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Obamacare

Obamacare 2023 Rates for Jefferson County

Obamacare > Rates > Texas > Jefferson County

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 Jefferson County, TX.

The health insurance rates listed below are for calendar year 2023.

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, 88 Plans and 2023 Rates for Jefferson County, Texas

Below, you’ll find a summary of the 88 plans for Jefferson County, Texas and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Community Health Choice

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

Toc - Plan #1 Community Health Choice
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 Annual Deductible
$9,100 $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
$296.39
$336.40
$378.79
$529.35
$804.40
$523.13
$563.14
$605.53
$756.09
$749.87
$789.88
$832.27
$982.83
$976.61
$1,016.62
$1,059.01
$1,209.57
$226.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$592.78
$672.80
$757.58
$1,058.70
$1,608.80
$819.52
$899.54
$984.32
$1,285.44
$1,046.26
$1,126.28
$1,211.06
$1,512.18
$1,273.00
$1,353.02
$1,437.80
$1,738.92
$226.74
Toc - Plan #2 Community Health Choice
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,300 $6,600 Annual Deductible
$9,100 $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
$435.97
$494.83
$557.17
$778.64
$1,183.22
$769.49
$828.35
$890.69
$1,112.16
$1,103.01
$1,161.87
$1,224.21
$1,445.68
$1,436.53
$1,495.39
$1,557.73
$1,779.20
$333.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871.94
$989.66
$1,114.34
$1,557.28
$2,366.44
$1,205.46
$1,323.18
$1,447.86
$1,890.80
$1,538.98
$1,656.70
$1,781.38
$2,224.32
$1,872.50
$1,990.22
$2,114.90
$2,557.84
$333.52
Toc - Plan #3 Community Health Choice
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 Annual Deductible
$9,100 $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
$373.32
$423.72
$477.10
$666.75
$1,013.19
$658.91
$709.31
$762.69
$952.34
$944.50
$994.90
$1,048.28
$1,237.93
$1,230.09
$1,280.49
$1,333.87
$1,523.52
$285.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.64
$847.44
$954.20
$1,333.50
$2,026.38
$1,032.23
$1,133.03
$1,239.79
$1,619.09
$1,317.82
$1,418.62
$1,525.38
$1,904.68
$1,603.41
$1,704.21
$1,810.97
$2,190.27
$285.59
Toc - Plan #4 Community Health Choice
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.07
$329.23
$370.71
$518.07
$787.26
$511.98
$551.14
$592.62
$739.98
$733.89
$773.05
$814.53
$961.89
$955.80
$994.96
$1,036.44
$1,183.80
$221.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.14
$658.46
$741.42
$1,036.14
$1,574.52
$802.05
$880.37
$963.33
$1,258.05
$1,023.96
$1,102.28
$1,185.24
$1,479.96
$1,245.87
$1,324.19
$1,407.15
$1,701.87
$221.91
Toc - Plan #5 Community Health Choice
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $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
$431.14
$489.34
$551.00
$770.01
$1,170.11
$760.96
$819.16
$880.82
$1,099.83
$1,090.78
$1,148.98
$1,210.64
$1,429.65
$1,420.60
$1,478.80
$1,540.46
$1,759.47
$329.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$862.28
$978.68
$1,102.00
$1,540.02
$2,340.22
$1,192.10
$1,308.50
$1,431.82
$1,869.84
$1,521.92
$1,638.32
$1,761.64
$2,199.66
$1,851.74
$1,968.14
$2,091.46
$2,529.48
$329.82
Toc - Plan #6 Community Health Choice
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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
$439.71
$499.07
$561.95
$785.32
$1,193.37
$776.09
$835.45
$898.33
$1,121.70
$1,112.47
$1,171.83
$1,234.71
$1,458.08
$1,448.85
$1,508.21
$1,571.09
$1,794.46
$336.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.42
$998.14
$1,123.90
$1,570.64
$2,386.74
$1,215.80
$1,334.52
$1,460.28
$1,907.02
$1,552.18
$1,670.90
$1,796.66
$2,243.40
$1,888.56
$2,007.28
$2,133.04
$2,579.78
$336.38
Toc - Plan #7 Community Health Choice
Bronze

(HMO) Community Premier Bronze 017 (No copay for Preventive Care, 24/7 Telehealth)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.45
$330.79
$372.47
$520.52
$790.99
$514.41
$553.75
$595.43
$743.48
$737.37
$776.71
$818.39
$966.44
$960.33
$999.67
$1,041.35
$1,189.40
$222.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.90
$661.58
$744.94
$1,041.04
$1,581.98
$805.86
$884.54
$967.90
$1,264.00
$1,028.82
$1,107.50
$1,190.86
$1,486.96
$1,251.78
$1,330.46
$1,413.82
$1,709.92
$222.96
Toc - Plan #8 Community Health Choice
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $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
$297.41
$337.56
$380.09
$531.18
$807.18
$524.93
$565.08
$607.61
$758.70
$752.45
$792.60
$835.13
$986.22
$979.97
$1,020.12
$1,062.65
$1,213.74
$227.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$594.82
$675.12
$760.18
$1,062.36
$1,614.36
$822.34
$902.64
$987.70
$1,289.88
$1,049.86
$1,130.16
$1,215.22
$1,517.40
$1,277.38
$1,357.68
$1,442.74
$1,744.92
$227.52
Toc - Plan #9 Community Health Choice
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 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
$426.56
$484.14
$545.14
$761.83
$1,157.68
$752.88
$810.46
$871.46
$1,088.15
$1,079.20
$1,136.78
$1,197.78
$1,414.47
$1,405.52
$1,463.10
$1,524.10
$1,740.79
$326.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.12
$968.28
$1,090.28
$1,523.66
$2,315.36
$1,179.44
$1,294.60
$1,416.60
$1,849.98
$1,505.76
$1,620.92
$1,742.92
$2,176.30
$1,832.08
$1,947.24
$2,069.24
$2,502.62
$326.32
Toc - Plan #10 Community Health Choice
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$373.84
$424.31
$477.76
$667.67
$1,014.60
$659.83
$710.30
$763.75
$953.66
$945.82
$996.29
$1,049.74
$1,239.65
$1,231.81
$1,282.28
$1,335.73
$1,525.64
$285.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.68
$848.62
$955.52
$1,335.34
$2,029.20
$1,033.67
$1,134.61
$1,241.51
$1,621.33
$1,319.66
$1,420.60
$1,527.50
$1,907.32
$1,605.65
$1,706.59
$1,813.49
$2,193.31
$285.99

ADVERTISEMENT

Ambetter from Superior HealthPlan

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

Toc - Plan #11 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
$393.30
$446.38
$502.62
$702.41
$1,067.39
$694.17
$747.25
$803.49
$1,003.28
$995.04
$1,048.12
$1,104.36
$1,304.15
$1,295.91
$1,348.99
$1,405.23
$1,605.02
$300.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.60
$892.76
$1,005.24
$1,404.82
$2,134.78
$1,087.47
$1,193.63
$1,306.11
$1,705.69
$1,388.34
$1,494.50
$1,606.98
$2,006.56
$1,689.21
$1,795.37
$1,907.85
$2,307.43
$300.87
Toc - Plan #12 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
$362.03
$410.90
$462.66
$646.57
$982.53
$638.98
$687.85
$739.61
$923.52
$915.93
$964.80
$1,016.56
$1,200.47
$1,192.88
$1,241.75
$1,293.51
$1,477.42
$276.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.06
$821.80
$925.32
$1,293.14
$1,965.06
$1,001.01
$1,098.75
$1,202.27
$1,570.09
$1,277.96
$1,375.70
$1,479.22
$1,847.04
$1,554.91
$1,652.65
$1,756.17
$2,123.99
$276.95
Toc - Plan #13 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
$389.37
$441.92
$497.60
$695.39
$1,056.71
$687.23
$739.78
$795.46
$993.25
$985.09
$1,037.64
$1,093.32
$1,291.11
$1,282.95
$1,335.50
$1,391.18
$1,588.97
$297.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.74
$883.84
$995.20
$1,390.78
$2,113.42
$1,076.60
$1,181.70
$1,293.06
$1,688.64
$1,374.46
$1,479.56
$1,590.92
$1,986.50
$1,672.32
$1,777.42
$1,888.78
$2,284.36
$297.86
Toc - Plan #14 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
$6,100 $12,200 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
$387.91
$440.27
$495.74
$692.79
$1,052.76
$684.65
$737.01
$792.48
$989.53
$981.39
$1,033.75
$1,089.22
$1,286.27
$1,278.13
$1,330.49
$1,385.96
$1,583.01
$296.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.82
$880.54
$991.48
$1,385.58
$2,105.52
$1,072.56
$1,177.28
$1,288.22
$1,682.32
$1,369.30
$1,474.02
$1,584.96
$1,979.06
$1,666.04
$1,770.76
$1,881.70
$2,275.80
$296.74
Toc - Plan #15 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
$352.32
$399.87
$450.25
$629.22
$956.17
$621.84
$669.39
$719.77
$898.74
$891.36
$938.91
$989.29
$1,168.26
$1,160.88
$1,208.43
$1,258.81
$1,437.78
$269.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704.64
$799.74
$900.50
$1,258.44
$1,912.34
$974.16
$1,069.26
$1,170.02
$1,527.96
$1,243.68
$1,338.78
$1,439.54
$1,797.48
$1,513.20
$1,608.30
$1,709.06
$2,067.00
$269.52
Toc - Plan #16 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
$350.19
$397.46
$447.54
$625.43
$950.40
$618.08
$665.35
$715.43
$893.32
$885.97
$933.24
$983.32
$1,161.21
$1,153.86
$1,201.13
$1,251.21
$1,429.10
$267.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700.38
$794.92
$895.08
$1,250.86
$1,900.80
$968.27
$1,062.81
$1,162.97
$1,518.75
$1,236.16
$1,330.70
$1,430.86
$1,786.64
$1,504.05
$1,598.59
$1,698.75
$2,054.53
$267.89
Toc - Plan #17 Ambetter from Superior HealthPlan
Silver

(EPO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 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
$387.64
$439.96
$495.39
$692.30
$1,052.02
$684.17
$736.49
$791.92
$988.83
$980.70
$1,033.02
$1,088.45
$1,285.36
$1,277.23
$1,329.55
$1,384.98
$1,581.89
$296.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.28
$879.92
$990.78
$1,384.60
$2,104.04
$1,071.81
$1,176.45
$1,287.31
$1,681.13
$1,368.34
$1,472.98
$1,583.84
$1,977.66
$1,664.87
$1,769.51
$1,880.37
$2,274.19
$296.53
Toc - Plan #18 Ambetter from Superior HealthPlan
Gold

(EPO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$349.53
$396.70
$446.68
$624.24
$948.59
$616.91
$664.08
$714.06
$891.62
$884.29
$931.46
$981.44
$1,159.00
$1,151.67
$1,198.84
$1,248.82
$1,426.38
$267.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$699.06
$793.40
$893.36
$1,248.48
$1,897.18
$966.44
$1,060.78
$1,160.74
$1,515.86
$1,233.82
$1,328.16
$1,428.12
$1,783.24
$1,501.20
$1,595.54
$1,695.50
$2,050.62
$267.38
Toc - Plan #19 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
$377.09
$427.99
$481.91
$673.47
$1,023.40
$665.56
$716.46
$770.38
$961.94
$954.03
$1,004.93
$1,058.85
$1,250.41
$1,242.50
$1,293.40
$1,347.32
$1,538.88
$288.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$754.18
$855.98
$963.82
$1,346.94
$2,046.80
$1,042.65
$1,144.45
$1,252.29
$1,635.41
$1,331.12
$1,432.92
$1,540.76
$1,923.88
$1,619.59
$1,721.39
$1,829.23
$2,212.35
$288.47
Toc - Plan #20 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
$409.66
$464.95
$523.53
$731.63
$1,111.78
$723.04
$778.33
$836.91
$1,045.01
$1,036.42
$1,091.71
$1,150.29
$1,358.39
$1,349.80
$1,405.09
$1,463.67
$1,671.77
$313.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$819.32
$929.90
$1,047.06
$1,463.26
$2,223.56
$1,132.70
$1,243.28
$1,360.44
$1,776.64
$1,446.08
$1,556.66
$1,673.82
$2,090.02
$1,759.46
$1,870.04
$1,987.20
$2,403.40
$313.38
Toc - Plan #21 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
$6,100 $12,200 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
$404.05
$458.58
$516.36
$721.61
$1,096.55
$713.14
$767.67
$825.45
$1,030.70
$1,022.23
$1,076.76
$1,134.54
$1,339.79
$1,331.32
$1,385.85
$1,443.63
$1,648.88
$309.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.10
$917.16
$1,032.72
$1,443.22
$2,193.10
$1,117.19
$1,226.25
$1,341.81
$1,752.31
$1,426.28
$1,535.34
$1,650.90
$2,061.40
$1,735.37
$1,844.43
$1,959.99
$2,370.49
$309.09
Toc - Plan #22 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
$366.97
$416.50
$468.98
$655.39
$995.94
$647.70
$697.23
$749.71
$936.12
$928.43
$977.96
$1,030.44
$1,216.85
$1,209.16
$1,258.69
$1,311.17
$1,497.58
$280.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.94
$833.00
$937.96
$1,310.78
$1,991.88
$1,014.67
$1,113.73
$1,218.69
$1,591.51
$1,295.40
$1,394.46
$1,499.42
$1,872.24
$1,576.13
$1,675.19
$1,780.15
$2,152.97
$280.73
Toc - Plan #23 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
$405.56
$460.30
$518.29
$724.31
$1,100.67
$715.81
$770.55
$828.54
$1,034.56
$1,026.06
$1,080.80
$1,138.79
$1,344.81
$1,336.31
$1,391.05
$1,449.04
$1,655.06
$310.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.12
$920.60
$1,036.58
$1,448.62
$2,201.34
$1,121.37
$1,230.85
$1,346.83
$1,758.87
$1,431.62
$1,541.10
$1,657.08
$2,069.12
$1,741.87
$1,851.35
$1,967.33
$2,379.37
$310.25
Toc - Plan #24 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
$364.76
$413.99
$466.15
$651.44
$989.93
$643.79
$693.02
$745.18
$930.47
$922.82
$972.05
$1,024.21
$1,209.50
$1,201.85
$1,251.08
$1,303.24
$1,488.53
$279.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.52
$827.98
$932.30
$1,302.88
$1,979.86
$1,008.55
$1,107.01
$1,211.33
$1,581.91
$1,287.58
$1,386.04
$1,490.36
$1,860.94
$1,566.61
$1,665.07
$1,769.39
$2,139.97
$279.03

ADVERTISEMENT

Blue Cross and Blue Shield of Texas

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

Toc - Plan #25 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 $2,250 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
$346.74
$393.55
$443.14
$619.28
$941.06
$612.00
$658.81
$708.40
$884.54
$877.26
$924.07
$973.66
$1,149.80
$1,142.52
$1,189.33
$1,238.92
$1,415.06
$265.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.48
$787.10
$886.28
$1,238.56
$1,882.12
$958.74
$1,052.36
$1,151.54
$1,503.82
$1,224.00
$1,317.62
$1,416.80
$1,769.08
$1,489.26
$1,582.88
$1,682.06
$2,034.34
$265.26
Toc - Plan #26 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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$253.95
$288.23
$324.54
$453.55
$689.21
$448.22
$482.50
$518.81
$647.82
$642.49
$676.77
$713.08
$842.09
$836.76
$871.04
$907.35
$1,036.36
$194.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$507.90
$576.46
$649.08
$907.10
$1,378.42
$702.17
$770.73
$843.35
$1,101.37
$896.44
$965.00
$1,037.62
$1,295.64
$1,090.71
$1,159.27
$1,231.89
$1,489.91
$194.27
Toc - Plan #27 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
$2,050 $6,150 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
$417.03
$473.33
$532.96
$744.81
$1,131.81
$736.06
$792.36
$851.99
$1,063.84
$1,055.09
$1,111.39
$1,171.02
$1,382.87
$1,374.12
$1,430.42
$1,490.05
$1,701.90
$319.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.06
$946.66
$1,065.92
$1,489.62
$2,263.62
$1,153.09
$1,265.69
$1,384.95
$1,808.65
$1,472.12
$1,584.72
$1,703.98
$2,127.68
$1,791.15
$1,903.75
$2,023.01
$2,446.71
$319.03
Toc - Plan #28 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 $17,400 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
$283.76
$322.07
$362.64
$506.79
$770.12
$500.84
$539.15
$579.72
$723.87
$717.92
$756.23
$796.80
$940.95
$935.00
$973.31
$1,013.88
$1,158.03
$217.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$567.52
$644.14
$725.28
$1,013.58
$1,540.24
$784.60
$861.22
$942.36
$1,230.66
$1,001.68
$1,078.30
$1,159.44
$1,447.74
$1,218.76
$1,295.38
$1,376.52
$1,664.82
$217.08
Toc - Plan #29 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
$7,000 $14,000 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
$295.11
$334.96
$377.16
$527.08
$800.94
$520.87
$560.72
$602.92
$752.84
$746.63
$786.48
$828.68
$978.60
$972.39
$1,012.24
$1,054.44
$1,204.36
$225.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$590.22
$669.92
$754.32
$1,054.16
$1,601.88
$815.98
$895.68
$980.08
$1,279.92
$1,041.74
$1,121.44
$1,205.84
$1,505.68
$1,267.50
$1,347.20
$1,431.60
$1,731.44
$225.76
Toc - Plan #30 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
$8,700 $17,400 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
$282.29
$320.40
$360.76
$504.17
$766.13
$498.24
$536.35
$576.71
$720.12
$714.19
$752.30
$792.66
$936.07
$930.14
$968.25
$1,008.61
$1,152.02
$215.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$564.58
$640.80
$721.52
$1,008.34
$1,532.26
$780.53
$856.75
$937.47
$1,224.29
$996.48
$1,072.70
$1,153.42
$1,440.24
$1,212.43
$1,288.65
$1,369.37
$1,656.19
$215.95
Toc - Plan #31 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 $4,500 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
$356.93
$405.11
$456.15
$637.47
$968.70
$629.98
$678.16
$729.20
$910.52
$903.03
$951.21
$1,002.25
$1,183.57
$1,176.08
$1,224.26
$1,275.30
$1,456.62
$273.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.86
$810.22
$912.30
$1,274.94
$1,937.40
$986.91
$1,083.27
$1,185.35
$1,547.99
$1,259.96
$1,356.32
$1,458.40
$1,821.04
$1,533.01
$1,629.37
$1,731.45
$2,094.09
$273.05
Toc - Plan #32 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 702

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$295.52
$335.41
$377.67
$527.79
$802.03
$521.59
$561.48
$603.74
$753.86
$747.66
$787.55
$829.81
$979.93
$973.73
$1,013.62
$1,055.88
$1,206.00
$226.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$591.04
$670.82
$755.34
$1,055.58
$1,604.06
$817.11
$896.89
$981.41
$1,281.65
$1,043.18
$1,122.96
$1,207.48
$1,507.72
$1,269.25
$1,349.03
$1,433.55
$1,733.79
$226.07
Toc - Plan #33 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
$2,000 $4,000 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
$351.45
$398.90
$449.16
$627.69
$953.84
$620.31
$667.76
$718.02
$896.55
$889.17
$936.62
$986.88
$1,165.41
$1,158.03
$1,205.48
$1,255.74
$1,434.27
$268.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.90
$797.80
$898.32
$1,255.38
$1,907.68
$971.76
$1,066.66
$1,167.18
$1,524.24
$1,240.62
$1,335.52
$1,436.04
$1,793.10
$1,509.48
$1,604.38
$1,704.90
$2,061.96
$268.86
Toc - Plan #34 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
$5,800 $11,600 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
$419.12
$475.70
$535.63
$748.55
$1,137.49
$739.75
$796.33
$856.26
$1,069.18
$1,060.38
$1,116.96
$1,176.89
$1,389.81
$1,381.01
$1,437.59
$1,497.52
$1,710.44
$320.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$838.24
$951.40
$1,071.26
$1,497.10
$2,274.98
$1,158.87
$1,272.03
$1,391.89
$1,817.73
$1,479.50
$1,592.66
$1,712.52
$2,138.36
$1,800.13
$1,913.29
$2,033.15
$2,458.99
$320.63
Toc - Plan #35 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO? 704

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$276.10
$313.38
$352.86
$493.12
$749.34
$487.32
$524.60
$564.08
$704.34
$698.54
$735.82
$775.30
$915.56
$909.76
$947.04
$986.52
$1,126.78
$211.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$552.20
$626.76
$705.72
$986.24
$1,498.68
$763.42
$837.98
$916.94
$1,197.46
$974.64
$1,049.20
$1,128.16
$1,408.68
$1,185.86
$1,260.42
$1,339.38
$1,619.90
$211.22
Toc - Plan #36 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
$9,000 $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
$294.54
$334.30
$376.42
$526.05
$799.38
$519.86
$559.62
$601.74
$751.37
$745.18
$784.94
$827.06
$976.69
$970.50
$1,010.26
$1,052.38
$1,202.01
$225.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$589.08
$668.60
$752.84
$1,052.10
$1,598.76
$814.40
$893.92
$978.16
$1,277.42
$1,039.72
$1,119.24
$1,203.48
$1,502.74
$1,265.04
$1,344.56
$1,428.80
$1,728.06
$225.32
Toc - Plan #37 Blue Cross and Blue Shield of Texas
Gold

(HMO) 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 $2,550 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
$393.36
$446.47
$502.72
$702.55
$1,067.59
$694.28
$747.39
$803.64
$1,003.47
$995.20
$1,048.31
$1,104.56
$1,304.39
$1,296.12
$1,349.23
$1,405.48
$1,605.31
$300.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.72
$892.94
$1,005.44
$1,405.10
$2,135.18
$1,087.64
$1,193.86
$1,306.36
$1,706.02
$1,388.56
$1,494.78
$1,607.28
$2,006.94
$1,689.48
$1,795.70
$1,908.20
$2,307.86
$300.92
Toc - Plan #38 Blue Cross and Blue Shield of Texas
Silver

(HMO) 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 $4,250 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$470.63
$534.16
$601.46
$840.54
$1,277.28
$830.66
$894.19
$961.49
$1,200.57
$1,190.69
$1,254.22
$1,321.52
$1,560.60
$1,550.72
$1,614.25
$1,681.55
$1,920.63
$360.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$941.26
$1,068.32
$1,202.92
$1,681.08
$2,554.56
$1,301.29
$1,428.35
$1,562.95
$2,041.11
$1,661.32
$1,788.38
$1,922.98
$2,401.14
$2,021.35
$2,148.41
$2,283.01
$2,761.17
$360.03
Toc - Plan #39 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) 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 $16,500 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
$322.66
$366.22
$412.36
$576.28
$875.71
$569.50
$613.06
$659.20
$823.12
$816.34
$859.90
$906.04
$1,069.96
$1,063.18
$1,106.74
$1,152.88
$1,316.80
$246.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$645.32
$732.44
$824.72
$1,152.56
$1,751.42
$892.16
$979.28
$1,071.56
$1,399.40
$1,139.00
$1,226.12
$1,318.40
$1,646.24
$1,385.84
$1,472.96
$1,565.24
$1,893.08
$246.84
Toc - Plan #40 Blue Cross and Blue Shield of Texas
Bronze

(HMO) 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 $17,400 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
$307.66
$349.19
$393.19
$549.48
$834.99
$543.02
$584.55
$628.55
$784.84
$778.38
$819.91
$863.91
$1,020.20
$1,013.74
$1,055.27
$1,099.27
$1,255.56
$235.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$615.32
$698.38
$786.38
$1,098.96
$1,669.98
$850.68
$933.74
$1,021.74
$1,334.32
$1,086.04
$1,169.10
$1,257.10
$1,569.68
$1,321.40
$1,404.46
$1,492.46
$1,805.04
$235.36
Toc - Plan #41 Blue Cross and Blue Shield of Texas
Silver

(HMO) 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
$9,100 $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
$475.11
$539.24
$607.19
$848.54
$1,289.44
$838.57
$902.70
$970.65
$1,212.00
$1,202.03
$1,266.16
$1,334.11
$1,575.46
$1,565.49
$1,629.62
$1,697.57
$1,938.92
$363.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$950.22
$1,078.48
$1,214.38
$1,697.08
$2,578.88
$1,313.68
$1,441.94
$1,577.84
$2,060.54
$1,677.14
$1,805.40
$1,941.30
$2,424.00
$2,040.60
$2,168.86
$2,304.76
$2,787.46
$363.46
Toc - Plan #42 Blue Cross and Blue Shield of Texas
Gold

(HMO) 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
$2,000 $4,000 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
$391.84
$444.74
$500.77
$699.83
$1,063.46
$691.60
$744.50
$800.53
$999.59
$991.36
$1,044.26
$1,100.29
$1,299.35
$1,291.12
$1,344.02
$1,400.05
$1,599.11
$299.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.68
$889.48
$1,001.54
$1,399.66
$2,126.92
$1,083.44
$1,189.24
$1,301.30
$1,699.42
$1,383.20
$1,489.00
$1,601.06
$1,999.18
$1,682.96
$1,788.76
$1,900.82
$2,298.94
$299.76
Toc - Plan #43 Blue Cross and Blue Shield of Texas
Silver

(HMO) 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
$5,800 $11,600 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
$467.79
$530.95
$597.84
$835.48
$1,269.59
$825.65
$888.81
$955.70
$1,193.34
$1,183.51
$1,246.67
$1,313.56
$1,551.20
$1,541.37
$1,604.53
$1,671.42
$1,909.06
$357.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$935.58
$1,061.90
$1,195.68
$1,670.96
$2,539.18
$1,293.44
$1,419.76
$1,553.54
$2,028.82
$1,651.30
$1,777.62
$1,911.40
$2,386.68
$2,009.16
$2,135.48
$2,269.26
$2,744.54
$357.86
Toc - Plan #44 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Plus Bronze? 704

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$308.93
$350.63
$394.81
$551.75
$838.43
$545.26
$586.96
$631.14
$788.08
$781.59
$823.29
$867.47
$1,024.41
$1,017.92
$1,059.62
$1,103.80
$1,260.74
$236.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$617.86
$701.26
$789.62
$1,103.50
$1,676.86
$854.19
$937.59
$1,025.95
$1,339.83
$1,090.52
$1,173.92
$1,262.28
$1,576.16
$1,326.85
$1,410.25
$1,498.61
$1,812.49
$236.33
Toc - Plan #45 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) 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
$9,000 $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
$328.82
$373.21
$420.23
$587.27
$892.41
$580.37
$624.76
$671.78
$838.82
$831.92
$876.31
$923.33
$1,090.37
$1,083.47
$1,127.86
$1,174.88
$1,341.92
$251.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$657.64
$746.42
$840.46
$1,174.54
$1,784.82
$909.19
$997.97
$1,092.01
$1,426.09
$1,160.74
$1,249.52
$1,343.56
$1,677.64
$1,412.29
$1,501.07
$1,595.11
$1,929.19
$251.55

ADVERTISEMENT

UnitedHealthcare

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

Toc - Plan #46 UnitedHealthcare
Gold

(HMO) UHC Gold Value $1,900 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.11
$426.89
$480.67
$671.74
$1,020.77
$663.84
$714.62
$768.40
$959.47
$951.57
$1,002.35
$1,056.13
$1,247.20
$1,239.30
$1,290.08
$1,343.86
$1,534.93
$287.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.22
$853.78
$961.34
$1,343.48
$2,041.54
$1,039.95
$1,141.51
$1,249.07
$1,631.21
$1,327.68
$1,429.24
$1,536.80
$1,918.94
$1,615.41
$1,716.97
$1,824.53
$2,206.67
$287.73
Toc - Plan #47 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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
$427.14
$484.80
$545.88
$762.87
$1,159.25
$753.90
$811.56
$872.64
$1,089.63
$1,080.66
$1,138.32
$1,199.40
$1,416.39
$1,407.42
$1,465.08
$1,526.16
$1,743.15
$326.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$854.28
$969.60
$1,091.76
$1,525.74
$2,318.50
$1,181.04
$1,296.36
$1,418.52
$1,852.50
$1,507.80
$1,623.12
$1,745.28
$2,179.26
$1,834.56
$1,949.88
$2,072.04
$2,506.02
$326.76
Toc - Plan #48 UnitedHealthcare
Silver

(HMO) UHC Silver Value HSA

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

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
$432.75
$491.17
$553.05
$772.89
$1,174.48
$763.80
$822.22
$884.10
$1,103.94
$1,094.85
$1,153.27
$1,215.15
$1,434.99
$1,425.90
$1,484.32
$1,546.20
$1,766.04
$331.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$865.50
$982.34
$1,106.10
$1,545.78
$2,348.96
$1,196.55
$1,313.39
$1,437.15
$1,876.83
$1,527.60
$1,644.44
$1,768.20
$2,207.88
$1,858.65
$1,975.49
$2,099.25
$2,538.93
$331.05
Toc - Plan #49 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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
$415.28
$471.35
$530.73
$741.70
$1,127.08
$732.97
$789.04
$848.42
$1,059.39
$1,050.66
$1,106.73
$1,166.11
$1,377.08
$1,368.35
$1,424.42
$1,483.80
$1,694.77
$317.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$830.56
$942.70
$1,061.46
$1,483.40
$2,254.16
$1,148.25
$1,260.39
$1,379.15
$1,801.09
$1,465.94
$1,578.08
$1,696.84
$2,118.78
$1,783.63
$1,895.77
$2,014.53
$2,436.47
$317.69
Toc - Plan #50 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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
$305.12
$346.31
$389.94
$544.94
$828.09
$538.53
$579.72
$623.35
$778.35
$771.94
$813.13
$856.76
$1,011.76
$1,005.35
$1,046.54
$1,090.17
$1,245.17
$233.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610.24
$692.62
$779.88
$1,089.88
$1,656.18
$843.65
$926.03
$1,013.29
$1,323.29
$1,077.06
$1,159.44
$1,246.70
$1,556.70
$1,310.47
$1,392.85
$1,480.11
$1,790.11
$233.41
Toc - Plan #51 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

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
$9,100 $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
$297.98
$338.21
$380.82
$532.19
$808.72
$525.94
$566.17
$608.78
$760.15
$753.90
$794.13
$836.74
$988.11
$981.86
$1,022.09
$1,064.70
$1,216.07
$227.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.96
$676.42
$761.64
$1,064.38
$1,617.44
$823.92
$904.38
$989.60
$1,292.34
$1,051.88
$1,132.34
$1,217.56
$1,520.30
$1,279.84
$1,360.30
$1,445.52
$1,748.26
$227.96
Toc - Plan #52 UnitedHealthcare
Gold

(HMO) UHC Gold Standard $0 Deductible ($3 T1 Preferred Rx)

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
$379.68
$430.94
$485.23
$678.11
$1,030.45
$670.13
$721.39
$775.68
$968.56
$960.58
$1,011.84
$1,066.13
$1,259.01
$1,251.03
$1,302.29
$1,356.58
$1,549.46
$290.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$759.36
$861.88
$970.46
$1,356.22
$2,060.90
$1,049.81
$1,152.33
$1,260.91
$1,646.67
$1,340.26
$1,442.78
$1,551.36
$1,937.12
$1,630.71
$1,733.23
$1,841.81
$2,227.57
$290.45
Toc - Plan #53 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$297.42
$337.57
$380.10
$531.19
$807.20
$524.95
$565.10
$607.63
$758.72
$752.48
$792.63
$835.16
$986.25
$980.01
$1,020.16
$1,062.69
$1,213.78
$227.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$594.84
$675.14
$760.20
$1,062.38
$1,614.40
$822.37
$902.67
$987.73
$1,289.91
$1,049.90
$1,130.20
$1,215.26
$1,517.44
$1,277.43
$1,357.73
$1,442.79
$1,744.97
$227.53
Toc - Plan #54 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

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
$9,000 $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
$304.86
$346.02
$389.61
$544.48
$827.39
$538.08
$579.24
$622.83
$777.70
$771.30
$812.46
$856.05
$1,010.92
$1,004.52
$1,045.68
$1,089.27
$1,244.14
$233.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$609.72
$692.04
$779.22
$1,088.96
$1,654.78
$842.94
$925.26
$1,012.44
$1,322.18
$1,076.16
$1,158.48
$1,245.66
$1,555.40
$1,309.38
$1,391.70
$1,478.88
$1,788.62
$233.22
Toc - Plan #55 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.62
$327.59
$368.86
$515.48
$783.32
$509.42
$548.39
$589.66
$736.28
$730.22
$769.19
$810.46
$957.08
$951.02
$989.99
$1,031.26
$1,177.88
$220.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$577.24
$655.18
$737.72
$1,030.96
$1,566.64
$798.04
$875.98
$958.52
$1,251.76
$1,018.84
$1,096.78
$1,179.32
$1,472.56
$1,239.64
$1,317.58
$1,400.12
$1,693.36
$220.80
Toc - Plan #56 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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
$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
$426.33
$483.89
$544.85
$761.43
$1,157.06
$752.47
$810.03
$870.99
$1,087.57
$1,078.61
$1,136.17
$1,197.13
$1,413.71
$1,404.75
$1,462.31
$1,523.27
$1,739.85
$326.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.66
$967.78
$1,089.70
$1,522.86
$2,314.12
$1,178.80
$1,293.92
$1,415.84
$1,849.00
$1,504.94
$1,620.06
$1,741.98
$2,175.14
$1,831.08
$1,946.20
$2,068.12
$2,501.28
$326.14
Toc - Plan #57 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, Dental + Vision)

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
$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
$445.06
$505.14
$568.79
$794.88
$1,207.90
$785.53
$845.61
$909.26
$1,135.35
$1,126.00
$1,186.08
$1,249.73
$1,475.82
$1,466.47
$1,526.55
$1,590.20
$1,816.29
$340.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$890.12
$1,010.28
$1,137.58
$1,589.76
$2,415.80
$1,230.59
$1,350.75
$1,478.05
$1,930.23
$1,571.06
$1,691.22
$1,818.52
$2,270.70
$1,911.53
$2,031.69
$2,158.99
$2,611.17
$340.47
Toc - Plan #58 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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
$444.18
$504.14
$567.66
$793.31
$1,205.50
$783.98
$843.94
$907.46
$1,133.11
$1,123.78
$1,183.74
$1,247.26
$1,472.91
$1,463.58
$1,523.54
$1,587.06
$1,812.71
$339.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.36
$1,008.28
$1,135.32
$1,586.62
$2,411.00
$1,228.16
$1,348.08
$1,475.12
$1,926.42
$1,567.96
$1,687.88
$1,814.92
$2,266.22
$1,907.76
$2,027.68
$2,154.72
$2,606.02
$339.80
Toc - Plan #59 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
$5,800 $11,600 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
$427.54
$485.25
$546.39
$763.58
$1,160.33
$754.60
$812.31
$873.45
$1,090.64
$1,081.66
$1,139.37
$1,200.51
$1,417.70
$1,408.72
$1,466.43
$1,527.57
$1,744.76
$327.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$855.08
$970.50
$1,092.78
$1,527.16
$2,320.66
$1,182.14
$1,297.56
$1,419.84
$1,854.22
$1,509.20
$1,624.62
$1,746.90
$2,181.28
$1,836.26
$1,951.68
$2,073.96
$2,508.34
$327.06
Toc - Plan #60 UnitedHealthcare
Gold

(HMO) UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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
$375.58
$426.29
$480.00
$670.79
$1,019.34
$662.90
$713.61
$767.32
$958.11
$950.22
$1,000.93
$1,054.64
$1,245.43
$1,237.54
$1,288.25
$1,341.96
$1,532.75
$287.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$751.16
$852.58
$960.00
$1,341.58
$2,038.68
$1,038.48
$1,139.90
$1,247.32
$1,628.90
$1,325.80
$1,427.22
$1,534.64
$1,916.22
$1,613.12
$1,714.54
$1,821.96
$2,203.54
$287.32
Toc - Plan #61 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.17
$425.82
$479.47
$670.06
$1,018.22
$662.18
$712.83
$766.48
$957.07
$949.19
$999.84
$1,053.49
$1,244.08
$1,236.20
$1,286.85
$1,340.50
$1,531.09
$287.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.34
$851.64
$958.94
$1,340.12
$2,036.44
$1,037.35
$1,138.65
$1,245.95
$1,627.13
$1,324.36
$1,425.66
$1,532.96
$1,914.14
$1,611.37
$1,712.67
$1,819.97
$2,201.15
$287.01
Toc - Plan #62 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, Dental + Vision)

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
$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
$393.90
$447.08
$503.41
$703.51
$1,069.05
$695.24
$748.42
$804.75
$1,004.85
$996.58
$1,049.76
$1,106.09
$1,306.19
$1,297.92
$1,351.10
$1,407.43
$1,607.53
$301.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.80
$894.16
$1,006.82
$1,407.02
$2,138.10
$1,089.14
$1,195.50
$1,308.16
$1,708.36
$1,390.48
$1,496.84
$1,609.50
$2,009.70
$1,691.82
$1,798.18
$1,910.84
$2,311.04
$301.34
Toc - Plan #63 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
$2,000 $4,000 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
$385.33
$437.35
$492.45
$688.20
$1,045.78
$680.11
$732.13
$787.23
$982.98
$974.89
$1,026.91
$1,082.01
$1,277.76
$1,269.67
$1,321.69
$1,376.79
$1,572.54
$294.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.66
$874.70
$984.90
$1,376.40
$2,091.56
$1,065.44
$1,169.48
$1,279.68
$1,671.18
$1,360.22
$1,464.26
$1,574.46
$1,965.96
$1,655.00
$1,759.04
$1,869.24
$2,260.74
$294.78

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #64 Molina Healthcare
Silver

(HMO) Molina Silver 3 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

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
$448.67
$509.23
$573.39
$801.32
$1,217.68
$791.90
$852.46
$916.62
$1,144.55
$1,135.13
$1,195.69
$1,259.85
$1,487.78
$1,478.36
$1,538.92
$1,603.08
$1,831.01
$343.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$897.34
$1,018.46
$1,146.78
$1,602.64
$2,435.36
$1,240.57
$1,361.69
$1,490.01
$1,945.87
$1,583.80
$1,704.92
$1,833.24
$2,289.10
$1,927.03
$2,048.15
$2,176.47
$2,632.33
$343.23
Toc - Plan #65 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 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
$385.72
$437.79
$492.95
$688.90
$1,046.85
$680.80
$732.87
$788.03
$983.98
$975.88
$1,027.95
$1,083.11
$1,279.06
$1,270.96
$1,323.03
$1,378.19
$1,574.14
$295.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.44
$875.58
$985.90
$1,377.80
$2,093.70
$1,066.52
$1,170.66
$1,280.98
$1,672.88
$1,361.60
$1,465.74
$1,576.06
$1,967.96
$1,656.68
$1,760.82
$1,871.14
$2,263.04
$295.08
Toc - Plan #66 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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
$445.29
$505.40
$569.07
$795.28
$1,208.50
$785.93
$846.04
$909.71
$1,135.92
$1,126.57
$1,186.68
$1,250.35
$1,476.56
$1,467.21
$1,527.32
$1,590.99
$1,817.20
$340.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$890.58
$1,010.80
$1,138.14
$1,590.56
$2,417.00
$1,231.22
$1,351.44
$1,478.78
$1,931.20
$1,571.86
$1,692.08
$1,819.42
$2,271.84
$1,912.50
$2,032.72
$2,160.06
$2,612.48
$340.64
Toc - Plan #67 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$385.68
$437.74
$492.90
$688.82
$1,046.73
$680.72
$732.78
$787.94
$983.86
$975.76
$1,027.82
$1,082.98
$1,278.90
$1,270.80
$1,322.86
$1,378.02
$1,573.94
$295.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.36
$875.48
$985.80
$1,377.64
$2,093.46
$1,066.40
$1,170.52
$1,280.84
$1,672.68
$1,361.44
$1,465.56
$1,575.88
$1,967.72
$1,656.48
$1,760.60
$1,870.92
$2,262.76
$295.04
Toc - Plan #68 Molina Healthcare
Silver

(HMO) Constant Care Silver 8 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 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
$438.19
$497.35
$560.01
$782.61
$1,189.25
$773.41
$832.57
$895.23
$1,117.83
$1,108.63
$1,167.79
$1,230.45
$1,453.05
$1,443.85
$1,503.01
$1,565.67
$1,788.27
$335.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$876.38
$994.70
$1,120.02
$1,565.22
$2,378.50
$1,211.60
$1,329.92
$1,455.24
$1,900.44
$1,546.82
$1,665.14
$1,790.46
$2,235.66
$1,882.04
$2,000.36
$2,125.68
$2,570.88
$335.22
Toc - Plan #69 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 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
$389.90
$442.54
$498.29
$696.36
$1,058.19
$688.17
$740.81
$796.56
$994.63
$986.44
$1,039.08
$1,094.83
$1,292.90
$1,284.71
$1,337.35
$1,393.10
$1,591.17
$298.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$779.80
$885.08
$996.58
$1,392.72
$2,116.38
$1,078.07
$1,183.35
$1,294.85
$1,690.99
$1,376.34
$1,481.62
$1,593.12
$1,989.26
$1,674.61
$1,779.89
$1,891.39
$2,287.53
$298.27
Toc - Plan #70 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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
$450.84
$511.71
$576.18
$805.21
$1,223.59
$795.74
$856.61
$921.08
$1,150.11
$1,140.64
$1,201.51
$1,265.98
$1,495.01
$1,485.54
$1,546.41
$1,610.88
$1,839.91
$344.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$901.68
$1,023.42
$1,152.36
$1,610.42
$2,447.18
$1,246.58
$1,368.32
$1,497.26
$1,955.32
$1,591.48
$1,713.22
$1,842.16
$2,300.22
$1,936.38
$2,058.12
$2,187.06
$2,645.12
$344.90

ADVERTISEMENT

CHRISTUS Health Plan

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

Toc - Plan #71 CHRISTUS Health Plan
Catastrophic

(HMO) CHRISTUS Catastrophic - 3 free PCP visits, includes Virtual

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$231.37
$262.61
$295.70
$413.23
$627.95
$408.37
$439.61
$472.70
$590.23
$585.37
$616.61
$649.70
$767.23
$762.37
$793.61
$826.70
$944.23
$177.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$462.74
$525.22
$591.40
$826.46
$1,255.90
$639.74
$702.22
$768.40
$1,003.46
$816.74
$879.22
$945.40
$1,180.46
$993.74
$1,056.22
$1,122.40
$1,357.46
$177.00
Toc - Plan #72 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHRISTUS Bronze - 2 free PCP visits;Virtual;$0 PrefGen;$30 NonPrefGen

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
$9,100 $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
$273.59
$310.53
$349.65
$488.63
$742.53
$482.89
$519.83
$558.95
$697.93
$692.19
$729.13
$768.25
$907.23
$901.49
$938.43
$977.55
$1,116.53
$209.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$547.18
$621.06
$699.30
$977.26
$1,485.06
$756.48
$830.36
$908.60
$1,186.56
$965.78
$1,039.66
$1,117.90
$1,395.86
$1,175.08
$1,248.96
$1,327.20
$1,605.16
$209.30
Toc - Plan #73 CHRISTUS Health Plan
Silver

(HMO) CHRISTUS Silver HD - 2 free PCP;Virtual;$25 PCP;$40 SPE;$40 Urgent;$0 PrefGen

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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.35
$487.31
$548.71
$766.81
$1,165.25
$757.80
$815.76
$877.16
$1,095.26
$1,086.25
$1,144.21
$1,205.61
$1,423.71
$1,414.70
$1,472.66
$1,534.06
$1,752.16
$328.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.70
$974.62
$1,097.42
$1,533.62
$2,330.50
$1,187.15
$1,303.07
$1,425.87
$1,862.07
$1,515.60
$1,631.52
$1,754.32
$2,190.52
$1,844.05
$1,959.97
$2,082.77
$2,518.97
$328.45
Toc - Plan #74 CHRISTUS Health Plan
Silver

(HMO) CHRISTUS Silver LD - 2 free PCP visits, includes Virtual; $1,000 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$440.71
$500.21
$563.23
$787.12
$1,196.10
$777.86
$837.36
$900.38
$1,124.27
$1,115.01
$1,174.51
$1,237.53
$1,461.42
$1,452.16
$1,511.66
$1,574.68
$1,798.57
$337.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$881.42
$1,000.42
$1,126.46
$1,574.24
$2,392.20
$1,218.57
$1,337.57
$1,463.61
$1,911.39
$1,555.72
$1,674.72
$1,800.76
$2,248.54
$1,892.87
$2,011.87
$2,137.91
$2,585.69
$337.15
Toc - Plan #75 CHRISTUS Health Plan
Gold

(HMO) CHRISTUS Gold - 2 free PCP visits;$10 PCP;$35 SPE;$35 UC;$1,600 Med Ded;$0 Rx Ded

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
$9,100 $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
$371.76
$421.94
$475.11
$663.96
$1,008.95
$656.15
$706.33
$759.50
$948.35
$940.54
$990.72
$1,043.89
$1,232.74
$1,224.93
$1,275.11
$1,328.28
$1,517.13
$284.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$743.52
$843.88
$950.22
$1,327.92
$2,017.90
$1,027.91
$1,128.27
$1,234.61
$1,612.31
$1,312.30
$1,412.66
$1,519.00
$1,896.70
$1,596.69
$1,697.05
$1,803.39
$2,181.09
$284.39
Toc - Plan #76 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHRISTUS Bronze HSA

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

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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
$282.27
$320.38
$360.75
$504.14
$766.09
$498.21
$536.32
$576.69
$720.08
$714.15
$752.26
$792.63
$936.02
$930.09
$968.20
$1,008.57
$1,151.96
$215.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$564.54
$640.76
$721.50
$1,008.28
$1,532.18
$780.48
$856.70
$937.44
$1,224.22
$996.42
$1,072.64
$1,153.38
$1,440.16
$1,212.36
$1,288.58
$1,369.32
$1,656.10
$215.94
Toc - Plan #77 CHRISTUS Health Plan
Gold

(HMO) CHRISTUS Gold Plus HD-2 Free PCP;$10 PCP;$35 SPE;$0 Rx Ded;Adult vision,dental,fitness

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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.65
$441.12
$496.69
$694.12
$1,054.79
$685.97
$738.44
$794.01
$991.44
$983.29
$1,035.76
$1,091.33
$1,288.76
$1,280.61
$1,333.08
$1,388.65
$1,586.08
$297.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.30
$882.24
$993.38
$1,388.24
$2,109.58
$1,074.62
$1,179.56
$1,290.70
$1,685.56
$1,371.94
$1,476.88
$1,588.02
$1,982.88
$1,669.26
$1,774.20
$1,885.34
$2,280.20
$297.32
Toc - Plan #78 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHRISTUS Bronze Plus-2 free PCP;$0 PrefGen;$30 Non-prefGen;Adult vision,dental,fitness

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
$9,100 $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
$290.48
$329.70
$371.24
$518.80
$788.37
$512.70
$551.92
$593.46
$741.02
$734.92
$774.14
$815.68
$963.24
$957.14
$996.36
$1,037.90
$1,185.46
$222.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.96
$659.40
$742.48
$1,037.60
$1,576.74
$803.18
$881.62
$964.70
$1,259.82
$1,025.40
$1,103.84
$1,186.92
$1,482.04
$1,247.62
$1,326.06
$1,409.14
$1,704.26
$222.22
Toc - Plan #79 CHRISTUS Health Plan
Silver

(HMO) CHRISTUS Silver Plus HD-2 Free PCP;$25 PCP;$40 SPE;$0 PrefGen;Adult vision,dental,fitness

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
$9,100 $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
$446.24
$506.48
$570.29
$796.98
$1,211.09
$787.61
$847.85
$911.66
$1,138.35
$1,128.98
$1,189.22
$1,253.03
$1,479.72
$1,470.35
$1,530.59
$1,594.40
$1,821.09
$341.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$892.48
$1,012.96
$1,140.58
$1,593.96
$2,422.18
$1,233.85
$1,354.33
$1,481.95
$1,935.33
$1,575.22
$1,695.70
$1,823.32
$2,276.70
$1,916.59
$2,037.07
$2,164.69
$2,618.07
$341.37
Toc - Plan #80 CHRISTUS Health Plan
Silver

(HMO) CHRISTUS Silver - 2 free PCP visits, includes Virtual

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$393.04
$446.10
$502.31
$701.97
$1,066.71
$693.72
$746.78
$802.99
$1,002.65
$994.40
$1,047.46
$1,103.67
$1,303.33
$1,295.08
$1,348.14
$1,404.35
$1,604.01
$300.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.08
$892.20
$1,004.62
$1,403.94
$2,133.42
$1,086.76
$1,192.88
$1,305.30
$1,704.62
$1,387.44
$1,493.56
$1,605.98
$2,005.30
$1,688.12
$1,794.24
$1,906.66
$2,305.98
$300.68
Toc - Plan #81 CHRISTUS Health Plan
Expanded Bronze

(HMO) CHRISTUS Bronze - 2 free PCP visits, includes Virtual

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$264.47
$300.18
$338.00
$472.35
$717.78
$466.79
$502.50
$540.32
$674.67
$669.11
$704.82
$742.64
$876.99
$871.43
$907.14
$944.96
$1,079.31
$202.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$528.94
$600.36
$676.00
$944.70
$1,435.56
$731.26
$802.68
$878.32
$1,147.02
$933.58
$1,005.00
$1,080.64
$1,349.34
$1,135.90
$1,207.32
$1,282.96
$1,551.66
$202.32
Toc - Plan #82 CHRISTUS Health Plan
Bronze

(HMO) CHRISTUS Standard Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$259.59
$294.63
$331.75
$463.62
$704.52
$458.17
$493.21
$530.33
$662.20
$656.75
$691.79
$728.91
$860.78
$855.33
$890.37
$927.49
$1,059.36
$198.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$519.18
$589.26
$663.50
$927.24
$1,409.04
$717.76
$787.84
$862.08
$1,125.82
$916.34
$986.42
$1,060.66
$1,324.40
$1,114.92
$1,185.00
$1,259.24
$1,522.98
$198.58
Toc - Plan #83 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
$5,800 $11,600 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
$403.52
$457.99
$515.70
$720.68
$1,095.15
$712.21
$766.68
$824.39
$1,029.37
$1,020.90
$1,075.37
$1,133.08
$1,338.06
$1,329.59
$1,384.06
$1,441.77
$1,646.75
$308.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$807.04
$915.98
$1,031.40
$1,441.36
$2,190.30
$1,115.73
$1,224.67
$1,340.09
$1,750.05
$1,424.42
$1,533.36
$1,648.78
$2,058.74
$1,733.11
$1,842.05
$1,957.47
$2,367.43
$308.69
Toc - Plan #84 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
$2,000 $4,000 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
$341.74
$387.88
$436.75
$610.35
$927.49
$603.17
$649.31
$698.18
$871.78
$864.60
$910.74
$959.61
$1,133.21
$1,126.03
$1,172.17
$1,221.04
$1,394.64
$261.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.48
$775.76
$873.50
$1,220.70
$1,854.98
$944.91
$1,037.19
$1,134.93
$1,482.13
$1,206.34
$1,298.62
$1,396.36
$1,743.56
$1,467.77
$1,560.05
$1,657.79
$2,004.99
$261.43

ADVERTISEMENT

Ambetter from Superior HealthPlan

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

Toc - Plan #85 Ambetter from Superior HealthPlan
Silver

(HMO) Ambetter Virtual Access Silver (Virtual PCP Selection Required for $0 Virtual Visits on Ambetter's Telehealth Platform)

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
$383.38
$435.12
$489.94
$684.69
$1,040.46
$676.65
$728.39
$783.21
$977.96
$969.92
$1,021.66
$1,076.48
$1,271.23
$1,263.19
$1,314.93
$1,369.75
$1,564.50
$293.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.76
$870.24
$979.88
$1,369.38
$2,080.92
$1,060.03
$1,163.51
$1,273.15
$1,662.65
$1,353.30
$1,456.78
$1,566.42
$1,955.92
$1,646.57
$1,750.05
$1,859.69
$2,249.19
$293.27
Toc - Plan #86 Ambetter from Superior HealthPlan
Gold

(HMO) Ambetter Virtual Access Gold (Virtual PCP Selection Required for $0 Virtual Visits on Ambetter's Telehealth Platform)

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
$360.52
$409.18
$460.73
$643.88
$978.43
$636.31
$684.97
$736.52
$919.67
$912.10
$960.76
$1,012.31
$1,195.46
$1,187.89
$1,236.55
$1,288.10
$1,471.25
$275.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.04
$818.36
$921.46
$1,287.76
$1,956.86
$996.83
$1,094.15
$1,197.25
$1,563.55
$1,272.62
$1,369.94
$1,473.04
$1,839.34
$1,548.41
$1,645.73
$1,748.83
$2,115.13
$275.79
Toc - Plan #87 Ambetter from Superior HealthPlan
Silver

(HMO) CMS Standard Virtual Access Basic Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 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
$395.98
$449.43
$506.05
$707.20
$1,074.66
$698.90
$752.35
$808.97
$1,010.12
$1,001.82
$1,055.27
$1,111.89
$1,313.04
$1,304.74
$1,358.19
$1,414.81
$1,615.96
$302.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.96
$898.86
$1,012.10
$1,414.40
$2,149.32
$1,094.88
$1,201.78
$1,315.02
$1,717.32
$1,397.80
$1,504.70
$1,617.94
$2,020.24
$1,700.72
$1,807.62
$1,920.86
$2,323.16
$302.92
Toc - Plan #88 Ambetter from Superior HealthPlan
Gold

(HMO) CMS Standard Virtual Access Basic Gold

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$357.08
$405.28
$456.34
$637.73
$969.09
$630.24
$678.44
$729.50
$910.89
$903.40
$951.60
$1,002.66
$1,184.05
$1,176.56
$1,224.76
$1,275.82
$1,457.21
$273.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714.16
$810.56
$912.68
$1,275.46
$1,938.18
$987.32
$1,083.72
$1,185.84
$1,548.62
$1,260.48
$1,356.88
$1,459.00
$1,821.78
$1,533.64
$1,630.04
$1,732.16
$2,094.94
$273.16

‡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 Jefferson County here.

Jefferson County is in “Rating Area 4” of Texas.

Currently, there are 88 plans offered in Rating Area 4.

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2023 Obamacare Plans for Jefferson County, TX

Plan Browser: 88 Plans
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