Hays 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 Hays 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, 115 Plans and 2024 Rates for Hays County, Texas

Below, you’ll find a summary of the 115 plans for Hays 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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Moda Health, Inc.

Local: 1-844-827-6571 | Toll Free: 1-844-827-6571 | TTY: 1-844-827-6571

Toc - Plan #1 Moda Health, Inc.
Gold

(EPO) Moda Select Gold 1000 ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$388.00
$440.00
$495.00
$692.00
$1,052.00
$684.00
$736.00
$791.00
$988.00
$980.00
$1,032.00
$1,087.00
$1,284.00
$1,276.00
$1,328.00
$1,383.00
$1,580.00
$296.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.00
$880.00
$990.00
$1,384.00
$2,104.00
$1,072.00
$1,176.00
$1,286.00
$1,680.00
$1,368.00
$1,472.00
$1,582.00
$1,976.00
$1,664.00
$1,768.00
$1,878.00
$2,272.00
$296.00
Toc - Plan #2 Moda Health, Inc.
Gold

(EPO) Moda Select Gold 1800 ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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
$389.00
$442.00
$497.00
$695.00
$1,056.00
$687.00
$740.00
$795.00
$993.00
$985.00
$1,038.00
$1,093.00
$1,291.00
$1,283.00
$1,336.00
$1,391.00
$1,589.00
$298.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.00
$884.00
$994.00
$1,390.00
$2,112.00
$1,076.00
$1,182.00
$1,292.00
$1,688.00
$1,374.00
$1,480.00
$1,590.00
$1,986.00
$1,672.00
$1,778.00
$1,888.00
$2,284.00
$298.00
Toc - Plan #3 Moda Health, Inc.
Silver

(EPO) Moda Select Silver 3500 ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$447.00
$508.00
$572.00
$799.00
$1,214.00
$789.00
$850.00
$914.00
$1,141.00
$1,131.00
$1,192.00
$1,256.00
$1,483.00
$1,473.00
$1,534.00
$1,598.00
$1,825.00
$342.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$894.00
$1,016.00
$1,144.00
$1,598.00
$2,428.00
$1,236.00
$1,358.00
$1,486.00
$1,940.00
$1,578.00
$1,700.00
$1,828.00
$2,282.00
$1,920.00
$2,042.00
$2,170.00
$2,624.00
$342.00
Toc - Plan #4 Moda Health, Inc.
Silver

(EPO) Moda Select Silver 4800 ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$445.00
$505.00
$569.00
$795.00
$1,208.00
$786.00
$846.00
$910.00
$1,136.00
$1,127.00
$1,187.00
$1,251.00
$1,477.00
$1,468.00
$1,528.00
$1,592.00
$1,818.00
$341.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$890.00
$1,010.00
$1,138.00
$1,590.00
$2,416.00
$1,231.00
$1,351.00
$1,479.00
$1,931.00
$1,572.00
$1,692.00
$1,820.00
$2,272.00
$1,913.00
$2,033.00
$2,161.00
$2,613.00
$341.00
Toc - Plan #5 Moda Health, Inc.
Silver

(EPO) Moda Select Silver 6400 ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 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
$450.00
$510.00
$575.00
$803.00
$1,221.00
$794.00
$854.00
$919.00
$1,147.00
$1,138.00
$1,198.00
$1,263.00
$1,491.00
$1,482.00
$1,542.00
$1,607.00
$1,835.00
$344.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$900.00
$1,020.00
$1,150.00
$1,606.00
$2,442.00
$1,244.00
$1,364.00
$1,494.00
$1,950.00
$1,588.00
$1,708.00
$1,838.00
$2,294.00
$1,932.00
$2,052.00
$2,182.00
$2,638.00
$344.00
Toc - Plan #6 Moda Health, Inc.
Expanded Bronze

(EPO) Moda Select Bronze 8700 ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 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
$285.00
$324.00
$365.00
$509.00
$774.00
$503.00
$542.00
$583.00
$727.00
$721.00
$760.00
$801.00
$945.00
$939.00
$978.00
$1,019.00
$1,163.00
$218.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$570.00
$648.00
$730.00
$1,018.00
$1,548.00
$788.00
$866.00
$948.00
$1,236.00
$1,006.00
$1,084.00
$1,166.00
$1,454.00
$1,224.00
$1,302.00
$1,384.00
$1,672.00
$218.00
Toc - Plan #7 Moda Health, Inc.
Expanded Bronze

(EPO) Moda Select Bronze HSA 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

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
$283.00
$322.00
$362.00
$506.00
$769.00
$500.00
$539.00
$579.00
$723.00
$717.00
$756.00
$796.00
$940.00
$934.00
$973.00
$1,013.00
$1,157.00
$217.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$566.00
$644.00
$724.00
$1,012.00
$1,538.00
$783.00
$861.00
$941.00
$1,229.00
$1,000.00
$1,078.00
$1,158.00
$1,446.00
$1,217.00
$1,295.00
$1,375.00
$1,663.00
$217.00
Toc - Plan #8 Moda Health, Inc.
Silver

(EPO) Moda Select Texas Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

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
$450.00
$510.00
$575.00
$803.00
$1,221.00
$794.00
$854.00
$919.00
$1,147.00
$1,138.00
$1,198.00
$1,263.00
$1,491.00
$1,482.00
$1,542.00
$1,607.00
$1,835.00
$344.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$900.00
$1,020.00
$1,150.00
$1,606.00
$2,442.00
$1,244.00
$1,364.00
$1,494.00
$1,950.00
$1,588.00
$1,708.00
$1,838.00
$2,294.00
$1,932.00
$2,052.00
$2,182.00
$2,638.00
$344.00
Toc - Plan #9 Moda Health, Inc.
Gold

(EPO) Moda Select Texas Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

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
$391.00
$443.00
$499.00
$697.00
$1,060.00
$690.00
$742.00
$798.00
$996.00
$989.00
$1,041.00
$1,097.00
$1,295.00
$1,288.00
$1,340.00
$1,396.00
$1,594.00
$299.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782.00
$886.00
$998.00
$1,394.00
$2,120.00
$1,081.00
$1,185.00
$1,297.00
$1,693.00
$1,380.00
$1,484.00
$1,596.00
$1,992.00
$1,679.00
$1,783.00
$1,895.00
$2,291.00
$299.00
Toc - Plan #10 Moda Health, Inc.
Expanded Bronze

(EPO) Moda Select Texas Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-827-6571

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
$282.00
$320.00
$360.00
$503.00
$764.00
$497.00
$535.00
$575.00
$718.00
$712.00
$750.00
$790.00
$933.00
$927.00
$965.00
$1,005.00
$1,148.00
$215.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$564.00
$640.00
$720.00
$1,006.00
$1,528.00
$779.00
$855.00
$935.00
$1,221.00
$994.00
$1,070.00
$1,150.00
$1,436.00
$1,209.00
$1,285.00
$1,365.00
$1,651.00
$215.00

ADVERTISEMENT

Oscar Insurance Company

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

Toc - Plan #11 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$359.46
$407.98
$459.38
$641.98
$975.55
$634.44
$682.96
$734.36
$916.96
$909.42
$957.94
$1,009.34
$1,191.94
$1,184.40
$1,232.92
$1,284.32
$1,466.92
$274.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$718.92
$815.96
$918.76
$1,283.96
$1,951.10
$993.90
$1,090.94
$1,193.74
$1,558.94
$1,268.88
$1,365.92
$1,468.72
$1,833.92
$1,543.86
$1,640.90
$1,743.70
$2,108.90
$274.98
Toc - Plan #12 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
$379.81
$431.07
$485.38
$678.32
$1,030.77
$670.35
$721.61
$775.92
$968.86
$960.89
$1,012.15
$1,066.46
$1,259.40
$1,251.43
$1,302.69
$1,357.00
$1,549.94
$290.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$759.62
$862.14
$970.76
$1,356.64
$2,061.54
$1,050.16
$1,152.68
$1,261.30
$1,647.18
$1,340.70
$1,443.22
$1,551.84
$1,937.72
$1,631.24
$1,733.76
$1,842.38
$2,228.26
$290.54
Toc - Plan #13 Oscar Insurance Company
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 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
$494.78
$561.57
$632.32
$883.67
$1,342.82
$873.28
$940.07
$1,010.82
$1,262.17
$1,251.78
$1,318.57
$1,389.32
$1,640.67
$1,630.28
$1,697.07
$1,767.82
$2,019.17
$378.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$989.56
$1,123.14
$1,264.64
$1,767.34
$2,685.64
$1,368.06
$1,501.64
$1,643.14
$2,145.84
$1,746.56
$1,880.14
$2,021.64
$2,524.34
$2,125.06
$2,258.64
$2,400.14
$2,902.84
$378.50
Toc - Plan #14 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
$489.47
$555.53
$625.52
$874.17
$1,328.38
$863.90
$929.96
$999.95
$1,248.60
$1,238.33
$1,304.39
$1,374.38
$1,623.03
$1,612.76
$1,678.82
$1,748.81
$1,997.46
$374.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$978.94
$1,111.06
$1,251.04
$1,748.34
$2,656.76
$1,353.37
$1,485.49
$1,625.47
$2,122.77
$1,727.80
$1,859.92
$1,999.90
$2,497.20
$2,102.23
$2,234.35
$2,374.33
$2,871.63
$374.43
Toc - Plan #15 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite + Specialist 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
$381.04
$432.47
$486.96
$680.52
$1,034.12
$672.53
$723.96
$778.45
$972.01
$964.02
$1,015.45
$1,069.94
$1,263.50
$1,255.51
$1,306.94
$1,361.43
$1,554.99
$291.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.08
$864.94
$973.92
$1,361.04
$2,068.24
$1,053.57
$1,156.43
$1,265.41
$1,652.53
$1,345.06
$1,447.92
$1,556.90
$1,944.02
$1,636.55
$1,739.41
$1,848.39
$2,235.51
$291.49
Toc - Plan #16 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
$365.63
$414.98
$467.26
$653.00
$992.29
$645.33
$694.68
$746.96
$932.70
$925.03
$974.38
$1,026.66
$1,212.40
$1,204.73
$1,254.08
$1,306.36
$1,492.10
$279.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.26
$829.96
$934.52
$1,306.00
$1,984.58
$1,010.96
$1,109.66
$1,214.22
$1,585.70
$1,290.66
$1,389.36
$1,493.92
$1,865.40
$1,570.36
$1,669.06
$1,773.62
$2,145.10
$279.70
Toc - Plan #17 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
$487.59
$553.40
$623.12
$870.81
$1,323.29
$860.59
$926.40
$996.12
$1,243.81
$1,233.59
$1,299.40
$1,369.12
$1,616.81
$1,606.59
$1,672.40
$1,742.12
$1,989.81
$373.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$975.18
$1,106.80
$1,246.24
$1,741.62
$2,646.58
$1,348.18
$1,479.80
$1,619.24
$2,114.62
$1,721.18
$1,852.80
$1,992.24
$2,487.62
$2,094.18
$2,225.80
$2,365.24
$2,860.62
$373.00
Toc - Plan #18 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
$514.08
$583.47
$656.99
$918.14
$1,395.20
$907.35
$976.74
$1,050.26
$1,311.41
$1,300.62
$1,370.01
$1,443.53
$1,704.68
$1,693.89
$1,763.28
$1,836.80
$2,097.95
$393.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,028.16
$1,166.94
$1,313.98
$1,836.28
$2,790.40
$1,421.43
$1,560.21
$1,707.25
$2,229.55
$1,814.70
$1,953.48
$2,100.52
$2,622.82
$2,207.97
$2,346.75
$2,493.79
$3,016.09
$393.27
Toc - Plan #19 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
$358.82
$407.25
$458.56
$640.84
$973.82
$633.31
$681.74
$733.05
$915.33
$907.80
$956.23
$1,007.54
$1,189.82
$1,182.29
$1,230.72
$1,282.03
$1,464.31
$274.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.64
$814.50
$917.12
$1,281.68
$1,947.64
$992.13
$1,088.99
$1,191.61
$1,556.17
$1,266.62
$1,363.48
$1,466.10
$1,830.66
$1,541.11
$1,637.97
$1,740.59
$2,105.15
$274.49
Toc - Plan #20 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
$481.95
$547.00
$615.92
$860.74
$1,307.98
$850.63
$915.68
$984.60
$1,229.42
$1,219.31
$1,284.36
$1,353.28
$1,598.10
$1,587.99
$1,653.04
$1,721.96
$1,966.78
$368.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$963.90
$1,094.00
$1,231.84
$1,721.48
$2,615.96
$1,332.58
$1,462.68
$1,600.52
$2,090.16
$1,701.26
$1,831.36
$1,969.20
$2,458.84
$2,069.94
$2,200.04
$2,337.88
$2,827.52
$368.68
Toc - Plan #21 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
$414.87
$470.87
$530.19
$740.94
$1,125.93
$732.24
$788.24
$847.56
$1,058.31
$1,049.61
$1,105.61
$1,164.93
$1,375.68
$1,366.98
$1,422.98
$1,482.30
$1,693.05
$317.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$829.74
$941.74
$1,060.38
$1,481.88
$2,251.86
$1,147.11
$1,259.11
$1,377.75
$1,799.25
$1,464.48
$1,576.48
$1,695.12
$2,116.62
$1,781.85
$1,893.85
$2,012.49
$2,433.99
$317.37
Toc - Plan #22 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
$428.04
$485.81
$547.02
$764.45
$1,161.66
$755.48
$813.25
$874.46
$1,091.89
$1,082.92
$1,140.69
$1,201.90
$1,419.33
$1,410.36
$1,468.13
$1,529.34
$1,746.77
$327.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.08
$971.62
$1,094.04
$1,528.90
$2,323.32
$1,183.52
$1,299.06
$1,421.48
$1,856.34
$1,510.96
$1,626.50
$1,748.92
$2,183.78
$1,838.40
$1,953.94
$2,076.36
$2,511.22
$327.44
Toc - Plan #23 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
$442.43
$502.15
$565.42
$790.17
$1,200.74
$780.88
$840.60
$903.87
$1,128.62
$1,119.33
$1,179.05
$1,242.32
$1,467.07
$1,457.78
$1,517.50
$1,580.77
$1,805.52
$338.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$884.86
$1,004.30
$1,130.84
$1,580.34
$2,401.48
$1,223.31
$1,342.75
$1,469.29
$1,918.79
$1,561.76
$1,681.20
$1,807.74
$2,257.24
$1,900.21
$2,019.65
$2,146.19
$2,595.69
$338.45

ADVERTISEMENT

Ambetter from Superior HealthPlan

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

Toc - Plan #24 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
$550.10
$624.35
$703.01
$982.46
$1,492.94
$970.92
$1,045.17
$1,123.83
$1,403.28
$1,391.74
$1,465.99
$1,544.65
$1,824.10
$1,812.56
$1,886.81
$1,965.47
$2,244.92
$420.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,100.20
$1,248.70
$1,406.02
$1,964.92
$2,985.88
$1,521.02
$1,669.52
$1,826.84
$2,385.74
$1,941.84
$2,090.34
$2,247.66
$2,806.56
$2,362.66
$2,511.16
$2,668.48
$3,227.38
$420.82
Toc - Plan #25 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
$498.61
$565.91
$637.21
$890.50
$1,353.19
$880.04
$947.34
$1,018.64
$1,271.93
$1,261.47
$1,328.77
$1,400.07
$1,653.36
$1,642.90
$1,710.20
$1,781.50
$2,034.79
$381.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$997.22
$1,131.82
$1,274.42
$1,781.00
$2,706.38
$1,378.65
$1,513.25
$1,655.85
$2,162.43
$1,760.08
$1,894.68
$2,037.28
$2,543.86
$2,141.51
$2,276.11
$2,418.71
$2,925.29
$381.43
Toc - Plan #26 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
$541.21
$614.26
$691.66
$966.59
$1,468.82
$955.23
$1,028.28
$1,105.68
$1,380.61
$1,369.25
$1,442.30
$1,519.70
$1,794.63
$1,783.27
$1,856.32
$1,933.72
$2,208.65
$414.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,082.42
$1,228.52
$1,383.32
$1,933.18
$2,937.64
$1,496.44
$1,642.54
$1,797.34
$2,347.20
$1,910.46
$2,056.56
$2,211.36
$2,761.22
$2,324.48
$2,470.58
$2,625.38
$3,175.24
$414.02
Toc - Plan #27 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
$544.55
$618.05
$695.92
$972.55
$1,477.89
$961.12
$1,034.62
$1,112.49
$1,389.12
$1,377.69
$1,451.19
$1,529.06
$1,805.69
$1,794.26
$1,867.76
$1,945.63
$2,222.26
$416.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,089.10
$1,236.10
$1,391.84
$1,945.10
$2,955.78
$1,505.67
$1,652.67
$1,808.41
$2,361.67
$1,922.24
$2,069.24
$2,224.98
$2,778.24
$2,338.81
$2,485.81
$2,641.55
$3,194.81
$416.57
Toc - Plan #28 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
$485.79
$551.36
$620.83
$867.60
$1,318.40
$857.41
$922.98
$992.45
$1,239.22
$1,229.03
$1,294.60
$1,364.07
$1,610.84
$1,600.65
$1,666.22
$1,735.69
$1,982.46
$371.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$971.58
$1,102.72
$1,241.66
$1,735.20
$2,636.80
$1,343.20
$1,474.34
$1,613.28
$2,106.82
$1,714.82
$1,845.96
$1,984.90
$2,478.44
$2,086.44
$2,217.58
$2,356.52
$2,850.06
$371.62
Toc - Plan #29 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
$481.80
$546.83
$615.73
$860.48
$1,307.59
$850.37
$915.40
$984.30
$1,229.05
$1,218.94
$1,283.97
$1,352.87
$1,597.62
$1,587.51
$1,652.54
$1,721.44
$1,966.19
$368.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$963.60
$1,093.66
$1,231.46
$1,720.96
$2,615.18
$1,332.17
$1,462.23
$1,600.03
$2,089.53
$1,700.74
$1,830.80
$1,968.60
$2,458.10
$2,069.31
$2,199.37
$2,337.17
$2,826.67
$368.57
Toc - Plan #30 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
$538.63
$611.33
$688.35
$961.97
$1,461.81
$950.67
$1,023.37
$1,100.39
$1,374.01
$1,362.71
$1,435.41
$1,512.43
$1,786.05
$1,774.75
$1,847.45
$1,924.47
$2,198.09
$412.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,077.26
$1,222.66
$1,376.70
$1,923.94
$2,923.62
$1,489.30
$1,634.70
$1,788.74
$2,335.98
$1,901.34
$2,046.74
$2,200.78
$2,748.02
$2,313.38
$2,458.78
$2,612.82
$3,160.06
$412.04
Toc - Plan #31 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
$487.40
$553.19
$622.89
$870.49
$1,322.79
$860.26
$926.05
$995.75
$1,243.35
$1,233.12
$1,298.91
$1,368.61
$1,616.21
$1,605.98
$1,671.77
$1,741.47
$1,989.07
$372.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$974.80
$1,106.38
$1,245.78
$1,740.98
$2,645.58
$1,347.66
$1,479.24
$1,618.64
$2,113.84
$1,720.52
$1,852.10
$1,991.50
$2,486.70
$2,093.38
$2,224.96
$2,364.36
$2,859.56
$372.86
Toc - Plan #32 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
$517.95
$587.86
$661.93
$925.04
$1,405.69
$914.18
$984.09
$1,058.16
$1,321.27
$1,310.41
$1,380.32
$1,454.39
$1,717.50
$1,706.64
$1,776.55
$1,850.62
$2,113.73
$396.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,035.90
$1,175.72
$1,323.86
$1,850.08
$2,811.38
$1,432.13
$1,571.95
$1,720.09
$2,246.31
$1,828.36
$1,968.18
$2,116.32
$2,642.54
$2,224.59
$2,364.41
$2,512.55
$3,038.77
$396.23
Toc - Plan #33 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
$571.44
$648.57
$730.29
$1,020.58
$1,550.86
$1,008.58
$1,085.71
$1,167.43
$1,457.72
$1,445.72
$1,522.85
$1,604.57
$1,894.86
$1,882.86
$1,959.99
$2,041.71
$2,332.00
$437.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,142.88
$1,297.14
$1,460.58
$2,041.16
$3,101.72
$1,580.02
$1,734.28
$1,897.72
$2,478.30
$2,017.16
$2,171.42
$2,334.86
$2,915.44
$2,454.30
$2,608.56
$2,772.00
$3,352.58
$437.14
Toc - Plan #34 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
$559.52
$635.05
$715.06
$999.29
$1,518.52
$987.55
$1,063.08
$1,143.09
$1,427.32
$1,415.58
$1,491.11
$1,571.12
$1,855.35
$1,843.61
$1,919.14
$1,999.15
$2,283.38
$428.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,119.04
$1,270.10
$1,430.12
$1,998.58
$3,037.04
$1,547.07
$1,698.13
$1,858.15
$2,426.61
$1,975.10
$2,126.16
$2,286.18
$2,854.64
$2,403.13
$2,554.19
$2,714.21
$3,282.67
$428.03
Toc - Plan #35 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
$506.31
$574.65
$647.06
$904.26
$1,374.11
$893.63
$961.97
$1,034.38
$1,291.58
$1,280.95
$1,349.29
$1,421.70
$1,678.90
$1,668.27
$1,736.61
$1,809.02
$2,066.22
$387.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,012.62
$1,149.30
$1,294.12
$1,808.52
$2,748.22
$1,399.94
$1,536.62
$1,681.44
$2,195.84
$1,787.26
$1,923.94
$2,068.76
$2,583.16
$2,174.58
$2,311.26
$2,456.08
$2,970.48
$387.32
Toc - Plan #36 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
$565.68
$642.03
$722.92
$1,010.28
$1,535.22
$998.42
$1,074.77
$1,155.66
$1,443.02
$1,431.16
$1,507.51
$1,588.40
$1,875.76
$1,863.90
$1,940.25
$2,021.14
$2,308.50
$432.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,131.36
$1,284.06
$1,445.84
$2,020.56
$3,070.44
$1,564.10
$1,716.80
$1,878.58
$2,453.30
$1,996.84
$2,149.54
$2,311.32
$2,886.04
$2,429.58
$2,582.28
$2,744.06
$3,318.78
$432.74
Toc - Plan #37 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
$504.63
$572.75
$644.91
$901.26
$1,369.55
$890.67
$958.79
$1,030.95
$1,287.30
$1,276.71
$1,344.83
$1,416.99
$1,673.34
$1,662.75
$1,730.87
$1,803.03
$2,059.38
$386.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,009.26
$1,145.50
$1,289.82
$1,802.52
$2,739.10
$1,395.30
$1,531.54
$1,675.86
$2,188.56
$1,781.34
$1,917.58
$2,061.90
$2,574.60
$2,167.38
$2,303.62
$2,447.94
$2,960.64
$386.04
Toc - Plan #38 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
$562.21
$638.10
$718.49
$1,004.09
$1,525.81
$992.29
$1,068.18
$1,148.57
$1,434.17
$1,422.37
$1,498.26
$1,578.65
$1,864.25
$1,852.45
$1,928.34
$2,008.73
$2,294.33
$430.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,124.42
$1,276.20
$1,436.98
$2,008.18
$3,051.62
$1,554.50
$1,706.28
$1,867.06
$2,438.26
$1,984.58
$2,136.36
$2,297.14
$2,868.34
$2,414.66
$2,566.44
$2,727.22
$3,298.42
$430.08
Toc - Plan #39 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
$500.49
$568.05
$639.62
$893.87
$1,358.31
$883.36
$950.92
$1,022.49
$1,276.74
$1,266.23
$1,333.79
$1,405.36
$1,659.61
$1,649.10
$1,716.66
$1,788.23
$2,042.48
$382.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,000.98
$1,136.10
$1,279.24
$1,787.74
$2,716.62
$1,383.85
$1,518.97
$1,662.11
$2,170.61
$1,766.72
$1,901.84
$2,044.98
$2,553.48
$2,149.59
$2,284.71
$2,427.85
$2,936.35
$382.87

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 #40 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
$441.58
$501.20
$564.34
$788.67
$1,198.46
$779.39
$839.01
$902.15
$1,126.48
$1,117.20
$1,176.82
$1,239.96
$1,464.29
$1,455.01
$1,514.63
$1,577.77
$1,802.10
$337.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$883.16
$1,002.40
$1,128.68
$1,577.34
$2,396.92
$1,220.97
$1,340.21
$1,466.49
$1,915.15
$1,558.78
$1,678.02
$1,804.30
$2,252.96
$1,896.59
$2,015.83
$2,142.11
$2,590.77
$337.81
Toc - Plan #41 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
$327.09
$371.25
$418.02
$584.18
$887.72
$577.31
$621.47
$668.24
$834.40
$827.53
$871.69
$918.46
$1,084.62
$1,077.75
$1,121.91
$1,168.68
$1,334.84
$250.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$654.18
$742.50
$836.04
$1,168.36
$1,775.44
$904.40
$992.72
$1,086.26
$1,418.58
$1,154.62
$1,242.94
$1,336.48
$1,668.80
$1,404.84
$1,493.16
$1,586.70
$1,919.02
$250.22
Toc - Plan #42 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
$524.36
$595.15
$670.13
$936.51
$1,423.12
$925.50
$996.29
$1,071.27
$1,337.65
$1,326.64
$1,397.43
$1,472.41
$1,738.79
$1,727.78
$1,798.57
$1,873.55
$2,139.93
$401.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,048.72
$1,190.30
$1,340.26
$1,873.02
$2,846.24
$1,449.86
$1,591.44
$1,741.40
$2,274.16
$1,851.00
$1,992.58
$2,142.54
$2,675.30
$2,252.14
$2,393.72
$2,543.68
$3,076.44
$401.14
Toc - Plan #43 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
$366.27
$415.72
$468.09
$654.16
$994.06
$646.47
$695.92
$748.29
$934.36
$926.67
$976.12
$1,028.49
$1,214.56
$1,206.87
$1,256.32
$1,308.69
$1,494.76
$280.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732.54
$831.44
$936.18
$1,308.32
$1,988.12
$1,012.74
$1,111.64
$1,216.38
$1,588.52
$1,292.94
$1,391.84
$1,496.58
$1,868.72
$1,573.14
$1,672.04
$1,776.78
$2,148.92
$280.20
Toc - Plan #44 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
$379.11
$430.29
$484.50
$677.09
$1,028.90
$669.13
$720.31
$774.52
$967.11
$959.15
$1,010.33
$1,064.54
$1,257.13
$1,249.17
$1,300.35
$1,354.56
$1,547.15
$290.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.22
$860.58
$969.00
$1,354.18
$2,057.80
$1,048.24
$1,150.60
$1,259.02
$1,644.20
$1,338.26
$1,440.62
$1,549.04
$1,934.22
$1,628.28
$1,730.64
$1,839.06
$2,224.24
$290.02
Toc - Plan #45 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
$360.81
$409.52
$461.12
$644.41
$979.25
$636.83
$685.54
$737.14
$920.43
$912.85
$961.56
$1,013.16
$1,196.45
$1,188.87
$1,237.58
$1,289.18
$1,472.47
$276.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.62
$819.04
$922.24
$1,288.82
$1,958.50
$997.64
$1,095.06
$1,198.26
$1,564.84
$1,273.66
$1,371.08
$1,474.28
$1,840.86
$1,549.68
$1,647.10
$1,750.30
$2,116.88
$276.02
Toc - Plan #46 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
$455.97
$517.53
$582.73
$814.36
$1,237.50
$804.79
$866.35
$931.55
$1,163.18
$1,153.61
$1,215.17
$1,280.37
$1,512.00
$1,502.43
$1,563.99
$1,629.19
$1,860.82
$348.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$911.94
$1,035.06
$1,165.46
$1,628.72
$2,475.00
$1,260.76
$1,383.88
$1,514.28
$1,977.54
$1,609.58
$1,732.70
$1,863.10
$2,326.36
$1,958.40
$2,081.52
$2,211.92
$2,675.18
$348.82
Toc - Plan #47 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
$452.96
$514.11
$578.88
$808.98
$1,229.33
$799.47
$860.62
$925.39
$1,155.49
$1,145.98
$1,207.13
$1,271.90
$1,502.00
$1,492.49
$1,553.64
$1,618.41
$1,848.51
$346.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$905.92
$1,028.22
$1,157.76
$1,617.96
$2,458.66
$1,252.43
$1,374.73
$1,504.27
$1,964.47
$1,598.94
$1,721.24
$1,850.78
$2,310.98
$1,945.45
$2,067.75
$2,197.29
$2,657.49
$346.51
Toc - Plan #48 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
$524.41
$595.21
$670.20
$936.60
$1,423.25
$925.59
$996.39
$1,071.38
$1,337.78
$1,326.77
$1,397.57
$1,472.56
$1,738.96
$1,727.95
$1,798.75
$1,873.74
$2,140.14
$401.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,048.82
$1,190.42
$1,340.40
$1,873.20
$2,846.50
$1,450.00
$1,591.60
$1,741.58
$2,274.38
$1,851.18
$1,992.78
$2,142.76
$2,675.56
$2,252.36
$2,393.96
$2,543.94
$3,076.74
$401.18
Toc - Plan #49 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
$365.03
$414.31
$466.51
$651.94
$990.69
$644.28
$693.56
$745.76
$931.19
$923.53
$972.81
$1,025.01
$1,210.44
$1,202.78
$1,252.06
$1,304.26
$1,489.69
$279.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.06
$828.62
$933.02
$1,303.88
$1,981.38
$1,009.31
$1,107.87
$1,212.27
$1,583.13
$1,288.56
$1,387.12
$1,491.52
$1,862.38
$1,567.81
$1,666.37
$1,770.77
$2,141.63
$279.25
Toc - Plan #50 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
$522.19
$592.68
$667.35
$932.62
$1,417.21
$921.66
$992.15
$1,066.82
$1,332.09
$1,321.13
$1,391.62
$1,466.29
$1,731.56
$1,720.60
$1,791.09
$1,865.76
$2,131.03
$399.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,044.38
$1,185.36
$1,334.70
$1,865.24
$2,834.42
$1,443.85
$1,584.83
$1,734.17
$2,264.71
$1,843.32
$1,984.30
$2,133.64
$2,664.18
$2,242.79
$2,383.77
$2,533.11
$3,063.65
$399.47
Toc - Plan #51 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
$417.78
$474.19
$533.93
$746.16
$1,133.87
$737.39
$793.80
$853.54
$1,065.77
$1,057.00
$1,113.41
$1,173.15
$1,385.38
$1,376.61
$1,433.02
$1,492.76
$1,704.99
$319.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.56
$948.38
$1,067.86
$1,492.32
$2,267.74
$1,155.17
$1,267.99
$1,387.47
$1,811.93
$1,474.78
$1,587.60
$1,707.08
$2,131.54
$1,794.39
$1,907.21
$2,026.69
$2,451.15
$319.61
Toc - Plan #52 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
$396.07
$449.54
$506.18
$707.38
$1,074.93
$699.06
$752.53
$809.17
$1,010.37
$1,002.05
$1,055.52
$1,112.16
$1,313.36
$1,305.04
$1,358.51
$1,415.15
$1,616.35
$302.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.14
$899.08
$1,012.36
$1,414.76
$2,149.86
$1,095.13
$1,202.07
$1,315.35
$1,717.75
$1,398.12
$1,505.06
$1,618.34
$2,020.74
$1,701.11
$1,808.05
$1,921.33
$2,323.73
$302.99
Toc - Plan #53 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
$406.52
$461.40
$519.53
$726.04
$1,103.30
$717.51
$772.39
$830.52
$1,037.03
$1,028.50
$1,083.38
$1,141.51
$1,348.02
$1,339.49
$1,394.37
$1,452.50
$1,659.01
$310.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$813.04
$922.80
$1,039.06
$1,452.08
$2,206.60
$1,124.03
$1,233.79
$1,350.05
$1,763.07
$1,435.02
$1,544.78
$1,661.04
$2,074.06
$1,746.01
$1,855.77
$1,972.03
$2,385.05
$310.99
Toc - Plan #54 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
$500.50
$568.07
$639.64
$893.90
$1,358.37
$883.39
$950.96
$1,022.53
$1,276.79
$1,266.28
$1,333.85
$1,405.42
$1,659.68
$1,649.17
$1,716.74
$1,788.31
$2,042.57
$382.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,001.00
$1,136.14
$1,279.28
$1,787.80
$2,716.74
$1,383.89
$1,519.03
$1,662.17
$2,170.69
$1,766.78
$1,901.92
$2,045.06
$2,553.58
$2,149.67
$2,284.81
$2,427.95
$2,936.47
$382.89
Toc - Plan #55 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
$504.22
$572.28
$644.39
$900.53
$1,368.44
$889.94
$958.00
$1,030.11
$1,286.25
$1,275.66
$1,343.72
$1,415.83
$1,671.97
$1,661.38
$1,729.44
$1,801.55
$2,057.69
$385.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,008.44
$1,144.56
$1,288.78
$1,801.06
$2,736.88
$1,394.16
$1,530.28
$1,674.50
$2,186.78
$1,779.88
$1,916.00
$2,060.22
$2,572.50
$2,165.60
$2,301.72
$2,445.94
$2,958.22
$385.72
Toc - Plan #56 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
$590.11
$669.78
$754.16
$1,053.94
$1,601.56
$1,041.54
$1,121.21
$1,205.59
$1,505.37
$1,492.97
$1,572.64
$1,657.02
$1,956.80
$1,944.40
$2,024.07
$2,108.45
$2,408.23
$451.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,180.22
$1,339.56
$1,508.32
$2,107.88
$3,203.12
$1,631.65
$1,790.99
$1,959.75
$2,559.31
$2,083.08
$2,242.42
$2,411.18
$3,010.74
$2,534.51
$2,693.85
$2,862.61
$3,462.17
$451.43
Toc - Plan #57 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
$598.52
$679.32
$764.90
$1,068.95
$1,624.37
$1,056.39
$1,137.19
$1,222.77
$1,526.82
$1,514.26
$1,595.06
$1,680.64
$1,984.69
$1,972.13
$2,052.93
$2,138.51
$2,442.56
$457.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,197.04
$1,358.64
$1,529.80
$2,137.90
$3,248.74
$1,654.91
$1,816.51
$1,987.67
$2,595.77
$2,112.78
$2,274.38
$2,445.54
$3,053.64
$2,570.65
$2,732.25
$2,903.41
$3,511.51
$457.87
Toc - Plan #58 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
$583.78
$662.58
$746.06
$1,042.62
$1,584.37
$1,030.37
$1,109.17
$1,192.65
$1,489.21
$1,476.96
$1,555.76
$1,639.24
$1,935.80
$1,923.55
$2,002.35
$2,085.83
$2,382.39
$446.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,167.56
$1,325.16
$1,492.12
$2,085.24
$3,168.74
$1,614.15
$1,771.75
$1,938.71
$2,531.83
$2,060.74
$2,218.34
$2,385.30
$2,978.42
$2,507.33
$2,664.93
$2,831.89
$3,425.01
$446.59
Toc - Plan #59 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
$491.87
$558.28
$628.61
$878.48
$1,334.94
$868.15
$934.56
$1,004.89
$1,254.76
$1,244.43
$1,310.84
$1,381.17
$1,631.04
$1,620.71
$1,687.12
$1,757.45
$2,007.32
$376.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$983.74
$1,116.56
$1,257.22
$1,756.96
$2,669.88
$1,360.02
$1,492.84
$1,633.50
$2,133.24
$1,736.30
$1,869.12
$2,009.78
$2,509.52
$2,112.58
$2,245.40
$2,386.06
$2,885.80
$376.28

ADVERTISEMENT

UnitedHealthcare

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

Toc - Plan #60 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
$422.70
$479.76
$540.21
$754.94
$1,147.21
$746.07
$803.13
$863.58
$1,078.31
$1,069.44
$1,126.50
$1,186.95
$1,401.68
$1,392.81
$1,449.87
$1,510.32
$1,725.05
$323.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.40
$959.52
$1,080.42
$1,509.88
$2,294.42
$1,168.77
$1,282.89
$1,403.79
$1,833.25
$1,492.14
$1,606.26
$1,727.16
$2,156.62
$1,815.51
$1,929.63
$2,050.53
$2,479.99
$323.37
Toc - Plan #61 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
$297.66
$337.84
$380.40
$531.61
$807.84
$525.37
$565.55
$608.11
$759.32
$753.08
$793.26
$835.82
$987.03
$980.79
$1,020.97
$1,063.53
$1,214.74
$227.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.32
$675.68
$760.80
$1,063.22
$1,615.68
$823.03
$903.39
$988.51
$1,290.93
$1,050.74
$1,131.10
$1,216.22
$1,518.64
$1,278.45
$1,358.81
$1,443.93
$1,746.35
$227.71
Toc - Plan #62 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
$301.47
$342.17
$385.28
$538.43
$818.19
$532.10
$572.80
$615.91
$769.06
$762.73
$803.43
$846.54
$999.69
$993.36
$1,034.06
$1,077.17
$1,230.32
$230.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$602.94
$684.34
$770.56
$1,076.86
$1,636.38
$833.57
$914.97
$1,001.19
$1,307.49
$1,064.20
$1,145.60
$1,231.82
$1,538.12
$1,294.83
$1,376.23
$1,462.45
$1,768.75
$230.63
Toc - Plan #63 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
$370.01
$419.96
$472.87
$660.83
$1,004.20
$653.07
$703.02
$755.93
$943.89
$936.13
$986.08
$1,038.99
$1,226.95
$1,219.19
$1,269.14
$1,322.05
$1,510.01
$283.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.02
$839.92
$945.74
$1,321.66
$2,008.40
$1,023.08
$1,122.98
$1,228.80
$1,604.72
$1,306.14
$1,406.04
$1,511.86
$1,887.78
$1,589.20
$1,689.10
$1,794.92
$2,170.84
$283.06
Toc - Plan #64 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
$302.14
$342.93
$386.14
$539.63
$820.01
$533.28
$574.07
$617.28
$770.77
$764.42
$805.21
$848.42
$1,001.91
$995.56
$1,036.35
$1,079.56
$1,233.05
$231.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.28
$685.86
$772.28
$1,079.26
$1,640.02
$835.42
$917.00
$1,003.42
$1,310.40
$1,066.56
$1,148.14
$1,234.56
$1,541.54
$1,297.70
$1,379.28
$1,465.70
$1,772.68
$231.14
Toc - Plan #65 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $5 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
$9,450 $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
$439.49
$498.83
$561.67
$784.94
$1,192.79
$775.70
$835.04
$897.88
$1,121.15
$1,111.91
$1,171.25
$1,234.09
$1,457.36
$1,448.12
$1,507.46
$1,570.30
$1,793.57
$336.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$878.98
$997.66
$1,123.34
$1,569.88
$2,385.58
$1,215.19
$1,333.87
$1,459.55
$1,906.09
$1,551.40
$1,670.08
$1,795.76
$2,242.30
$1,887.61
$2,006.29
$2,131.97
$2,578.51
$336.21
Toc - Plan #66 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
$422.61
$479.66
$540.10
$754.79
$1,146.97
$745.91
$802.96
$863.40
$1,078.09
$1,069.21
$1,126.26
$1,186.70
$1,401.39
$1,392.51
$1,449.56
$1,510.00
$1,724.69
$323.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.22
$959.32
$1,080.20
$1,509.58
$2,293.94
$1,168.52
$1,282.62
$1,403.50
$1,832.88
$1,491.82
$1,605.92
$1,726.80
$2,156.18
$1,815.12
$1,929.22
$2,050.10
$2,479.48
$323.30
Toc - Plan #67 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
$382.79
$434.46
$489.20
$683.66
$1,038.88
$675.62
$727.29
$782.03
$976.49
$968.45
$1,020.12
$1,074.86
$1,269.32
$1,261.28
$1,312.95
$1,367.69
$1,562.15
$292.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.58
$868.92
$978.40
$1,367.32
$2,077.76
$1,058.41
$1,161.75
$1,271.23
$1,660.15
$1,351.24
$1,454.58
$1,564.06
$1,952.98
$1,644.07
$1,747.41
$1,856.89
$2,245.81
$292.83
Toc - Plan #68 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
$411.61
$467.18
$526.04
$735.14
$1,117.12
$726.49
$782.06
$840.92
$1,050.02
$1,041.37
$1,096.94
$1,155.80
$1,364.90
$1,356.25
$1,411.82
$1,470.68
$1,679.78
$314.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$823.22
$934.36
$1,052.08
$1,470.28
$2,234.24
$1,138.10
$1,249.24
$1,366.96
$1,785.16
$1,452.98
$1,564.12
$1,681.84
$2,100.04
$1,767.86
$1,879.00
$1,996.72
$2,414.92
$314.88
Toc - Plan #69 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
$418.89
$475.43
$535.34
$748.13
$1,136.85
$739.34
$795.88
$855.79
$1,068.58
$1,059.79
$1,116.33
$1,176.24
$1,389.03
$1,380.24
$1,436.78
$1,496.69
$1,709.48
$320.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$837.78
$950.86
$1,070.68
$1,496.26
$2,273.70
$1,158.23
$1,271.31
$1,391.13
$1,816.71
$1,478.68
$1,591.76
$1,711.58
$2,137.16
$1,799.13
$1,912.21
$2,032.03
$2,457.61
$320.45
Toc - Plan #70 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
$360.97
$409.70
$461.32
$644.69
$979.67
$637.11
$685.84
$737.46
$920.83
$913.25
$961.98
$1,013.60
$1,196.97
$1,189.39
$1,238.12
$1,289.74
$1,473.11
$276.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.94
$819.40
$922.64
$1,289.38
$1,959.34
$998.08
$1,095.54
$1,198.78
$1,565.52
$1,274.22
$1,371.68
$1,474.92
$1,841.66
$1,550.36
$1,647.82
$1,751.06
$2,117.80
$276.14
Toc - Plan #71 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
$373.26
$423.65
$477.03
$666.64
$1,013.03
$658.80
$709.19
$762.57
$952.18
$944.34
$994.73
$1,048.11
$1,237.72
$1,229.88
$1,280.27
$1,333.65
$1,523.26
$285.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.52
$847.30
$954.06
$1,333.28
$2,026.06
$1,032.06
$1,132.84
$1,239.60
$1,618.82
$1,317.60
$1,418.38
$1,525.14
$1,904.36
$1,603.14
$1,703.92
$1,810.68
$2,189.90
$285.54
Toc - Plan #72 UnitedHealthcare
Gold

(HMO) UHC Gold 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
$1,000 $2,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370.92
$420.99
$474.03
$662.46
$1,006.67
$654.67
$704.74
$757.78
$946.21
$938.42
$988.49
$1,041.53
$1,229.96
$1,222.17
$1,272.24
$1,325.28
$1,513.71
$283.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$741.84
$841.98
$948.06
$1,324.92
$2,013.34
$1,025.59
$1,125.73
$1,231.81
$1,608.67
$1,309.34
$1,409.48
$1,515.56
$1,892.42
$1,593.09
$1,693.23
$1,799.31
$2,176.17
$283.75
Toc - Plan #73 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus $0 Indiv Med Ded ($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
$318.58
$361.59
$407.15
$568.99
$864.64
$562.30
$605.31
$650.87
$812.71
$806.02
$849.03
$894.59
$1,056.43
$1,049.74
$1,092.75
$1,138.31
$1,300.15
$243.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$637.16
$723.18
$814.30
$1,137.98
$1,729.28
$880.88
$966.90
$1,058.02
$1,381.70
$1,124.60
$1,210.62
$1,301.74
$1,625.42
$1,368.32
$1,454.34
$1,545.46
$1,869.14
$243.72
Toc - Plan #74 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
$298.59
$338.90
$381.60
$533.28
$810.37
$527.01
$567.32
$610.02
$761.70
$755.43
$795.74
$838.44
$990.12
$983.85
$1,024.16
$1,066.86
$1,218.54
$228.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$597.18
$677.80
$763.20
$1,066.56
$1,620.74
$825.60
$906.22
$991.62
$1,294.98
$1,054.02
$1,134.64
$1,220.04
$1,523.40
$1,282.44
$1,363.06
$1,448.46
$1,751.82
$228.42
Toc - Plan #75 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
$437.51
$496.58
$559.14
$781.39
$1,187.41
$772.21
$831.28
$893.84
$1,116.09
$1,106.91
$1,165.98
$1,228.54
$1,450.79
$1,441.61
$1,500.68
$1,563.24
$1,785.49
$334.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$875.02
$993.16
$1,118.28
$1,562.78
$2,374.82
$1,209.72
$1,327.86
$1,452.98
$1,897.48
$1,544.42
$1,662.56
$1,787.68
$2,232.18
$1,879.12
$1,997.26
$2,122.38
$2,566.88
$334.70
Toc - Plan #76 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
$391.89
$444.79
$500.83
$699.91
$1,063.58
$691.68
$744.58
$800.62
$999.70
$991.47
$1,044.37
$1,100.41
$1,299.49
$1,291.26
$1,344.16
$1,400.20
$1,599.28
$299.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.78
$889.58
$1,001.66
$1,399.82
$2,127.16
$1,083.57
$1,189.37
$1,301.45
$1,699.61
$1,383.36
$1,489.16
$1,601.24
$1,999.40
$1,683.15
$1,788.95
$1,901.03
$2,299.19
$299.79

ADVERTISEMENT

US Health and Life

Local: 1-833-600-1311 | Toll Free: 

Toc - Plan #77 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Balanced Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$289.62
$328.72
$370.14
$517.26
$786.03
$511.18
$550.28
$591.70
$738.82
$732.74
$771.84
$813.26
$960.38
$954.30
$993.40
$1,034.82
$1,181.94
$221.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$579.24
$657.44
$740.28
$1,034.52
$1,572.06
$800.80
$879.00
$961.84
$1,256.08
$1,022.36
$1,100.56
$1,183.40
$1,477.64
$1,243.92
$1,322.12
$1,404.96
$1,699.20
$221.56
Toc - Plan #78 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care No Medical Deductible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$303.00
$343.90
$387.23
$541.16
$822.34
$534.79
$575.69
$619.02
$772.95
$766.58
$807.48
$850.81
$1,004.74
$998.37
$1,039.27
$1,082.60
$1,236.53
$231.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$606.00
$687.80
$774.46
$1,082.32
$1,644.68
$837.79
$919.59
$1,006.25
$1,314.11
$1,069.58
$1,151.38
$1,238.04
$1,545.90
$1,301.37
$1,383.17
$1,469.83
$1,777.69
$231.79
Toc - Plan #79 US Health and Life
Silver

(EPO) Ascension Personalized Care No Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$459.88
$521.97
$587.73
$821.35
$1,248.13
$811.69
$873.78
$939.54
$1,173.16
$1,163.50
$1,225.59
$1,291.35
$1,524.97
$1,515.31
$1,577.40
$1,643.16
$1,876.78
$351.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$919.76
$1,043.94
$1,175.46
$1,642.70
$2,496.26
$1,271.57
$1,395.75
$1,527.27
$1,994.51
$1,623.38
$1,747.56
$1,879.08
$2,346.32
$1,975.19
$2,099.37
$2,230.89
$2,698.13
$351.81
Toc - Plan #80 US Health and Life
Silver

(EPO) Ascension Personalized Care Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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
$437.87
$496.98
$559.59
$782.03
$1,188.37
$772.84
$831.95
$894.56
$1,117.00
$1,107.81
$1,166.92
$1,229.53
$1,451.97
$1,442.78
$1,501.89
$1,564.50
$1,786.94
$334.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$875.74
$993.96
$1,119.18
$1,564.06
$2,376.74
$1,210.71
$1,328.93
$1,454.15
$1,899.03
$1,545.68
$1,663.90
$1,789.12
$2,234.00
$1,880.65
$1,998.87
$2,124.09
$2,568.97
$334.97
Toc - Plan #81 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$294.55
$334.31
$376.44
$526.07
$799.41
$519.88
$559.64
$601.77
$751.40
$745.21
$784.97
$827.10
$976.73
$970.54
$1,010.30
$1,052.43
$1,202.06
$225.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$589.10
$668.62
$752.88
$1,052.14
$1,598.82
$814.43
$893.95
$978.21
$1,277.47
$1,039.76
$1,119.28
$1,203.54
$1,502.80
$1,265.09
$1,344.61
$1,428.87
$1,728.13
$225.33
Toc - Plan #82 US Health and Life
Silver

(EPO) Ascension Personalized Care Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$439.53
$498.86
$561.71
$784.99
$1,192.87
$775.77
$835.10
$897.95
$1,121.23
$1,112.01
$1,171.34
$1,234.19
$1,457.47
$1,448.25
$1,507.58
$1,570.43
$1,793.71
$336.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.06
$997.72
$1,123.42
$1,569.98
$2,385.74
$1,215.30
$1,333.96
$1,459.66
$1,906.22
$1,551.54
$1,670.20
$1,795.90
$2,242.46
$1,887.78
$2,006.44
$2,132.14
$2,578.70
$336.24
Toc - Plan #83 US Health and Life
Gold

(EPO) Ascension Personalized Care Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$391.04
$443.83
$499.75
$698.40
$1,061.28
$690.19
$742.98
$798.90
$997.55
$989.34
$1,042.13
$1,098.05
$1,296.70
$1,288.49
$1,341.28
$1,397.20
$1,595.85
$299.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782.08
$887.66
$999.50
$1,396.80
$2,122.56
$1,081.23
$1,186.81
$1,298.65
$1,695.95
$1,380.38
$1,485.96
$1,597.80
$1,995.10
$1,679.53
$1,785.11
$1,896.95
$2,294.25
$299.15

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #84 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
$440.41
$499.87
$562.85
$786.58
$1,195.27
$777.33
$836.79
$899.77
$1,123.50
$1,114.25
$1,173.71
$1,236.69
$1,460.42
$1,451.17
$1,510.63
$1,573.61
$1,797.34
$336.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$880.82
$999.74
$1,125.70
$1,573.16
$2,390.54
$1,217.74
$1,336.66
$1,462.62
$1,910.08
$1,554.66
$1,673.58
$1,799.54
$2,247.00
$1,891.58
$2,010.50
$2,136.46
$2,583.92
$336.92
Toc - Plan #85 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
$395.67
$449.08
$505.66
$706.65
$1,073.83
$698.36
$751.77
$808.35
$1,009.34
$1,001.05
$1,054.46
$1,111.04
$1,312.03
$1,303.74
$1,357.15
$1,413.73
$1,614.72
$302.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.34
$898.16
$1,011.32
$1,413.30
$2,147.66
$1,094.03
$1,200.85
$1,314.01
$1,715.99
$1,396.72
$1,503.54
$1,616.70
$2,018.68
$1,699.41
$1,806.23
$1,919.39
$2,321.37
$302.69
Toc - Plan #86 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
$427.30
$484.98
$546.09
$763.15
$1,159.68
$754.18
$811.86
$872.97
$1,090.03
$1,081.06
$1,138.74
$1,199.85
$1,416.91
$1,407.94
$1,465.62
$1,526.73
$1,743.79
$326.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$854.60
$969.96
$1,092.18
$1,526.30
$2,319.36
$1,181.48
$1,296.84
$1,419.06
$1,853.18
$1,508.36
$1,623.72
$1,745.94
$2,180.06
$1,835.24
$1,950.60
$2,072.82
$2,506.94
$326.88
Toc - Plan #87 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
$394.40
$447.65
$504.04
$704.40
$1,070.40
$696.12
$749.37
$805.76
$1,006.12
$997.84
$1,051.09
$1,107.48
$1,307.84
$1,299.56
$1,352.81
$1,409.20
$1,609.56
$301.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.80
$895.30
$1,008.08
$1,408.80
$2,140.80
$1,090.52
$1,197.02
$1,309.80
$1,710.52
$1,392.24
$1,498.74
$1,611.52
$2,012.24
$1,693.96
$1,800.46
$1,913.24
$2,313.96
$301.72
Toc - Plan #88 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
$399.89
$453.87
$511.05
$714.19
$1,085.28
$705.80
$759.78
$816.96
$1,020.10
$1,011.71
$1,065.69
$1,122.87
$1,326.01
$1,317.62
$1,371.60
$1,428.78
$1,631.92
$305.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$799.78
$907.74
$1,022.10
$1,428.38
$2,170.56
$1,105.69
$1,213.65
$1,328.01
$1,734.29
$1,411.60
$1,519.56
$1,633.92
$2,040.20
$1,717.51
$1,825.47
$1,939.83
$2,346.11
$305.91
Toc - Plan #89 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
$426.80
$484.42
$545.45
$762.27
$1,158.33
$753.31
$810.93
$871.96
$1,088.78
$1,079.82
$1,137.44
$1,198.47
$1,415.29
$1,406.33
$1,463.95
$1,524.98
$1,741.80
$326.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.60
$968.84
$1,090.90
$1,524.54
$2,316.66
$1,180.11
$1,295.35
$1,417.41
$1,851.05
$1,506.62
$1,621.86
$1,743.92
$2,177.56
$1,833.13
$1,948.37
$2,070.43
$2,504.07
$326.51
Toc - Plan #90 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
$436.20
$495.09
$557.46
$779.05
$1,183.84
$769.89
$828.78
$891.15
$1,112.74
$1,103.58
$1,162.47
$1,224.84
$1,446.43
$1,437.27
$1,496.16
$1,558.53
$1,780.12
$333.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$872.40
$990.18
$1,114.92
$1,558.10
$2,367.68
$1,206.09
$1,323.87
$1,448.61
$1,891.79
$1,539.78
$1,657.56
$1,782.30
$2,225.48
$1,873.47
$1,991.25
$2,115.99
$2,559.17
$333.69
Toc - Plan #91 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
$436.70
$495.65
$558.10
$779.94
$1,185.19
$770.77
$829.72
$892.17
$1,114.01
$1,104.84
$1,163.79
$1,226.24
$1,448.08
$1,438.91
$1,497.86
$1,560.31
$1,782.15
$334.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.40
$991.30
$1,116.20
$1,559.88
$2,370.38
$1,207.47
$1,325.37
$1,450.27
$1,893.95
$1,541.54
$1,659.44
$1,784.34
$2,228.02
$1,875.61
$1,993.51
$2,118.41
$2,562.09
$334.07

ADVERTISEMENT

CHRISTUS Health Plan

Local: 1-844-282-3025 | Toll Free: 1-844-282-3025 | TTY: 1-800-659-8331

Toc - Plan #92 CHRISTUS Health Plan
Catastrophic

(HMO) CHRISTUS Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

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
$233.68
$265.22
$298.64
$417.35
$634.20
$412.44
$443.98
$477.40
$596.11
$591.20
$622.74
$656.16
$774.87
$769.96
$801.50
$834.92
$953.63
$178.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$467.36
$530.44
$597.28
$834.70
$1,268.40
$646.12
$709.20
$776.04
$1,013.46
$824.88
$887.96
$954.80
$1,192.22
$1,003.64
$1,066.72
$1,133.56
$1,370.98
$178.76
Toc - Plan #93 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHRISTUS Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 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
$276.31
$313.61
$353.12
$493.49
$749.90
$487.69
$524.99
$564.50
$704.87
$699.07
$736.37
$775.88
$916.25
$910.45
$947.75
$987.26
$1,127.63
$211.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$552.62
$627.22
$706.24
$986.98
$1,499.80
$764.00
$838.60
$917.62
$1,198.36
$975.38
$1,049.98
$1,129.00
$1,409.74
$1,186.76
$1,261.36
$1,340.38
$1,621.12
$211.38
Toc - Plan #94 CHRISTUS Health Plan
Silver

(HMO) CHRISTUS Silver HD

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 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
$433.62
$492.15
$554.16
$774.44
$1,176.83
$765.34
$823.87
$885.88
$1,106.16
$1,097.06
$1,155.59
$1,217.60
$1,437.88
$1,428.78
$1,487.31
$1,549.32
$1,769.60
$331.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.24
$984.30
$1,108.32
$1,548.88
$2,353.66
$1,198.96
$1,316.02
$1,440.04
$1,880.60
$1,530.68
$1,647.74
$1,771.76
$2,212.32
$1,862.40
$1,979.46
$2,103.48
$2,544.04
$331.72
Toc - Plan #95 CHRISTUS Health Plan
Gold

(HMO) CHRISTUS Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 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
$350.71
$398.05
$448.21
$626.36
$951.82
$619.00
$666.34
$716.50
$894.65
$887.29
$934.63
$984.79
$1,162.94
$1,155.58
$1,202.92
$1,253.08
$1,431.23
$268.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$701.42
$796.10
$896.42
$1,252.72
$1,903.64
$969.71
$1,064.39
$1,164.71
$1,521.01
$1,238.00
$1,332.68
$1,433.00
$1,789.30
$1,506.29
$1,600.97
$1,701.29
$2,057.59
$268.29
Toc - Plan #96 CHRISTUS Health Plan
Gold

(HMO) CHRISTUS Gold Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

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
$401.40
$455.58
$512.98
$716.89
$1,089.39
$708.47
$762.65
$820.05
$1,023.96
$1,015.54
$1,069.72
$1,127.12
$1,331.03
$1,322.61
$1,376.79
$1,434.19
$1,638.10
$307.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802.80
$911.16
$1,025.96
$1,433.78
$2,178.78
$1,109.87
$1,218.23
$1,333.03
$1,740.85
$1,416.94
$1,525.30
$1,640.10
$2,047.92
$1,724.01
$1,832.37
$1,947.17
$2,354.99
$307.07
Toc - Plan #97 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHRISTUS Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 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
$302.24
$343.04
$386.27
$539.80
$820.28
$533.46
$574.26
$617.49
$771.02
$764.68
$805.48
$848.71
$1,002.24
$995.90
$1,036.70
$1,079.93
$1,233.46
$231.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.48
$686.08
$772.54
$1,079.60
$1,640.56
$835.70
$917.30
$1,003.76
$1,310.82
$1,066.92
$1,148.52
$1,234.98
$1,542.04
$1,298.14
$1,379.74
$1,466.20
$1,773.26
$231.22
Toc - Plan #98 CHRISTUS Health Plan
Silver

(HMO) CHRISTUS Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 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
$396.95
$450.54
$507.31
$708.96
$1,077.33
$700.62
$754.21
$810.98
$1,012.63
$1,004.29
$1,057.88
$1,114.65
$1,316.30
$1,307.96
$1,361.55
$1,418.32
$1,619.97
$303.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793.90
$901.08
$1,014.62
$1,417.92
$2,154.66
$1,097.57
$1,204.75
$1,318.29
$1,721.59
$1,401.24
$1,508.42
$1,621.96
$2,025.26
$1,704.91
$1,812.09
$1,925.63
$2,328.93
$303.67
Toc - Plan #99 CHRISTUS Health Plan
Silver

(HMO) CHRISTUS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.54
$462.56
$520.83
$727.86
$1,106.06
$719.31
$774.33
$832.60
$1,039.63
$1,031.08
$1,086.10
$1,144.37
$1,351.40
$1,342.85
$1,397.87
$1,456.14
$1,663.17
$311.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$815.08
$925.12
$1,041.66
$1,455.72
$2,212.12
$1,126.85
$1,236.89
$1,353.43
$1,767.49
$1,438.62
$1,548.66
$1,665.20
$2,079.26
$1,750.39
$1,860.43
$1,976.97
$2,391.03
$311.77
Toc - Plan #100 CHRISTUS Health Plan
Gold

(HMO) CHRISTUS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

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
$351.02
$398.40
$448.60
$626.92
$952.66
$619.55
$666.93
$717.13
$895.45
$888.08
$935.46
$985.66
$1,163.98
$1,156.61
$1,203.99
$1,254.19
$1,432.51
$268.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.04
$796.80
$897.20
$1,253.84
$1,905.32
$970.57
$1,065.33
$1,165.73
$1,522.37
$1,239.10
$1,333.86
$1,434.26
$1,790.90
$1,507.63
$1,602.39
$1,702.79
$2,059.43
$268.53
Toc - Plan #101 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHRISTUS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-282-3025

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
$276.31
$313.61
$353.12
$493.49
$749.90
$487.69
$524.99
$564.50
$704.87
$699.07
$736.37
$775.88
$916.25
$910.45
$947.75
$987.26
$1,127.63
$211.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$552.62
$627.22
$706.24
$986.98
$1,499.80
$764.00
$838.60
$917.62
$1,198.36
$975.38
$1,049.98
$1,129.00
$1,409.74
$1,186.76
$1,261.36
$1,340.38
$1,621.12
$211.38

ADVERTISEMENT

Sendero Health Plans, Local Nonprofit

Local: 1-844-800-4693 | Toll Free: 1-844-800-4693 | TTY: 1-800-855-2880

Toc - Plan #102 Sendero Health Plans, Local Nonprofit
Silver

(HMO) Sendero Health Original Silver / $20 PCP / $10 Gen Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$4,250 $8,500 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
$425.03
$482.41
$543.19
$759.10
$1,153.53
$750.18
$807.56
$868.34
$1,084.25
$1,075.33
$1,132.71
$1,193.49
$1,409.40
$1,400.48
$1,457.86
$1,518.64
$1,734.55
$325.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$850.06
$964.82
$1,086.38
$1,518.20
$2,307.06
$1,175.21
$1,289.97
$1,411.53
$1,843.35
$1,500.36
$1,615.12
$1,736.68
$2,168.50
$1,825.51
$1,940.27
$2,061.83
$2,493.65
$325.15
Toc - Plan #103 Sendero Health Plans, Local Nonprofit
Gold

(HMO) Sendero Health Real Gold / $350 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$350 $700 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
$392.56
$445.55
$501.69
$701.10
$1,065.39
$692.86
$745.85
$801.99
$1,001.40
$993.16
$1,046.15
$1,102.29
$1,301.70
$1,293.46
$1,346.45
$1,402.59
$1,602.00
$300.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$785.12
$891.10
$1,003.38
$1,402.20
$2,130.78
$1,085.42
$1,191.40
$1,303.68
$1,702.50
$1,385.72
$1,491.70
$1,603.98
$2,002.80
$1,686.02
$1,792.00
$1,904.28
$2,303.10
$300.30
Toc - Plan #104 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero Health Ideal Bronze / $25 PCP / $11 Gen Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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
$283.97
$322.30
$362.91
$507.17
$770.69
$501.21
$539.54
$580.15
$724.41
$718.45
$756.78
$797.39
$941.65
$935.69
$974.02
$1,014.63
$1,158.89
$217.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$567.94
$644.60
$725.82
$1,014.34
$1,541.38
$785.18
$861.84
$943.06
$1,231.58
$1,002.42
$1,079.08
$1,160.30
$1,448.82
$1,219.66
$1,296.32
$1,377.54
$1,666.06
$217.24
Toc - Plan #105 Sendero Health Plans, Local Nonprofit
Bronze

(HMO) Sendero Health Reliable Bronze High Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$8,480 $16,960 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
$272.21
$308.95
$347.88
$486.16
$738.76
$480.45
$517.19
$556.12
$694.40
$688.69
$725.43
$764.36
$902.64
$896.93
$933.67
$972.60
$1,110.88
$208.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$544.42
$617.90
$695.76
$972.32
$1,477.52
$752.66
$826.14
$904.00
$1,180.56
$960.90
$1,034.38
$1,112.24
$1,388.80
$1,169.14
$1,242.62
$1,320.48
$1,597.04
$208.24
Toc - Plan #106 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero Health Preferred Bronze / $25 PCP / $75 Specialist / $22 Gen Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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
$291.20
$330.51
$372.15
$520.08
$790.31
$513.97
$553.28
$594.92
$742.85
$736.74
$776.05
$817.69
$965.62
$959.51
$998.82
$1,040.46
$1,188.39
$222.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.40
$661.02
$744.30
$1,040.16
$1,580.62
$805.17
$883.79
$967.07
$1,262.93
$1,027.94
$1,106.56
$1,189.84
$1,485.70
$1,250.71
$1,329.33
$1,412.61
$1,708.47
$222.77
Toc - Plan #107 Sendero Health Plans, Local Nonprofit
Silver

(HMO) Sendero Health Capital Silver / $40 PCP / $80 Specialist / $20 Gen Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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
$420.40
$477.15
$537.27
$750.83
$1,140.96
$742.00
$798.75
$858.87
$1,072.43
$1,063.60
$1,120.35
$1,180.47
$1,394.03
$1,385.20
$1,441.95
$1,502.07
$1,715.63
$321.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$840.80
$954.30
$1,074.54
$1,501.66
$2,281.92
$1,162.40
$1,275.90
$1,396.14
$1,823.26
$1,484.00
$1,597.50
$1,717.74
$2,144.86
$1,805.60
$1,919.10
$2,039.34
$2,466.46
$321.60
Toc - Plan #108 Sendero Health Plans, Local Nonprofit
Gold

(HMO) Sendero Health Hill Country Gold / $30 PCP / $60 Specialist / $15 Gen Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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
$390.88
$443.65
$499.54
$698.11
$1,060.84
$689.90
$742.67
$798.56
$997.13
$988.92
$1,041.69
$1,097.58
$1,296.15
$1,287.94
$1,340.71
$1,396.60
$1,595.17
$299.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.76
$887.30
$999.08
$1,396.22
$2,121.68
$1,080.78
$1,186.32
$1,298.10
$1,695.24
$1,379.80
$1,485.34
$1,597.12
$1,994.26
$1,678.82
$1,784.36
$1,896.14
$2,293.28
$299.02
Toc - Plan #109 Sendero Health Plans, Local Nonprofit
Expanded Bronze

(HMO) Sendero Health Quality Care Bronze High Deductible / $50 PCP / $25 Gen Rx / $100 Specialist

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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
$288.31
$327.24
$368.47
$514.93
$782.48
$508.87
$547.80
$589.03
$735.49
$729.43
$768.36
$809.59
$956.05
$949.99
$988.92
$1,030.15
$1,176.61
$220.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.62
$654.48
$736.94
$1,029.86
$1,564.96
$797.18
$875.04
$957.50
$1,250.42
$1,017.74
$1,095.60
$1,178.06
$1,470.98
$1,238.30
$1,316.16
$1,398.62
$1,691.54
$220.56
Toc - Plan #110 Sendero Health Plans, Local Nonprofit
Silver

(HMO) Sendero Health Pure Silver / $30 PCP / $70 Specialist / $20 Gen Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$436.42
$495.33
$557.74
$779.44
$1,184.43
$770.28
$829.19
$891.60
$1,113.30
$1,104.14
$1,163.05
$1,225.46
$1,447.16
$1,438.00
$1,496.91
$1,559.32
$1,781.02
$333.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$872.84
$990.66
$1,115.48
$1,558.88
$2,368.86
$1,206.70
$1,324.52
$1,449.34
$1,892.74
$1,540.56
$1,658.38
$1,783.20
$2,226.60
$1,874.42
$1,992.24
$2,117.06
$2,560.46
$333.86
Toc - Plan #111 Sendero Health Plans, Local Nonprofit
Silver

(HMO) Sendero Health Austin512 Silver / $40 PCP / $75 Specialist / $15 Gen Rx / $0 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-800-4693

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
$463.67
$526.27
$592.57
$828.12
$1,258.40
$818.38
$880.98
$947.28
$1,182.83
$1,173.09
$1,235.69
$1,301.99
$1,537.54
$1,527.80
$1,590.40
$1,656.70
$1,892.25
$354.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$927.34
$1,052.54
$1,185.14
$1,656.24
$2,516.80
$1,282.05
$1,407.25
$1,539.85
$2,010.95
$1,636.76
$1,761.96
$1,894.56
$2,365.66
$1,991.47
$2,116.67
$2,249.27
$2,720.37
$354.71

ADVERTISEMENT

Ambetter from Superior HealthPlan

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

Toc - Plan #112 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
$550.95
$625.32
$704.10
$983.98
$1,495.25
$972.42
$1,046.79
$1,125.57
$1,405.45
$1,393.89
$1,468.26
$1,547.04
$1,826.92
$1,815.36
$1,889.73
$1,968.51
$2,248.39
$421.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,101.90
$1,250.64
$1,408.20
$1,967.96
$2,990.50
$1,523.37
$1,672.11
$1,829.67
$2,389.43
$1,944.84
$2,093.58
$2,251.14
$2,810.90
$2,366.31
$2,515.05
$2,672.61
$3,232.37
$421.47
Toc - Plan #113 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
$508.12
$576.70
$649.36
$907.48
$1,379.01
$896.82
$965.40
$1,038.06
$1,296.18
$1,285.52
$1,354.10
$1,426.76
$1,684.88
$1,674.22
$1,742.80
$1,815.46
$2,073.58
$388.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,016.24
$1,153.40
$1,298.72
$1,814.96
$2,758.02
$1,404.94
$1,542.10
$1,687.42
$2,203.66
$1,793.64
$1,930.80
$2,076.12
$2,592.36
$2,182.34
$2,319.50
$2,464.82
$2,981.06
$388.70
Toc - Plan #114 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
$550.25
$624.52
$703.20
$982.72
$1,493.35
$971.18
$1,045.45
$1,124.13
$1,403.65
$1,392.11
$1,466.38
$1,545.06
$1,824.58
$1,813.04
$1,887.31
$1,965.99
$2,245.51
$420.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,100.50
$1,249.04
$1,406.40
$1,965.44
$2,986.70
$1,521.43
$1,669.97
$1,827.33
$2,386.37
$1,942.36
$2,090.90
$2,248.26
$2,807.30
$2,363.29
$2,511.83
$2,669.19
$3,228.23
$420.93
Toc - Plan #115 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
$497.89
$565.09
$636.29
$889.22
$1,351.25
$878.77
$945.97
$1,017.17
$1,270.10
$1,259.65
$1,326.85
$1,398.05
$1,650.98
$1,640.53
$1,707.73
$1,778.93
$2,031.86
$380.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$995.78
$1,130.18
$1,272.58
$1,778.44
$2,702.50
$1,376.66
$1,511.06
$1,653.46
$2,159.32
$1,757.54
$1,891.94
$2,034.34
$2,540.20
$2,138.42
$2,272.82
$2,415.22
$2,921.08
$380.88

‡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 Hays County here.

Hays County is in “Rating Area 3” of Texas.

Currently, there are 115 plans offered in Rating Area 3.

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2024 Obamacare Plans for Hays County, TX

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