 148,66
$1 500,08

$1 220,96
$1 314,34
$1 413,26
$1 764,68

$1 485,56
$1 578,94
$1 677,86
$2 029,28

$610,48
$657,17
$706,63
$882,34

$875,08
$921,77
$971,23
$1 146,94

$1 139,68
$1 186,37
$1 235,83
$1 411,54

$264,60

Toc - Plan #69

Silver

(HMO) Constant Care Silver 1 250

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,500 $17,000 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,500 | Family: $17,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$322,46
$365,99
$412,10
$575,91
$875,15

$644,92
$731,98
$824,20
$1 151,82
$1 750,30

$891,60
$978,66
$1 070,88
$1 398,50

$1 138,28
$1 225,34
$1 317,56
$1 645,18

$1 384,96
$1 472,02
$1 564,24
$1 891,86

$569,14
$612,67
$658,78
$822,59

$815,82
$859,35
$905,46
$1 069,27

$1 062,50
$1 106,03
$1 152,14
$1 315,95

$246,68

Toc - Plan #70

Bronze

(HMO) Core Care Bronze 1

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$6,100 $12,200 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,100 | Family: $12,200
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$228,27
$259,09
$291,73
$407,69
$619,52

$456,54
$518,18
$583,46
$815,38
$1 239,04

$631,17
$692,81
$758,09
$990,01

$805,80
$867,44
$932,72
$1 164,64

$980,43
$1 042,07
$1 107,35
$1 339,27

$402,90
$433,72
$466,36
$582,32

$577,53
$608,35
$640,99
$756,95

$752,16
$782,98
$815,62
$931,58

$174,63

Toc - Plan #71

Silver

(HMO) Constant Care Silver 2 250

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$5,200 $10,400 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Deductible: Individual: $5,200 | Family: $10,400
Out of Pocket Maximum per year: Individual: $8,150 | Family: $16,300

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$322,16
$365,65
$411,72
$575,38
$874,35

$644,32
$731,30
$823,44
$1 150,76
$1 748,70

$890,77
$977,75
$1 069,89
$1 397,21

$1 137,22
$1 224,20
$1 316,34
$1 643,66

$1 383,67
$1 470,65
$1 562,79
$1 890,11

$568,61
$612,10
$658,17
$821,83

$815,06
$858,55
$904,62
$1 068,28

$1 061,51
$1 105,00
$1 151,07
$1 314,73

$246,45

Toc - Plan #72

Bronze

(HMO) Core Care Bronze 2

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$8,000 $16,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,000 | Family: $16,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$226,30
$256,85
$289,21
$404,17
$614,17

$452,60
$513,70
$578,42
$808,34
$1 228,34

$625,72
$686,82
$751,54
$981,46

$798,84
$859,94
$924,66
$1 154,58

$971,96
$1 033,06
$1 097,78
$1 327,70

$399,42
$429,97
$462,33
$577,29

$572,54
$603,09
$635,45
$750,41

$745,66
$776,21
$808,57
$923,53

$173,12

Toc - Plan #73

Silver

(HMO) Constant Care Silver 4 250

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$7,450 $14,900 Annual Deductible

$7,450 $14,900 Maximum Out of Pocket Per Year

Deductible: Individual: $7,450 | Family: $14,900
Out of Pocket Maximum per year: Individual: $7,450 | Family: $14,900

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$318,83
$361,88
$407,47
$569,44
$865,32

$637,66
$723,76
$814,94
$1 138,88
$1 730,64

$881,57
$967,67
$1 058,85
$1 382,79

$1 125,48
$1 211,58
$1 302,76
$1 626,70

$1 369,39
$1 455,49
$1 546,67
$1 870,61

$562,74
$605,79
$651,38
$813,35

$806,65
$849,70
$895,29
$1 057,26

$1 050,56
$1 093,61
$1 139,20
$1 301,17

$243,91

Toc - Plan #74

Expanded Bronze

(HMO) Core Care Bronze 4

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$238,86
$271,11
$305,26
$426,61
$648,27

$477,72
$542,22
$610,52
$853,22
$1 296,54

$660,45
$724,95
$793,25
$1 035,95

$843,18
$907,68
$975,98
$1 218,68

$1 025,91
$1 090,41
$1 158,71
$1 401,41

$421,59
$453,84
$487,99
$609,34

$604,32
$636,57
$670,72
$792,07

$787,05
$819,30
$853,45
$974,80

$182,73

Toc - Plan #75

Expanded Bronze

(HMO) Core Care Bronze 5

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$232,39
$263,76
$296,99
$415,04
$630,70

$464,78
$527,52
$593,98
$830,08
$1 261,40

$642,56
$705,30
$771,76
$1 007,86

$820,34
$883,08
$949,54
$1 185,64

$998,12
$1 060,86
$1 127,32
$1 363,42

$410,17
$441,54
$474,77
$592,82

$587,95
$619,32
$652,55
$770,60

$765,73
$797,10
$830,33
$948,38

$177,78

Toc - Plan #76

Gold

(HMO) Confident Care Gold 1 + Vision

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$2,925 $5,850 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Deductible: Individual: $2,925 | Family: $5,850
Out of Pocket Maximum per year: Individual: $6,500 | Family: $13,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$349,24
$396,39
$446,33
$623,74
$947,84

$698,48
$792,78
$892,66
$1 247,48
$1 895,68

$965,65
$1 059,95
$1 159,83
$1 514,65

$1 232,82
$1 327,12
$1 427,00
$1 781,82

$1 499,99
$1 594,29
$1 694,17
$2 048,99

$616,41
$663,56
$713,50
$890,91

$883,58
$930,73
$980,67
$1 158,08

$1 150,75
$1 197,90
$1 247,84
$1 425,25

$267,17

Toc - Plan #77

Silver

(HMO) Constant Care Silver 1 250 + Vision

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$0 $0 Annual Deductible

$8,500 $17,000 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,500 | Family: $17,000

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$325,82
$369,80
$416,40
$581,91
$884,27

$651,64
$739,60
$832,80
$1 163,82
$1 768,54

$900,89
$988,85
$1 082,05
$1 413,07

$1 150,14
$1 238,10
$1 331,30
$1 662,32

$1 399,39
$1 487,35
$1 580,55
$1 911,57

$575,07
$619,05
$665,65
$831,16

$824,32
$868,30
$914,90
$1 080,41

$1 073,57
$1 117,55
$1 164,15
$1 329,66

$249,25

Toc - Plan #78

Bronze

(HMO) Core Care Bronze 1 + Vision

Summary of Benefits and Coverage
Plan Brochure
Provider Directory for Molina Healthcare
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses

Individual Family

$6,100 $12,200 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,100 | Family: $12,200
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Age

Individual

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$231,63
$262,90
$296,02
$413,69
$628,65

$463,26
$525,80
$592,04
$827,38
$1 257,30

$640,46
$703,00
$769,24
$1 004,58

$817,66
$880,20
$946,44
$1 181,78

$994,86
$1 057,40
$1 123,64
$1 358,98

$408,83
$440,10
$473,22
$590,89

$586,03
$617,30
$650,42
$768,09

$763,23
$794,50
$827,62
$945,29

$177,20

‡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 Fort Bend County here.

Fort Bend County is in “Rating Area 10” of Texas.

Currently, there are 78 plans offered in Rating Area 10.

Obamacare Rates and Providers for Other Years

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

Ways to Save Money on Obamacare in Texas

There are three primary ways to reduce the cost of health plans under the Affordable Care Act in Texas.

You may be able to lower the cost of monthly premiums when you sign up for a private health insurance plan. Your subsidies will come in the form of a federal tax credit. This article is updated to cover the new tax credits available under the American Rescue Plan Act of 2021.
You may be able to reduce your out-of-pocket costs -- including copayments, deductibles, and coinsurance -- with cost-sharing subsidies paid for by insurers.
You may qualify for free or low-cost coverage through Medicaid in Texas, or your children may be able to obtain coverage through the Children’s Health Insurance Program (CHIP).

Each of these forms of assistance depends on your income and family size.

Many people who apply for coverage at the Texas exchange will be eligible for some form of financial assistance. Read on to learn more about each option.

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?

What's New

Quick Links

Obamacare Rates and Providers for Other Years

Obamacare Providers, Plans and 2021 Rates for Fort Bend County, Texas

Oscar Insurance Company

Community Health Choice

Ambetter from Superior HealthPlan

Blue Cross and Blue Shield of Texas

Molina Healthcare

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

2021 Obamacare Rates, Providers, and Plans for Fort Bend County

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 Deductible: Individual: $7,300 | Family: $14,600 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

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 Deductible: Individual: $6,000 | Family: $12,000 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

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 Deductible: Individual: $6,000 | Family: $12,000 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

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 Deductible: Individual: $0 | Family: $0 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

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 Deductible: Individual: $5,000 | Family: $10,000 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

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 Deductible: Individual: $6,200 | Family: $12,400 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

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 Deductible: Individual: $6,000 | Family: $12,000 Out of Pocket Maximum per year: Individual: $8,000 | Family: $16,000

Monthly Premiums:

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 Deductible: Individual: $8,550 | Family: $17,100 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

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 Deductible: Individual: $0 | Family: $0 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

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 Deductible: Individual: $2,500 | Family: $5,000 Out of Pocket Maximum per year: Individual: $6,000 | Family: $12,000

Monthly Premiums:

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 Deductible: Individual: $5,200 | Family: $10,400 Out of Pocket Maximum per year: Individual: $7,000 | Family: $14,000

Monthly Premiums:

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 Deductible: Individual: $7,000 | Family: $14,000 Out of Pocket Maximum per year: Individual: $8,200 | Family: $16,400

Monthly Premiums:

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 Deductible: Individual: $0 | Family: $0 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Monthly Premiums:

Community Health Choice

Expanded Bronze

(HMO) Community Vital Bronze 003 (No Deductible for PCP, Free Preventive Care, 24/7 Telehealth)

Annual Out of Pocket Expenses

Individual Family $7,700 $15,400 Annual Deductible $8,550 $17,100 Maximum Out of Pocket Per Year Deductible: Individual: $7,700 | Family: $15,400 Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$7,300 $14,600 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $7,300 | Family: $14,600
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$6,000 $12,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$6,000 $12,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$0 $0 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$5,000 $10,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $5,000 | Family: $10,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$6,200 $12,400 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,200 | Family: $12,400
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$6,000 $12,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,000 | Family: $16,000

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$0 $0 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$2,500 $5,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Deductible: Individual: $2,500 | Family: $5,000
Out of Pocket Maximum per year: Individual: $6,000 | Family: $12,000

Individual Family

$5,200 $10,400 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Deductible: Individual: $5,200 | Family: $10,400
Out of Pocket Maximum per year: Individual: $7,000 | Family: $14,000

Individual Family

$7,000 $14,000 Annual Deductible

$8,200 $16,400 Maximum Out of Pocket Per Year

Deductible: Individual: $7,000 | Family: $14,000
Out of Pocket Maximum per year: Individual: $8,200 | Family: $16,400

Individual Family

$0 $0 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $0 | Family: $0
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$7,700 $15,400 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $7,700 | Family: $15,400
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$3,000 $6,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $3,000 | Family: $6,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$2,000 $4,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $2,000 | Family: $4,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$7,000 $14,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Deductible: Individual: $7,000 | Family: $14,000
Out of Pocket Maximum per year: Individual: $7,000 | Family: $14,000

Individual Family

$5,000 $10,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Deductible: Individual: $5,000 | Family: $10,000
Out of Pocket Maximum per year: Individual: $7,000 | Family: $14,000

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$6,000 $12,000 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$8,550 $17,100 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Deductible: Individual: $8,550 | Family: $17,100
Out of Pocket Maximum per year: Individual: $8,550 | Family: $17,100

Individual Family

$6,000 $12,000 Annual Deductible

$8,500 $17,000 Maximum Out of Pocket Per Year

Deductible: Individual: $6,000 | Family: $12,000
Out of Pocket Maximum per year: Individual: $8,500 | Family: $17,000

Individual Family

$8,300 $16,600 Annual Deductible

$8,300 $16,600 Maximum Out of Pocket Per Year

Deductible: Individual: $8,300 | Family: $16,600
Out of Pocket Maximum per year: Individual: $8,300 | Family: $16,600

Individual Family

$7,200 $14,400 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Deductible: Individual: $7,200 | Family: $14,400
Out of Pocket Maximum per year: Individual: $8,400 | Family: $16,800

Individual Family

$1,450 $2,900 Annual Deductible

$6,300 $12,600 Maximum Out of Pocket Per Year

Deductible: Individual: $1,450 | Family: $2,900
Out of Pocket Maximum per year: Individual: $6,300 | Family: $12,600