Galveston County, Texas Obamacare 2024 Rates

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

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

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

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

Obamacare Providers, 92 Plans and 2024 Rates for Galveston County, Texas

Below, you’ll find a summary of the 92 plans for Galveston County, Texas and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

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Oscar Insurance Company

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

Toc - Plan #1 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite + PCP Saver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.07
$367.81
$414.15
$578.77
$879.50
$571.98
$615.72
$662.06
$826.68
$819.89
$863.63
$909.97
$1,074.59
$1,067.80
$1,111.54
$1,157.88
$1,322.50
$247.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.14
$735.62
$828.30
$1,157.54
$1,759.00
$896.05
$983.53
$1,076.21
$1,405.45
$1,143.96
$1,231.44
$1,324.12
$1,653.36
$1,391.87
$1,479.35
$1,572.03
$1,901.27
$247.91
Toc - Plan #2 Oscar Insurance Company
Silver

(EPO) Silver Simple Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,200 $18,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.64
$474.01
$533.73
$745.88
$1,133.44
$737.13
$793.50
$853.22
$1,065.37
$1,056.62
$1,112.99
$1,172.71
$1,384.86
$1,376.11
$1,432.48
$1,492.20
$1,704.35
$319.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.28
$948.02
$1,067.46
$1,491.76
$2,266.88
$1,154.77
$1,267.51
$1,386.95
$1,811.25
$1,474.26
$1,587.00
$1,706.44
$2,130.74
$1,793.75
$1,906.49
$2,025.93
$2,450.23
$319.49
Toc - Plan #3 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic 4700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$311.98
$354.08
$398.69
$557.17
$846.67
$550.63
$592.73
$637.34
$795.82
$789.28
$831.38
$875.99
$1,034.47
$1,027.93
$1,070.03
$1,114.64
$1,273.12
$238.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$623.96
$708.16
$797.38
$1,114.34
$1,693.34
$862.61
$946.81
$1,036.03
$1,352.99
$1,101.26
$1,185.46
$1,274.68
$1,591.64
$1,339.91
$1,424.11
$1,513.33
$1,830.29
$238.65
Toc - Plan #4 Oscar Insurance Company
Silver

(EPO) Silver Simple PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.04
$472.19
$531.68
$743.02
$1,129.09
$734.30
$790.45
$849.94
$1,061.28
$1,052.56
$1,108.71
$1,168.20
$1,379.54
$1,370.82
$1,426.97
$1,486.46
$1,697.80
$318.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.08
$944.38
$1,063.36
$1,486.04
$2,258.18
$1,150.34
$1,262.64
$1,381.62
$1,804.30
$1,468.60
$1,580.90
$1,699.88
$2,122.56
$1,786.86
$1,899.16
$2,018.14
$2,440.82
$318.26
Toc - Plan #5 Oscar Insurance Company
Silver

(EPO) Silver Elite Saver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$438.64
$497.85
$560.57
$783.40
$1,190.45
$774.19
$833.40
$896.12
$1,118.95
$1,109.74
$1,168.95
$1,231.67
$1,454.50
$1,445.29
$1,504.50
$1,567.22
$1,790.05
$335.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$877.28
$995.70
$1,121.14
$1,566.80
$2,380.90
$1,212.83
$1,331.25
$1,456.69
$1,902.35
$1,548.38
$1,666.80
$1,792.24
$2,237.90
$1,883.93
$2,002.35
$2,127.79
$2,573.45
$335.55
Toc - Plan #6 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$306.17
$347.49
$391.27
$546.80
$830.91
$540.38
$581.70
$625.48
$781.01
$774.59
$815.91
$859.69
$1,015.22
$1,008.80
$1,050.12
$1,093.90
$1,249.43
$234.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.34
$694.98
$782.54
$1,093.60
$1,661.82
$846.55
$929.19
$1,016.75
$1,327.81
$1,080.76
$1,163.40
$1,250.96
$1,562.02
$1,314.97
$1,397.61
$1,485.17
$1,796.23
$234.21
Toc - Plan #7 Oscar Insurance Company
Silver

(EPO) Silver Classic Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.22
$466.73
$525.53
$734.43
$1,116.03
$725.80
$781.31
$840.11
$1,049.01
$1,040.38
$1,095.89
$1,154.69
$1,363.59
$1,354.96
$1,410.47
$1,469.27
$1,678.17
$314.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.44
$933.46
$1,051.06
$1,468.86
$2,232.06
$1,137.02
$1,248.04
$1,365.64
$1,783.44
$1,451.60
$1,562.62
$1,680.22
$2,098.02
$1,766.18
$1,877.20
$1,994.80
$2,412.60
$314.58
Toc - Plan #8 Oscar Insurance Company
Gold

(EPO) Gold Classic Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.99
$401.77
$452.39
$632.21
$960.70
$624.79
$672.57
$723.19
$903.01
$895.59
$943.37
$993.99
$1,173.81
$1,166.39
$1,214.17
$1,264.79
$1,444.61
$270.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.98
$803.54
$904.78
$1,264.42
$1,921.40
$978.78
$1,074.34
$1,175.58
$1,535.22
$1,249.58
$1,345.14
$1,446.38
$1,806.02
$1,520.38
$1,615.94
$1,717.18
$2,076.82
$270.80
Toc - Plan #9 Oscar Insurance Company
Gold

(EPO) Gold Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$365.22
$414.52
$466.74
$652.27
$991.19
$644.61
$693.91
$746.13
$931.66
$924.00
$973.30
$1,025.52
$1,211.05
$1,203.39
$1,252.69
$1,304.91
$1,490.44
$279.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.44
$829.04
$933.48
$1,304.54
$1,982.38
$1,009.83
$1,108.43
$1,212.87
$1,583.93
$1,289.22
$1,387.82
$1,492.26
$1,863.32
$1,568.61
$1,667.21
$1,771.65
$2,142.71
$279.39
Toc - Plan #10 Oscar Insurance Company
Gold

(EPO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$377.51
$428.46
$482.44
$674.21
$1,024.53
$666.30
$717.25
$771.23
$963.00
$955.09
$1,006.04
$1,060.02
$1,251.79
$1,243.88
$1,294.83
$1,348.81
$1,540.58
$288.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$755.02
$856.92
$964.88
$1,348.42
$2,049.06
$1,043.81
$1,145.71
$1,253.67
$1,637.21
$1,332.60
$1,434.50
$1,542.46
$1,926.00
$1,621.39
$1,723.29
$1,831.25
$2,214.79
$288.79
Toc - Plan #11 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite + PCP Saver Plus (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.47
$378.48
$426.17
$595.56
$905.02
$588.57
$633.58
$681.27
$850.66
$843.67
$888.68
$936.37
$1,105.76
$1,098.77
$1,143.78
$1,191.47
$1,360.86
$255.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.94
$756.96
$852.34
$1,191.12
$1,810.04
$922.04
$1,012.06
$1,107.44
$1,446.22
$1,177.14
$1,267.16
$1,362.54
$1,701.32
$1,432.24
$1,522.26
$1,617.64
$1,956.42
$255.10
Toc - Plan #12 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic 4700 (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.01
$364.34
$410.24
$573.31
$871.20
$566.58
$609.91
$655.81
$818.88
$812.15
$855.48
$901.38
$1,064.45
$1,057.72
$1,101.05
$1,146.95
$1,310.02
$245.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$642.02
$728.68
$820.48
$1,146.62
$1,742.40
$887.59
$974.25
$1,066.05
$1,392.19
$1,133.16
$1,219.82
$1,311.62
$1,637.76
$1,378.73
$1,465.39
$1,557.19
$1,883.33
$245.57
Toc - Plan #13 Oscar Insurance Company
Silver

(EPO) Silver Simple PCP Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$428.21
$486.01
$547.24
$764.76
$1,162.13
$755.78
$813.58
$874.81
$1,092.33
$1,083.35
$1,141.15
$1,202.38
$1,419.90
$1,410.92
$1,468.72
$1,529.95
$1,747.47
$327.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.42
$972.02
$1,094.48
$1,529.52
$2,324.26
$1,183.99
$1,299.59
$1,422.05
$1,857.09
$1,511.56
$1,627.16
$1,749.62
$2,184.66
$1,839.13
$1,954.73
$2,077.19
$2,512.23
$327.57
Toc - Plan #14 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.03
$357.55
$402.59
$562.62
$854.96
$556.02
$598.54
$643.58
$803.61
$797.01
$839.53
$884.57
$1,044.60
$1,038.00
$1,080.52
$1,125.56
$1,285.59
$240.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.06
$715.10
$805.18
$1,125.24
$1,709.92
$871.05
$956.09
$1,046.17
$1,366.23
$1,112.04
$1,197.08
$1,287.16
$1,607.22
$1,353.03
$1,438.07
$1,528.15
$1,848.21
$240.99
Toc - Plan #15 Oscar Insurance Company
Silver

(EPO) Silver Classic Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.25
$480.38
$540.90
$755.91
$1,148.68
$747.03
$804.16
$864.68
$1,079.69
$1,070.81
$1,127.94
$1,188.46
$1,403.47
$1,394.59
$1,451.72
$1,512.24
$1,727.25
$323.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$846.50
$960.76
$1,081.80
$1,511.82
$2,297.36
$1,170.28
$1,284.54
$1,405.58
$1,835.60
$1,494.06
$1,608.32
$1,729.36
$2,159.38
$1,817.84
$1,932.10
$2,053.14
$2,483.16
$323.78
Toc - Plan #16 Oscar Insurance Company
Gold

(EPO) Gold Classic Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364.29
$413.46
$465.55
$650.61
$988.67
$642.97
$692.14
$744.23
$929.29
$921.65
$970.82
$1,022.91
$1,207.97
$1,200.33
$1,249.50
$1,301.59
$1,486.65
$278.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728.58
$826.92
$931.10
$1,301.22
$1,977.34
$1,007.26
$1,105.60
$1,209.78
$1,579.90
$1,285.94
$1,384.28
$1,488.46
$1,858.58
$1,564.62
$1,662.96
$1,767.14
$2,137.26
$278.68
Toc - Plan #17 Oscar Insurance Company
Gold

(EPO) Gold Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.87
$426.60
$480.34
$671.28
$1,020.07
$663.40
$714.13
$767.87
$958.81
$950.93
$1,001.66
$1,055.40
$1,246.34
$1,238.46
$1,289.19
$1,342.93
$1,533.87
$287.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$751.74
$853.20
$960.68
$1,342.56
$2,040.14
$1,039.27
$1,140.73
$1,248.21
$1,630.09
$1,326.80
$1,428.26
$1,535.74
$1,917.62
$1,614.33
$1,715.79
$1,823.27
$2,205.15
$287.53
Toc - Plan #18 Oscar Insurance Company
Gold

(EPO) Gold Elite (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.52
$440.96
$496.52
$693.88
$1,054.42
$685.73
$738.17
$793.73
$991.09
$982.94
$1,035.38
$1,090.94
$1,288.30
$1,280.15
$1,332.59
$1,388.15
$1,585.51
$297.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.04
$881.92
$993.04
$1,387.76
$2,108.84
$1,074.25
$1,179.13
$1,290.25
$1,684.97
$1,371.46
$1,476.34
$1,587.46
$1,982.18
$1,668.67
$1,773.55
$1,884.67
$2,279.39
$297.21

ADVERTISEMENT

Community Health Choice

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

Toc - Plan #19 Community Health Choice
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.17
$358.85
$404.07
$564.68
$858.09
$558.04
$600.72
$645.94
$806.55
$799.91
$842.59
$887.81
$1,048.42
$1,041.78
$1,084.46
$1,129.68
$1,290.29
$241.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.34
$717.70
$808.14
$1,129.36
$1,716.18
$874.21
$959.57
$1,050.01
$1,371.23
$1,116.08
$1,201.44
$1,291.88
$1,613.10
$1,357.95
$1,443.31
$1,533.75
$1,854.97
$241.87
Toc - Plan #20 Community Health Choice
Silver

(HMO) Community Premier Silver 004 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$3,300 $6,600 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$469.31
$532.67
$599.78
$838.19
$1,273.71
$828.33
$891.69
$958.80
$1,197.21
$1,187.35
$1,250.71
$1,317.82
$1,556.23
$1,546.37
$1,609.73
$1,676.84
$1,915.25
$359.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$938.62
$1,065.34
$1,199.56
$1,676.38
$2,547.42
$1,297.64
$1,424.36
$1,558.58
$2,035.40
$1,656.66
$1,783.38
$1,917.60
$2,394.42
$2,015.68
$2,142.40
$2,276.62
$2,753.44
$359.02
Toc - Plan #21 Community Health Choice
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$400.98
$455.11
$512.45
$716.15
$1,088.26
$707.73
$761.86
$819.20
$1,022.90
$1,014.48
$1,068.61
$1,125.95
$1,329.65
$1,321.23
$1,375.36
$1,432.70
$1,636.40
$306.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$801.96
$910.22
$1,024.90
$1,432.30
$2,176.52
$1,108.71
$1,216.97
$1,331.65
$1,739.05
$1,415.46
$1,523.72
$1,638.40
$2,045.80
$1,722.21
$1,830.47
$1,945.15
$2,352.55
$306.75
Toc - Plan #22 Community Health Choice
Expanded Bronze

(HMO) Community Premier Virtual Bronze 011 (Unlimited Free 24/7 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.34
$367.00
$413.23
$577.49
$877.56
$570.70
$614.36
$660.59
$824.85
$818.06
$861.72
$907.95
$1,072.21
$1,065.42
$1,109.08
$1,155.31
$1,319.57
$247.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.68
$734.00
$826.46
$1,154.98
$1,755.12
$894.04
$981.36
$1,073.82
$1,402.34
$1,141.40
$1,228.72
$1,321.18
$1,649.70
$1,388.76
$1,476.08
$1,568.54
$1,897.06
$247.36
Toc - Plan #23 Community Health Choice
Silver

(HMO) Community Premier Silver 012 (No deductible for PCP, Urgent Care & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$465.02
$527.80
$594.30
$830.53
$1,262.07
$820.76
$883.54
$950.04
$1,186.27
$1,176.50
$1,239.28
$1,305.78
$1,542.01
$1,532.24
$1,595.02
$1,661.52
$1,897.75
$355.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$930.04
$1,055.60
$1,188.60
$1,661.06
$2,524.14
$1,285.78
$1,411.34
$1,544.34
$2,016.80
$1,641.52
$1,767.08
$1,900.08
$2,372.54
$1,997.26
$2,122.82
$2,255.82
$2,728.28
$355.74
Toc - Plan #24 Community Health Choice
Silver

(HMO) Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$456.47
$518.09
$583.37
$815.25
$1,238.86
$805.67
$867.29
$932.57
$1,164.45
$1,154.87
$1,216.49
$1,281.77
$1,513.65
$1,504.07
$1,565.69
$1,630.97
$1,862.85
$349.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$912.94
$1,036.18
$1,166.74
$1,630.50
$2,477.72
$1,262.14
$1,385.38
$1,515.94
$1,979.70
$1,611.34
$1,734.58
$1,865.14
$2,328.90
$1,960.54
$2,083.78
$2,214.34
$2,678.10
$349.20
Toc - Plan #25 Community Health Choice
Expanded Bronze

(HMO) Community Premier Bronze 018 (No deductible for PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$314.26
$356.68
$401.62
$561.26
$852.89
$554.67
$597.09
$642.03
$801.67
$795.08
$837.50
$882.44
$1,042.08
$1,035.49
$1,077.91
$1,122.85
$1,282.49
$240.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$628.52
$713.36
$803.24
$1,122.52
$1,705.78
$868.93
$953.77
$1,043.65
$1,362.93
$1,109.34
$1,194.18
$1,284.06
$1,603.34
$1,349.75
$1,434.59
$1,524.47
$1,843.75
$240.41
Toc - Plan #26 Community Health Choice
Silver

(HMO) Community Premier Silver 020 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$460.12
$522.23
$588.03
$821.77
$1,248.75
$812.11
$874.22
$940.02
$1,173.76
$1,164.10
$1,226.21
$1,292.01
$1,525.75
$1,516.09
$1,578.20
$1,644.00
$1,877.74
$351.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$920.24
$1,044.46
$1,176.06
$1,643.54
$2,497.50
$1,272.23
$1,396.45
$1,528.05
$1,995.53
$1,624.22
$1,748.44
$1,880.04
$2,347.52
$1,976.21
$2,100.43
$2,232.03
$2,699.51
$351.99
Toc - Plan #27 Community Health Choice
Gold

(HMO) Community Premier Gold 021 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$422.48
$479.52
$539.93
$754.56
$1,146.62
$745.68
$802.72
$863.13
$1,077.76
$1,068.88
$1,125.92
$1,186.33
$1,400.96
$1,392.08
$1,449.12
$1,509.53
$1,724.16
$323.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$844.96
$959.04
$1,079.86
$1,509.12
$2,293.24
$1,168.16
$1,282.24
$1,403.06
$1,832.32
$1,491.36
$1,605.44
$1,726.26
$2,155.52
$1,814.56
$1,928.64
$2,049.46
$2,478.72
$323.20

ADVERTISEMENT

Ambetter from Superior HealthPlan

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

Toc - Plan #28 Ambetter from Superior HealthPlan
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$470.61
$534.13
$601.43
$840.50
$1,277.21
$830.62
$894.14
$961.44
$1,200.51
$1,190.63
$1,254.15
$1,321.45
$1,560.52
$1,550.64
$1,614.16
$1,681.46
$1,920.53
$360.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$941.22
$1,068.26
$1,202.86
$1,681.00
$2,554.42
$1,301.23
$1,428.27
$1,562.87
$2,041.01
$1,661.24
$1,788.28
$1,922.88
$2,401.02
$2,021.25
$2,148.29
$2,282.89
$2,761.03
$360.01
Toc - Plan #29 Ambetter from Superior HealthPlan
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.56
$484.14
$545.13
$761.82
$1,157.66
$752.87
$810.45
$871.44
$1,088.13
$1,079.18
$1,136.76
$1,197.75
$1,414.44
$1,405.49
$1,463.07
$1,524.06
$1,740.75
$326.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.12
$968.28
$1,090.26
$1,523.64
$2,315.32
$1,179.43
$1,294.59
$1,416.57
$1,849.95
$1,505.74
$1,620.90
$1,742.88
$2,176.26
$1,832.05
$1,947.21
$2,069.19
$2,502.57
$326.31
Toc - Plan #30 Ambetter from Superior HealthPlan
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$463.01
$525.50
$591.71
$826.92
$1,256.58
$817.20
$879.69
$945.90
$1,181.11
$1,171.39
$1,233.88
$1,300.09
$1,535.30
$1,525.58
$1,588.07
$1,654.28
$1,889.49
$354.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$926.02
$1,051.00
$1,183.42
$1,653.84
$2,513.16
$1,280.21
$1,405.19
$1,537.61
$2,008.03
$1,634.40
$1,759.38
$1,891.80
$2,362.22
$1,988.59
$2,113.57
$2,245.99
$2,716.41
$354.19
Toc - Plan #31 Ambetter from Superior HealthPlan
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$465.87
$528.75
$595.36
$832.02
$1,264.33
$822.25
$885.13
$951.74
$1,188.40
$1,178.63
$1,241.51
$1,308.12
$1,544.78
$1,535.01
$1,597.89
$1,664.50
$1,901.16
$356.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$931.74
$1,057.50
$1,190.72
$1,664.04
$2,528.66
$1,288.12
$1,413.88
$1,547.10
$2,020.42
$1,644.50
$1,770.26
$1,903.48
$2,376.80
$2,000.88
$2,126.64
$2,259.86
$2,733.18
$356.38
Toc - Plan #32 Ambetter from Superior HealthPlan
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415.59
$471.69
$531.12
$742.23
$1,127.90
$733.51
$789.61
$849.04
$1,060.15
$1,051.43
$1,107.53
$1,166.96
$1,378.07
$1,369.35
$1,425.45
$1,484.88
$1,695.99
$317.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$831.18
$943.38
$1,062.24
$1,484.46
$2,255.80
$1,149.10
$1,261.30
$1,380.16
$1,802.38
$1,467.02
$1,579.22
$1,698.08
$2,120.30
$1,784.94
$1,897.14
$2,016.00
$2,438.22
$317.92
Toc - Plan #33 Ambetter from Superior HealthPlan
Gold

(EPO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412.18
$467.82
$526.76
$736.14
$1,118.64
$727.49
$783.13
$842.07
$1,051.45
$1,042.80
$1,098.44
$1,157.38
$1,366.76
$1,358.11
$1,413.75
$1,472.69
$1,682.07
$315.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$824.36
$935.64
$1,053.52
$1,472.28
$2,237.28
$1,139.67
$1,250.95
$1,368.83
$1,787.59
$1,454.98
$1,566.26
$1,684.14
$2,102.90
$1,770.29
$1,881.57
$1,999.45
$2,418.21
$315.31
Toc - Plan #34 Ambetter from Superior HealthPlan
Silver

(EPO) Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$460.80
$522.99
$588.89
$822.97
$1,250.58
$813.30
$875.49
$941.39
$1,175.47
$1,165.80
$1,227.99
$1,293.89
$1,527.97
$1,518.30
$1,580.49
$1,646.39
$1,880.47
$352.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$921.60
$1,045.98
$1,177.78
$1,645.94
$2,501.16
$1,274.10
$1,398.48
$1,530.28
$1,998.44
$1,626.60
$1,750.98
$1,882.78
$2,350.94
$1,979.10
$2,103.48
$2,235.28
$2,703.44
$352.50
Toc - Plan #35 Ambetter from Superior HealthPlan
Gold

(EPO) Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.98
$473.26
$532.88
$744.70
$1,131.65
$735.96
$792.24
$851.86
$1,063.68
$1,054.94
$1,111.22
$1,170.84
$1,382.66
$1,373.92
$1,430.20
$1,489.82
$1,701.64
$318.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$833.96
$946.52
$1,065.76
$1,489.40
$2,263.30
$1,152.94
$1,265.50
$1,384.74
$1,808.38
$1,471.92
$1,584.48
$1,703.72
$2,127.36
$1,790.90
$1,903.46
$2,022.70
$2,446.34
$318.98
Toc - Plan #36 Ambetter from Superior HealthPlan
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$443.11
$502.92
$566.28
$791.38
$1,202.57
$782.08
$841.89
$905.25
$1,130.35
$1,121.05
$1,180.86
$1,244.22
$1,469.32
$1,460.02
$1,519.83
$1,583.19
$1,808.29
$338.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.22
$1,005.84
$1,132.56
$1,582.76
$2,405.14
$1,225.19
$1,344.81
$1,471.53
$1,921.73
$1,564.16
$1,683.78
$1,810.50
$2,260.70
$1,903.13
$2,022.75
$2,149.47
$2,599.67
$338.97
Toc - Plan #37 Ambetter from Superior HealthPlan
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$488.87
$554.86
$624.76
$873.10
$1,326.77
$862.85
$928.84
$998.74
$1,247.08
$1,236.83
$1,302.82
$1,372.72
$1,621.06
$1,610.81
$1,676.80
$1,746.70
$1,995.04
$373.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$977.74
$1,109.72
$1,249.52
$1,746.20
$2,653.54
$1,351.72
$1,483.70
$1,623.50
$2,120.18
$1,725.70
$1,857.68
$1,997.48
$2,494.16
$2,099.68
$2,231.66
$2,371.46
$2,868.14
$373.98
Toc - Plan #38 Ambetter from Superior HealthPlan
Silver

(EPO) Standard Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$478.67
$543.28
$611.73
$854.89
$1,299.09
$844.85
$909.46
$977.91
$1,221.07
$1,211.03
$1,275.64
$1,344.09
$1,587.25
$1,577.21
$1,641.82
$1,710.27
$1,953.43
$366.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$957.34
$1,086.56
$1,223.46
$1,709.78
$2,598.18
$1,323.52
$1,452.74
$1,589.64
$2,075.96
$1,689.70
$1,818.92
$1,955.82
$2,442.14
$2,055.88
$2,185.10
$2,322.00
$2,808.32
$366.18
Toc - Plan #39 Ambetter from Superior HealthPlan
Gold

(EPO) Standard Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.15
$491.62
$553.56
$773.59
$1,175.55
$764.50
$822.97
$884.91
$1,104.94
$1,095.85
$1,154.32
$1,216.26
$1,436.29
$1,427.20
$1,485.67
$1,547.61
$1,767.64
$331.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$866.30
$983.24
$1,107.12
$1,547.18
$2,351.10
$1,197.65
$1,314.59
$1,438.47
$1,878.53
$1,529.00
$1,645.94
$1,769.82
$2,209.88
$1,860.35
$1,977.29
$2,101.17
$2,541.23
$331.35
Toc - Plan #40 Ambetter from Superior HealthPlan
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$483.94
$549.26
$618.46
$864.30
$1,313.38
$854.15
$919.47
$988.67
$1,234.51
$1,224.36
$1,289.68
$1,358.88
$1,604.72
$1,594.57
$1,659.89
$1,729.09
$1,974.93
$370.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$967.88
$1,098.52
$1,236.92
$1,728.60
$2,626.76
$1,338.09
$1,468.73
$1,607.13
$2,098.81
$1,708.30
$1,838.94
$1,977.34
$2,469.02
$2,078.51
$2,209.15
$2,347.55
$2,839.23
$370.21
Toc - Plan #41 Ambetter from Superior HealthPlan
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$431.72
$489.99
$551.72
$771.03
$1,171.65
$761.98
$820.25
$881.98
$1,101.29
$1,092.24
$1,150.51
$1,212.24
$1,431.55
$1,422.50
$1,480.77
$1,542.50
$1,761.81
$330.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$863.44
$979.98
$1,103.44
$1,542.06
$2,343.30
$1,193.70
$1,310.24
$1,433.70
$1,872.32
$1,523.96
$1,640.50
$1,763.96
$2,202.58
$1,854.22
$1,970.76
$2,094.22
$2,532.84
$330.26
Toc - Plan #42 Ambetter from Superior HealthPlan
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$480.97
$545.89
$614.67
$859.00
$1,305.33
$848.91
$913.83
$982.61
$1,226.94
$1,216.85
$1,281.77
$1,350.55
$1,594.88
$1,584.79
$1,649.71
$1,718.49
$1,962.82
$367.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$961.94
$1,091.78
$1,229.34
$1,718.00
$2,610.66
$1,329.88
$1,459.72
$1,597.28
$2,085.94
$1,697.82
$1,827.66
$1,965.22
$2,453.88
$2,065.76
$2,195.60
$2,333.16
$2,821.82
$367.94
Toc - Plan #43 Ambetter from Superior HealthPlan
Gold

(EPO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$428.18
$485.97
$547.19
$764.70
$1,162.04
$755.73
$813.52
$874.74
$1,092.25
$1,083.28
$1,141.07
$1,202.29
$1,419.80
$1,410.83
$1,468.62
$1,529.84
$1,747.35
$327.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.36
$971.94
$1,094.38
$1,529.40
$2,324.08
$1,183.91
$1,299.49
$1,421.93
$1,856.95
$1,511.46
$1,627.04
$1,749.48
$2,184.50
$1,839.01
$1,954.59
$2,077.03
$2,512.05
$327.55

ADVERTISEMENT

Blue Cross and Blue Shield of Texas

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

Toc - Plan #44 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.85
$433.40
$488.01
$681.99
$1,036.35
$673.97
$725.52
$780.13
$974.11
$966.09
$1,017.64
$1,072.25
$1,266.23
$1,258.21
$1,309.76
$1,364.37
$1,558.35
$292.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.70
$866.80
$976.02
$1,363.98
$2,072.70
$1,055.82
$1,158.92
$1,268.14
$1,656.10
$1,347.94
$1,451.04
$1,560.26
$1,948.22
$1,640.06
$1,743.16
$1,852.38
$2,240.34
$292.12
Toc - Plan #45 Blue Cross and Blue Shield of Texas
Catastrophic

(HMO) Blue Advantage Security HMO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$282.85
$321.03
$361.48
$505.16
$767.65
$499.23
$537.41
$577.86
$721.54
$715.61
$753.79
$794.24
$937.92
$931.99
$970.17
$1,010.62
$1,154.30
$216.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$565.70
$642.06
$722.96
$1,010.32
$1,535.30
$782.08
$858.44
$939.34
$1,226.70
$998.46
$1,074.82
$1,155.72
$1,443.08
$1,214.84
$1,291.20
$1,372.10
$1,659.46
$216.38
Toc - Plan #46 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$1,950 $3,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$453.43
$514.65
$579.49
$809.83
$1,230.62
$800.31
$861.53
$926.37
$1,156.71
$1,147.19
$1,208.41
$1,273.25
$1,503.59
$1,494.07
$1,555.29
$1,620.13
$1,850.47
$346.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$906.86
$1,029.30
$1,158.98
$1,619.66
$2,461.24
$1,253.74
$1,376.18
$1,505.86
$1,966.54
$1,600.62
$1,723.06
$1,852.74
$2,313.42
$1,947.50
$2,069.94
$2,199.62
$2,660.30
$346.88
Toc - Plan #47 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.73
$359.49
$404.78
$565.68
$859.60
$559.03
$601.79
$647.08
$807.98
$801.33
$844.09
$889.38
$1,050.28
$1,043.63
$1,086.39
$1,131.68
$1,292.58
$242.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$633.46
$718.98
$809.56
$1,131.36
$1,719.20
$875.76
$961.28
$1,051.86
$1,373.66
$1,118.06
$1,203.58
$1,294.16
$1,615.96
$1,360.36
$1,445.88
$1,536.46
$1,858.26
$242.30
Toc - Plan #48 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 302

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$327.83
$372.08
$418.96
$585.50
$889.73
$578.62
$622.87
$669.75
$836.29
$829.41
$873.66
$920.54
$1,087.08
$1,080.20
$1,124.45
$1,171.33
$1,337.87
$250.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$655.66
$744.16
$837.92
$1,171.00
$1,779.46
$906.45
$994.95
$1,088.71
$1,421.79
$1,157.24
$1,245.74
$1,339.50
$1,672.58
$1,408.03
$1,496.53
$1,590.29
$1,923.37
$250.79
Toc - Plan #49 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO? 301

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312.01
$354.13
$398.75
$557.25
$846.79
$550.70
$592.82
$637.44
$795.94
$789.39
$831.51
$876.13
$1,034.63
$1,028.08
$1,070.20
$1,114.82
$1,273.32
$238.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$624.02
$708.26
$797.50
$1,114.50
$1,693.58
$862.71
$946.95
$1,036.19
$1,353.19
$1,101.40
$1,185.64
$1,274.88
$1,591.88
$1,340.09
$1,424.33
$1,513.57
$1,830.57
$238.69
Toc - Plan #50 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 603

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.29
$447.52
$503.91
$704.21
$1,070.11
$695.93
$749.16
$805.55
$1,005.85
$997.57
$1,050.80
$1,107.19
$1,307.49
$1,299.21
$1,352.44
$1,408.83
$1,609.13
$301.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.58
$895.04
$1,007.82
$1,408.42
$2,140.22
$1,090.22
$1,196.68
$1,309.46
$1,710.06
$1,391.86
$1,498.32
$1,611.10
$2,011.70
$1,693.50
$1,799.96
$1,912.74
$2,313.34
$301.64
Toc - Plan #51 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 706

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.69
$444.57
$500.58
$699.56
$1,063.04
$691.33
$744.21
$800.22
$999.20
$990.97
$1,043.85
$1,099.86
$1,298.84
$1,290.61
$1,343.49
$1,399.50
$1,598.48
$299.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.38
$889.14
$1,001.16
$1,399.12
$2,126.08
$1,083.02
$1,188.78
$1,300.80
$1,698.76
$1,382.66
$1,488.42
$1,600.44
$1,998.40
$1,682.30
$1,788.06
$1,900.08
$2,298.04
$299.64
Toc - Plan #52 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$453.48
$514.70
$579.55
$809.91
$1,230.74
$800.39
$861.61
$926.46
$1,156.82
$1,147.30
$1,208.52
$1,273.37
$1,503.73
$1,494.21
$1,555.43
$1,620.28
$1,850.64
$346.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$906.96
$1,029.40
$1,159.10
$1,619.82
$2,461.48
$1,253.87
$1,376.31
$1,506.01
$1,966.73
$1,600.78
$1,723.22
$1,852.92
$2,313.64
$1,947.69
$2,070.13
$2,199.83
$2,660.55
$346.91
Toc - Plan #53 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 707

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.66
$358.27
$403.41
$563.76
$856.69
$557.14
$599.75
$644.89
$805.24
$798.62
$841.23
$886.37
$1,046.72
$1,040.10
$1,082.71
$1,127.85
$1,288.20
$241.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$631.32
$716.54
$806.82
$1,127.52
$1,713.38
$872.80
$958.02
$1,048.30
$1,369.00
$1,114.28
$1,199.50
$1,289.78
$1,610.48
$1,355.76
$1,440.98
$1,531.26
$1,851.96
$241.48
Toc - Plan #54 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 801

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$451.55
$512.51
$577.09
$806.48
$1,225.52
$796.99
$857.95
$922.53
$1,151.92
$1,142.43
$1,203.39
$1,267.97
$1,497.36
$1,487.87
$1,548.83
$1,613.41
$1,842.80
$345.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$903.10
$1,025.02
$1,154.18
$1,612.96
$2,451.04
$1,248.54
$1,370.46
$1,499.62
$1,958.40
$1,593.98
$1,715.90
$1,845.06
$2,303.84
$1,939.42
$2,061.34
$2,190.50
$2,649.28
$345.44
Toc - Plan #55 Blue Cross and Blue Shield of Texas
Expanded Bronze

(POS) Blue Advantage Plus Bronze? 303

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.67
$450.23
$506.95
$708.46
$1,076.57
$700.13
$753.69
$810.41
$1,011.92
$1,003.59
$1,057.15
$1,113.87
$1,315.38
$1,307.05
$1,360.61
$1,417.33
$1,618.84
$303.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793.34
$900.46
$1,013.90
$1,416.92
$2,153.14
$1,096.80
$1,203.92
$1,317.36
$1,720.38
$1,400.26
$1,507.38
$1,620.82
$2,023.84
$1,703.72
$1,810.84
$1,924.28
$2,327.30
$303.46
Toc - Plan #56 Blue Cross and Blue Shield of Texas
Bronze

(POS) Blue Advantage Plus Bronze? 305

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.06
$426.82
$480.60
$671.64
$1,020.61
$663.74
$714.50
$768.28
$959.32
$951.42
$1,002.18
$1,055.96
$1,247.00
$1,239.10
$1,289.86
$1,343.64
$1,534.68
$287.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.12
$853.64
$961.20
$1,343.28
$2,041.22
$1,039.80
$1,141.32
$1,248.88
$1,630.96
$1,327.48
$1,429.00
$1,536.56
$1,918.64
$1,615.16
$1,716.68
$1,824.24
$2,206.32
$287.68
Toc - Plan #57 Blue Cross and Blue Shield of Texas
Expanded Bronze

(POS) Blue Advantage Plus Bronze? 707

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.98
$438.09
$493.28
$689.36
$1,047.55
$681.25
$733.36
$788.55
$984.63
$976.52
$1,028.63
$1,083.82
$1,279.90
$1,271.79
$1,323.90
$1,379.09
$1,575.17
$295.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.96
$876.18
$986.56
$1,378.72
$2,095.10
$1,067.23
$1,171.45
$1,281.83
$1,673.99
$1,362.50
$1,466.72
$1,577.10
$1,969.26
$1,657.77
$1,761.99
$1,872.37
$2,264.53
$295.27
Toc - Plan #58 Blue Cross and Blue Shield of Texas
Gold

(POS) Blue Advantage Plus Gold? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$850 $1,700 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$475.21
$539.37
$607.32
$848.73
$1,289.73
$838.75
$902.91
$970.86
$1,212.27
$1,202.29
$1,266.45
$1,334.40
$1,575.81
$1,565.83
$1,629.99
$1,697.94
$1,939.35
$363.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$950.42
$1,078.74
$1,214.64
$1,697.46
$2,579.46
$1,313.96
$1,442.28
$1,578.18
$2,061.00
$1,677.50
$1,805.82
$1,941.72
$2,424.54
$2,041.04
$2,169.36
$2,305.26
$2,788.08
$363.54
Toc - Plan #59 Blue Cross and Blue Shield of Texas
Gold

(POS) Blue Advantage Plus Gold? 706

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$478.74
$543.37
$611.83
$855.02
$1,299.29
$844.97
$909.60
$978.06
$1,221.25
$1,211.20
$1,275.83
$1,344.29
$1,587.48
$1,577.43
$1,642.06
$1,710.52
$1,953.71
$366.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$957.48
$1,086.74
$1,223.66
$1,710.04
$2,598.58
$1,323.71
$1,452.97
$1,589.89
$2,076.27
$1,689.94
$1,819.20
$1,956.12
$2,442.50
$2,056.17
$2,185.43
$2,322.35
$2,808.73
$366.23
Toc - Plan #60 Blue Cross and Blue Shield of Texas
Silver

(POS) Blue Advantage Plus Silver? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$560.29
$635.93
$716.05
$1,000.68
$1,520.63
$988.91
$1,064.55
$1,144.67
$1,429.30
$1,417.53
$1,493.17
$1,573.29
$1,857.92
$1,846.15
$1,921.79
$2,001.91
$2,286.54
$428.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,120.58
$1,271.86
$1,432.10
$2,001.36
$3,041.26
$1,549.20
$1,700.48
$1,860.72
$2,429.98
$1,977.82
$2,129.10
$2,289.34
$2,858.60
$2,406.44
$2,557.72
$2,717.96
$3,287.22
$428.62
Toc - Plan #61 Blue Cross and Blue Shield of Texas
Silver

(POS) Blue Advantage Plus Silver? 605

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$568.27
$644.99
$726.25
$1,014.94
$1,542.30
$1,003.00
$1,079.72
$1,160.98
$1,449.67
$1,437.73
$1,514.45
$1,595.71
$1,884.40
$1,872.46
$1,949.18
$2,030.44
$2,319.13
$434.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,136.54
$1,289.98
$1,452.50
$2,029.88
$3,084.60
$1,571.27
$1,724.71
$1,887.23
$2,464.61
$2,006.00
$2,159.44
$2,321.96
$2,899.34
$2,440.73
$2,594.17
$2,756.69
$3,334.07
$434.73
Toc - Plan #62 Blue Cross and Blue Shield of Texas
Silver

(POS) Blue Advantage Plus Silver? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$554.28
$629.10
$708.37
$989.94
$1,504.31
$978.30
$1,053.12
$1,132.39
$1,413.96
$1,402.32
$1,477.14
$1,556.41
$1,837.98
$1,826.34
$1,901.16
$1,980.43
$2,262.00
$424.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,108.56
$1,258.20
$1,416.74
$1,979.88
$3,008.62
$1,532.58
$1,682.22
$1,840.76
$2,403.90
$1,956.60
$2,106.24
$2,264.78
$2,827.92
$2,380.62
$2,530.26
$2,688.80
$3,251.94
$424.02
Toc - Plan #63 Blue Cross and Blue Shield of Texas
Gold

(POS) Blue Advantage Plus Gold? 803

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-697-0683

Annual Out of Pocket Expenses:

Individual Family
$1,850 $3,700 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$467.02
$530.07
$596.85
$834.10
$1,267.49
$824.29
$887.34
$954.12
$1,191.37
$1,181.56
$1,244.61
$1,311.39
$1,548.64
$1,538.83
$1,601.88
$1,668.66
$1,905.91
$357.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$934.04
$1,060.14
$1,193.70
$1,668.20
$2,534.98
$1,291.31
$1,417.41
$1,550.97
$2,025.47
$1,648.58
$1,774.68
$1,908.24
$2,382.74
$2,005.85
$2,131.95
$2,265.51
$2,740.01
$357.27

ADVERTISEMENT

UnitedHealthcare

Local: 1-866-811-2704 | Toll Free: 1-866-811-2704 | TTY: 1-866-811-2704

Toc - Plan #64 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx, $0 Insulin) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.15
$487.09
$548.46
$766.46
$1,164.72
$757.45
$815.39
$876.76
$1,094.76
$1,085.75
$1,143.69
$1,205.06
$1,423.06
$1,414.05
$1,471.99
$1,533.36
$1,751.36
$328.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.30
$974.18
$1,096.92
$1,532.92
$2,329.44
$1,186.60
$1,302.48
$1,425.22
$1,861.22
$1,514.90
$1,630.78
$1,753.52
$2,189.52
$1,843.20
$1,959.08
$2,081.82
$2,517.82
$328.30
Toc - Plan #65 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$302.20
$342.99
$386.21
$539.73
$820.17
$533.38
$574.17
$617.39
$770.91
$764.56
$805.35
$848.57
$1,002.09
$995.74
$1,036.53
$1,079.75
$1,233.27
$231.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.40
$685.98
$772.42
$1,079.46
$1,640.34
$835.58
$917.16
$1,003.60
$1,310.64
$1,066.76
$1,148.34
$1,234.78
$1,541.82
$1,297.94
$1,379.52
$1,465.96
$1,773.00
$231.18
Toc - Plan #66 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx, $0 Insulin) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$306.07
$347.39
$391.16
$546.65
$830.68
$540.22
$581.54
$625.31
$780.80
$774.37
$815.69
$859.46
$1,014.95
$1,008.52
$1,049.84
$1,093.61
$1,249.10
$234.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.14
$694.78
$782.32
$1,093.30
$1,661.36
$846.29
$928.93
$1,016.47
$1,327.45
$1,080.44
$1,163.08
$1,250.62
$1,561.60
$1,314.59
$1,397.23
$1,484.77
$1,795.75
$234.15
Toc - Plan #67 UnitedHealthcare
Gold

(HMO) UHC Gold Standard $0 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.65
$426.37
$480.09
$670.92
$1,019.53
$663.03
$713.75
$767.47
$958.30
$950.41
$1,001.13
$1,054.85
$1,245.68
$1,237.79
$1,288.51
$1,342.23
$1,533.06
$287.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$751.30
$852.74
$960.18
$1,341.84
$2,039.06
$1,038.68
$1,140.12
$1,247.56
$1,629.22
$1,326.06
$1,427.50
$1,534.94
$1,916.60
$1,613.44
$1,714.88
$1,822.32
$2,203.98
$287.38
Toc - Plan #68 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$306.75
$348.16
$392.03
$547.86
$832.53
$541.42
$582.83
$626.70
$782.53
$776.09
$817.50
$861.37
$1,017.20
$1,010.76
$1,052.17
$1,096.04
$1,251.87
$234.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$613.50
$696.32
$784.06
$1,095.72
$1,665.06
$848.17
$930.99
$1,018.73
$1,330.39
$1,082.84
$1,165.66
$1,253.40
$1,565.06
$1,317.51
$1,400.33
$1,488.07
$1,799.73
$234.67
Toc - Plan #69 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.06
$486.99
$548.34
$766.31
$1,164.47
$757.29
$815.22
$876.57
$1,094.54
$1,085.52
$1,143.45
$1,204.80
$1,422.77
$1,413.75
$1,471.68
$1,533.03
$1,751.00
$328.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.12
$973.98
$1,096.68
$1,532.62
$2,328.94
$1,186.35
$1,302.21
$1,424.91
$1,860.85
$1,514.58
$1,630.44
$1,753.14
$2,189.08
$1,842.81
$1,958.67
$2,081.37
$2,517.31
$328.23
Toc - Plan #70 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.63
$441.09
$496.67
$694.09
$1,054.74
$685.93
$738.39
$793.97
$991.39
$983.23
$1,035.69
$1,091.27
$1,288.69
$1,280.53
$1,332.99
$1,388.57
$1,585.99
$297.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.26
$882.18
$993.34
$1,388.18
$2,109.48
$1,074.56
$1,179.48
$1,290.64
$1,685.48
$1,371.86
$1,476.78
$1,587.94
$1,982.78
$1,669.16
$1,774.08
$1,885.24
$2,280.08
$297.30
Toc - Plan #71 UnitedHealthcare
Silver

(HMO) UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.89
$474.31
$534.07
$746.36
$1,134.17
$737.58
$794.00
$853.76
$1,066.05
$1,057.27
$1,113.69
$1,173.45
$1,385.74
$1,376.96
$1,433.38
$1,493.14
$1,705.43
$319.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.78
$948.62
$1,068.14
$1,492.72
$2,268.34
$1,155.47
$1,268.31
$1,387.83
$1,812.41
$1,475.16
$1,588.00
$1,707.52
$2,132.10
$1,794.85
$1,907.69
$2,027.21
$2,451.79
$319.69
Toc - Plan #72 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$425.28
$482.69
$543.51
$759.55
$1,154.20
$750.62
$808.03
$868.85
$1,084.89
$1,075.96
$1,133.37
$1,194.19
$1,410.23
$1,401.30
$1,458.71
$1,519.53
$1,735.57
$325.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$850.56
$965.38
$1,087.02
$1,519.10
$2,308.40
$1,175.90
$1,290.72
$1,412.36
$1,844.44
$1,501.24
$1,616.06
$1,737.70
$2,169.78
$1,826.58
$1,941.40
$2,063.04
$2,495.12
$325.34
Toc - Plan #73 UnitedHealthcare
Gold

(HMO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Tier 2 Rx, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.48
$415.95
$468.36
$654.53
$994.63
$646.84
$696.31
$748.72
$934.89
$927.20
$976.67
$1,029.08
$1,215.25
$1,207.56
$1,257.03
$1,309.44
$1,495.61
$280.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732.96
$831.90
$936.72
$1,309.06
$1,989.26
$1,013.32
$1,112.26
$1,217.08
$1,589.42
$1,293.68
$1,392.62
$1,497.44
$1,869.78
$1,574.04
$1,672.98
$1,777.80
$2,150.14
$280.36
Toc - Plan #74 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$378.96
$430.12
$484.31
$676.82
$1,028.49
$668.86
$720.02
$774.21
$966.72
$958.76
$1,009.92
$1,064.11
$1,256.62
$1,248.66
$1,299.82
$1,354.01
$1,546.52
$289.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.92
$860.24
$968.62
$1,353.64
$2,056.98
$1,047.82
$1,150.14
$1,258.52
$1,643.54
$1,337.72
$1,440.04
$1,548.42
$1,933.44
$1,627.62
$1,729.94
$1,838.32
$2,223.34
$289.90
Toc - Plan #75 UnitedHealthcare
Expanded Bronze

(HMO) UHC Kelsey-Seybold Bronze Copay Focus ($0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$273.11
$309.97
$349.03
$487.77
$741.21
$482.04
$518.90
$557.96
$696.70
$690.97
$727.83
$766.89
$905.63
$899.90
$936.76
$975.82
$1,114.56
$208.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$546.22
$619.94
$698.06
$975.54
$1,482.42
$755.15
$828.87
$906.99
$1,184.47
$964.08
$1,037.80
$1,115.92
$1,393.40
$1,173.01
$1,246.73
$1,324.85
$1,602.33
$208.93
Toc - Plan #76 UnitedHealthcare
Silver

(HMO) UHC Kelsey-Seybold Silver Copay Focus ($0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.71
$426.43
$480.16
$671.02
$1,019.68
$663.13
$713.85
$767.58
$958.44
$950.55
$1,001.27
$1,055.00
$1,245.86
$1,237.97
$1,288.69
$1,342.42
$1,533.28
$287.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$751.42
$852.86
$960.32
$1,342.04
$2,039.36
$1,038.84
$1,140.28
$1,247.74
$1,629.46
$1,326.26
$1,427.70
$1,535.16
$1,916.88
$1,613.68
$1,715.12
$1,822.58
$2,204.30
$287.42
Toc - Plan #77 UnitedHealthcare
Gold

(HMO) UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$330.40
$375.01
$422.25
$590.10
$896.71
$583.16
$627.77
$675.01
$842.86
$835.92
$880.53
$927.77
$1,095.62
$1,088.68
$1,133.29
$1,180.53
$1,348.38
$252.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$660.80
$750.02
$844.50
$1,180.20
$1,793.42
$913.56
$1,002.78
$1,097.26
$1,432.96
$1,166.32
$1,255.54
$1,350.02
$1,685.72
$1,419.08
$1,508.30
$1,602.78
$1,938.48
$252.76
Toc - Plan #78 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$8,050 $16,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.15
$344.07
$387.42
$541.42
$822.74
$535.06
$575.98
$619.33
$773.33
$766.97
$807.89
$851.24
$1,005.24
$998.88
$1,039.80
$1,083.15
$1,237.15
$231.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$606.30
$688.14
$774.84
$1,082.84
$1,645.48
$838.21
$920.05
$1,006.75
$1,314.75
$1,070.12
$1,151.96
$1,238.66
$1,546.66
$1,302.03
$1,383.87
$1,470.57
$1,778.57
$231.91
Toc - Plan #79 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, $0 Insulin, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.19
$504.15
$567.67
$793.32
$1,205.53
$783.99
$843.95
$907.47
$1,133.12
$1,123.79
$1,183.75
$1,247.27
$1,472.92
$1,463.59
$1,523.55
$1,587.07
$1,812.72
$339.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.38
$1,008.30
$1,135.34
$1,586.64
$2,411.06
$1,228.18
$1,348.10
$1,475.14
$1,926.44
$1,567.98
$1,687.90
$1,814.94
$2,266.24
$1,907.78
$2,027.70
$2,154.74
$2,606.04
$339.80
Toc - Plan #80 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-811-2704

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$397.87
$451.58
$508.48
$710.59
$1,079.81
$702.24
$755.95
$812.85
$1,014.96
$1,006.61
$1,060.32
$1,117.22
$1,319.33
$1,310.98
$1,364.69
$1,421.59
$1,623.70
$304.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.74
$903.16
$1,016.96
$1,421.18
$2,159.62
$1,100.11
$1,207.53
$1,321.33
$1,725.55
$1,404.48
$1,511.90
$1,625.70
$2,029.92
$1,708.85
$1,816.27
$1,930.07
$2,334.29
$304.37

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #81 Aetna CVS Health
Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.35
$440.78
$496.32
$693.60
$1,053.99
$685.44
$737.87
$793.41
$990.69
$982.53
$1,034.96
$1,090.50
$1,287.78
$1,279.62
$1,332.05
$1,387.59
$1,584.87
$297.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.70
$881.56
$992.64
$1,387.20
$2,107.98
$1,073.79
$1,178.65
$1,289.73
$1,684.29
$1,370.88
$1,475.74
$1,586.82
$1,981.38
$1,667.97
$1,772.83
$1,883.91
$2,278.47
$297.09
Toc - Plan #82 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$348.90
$396.00
$445.89
$623.12
$946.89
$615.81
$662.91
$712.80
$890.03
$882.72
$929.82
$979.71
$1,156.94
$1,149.63
$1,196.73
$1,246.62
$1,423.85
$266.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$697.80
$792.00
$891.78
$1,246.24
$1,893.78
$964.71
$1,058.91
$1,158.69
$1,513.15
$1,231.62
$1,325.82
$1,425.60
$1,780.06
$1,498.53
$1,592.73
$1,692.51
$2,046.97
$266.91
Toc - Plan #83 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.79
$427.66
$481.54
$672.94
$1,022.60
$665.04
$715.91
$769.79
$961.19
$953.29
$1,004.16
$1,058.04
$1,249.44
$1,241.54
$1,292.41
$1,346.29
$1,537.69
$288.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.58
$855.32
$963.08
$1,345.88
$2,045.20
$1,041.83
$1,143.57
$1,251.33
$1,634.13
$1,330.08
$1,431.82
$1,539.58
$1,922.38
$1,618.33
$1,720.07
$1,827.83
$2,210.63
$288.25
Toc - Plan #84 Aetna CVS Health
Gold

(HMO) Gold 3: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$795 $1,590 Annual Deductible
$9,195 $18,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$347.78
$394.73
$444.46
$621.13
$943.87
$613.83
$660.78
$710.51
$887.18
$879.88
$926.83
$976.56
$1,153.23
$1,145.93
$1,192.88
$1,242.61
$1,419.28
$266.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$695.56
$789.46
$888.92
$1,242.26
$1,887.74
$961.61
$1,055.51
$1,154.97
$1,508.31
$1,227.66
$1,321.56
$1,421.02
$1,774.36
$1,493.71
$1,587.61
$1,687.07
$2,040.41
$266.05
Toc - Plan #85 Aetna CVS Health
Gold

(HMO) Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$352.62
$400.22
$450.64
$629.77
$956.99
$622.37
$669.97
$720.39
$899.52
$892.12
$939.72
$990.14
$1,169.27
$1,161.87
$1,209.47
$1,259.89
$1,439.02
$269.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$705.24
$800.44
$901.28
$1,259.54
$1,913.98
$974.99
$1,070.19
$1,171.03
$1,529.29
$1,244.74
$1,339.94
$1,440.78
$1,799.04
$1,514.49
$1,609.69
$1,710.53
$2,068.79
$269.75
Toc - Plan #86 Aetna CVS Health
Silver

(HMO) Silver 5: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$8,395 $16,790 Annual Deductible
$8,885 $17,770 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.35
$427.16
$480.98
$672.16
$1,021.41
$664.26
$715.07
$768.89
$960.07
$952.17
$1,002.98
$1,056.80
$1,247.98
$1,240.08
$1,290.89
$1,344.71
$1,535.89
$287.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.70
$854.32
$961.96
$1,344.32
$2,042.82
$1,040.61
$1,142.23
$1,249.87
$1,632.23
$1,328.52
$1,430.14
$1,537.78
$1,920.14
$1,616.43
$1,718.05
$1,825.69
$2,208.05
$287.91
Toc - Plan #87 Aetna CVS Health
Silver

(HMO) Silver 6: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,445 $16,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384.64
$436.56
$491.57
$686.96
$1,043.90
$678.89
$730.81
$785.82
$981.21
$973.14
$1,025.06
$1,080.07
$1,275.46
$1,267.39
$1,319.31
$1,374.32
$1,569.71
$294.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$769.28
$873.12
$983.14
$1,373.92
$2,087.80
$1,063.53
$1,167.37
$1,277.39
$1,668.17
$1,357.78
$1,461.62
$1,571.64
$1,962.42
$1,652.03
$1,755.87
$1,865.89
$2,256.67
$294.25
Toc - Plan #88 Aetna CVS Health
Silver

(HMO) Silver 7: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,845 $17,690 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.08
$437.06
$492.13
$687.74
$1,045.09
$679.66
$731.64
$786.71
$982.32
$974.24
$1,026.22
$1,081.29
$1,276.90
$1,268.82
$1,320.80
$1,375.87
$1,571.48
$294.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.16
$874.12
$984.26
$1,375.48
$2,090.18
$1,064.74
$1,168.70
$1,278.84
$1,670.06
$1,359.32
$1,463.28
$1,573.42
$1,964.64
$1,653.90
$1,757.86
$1,868.00
$2,259.22
$294.58

ADVERTISEMENT

Ambetter from Superior HealthPlan

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

Toc - Plan #89 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$471.04
$534.62
$601.98
$841.27
$1,278.39
$831.38
$894.96
$962.32
$1,201.61
$1,191.72
$1,255.30
$1,322.66
$1,561.95
$1,552.06
$1,615.64
$1,683.00
$1,922.29
$360.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$942.08
$1,069.24
$1,203.96
$1,682.54
$2,556.78
$1,302.42
$1,429.58
$1,564.30
$2,042.88
$1,662.76
$1,789.92
$1,924.64
$2,403.22
$2,023.10
$2,150.26
$2,284.98
$2,763.56
$360.34
Toc - Plan #90 Ambetter from Superior HealthPlan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.43
$493.06
$555.18
$775.87
$1,179.01
$766.76
$825.39
$887.51
$1,108.20
$1,099.09
$1,157.72
$1,219.84
$1,440.53
$1,431.42
$1,490.05
$1,552.17
$1,772.86
$332.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.86
$986.12
$1,110.36
$1,551.74
$2,358.02
$1,201.19
$1,318.45
$1,442.69
$1,884.07
$1,533.52
$1,650.78
$1,775.02
$2,216.40
$1,865.85
$1,983.11
$2,107.35
$2,548.73
$332.33
Toc - Plan #91 Ambetter from Superior HealthPlan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$470.44
$533.94
$601.22
$840.20
$1,276.76
$830.32
$893.82
$961.10
$1,200.08
$1,190.20
$1,253.70
$1,320.98
$1,559.96
$1,550.08
$1,613.58
$1,680.86
$1,919.84
$359.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$940.88
$1,067.88
$1,202.44
$1,680.40
$2,553.52
$1,300.76
$1,427.76
$1,562.32
$2,040.28
$1,660.64
$1,787.64
$1,922.20
$2,400.16
$2,020.52
$2,147.52
$2,282.08
$2,760.04
$359.88
Toc - Plan #92 Ambetter from Superior HealthPlan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1196

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$425.68
$483.14
$544.01
$760.25
$1,155.27
$751.32
$808.78
$869.65
$1,085.89
$1,076.96
$1,134.42
$1,195.29
$1,411.53
$1,402.60
$1,460.06
$1,520.93
$1,737.17
$325.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$851.36
$966.28
$1,088.02
$1,520.50
$2,310.54
$1,177.00
$1,291.92
$1,413.66
$1,846.14
$1,502.64
$1,617.56
$1,739.30
$2,171.78
$1,828.28
$1,943.20
$2,064.94
$2,497.42
$325.64

‡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 Galveston County here.

Galveston County is in “Rating Area 10” of Texas.

Currently, there are 92 plans offered in Rating Area 10.

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2024 Obamacare Plans for Galveston County, TX

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