justice fist holding scales LegalConsumer.com
Empowering Consumers Since 2006
Obamacare
☰
Obamacare by State
Obamacare Guide
Search
Help
You are viewing information for Limestone County, TX

Obamacare 2023 Rates for Limestone County

Obamacare > Rates > Texas > Limestone 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 Limestone 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, 66 Plans and 2023 Rates for Limestone County, Texas

Below, you’ll find a summary of the 66 plans for Limestone 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

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

ADVERTISEMENT

ADVERTISEMENT

FirstCare Health Plans

Local: 1-855-572-7238 | Toll Free: 1-855-572-7238 | TTY: 1-800-562-5259
Toc - Plan #1 FirstCare Health Plans
Gold

(HMO) FirstCare Elite Gold HMO 001 (CMS Standardized Plan with $0 Pediatric PCP copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-572-7238

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 		$420.16
$476.88
$536.96
$750.40
$1,140.31 		$741.58
$798.30
$858.38
$1,071.82 		$1,063.00
$1,119.72
$1,179.80
$1,393.24 		$1,384.42
$1,441.14
$1,501.22
$1,714.66 		$321.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.32
$953.76
$1,073.92
$1,500.80
$2,280.62 		$1,161.74
$1,275.18
$1,395.34
$1,822.22 		$1,483.16
$1,596.60
$1,716.76
$2,143.64 		$1,804.58
$1,918.02
$2,038.18
$2,465.06 		$321.42
Toc - Plan #2 FirstCare Health Plans
Silver

(HMO) FirstCare Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-572-7238

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 		$425.46
$482.90
$543.74
$759.87
$1,154.70 		$750.94
$808.38
$869.22
$1,085.35 		$1,076.42
$1,133.86
$1,194.70
$1,410.83 		$1,401.90
$1,459.34
$1,520.18
$1,736.31 		$325.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.92
$965.80
$1,087.48
$1,519.74
$2,309.40 		$1,176.40
$1,291.28
$1,412.96
$1,845.22 		$1,501.88
$1,616.76
$1,738.44
$2,170.70 		$1,827.36
$1,942.24
$2,063.92
$2,496.18 		$325.48
Toc - Plan #3 FirstCare Health Plans
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-572-7238

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 		$349.39
$396.56
$446.52
$624.01
$948.24 		$616.67
$663.84
$713.80
$891.29 		$883.95
$931.12
$981.08
$1,158.57 		$1,151.23
$1,198.40
$1,248.36
$1,425.85 		$267.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.78
$793.12
$893.04
$1,248.02
$1,896.48 		$966.06
$1,060.40
$1,160.32
$1,515.30 		$1,233.34
$1,327.68
$1,427.60
$1,782.58 		$1,500.62
$1,594.96
$1,694.88
$2,049.86 		$267.28
Toc - Plan #4 FirstCare Health Plans
Silver

(HMO) FirstCare Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-572-7238

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$432.75
$491.17
$553.05
$772.88
$1,174.47 		$763.80
$822.22
$884.10
$1,103.93 		$1,094.85
$1,153.27
$1,215.15
$1,434.98 		$1,425.90
$1,484.32
$1,546.20
$1,766.03 		$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
$1,545.76
$2,348.94 		$1,196.55
$1,313.39
$1,437.15
$1,876.81 		$1,527.60
$1,644.44
$1,768.20
$2,207.86 		$1,858.65
$1,975.49
$2,099.25
$2,538.91 		$331.05
Toc - Plan #5 FirstCare Health Plans
Expanded Bronze

(HMO) FirstCare Vital Bronze HMO 009 (One free PCP visit, $0 Pediatric PCP visit)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-572-7238

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 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 		$341.31
$387.39
$436.19
$609.58
$926.32 		$602.41
$648.49
$697.29
$870.68 		$863.51
$909.59
$958.39
$1,131.78 		$1,124.61
$1,170.69
$1,219.49
$1,392.88 		$261.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.62
$774.78
$872.38
$1,219.16
$1,852.64 		$943.72
$1,035.88
$1,133.48
$1,480.26 		$1,204.82
$1,296.98
$1,394.58
$1,741.36 		$1,465.92
$1,558.08
$1,655.68
$2,002.46 		$261.10
Toc - Plan #6 FirstCare Health Plans
Gold

(HMO) FirstCare Elite Gold HMO 011 (Low deductible, two free PCP visits, $0 Pediatric PCP visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-572-7238

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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 		$443.75
$503.65
$567.11
$792.53
$1,204.33 		$783.22
$843.12
$906.58
$1,132.00 		$1,122.69
$1,182.59
$1,246.05
$1,471.47 		$1,462.16
$1,522.06
$1,585.52
$1,810.94 		$339.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.50
$1,007.30
$1,134.22
$1,585.06
$2,408.66 		$1,226.97
$1,346.77
$1,473.69
$1,924.53 		$1,566.44
$1,686.24
$1,813.16
$2,264.00 		$1,905.91
$2,025.71
$2,152.63
$2,603.47 		$339.47
Toc - Plan #7 FirstCare Health Plans
Silver

(HMO) FirstCare Prime Silver HMO 012 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-572-7238

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 		$471.80
$535.49
$602.96
$842.63
$1,280.46 		$832.73
$896.42
$963.89
$1,203.56 		$1,193.66
$1,257.35
$1,324.82
$1,564.49 		$1,554.59
$1,618.28
$1,685.75
$1,925.42 		$360.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$943.60
$1,070.98
$1,205.92
$1,685.26
$2,560.92 		$1,304.53
$1,431.91
$1,566.85
$2,046.19 		$1,665.46
$1,792.84
$1,927.78
$2,407.12 		$2,026.39
$2,153.77
$2,288.71
$2,768.05 		$360.93
Toc - Plan #8 FirstCare Health Plans
Expanded Bronze

(HMO) FirstCare Vital Bronze HMO 013 (CMS Standardized Plan with $0 Pediatric PCP copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-572-7238

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 		$344.43
$390.93
$440.18
$615.16
$934.79 		$607.92
$654.42
$703.67
$878.65 		$871.41
$917.91
$967.16
$1,142.14 		$1,134.90
$1,181.40
$1,230.65
$1,405.63 		$263.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.86
$781.86
$880.36
$1,230.32
$1,869.58 		$952.35
$1,045.35
$1,143.85
$1,493.81 		$1,215.84
$1,308.84
$1,407.34
$1,757.30 		$1,479.33
$1,572.33
$1,670.83
$2,020.79 		$263.49
Toc - Plan #9 FirstCare Health Plans
Gold

(HMO) FirstCare Elite Gold HMO 015 ($0 PCP unlimited visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-572-7238

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 		$408.07
$463.15
$521.51
$728.81
$1,107.49 		$720.24
$775.32
$833.68
$1,040.98 		$1,032.41
$1,087.49
$1,145.85
$1,353.15 		$1,344.58
$1,399.66
$1,458.02
$1,665.32 		$312.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.14
$926.30
$1,043.02
$1,457.62
$2,214.98 		$1,128.31
$1,238.47
$1,355.19
$1,769.79 		$1,440.48
$1,550.64
$1,667.36
$2,081.96 		$1,752.65
$1,862.81
$1,979.53
$2,394.13 		$312.17

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #10 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 		$411.76
$467.34
$526.22
$735.39
$1,117.49 		$726.75
$782.33
$841.21
$1,050.38 		$1,041.74
$1,097.32
$1,156.20
$1,365.37 		$1,356.73
$1,412.31
$1,471.19
$1,680.36 		$314.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.52
$934.68
$1,052.44
$1,470.78
$2,234.98 		$1,138.51
$1,249.67
$1,367.43
$1,785.77 		$1,453.50
$1,564.66
$1,682.42
$2,100.76 		$1,768.49
$1,879.65
$1,997.41
$2,415.75 		$314.99
Toc - Plan #11 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 		$379.03
$430.18
$484.38
$676.92
$1,028.65 		$668.98
$720.13
$774.33
$966.87 		$958.93
$1,010.08
$1,064.28
$1,256.82 		$1,248.88
$1,300.03
$1,354.23
$1,546.77 		$289.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.06
$860.36
$968.76
$1,353.84
$2,057.30 		$1,048.01
$1,150.31
$1,258.71
$1,643.79 		$1,337.96
$1,440.26
$1,548.66
$1,933.74 		$1,627.91
$1,730.21
$1,838.61
$2,223.69 		$289.95
Toc - Plan #12 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 		$407.64
$462.66
$520.95
$728.03
$1,106.32 		$719.48
$774.50
$832.79
$1,039.87 		$1,031.32
$1,086.34
$1,144.63
$1,351.71 		$1,343.16
$1,398.18
$1,456.47
$1,663.55 		$311.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.28
$925.32
$1,041.90
$1,456.06
$2,212.64 		$1,127.12
$1,237.16
$1,353.74
$1,767.90 		$1,438.96
$1,549.00
$1,665.58
$2,079.74 		$1,750.80
$1,860.84
$1,977.42
$2,391.58 		$311.84
Toc - Plan #13 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 		$406.12
$460.93
$519.01
$725.31
$1,102.18 		$716.79
$771.60
$829.68
$1,035.98 		$1,027.46
$1,082.27
$1,140.35
$1,346.65 		$1,338.13
$1,392.94
$1,451.02
$1,657.32 		$310.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.24
$921.86
$1,038.02
$1,450.62
$2,204.36 		$1,122.91
$1,232.53
$1,348.69
$1,761.29 		$1,433.58
$1,543.20
$1,659.36
$2,071.96 		$1,744.25
$1,853.87
$1,970.03
$2,382.63 		$310.67
Toc - Plan #14 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 		$368.86
$418.64
$471.39
$658.76
$1,001.05 		$651.03
$700.81
$753.56
$940.93 		$933.20
$982.98
$1,035.73
$1,223.10 		$1,215.37
$1,265.15
$1,317.90
$1,505.27 		$282.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.72
$837.28
$942.78
$1,317.52
$2,002.10 		$1,019.89
$1,119.45
$1,224.95
$1,599.69 		$1,302.06
$1,401.62
$1,507.12
$1,881.86 		$1,584.23
$1,683.79
$1,789.29
$2,164.03 		$282.17
Toc - Plan #15 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 		$366.63
$416.12
$468.54
$654.79
$995.01 		$647.10
$696.59
$749.01
$935.26 		$927.57
$977.06
$1,029.48
$1,215.73 		$1,208.04
$1,257.53
$1,309.95
$1,496.20 		$280.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.26
$832.24
$937.08
$1,309.58
$1,990.02 		$1,013.73
$1,112.71
$1,217.55
$1,590.05 		$1,294.20
$1,393.18
$1,498.02
$1,870.52 		$1,574.67
$1,673.65
$1,778.49
$2,150.99 		$280.47
Toc - Plan #16 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 		$405.83
$460.61
$518.64
$724.80
$1,101.40 		$716.28
$771.06
$829.09
$1,035.25 		$1,026.73
$1,081.51
$1,139.54
$1,345.70 		$1,337.18
$1,391.96
$1,449.99
$1,656.15 		$310.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.66
$921.22
$1,037.28
$1,449.60
$2,202.80 		$1,122.11
$1,231.67
$1,347.73
$1,760.05 		$1,432.56
$1,542.12
$1,658.18
$2,070.50 		$1,743.01
$1,852.57
$1,968.63
$2,380.95 		$310.45
Toc - Plan #17 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 		$365.93
$415.32
$467.65
$653.54
$993.11 		$645.86
$695.25
$747.58
$933.47 		$925.79
$975.18
$1,027.51
$1,213.40 		$1,205.72
$1,255.11
$1,307.44
$1,493.33 		$279.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.86
$830.64
$935.30
$1,307.08
$1,986.22 		$1,011.79
$1,110.57
$1,215.23
$1,587.01 		$1,291.72
$1,390.50
$1,495.16
$1,866.94 		$1,571.65
$1,670.43
$1,775.09
$2,146.87 		$279.93
Toc - Plan #18 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 		$394.79
$448.08
$504.53
$705.08
$1,071.44 		$696.80
$750.09
$806.54
$1,007.09 		$998.81
$1,052.10
$1,108.55
$1,309.10 		$1,300.82
$1,354.11
$1,410.56
$1,611.11 		$302.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.58
$896.16
$1,009.06
$1,410.16
$2,142.88 		$1,091.59
$1,198.17
$1,311.07
$1,712.17 		$1,393.60
$1,500.18
$1,613.08
$2,014.18 		$1,695.61
$1,802.19
$1,915.09
$2,316.19 		$302.01
Toc - Plan #19 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 		$428.89
$486.77
$548.10
$765.97
$1,163.97 		$756.98
$814.86
$876.19
$1,094.06 		$1,085.07
$1,142.95
$1,204.28
$1,422.15 		$1,413.16
$1,471.04
$1,532.37
$1,750.24 		$328.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.78
$973.54
$1,096.20
$1,531.94
$2,327.94 		$1,185.87
$1,301.63
$1,424.29
$1,860.03 		$1,513.96
$1,629.72
$1,752.38
$2,188.12 		$1,842.05
$1,957.81
$2,080.47
$2,516.21 		$328.09
Toc - Plan #20 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 		$423.01
$480.11
$540.60
$755.48
$1,148.02 		$746.61
$803.71
$864.20
$1,079.08 		$1,070.21
$1,127.31
$1,187.80
$1,402.68 		$1,393.81
$1,450.91
$1,511.40
$1,726.28 		$323.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.02
$960.22
$1,081.20
$1,510.96
$2,296.04 		$1,169.62
$1,283.82
$1,404.80
$1,834.56 		$1,493.22
$1,607.42
$1,728.40
$2,158.16 		$1,816.82
$1,931.02
$2,052.00
$2,481.76 		$323.60
Toc - Plan #21 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 		$384.20
$436.05
$490.99
$686.16
$1,042.69 		$678.10
$729.95
$784.89
$980.06 		$972.00
$1,023.85
$1,078.79
$1,273.96 		$1,265.90
$1,317.75
$1,372.69
$1,567.86 		$293.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$768.40
$872.10
$981.98
$1,372.32
$2,085.38 		$1,062.30
$1,166.00
$1,275.88
$1,666.22 		$1,356.20
$1,459.90
$1,569.78
$1,960.12 		$1,650.10
$1,753.80
$1,863.68
$2,254.02 		$293.90
Toc - Plan #22 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 		$424.60
$481.91
$542.62
$758.31
$1,152.33 		$749.41
$806.72
$867.43
$1,083.12 		$1,074.22
$1,131.53
$1,192.24
$1,407.93 		$1,399.03
$1,456.34
$1,517.05
$1,732.74 		$324.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.20
$963.82
$1,085.24
$1,516.62
$2,304.66 		$1,174.01
$1,288.63
$1,410.05
$1,841.43 		$1,498.82
$1,613.44
$1,734.86
$2,166.24 		$1,823.63
$1,938.25
$2,059.67
$2,491.05 		$324.81
Toc - Plan #23 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 		$381.88
$433.42
$488.03
$682.02
$1,036.40 		$674.01
$725.55
$780.16
$974.15 		$966.14
$1,017.68
$1,072.29
$1,266.28 		$1,258.27
$1,309.81
$1,364.42
$1,558.41 		$292.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.76
$866.84
$976.06
$1,364.04
$2,072.80 		$1,055.89
$1,158.97
$1,268.19
$1,656.17 		$1,348.02
$1,451.10
$1,560.32
$1,948.30 		$1,640.15
$1,743.23
$1,852.45
$2,240.43 		$292.13

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 #24 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 		$391.21
$444.02
$499.97
$698.70
$1,061.75 		$690.49
$743.30
$799.25
$997.98 		$989.77
$1,042.58
$1,098.53
$1,297.26 		$1,289.05
$1,341.86
$1,397.81
$1,596.54 		$299.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.42
$888.04
$999.94
$1,397.40
$2,123.50 		$1,081.70
$1,187.32
$1,299.22
$1,696.68 		$1,380.98
$1,486.60
$1,598.50
$1,995.96 		$1,680.26
$1,785.88
$1,897.78
$2,295.24 		$299.28
Toc - Plan #25 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 		$286.51
$325.19
$366.16
$511.71
$777.60 		$505.69
$544.37
$585.34
$730.89 		$724.87
$763.55
$804.52
$950.07 		$944.05
$982.73
$1,023.70
$1,169.25 		$219.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.02
$650.38
$732.32
$1,023.42
$1,555.20 		$792.20
$869.56
$951.50
$1,242.60 		$1,011.38
$1,088.74
$1,170.68
$1,461.78 		$1,230.56
$1,307.92
$1,389.86
$1,680.96 		$219.18
Toc - Plan #26 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 		$470.51
$534.03
$601.31
$840.33
$1,276.96 		$830.45
$893.97
$961.25
$1,200.27 		$1,190.39
$1,253.91
$1,321.19
$1,560.21 		$1,550.33
$1,613.85
$1,681.13
$1,920.15 		$359.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$941.02
$1,068.06
$1,202.62
$1,680.66
$2,553.92 		$1,300.96
$1,428.00
$1,562.56
$2,040.60 		$1,660.90
$1,787.94
$1,922.50
$2,400.54 		$2,020.84
$2,147.88
$2,282.44
$2,760.48 		$359.94
Toc - Plan #27 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 		$320.15
$363.37
$409.15
$571.79
$868.88 		$565.06
$608.28
$654.06
$816.70 		$809.97
$853.19
$898.97
$1,061.61 		$1,054.88
$1,098.10
$1,143.88
$1,306.52 		$244.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.30
$726.74
$818.30
$1,143.58
$1,737.76 		$885.21
$971.65
$1,063.21
$1,388.49 		$1,130.12
$1,216.56
$1,308.12
$1,633.40 		$1,375.03
$1,461.47
$1,553.03
$1,878.31 		$244.91
Toc - Plan #28 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 		$332.96
$377.91
$425.53
$594.67
$903.66 		$587.68
$632.63
$680.25
$849.39 		$842.40
$887.35
$934.97
$1,104.11 		$1,097.12
$1,142.07
$1,189.69
$1,358.83 		$254.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.92
$755.82
$851.06
$1,189.34
$1,807.32 		$920.64
$1,010.54
$1,105.78
$1,444.06 		$1,175.36
$1,265.26
$1,360.50
$1,698.78 		$1,430.08
$1,519.98
$1,615.22
$1,953.50 		$254.72
Toc - Plan #29 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 		$318.49
$361.49
$407.03
$568.82
$864.38 		$562.14
$605.14
$650.68
$812.47 		$805.79
$848.79
$894.33
$1,056.12 		$1,049.44
$1,092.44
$1,137.98
$1,299.77 		$243.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.98
$722.98
$814.06
$1,137.64
$1,728.76 		$880.63
$966.63
$1,057.71
$1,381.29 		$1,124.28
$1,210.28
$1,301.36
$1,624.94 		$1,367.93
$1,453.93
$1,545.01
$1,868.59 		$243.65
Toc - Plan #30 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 		$402.70
$457.06
$514.65
$719.22
$1,092.93 		$710.77
$765.13
$822.72
$1,027.29 		$1,018.84
$1,073.20
$1,130.79
$1,335.36 		$1,326.91
$1,381.27
$1,438.86
$1,643.43 		$308.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.40
$914.12
$1,029.30
$1,438.44
$2,185.86 		$1,113.47
$1,222.19
$1,337.37
$1,746.51 		$1,421.54
$1,530.26
$1,645.44
$2,054.58 		$1,729.61
$1,838.33
$1,953.51
$2,362.65 		$308.07
Toc - Plan #31 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 		$333.41
$378.43
$426.10
$595.48
$904.89 		$588.47
$633.49
$681.16
$850.54 		$843.53
$888.55
$936.22
$1,105.60 		$1,098.59
$1,143.61
$1,191.28
$1,360.66 		$255.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.82
$756.86
$852.20
$1,190.96
$1,809.78 		$921.88
$1,011.92
$1,107.26
$1,446.02 		$1,176.94
$1,266.98
$1,362.32
$1,701.08 		$1,432.00
$1,522.04
$1,617.38
$1,956.14 		$255.06
Toc - Plan #32 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 		$396.52
$450.05
$506.76
$708.19
$1,076.17 		$699.86
$753.39
$810.10
$1,011.53 		$1,003.20
$1,056.73
$1,113.44
$1,314.87 		$1,306.54
$1,360.07
$1,416.78
$1,618.21 		$303.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.04
$900.10
$1,013.52
$1,416.38
$2,152.34 		$1,096.38
$1,203.44
$1,316.86
$1,719.72 		$1,399.72
$1,506.78
$1,620.20
$2,023.06 		$1,703.06
$1,810.12
$1,923.54
$2,326.40 		$303.34
Toc - Plan #33 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 		$472.87
$536.71
$604.33
$844.54
$1,283.36 		$834.61
$898.45
$966.07
$1,206.28 		$1,196.35
$1,260.19
$1,327.81
$1,568.02 		$1,558.09
$1,621.93
$1,689.55
$1,929.76 		$361.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945.74
$1,073.42
$1,208.66
$1,689.08
$2,566.72 		$1,307.48
$1,435.16
$1,570.40
$2,050.82 		$1,669.22
$1,796.90
$1,932.14
$2,412.56 		$2,030.96
$2,158.64
$2,293.88
$2,774.30 		$361.74
Toc - Plan #34 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 		$311.51
$353.56
$398.11
$556.36
$845.44 		$549.82
$591.87
$636.42
$794.67 		$788.13
$830.18
$874.73
$1,032.98 		$1,026.44
$1,068.49
$1,113.04
$1,271.29 		$238.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.02
$707.12
$796.22
$1,112.72
$1,690.88 		$861.33
$945.43
$1,034.53
$1,351.03 		$1,099.64
$1,183.74
$1,272.84
$1,589.34 		$1,337.95
$1,422.05
$1,511.15
$1,827.65 		$238.31
Toc - Plan #35 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 		$332.31
$377.18
$424.70
$593.51
$901.90 		$586.53
$631.40
$678.92
$847.73 		$840.75
$885.62
$933.14
$1,101.95 		$1,094.97
$1,139.84
$1,187.36
$1,356.17 		$254.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.62
$754.36
$849.40
$1,187.02
$1,803.80 		$918.84
$1,008.58
$1,103.62
$1,441.24 		$1,173.06
$1,262.80
$1,357.84
$1,695.46 		$1,427.28
$1,517.02
$1,612.06
$1,949.68 		$254.22
Toc - Plan #36 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 		$443.97
$503.91
$567.40
$792.94
$1,204.94 		$783.61
$843.55
$907.04
$1,132.58 		$1,123.25
$1,183.19
$1,246.68
$1,472.22 		$1,462.89
$1,522.83
$1,586.32
$1,811.86 		$339.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.94
$1,007.82
$1,134.80
$1,585.88
$2,409.88 		$1,227.58
$1,347.46
$1,474.44
$1,925.52 		$1,567.22
$1,687.10
$1,814.08
$2,265.16 		$1,906.86
$2,026.74
$2,153.72
$2,604.80 		$339.64
Toc - Plan #37 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 		$531.18
$602.89
$678.84
$948.68
$1,441.61 		$937.53
$1,009.24
$1,085.19
$1,355.03 		$1,343.88
$1,415.59
$1,491.54
$1,761.38 		$1,750.23
$1,821.94
$1,897.89
$2,167.73 		$406.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,062.36
$1,205.78
$1,357.68
$1,897.36
$2,883.22 		$1,468.71
$1,612.13
$1,764.03
$2,303.71 		$1,875.06
$2,018.48
$2,170.38
$2,710.06 		$2,281.41
$2,424.83
$2,576.73
$3,116.41 		$406.35
Toc - Plan #38 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 		$364.18
$413.34
$465.42
$650.42
$988.38 		$642.78
$691.94
$744.02
$929.02 		$921.38
$970.54
$1,022.62
$1,207.62 		$1,199.98
$1,249.14
$1,301.22
$1,486.22 		$278.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.36
$826.68
$930.84
$1,300.84
$1,976.76 		$1,006.96
$1,105.28
$1,209.44
$1,579.44 		$1,285.56
$1,383.88
$1,488.04
$1,858.04 		$1,564.16
$1,662.48
$1,766.64
$2,136.64 		$278.60
Toc - Plan #39 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 		$347.24
$394.12
$443.78
$620.18
$942.42 		$612.88
$659.76
$709.42
$885.82 		$878.52
$925.40
$975.06
$1,151.46 		$1,144.16
$1,191.04
$1,240.70
$1,417.10 		$265.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.48
$788.24
$887.56
$1,240.36
$1,884.84 		$960.12
$1,053.88
$1,153.20
$1,506.00 		$1,225.76
$1,319.52
$1,418.84
$1,771.64 		$1,491.40
$1,585.16
$1,684.48
$2,037.28 		$265.64
Toc - Plan #40 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 		$536.23
$608.62
$685.30
$957.71
$1,455.33 		$946.45
$1,018.84
$1,095.52
$1,367.93 		$1,356.67
$1,429.06
$1,505.74
$1,778.15 		$1,766.89
$1,839.28
$1,915.96
$2,188.37 		$410.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,072.46
$1,217.24
$1,370.60
$1,915.42
$2,910.66 		$1,482.68
$1,627.46
$1,780.82
$2,325.64 		$1,892.90
$2,037.68
$2,191.04
$2,735.86 		$2,303.12
$2,447.90
$2,601.26
$3,146.08 		$410.22
Toc - Plan #41 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 		$442.26
$501.96
$565.20
$789.87
$1,200.28 		$780.59
$840.29
$903.53
$1,128.20 		$1,118.92
$1,178.62
$1,241.86
$1,466.53 		$1,457.25
$1,516.95
$1,580.19
$1,804.86 		$338.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.52
$1,003.92
$1,130.40
$1,579.74
$2,400.56 		$1,222.85
$1,342.25
$1,468.73
$1,918.07 		$1,561.18
$1,680.58
$1,807.06
$2,256.40 		$1,899.51
$2,018.91
$2,145.39
$2,594.73 		$338.33
Toc - Plan #42 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 		$527.98
$599.26
$674.76
$942.97
$1,432.93 		$931.88
$1,003.16
$1,078.66
$1,346.87 		$1,335.78
$1,407.06
$1,482.56
$1,750.77 		$1,739.68
$1,810.96
$1,886.46
$2,154.67 		$403.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,055.96
$1,198.52
$1,349.52
$1,885.94
$2,865.86 		$1,459.86
$1,602.42
$1,753.42
$2,289.84 		$1,863.76
$2,006.32
$2,157.32
$2,693.74 		$2,267.66
$2,410.22
$2,561.22
$3,097.64 		$403.90
Toc - Plan #43 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 		$348.67
$395.75
$445.61
$622.73
$946.30 		$615.41
$662.49
$712.35
$889.47 		$882.15
$929.23
$979.09
$1,156.21 		$1,148.89
$1,195.97
$1,245.83
$1,422.95 		$266.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.34
$791.50
$891.22
$1,245.46
$1,892.60 		$964.08
$1,058.24
$1,157.96
$1,512.20 		$1,230.82
$1,324.98
$1,424.70
$1,778.94 		$1,497.56
$1,591.72
$1,691.44
$2,045.68 		$266.74
Toc - Plan #44 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 		$371.12
$421.23
$474.30
$662.83
$1,007.23 		$655.03
$705.14
$758.21
$946.74 		$938.94
$989.05
$1,042.12
$1,230.65 		$1,222.85
$1,272.96
$1,326.03
$1,514.56 		$283.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.24
$842.46
$948.60
$1,325.66
$2,014.46 		$1,026.15
$1,126.37
$1,232.51
$1,609.57 		$1,310.06
$1,410.28
$1,516.42
$1,893.48 		$1,593.97
$1,694.19
$1,800.33
$2,177.39 		$283.91

ADVERTISEMENT

Baylor Scott and White Health Plan

Local: 1-844-633-5325 | Toll Free: 1-844-633-5325 | TTY: 1-800-735-2989
Toc - Plan #45 Baylor Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 001 (CMS Standardized Plan with $0 Pediatric PCP copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$341.15
$387.20
$435.98
$609.29
$925.87 		$602.13
$648.18
$696.96
$870.27 		$863.11
$909.16
$957.94
$1,131.25 		$1,124.09
$1,170.14
$1,218.92
$1,392.23 		$260.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.30
$774.40
$871.96
$1,218.58
$1,851.74 		$943.28
$1,035.38
$1,132.94
$1,479.56 		$1,204.26
$1,296.36
$1,393.92
$1,740.54 		$1,465.24
$1,557.34
$1,654.90
$2,001.52 		$260.98
Toc - Plan #46 Baylor Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$345.45
$392.09
$441.49
$616.98
$937.55 		$609.72
$656.36
$705.76
$881.25 		$873.99
$920.63
$970.03
$1,145.52 		$1,138.26
$1,184.90
$1,234.30
$1,409.79 		$264.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.90
$784.18
$882.98
$1,233.96
$1,875.10 		$955.17
$1,048.45
$1,147.25
$1,498.23 		$1,219.44
$1,312.72
$1,411.52
$1,762.50 		$1,483.71
$1,576.99
$1,675.79
$2,026.77 		$264.27
Toc - Plan #47 Baylor Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 004 (Low deductible, two free PCP visits, $0 Pediatric PCP visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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 		$360.30
$408.94
$460.46
$643.49
$977.85 		$635.93
$684.57
$736.09
$919.12 		$911.56
$960.20
$1,011.72
$1,194.75 		$1,187.19
$1,235.83
$1,287.35
$1,470.38 		$275.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.60
$817.88
$920.92
$1,286.98
$1,955.70 		$996.23
$1,093.51
$1,196.55
$1,562.61 		$1,271.86
$1,369.14
$1,472.18
$1,838.24 		$1,547.49
$1,644.77
$1,747.81
$2,113.87 		$275.63
Toc - Plan #48 Baylor Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 005 ($0 deductible, one free PCP visit, $0 Pediatric PCP visit)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$383.07
$434.79
$489.57
$684.17
$1,039.66 		$676.12
$727.84
$782.62
$977.22 		$969.17
$1,020.89
$1,075.67
$1,270.27 		$1,262.22
$1,313.94
$1,368.72
$1,563.32 		$293.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.14
$869.58
$979.14
$1,368.34
$2,079.32 		$1,059.19
$1,162.63
$1,272.19
$1,661.39 		$1,352.24
$1,455.68
$1,565.24
$1,954.44 		$1,645.29
$1,748.73
$1,858.29
$2,247.49 		$293.05
Toc - Plan #49 Baylor Scott and White Health Plan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$283.68
$321.98
$362.55
$506.66
$769.92 		$500.70
$539.00
$579.57
$723.68 		$717.72
$756.02
$796.59
$940.70 		$934.74
$973.04
$1,013.61
$1,157.72 		$217.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.36
$643.96
$725.10
$1,013.32
$1,539.84 		$784.38
$860.98
$942.12
$1,230.34 		$1,001.40
$1,078.00
$1,159.14
$1,447.36 		$1,218.42
$1,295.02
$1,376.16
$1,664.38 		$217.02
Toc - Plan #50 Baylor Scott and White Health Plan
Expanded Bronze

(HMO) BSW Vital Bronze HMO 007 (CMS Standardized Plan with $0 Pediatric PCP copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$279.66
$317.41
$357.41
$499.47
$759.00 		$493.60
$531.35
$571.35
$713.41 		$707.54
$745.29
$785.29
$927.35 		$921.48
$959.23
$999.23
$1,141.29 		$213.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559.32
$634.82
$714.82
$998.94
$1,518.00 		$773.26
$848.76
$928.76
$1,212.88 		$987.20
$1,062.70
$1,142.70
$1,426.82 		$1,201.14
$1,276.64
$1,356.64
$1,640.76 		$213.94
Toc - Plan #51 Baylor Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 008 (Two free PCP visits, $0 Pediatric PCP visit)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$351.37
$398.80
$449.05
$627.54
$953.61 		$620.16
$667.59
$717.84
$896.33 		$888.95
$936.38
$986.63
$1,165.12 		$1,157.74
$1,205.17
$1,255.42
$1,433.91 		$268.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.74
$797.60
$898.10
$1,255.08
$1,907.22 		$971.53
$1,066.39
$1,166.89
$1,523.87 		$1,240.32
$1,335.18
$1,435.68
$1,792.66 		$1,509.11
$1,603.97
$1,704.47
$2,061.45 		$268.79
Toc - Plan #52 Baylor Scott and White Health Plan
Expanded Bronze

(HMO) BSW Vital Bronze HMO 009 (One free PCP visit, $0 Pediatric PCP visit)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 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 		$277.13
$314.54
$354.17
$494.95
$752.12 		$489.13
$526.54
$566.17
$706.95 		$701.13
$738.54
$778.17
$918.95 		$913.13
$950.54
$990.17
$1,130.95 		$212.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.26
$629.08
$708.34
$989.90
$1,504.24 		$766.26
$841.08
$920.34
$1,201.90 		$978.26
$1,053.08
$1,132.34
$1,413.90 		$1,190.26
$1,265.08
$1,344.34
$1,625.90 		$212.00
Toc - Plan #53 Baylor Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 012 ($0 PCP unlimited visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-633-5325

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 		$331.33
$376.06
$423.44
$591.75
$899.22 		$584.80
$629.53
$676.91
$845.22 		$838.27
$883.00
$930.38
$1,098.69 		$1,091.74
$1,136.47
$1,183.85
$1,352.16 		$253.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662.66
$752.12
$846.88
$1,183.50
$1,798.44 		$916.13
$1,005.59
$1,100.35
$1,436.97 		$1,169.60
$1,259.06
$1,353.82
$1,690.44 		$1,423.07
$1,512.53
$1,607.29
$1,943.91 		$253.47

ADVERTISEMENT

US Health and Life

Local: 1-833-600-1311 | Toll Free: 

Toc - Plan #54 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Balanced Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$274.54
$311.60
$350.86
$490.32
$745.09 		$484.56
$521.62
$560.88
$700.34 		$694.58
$731.64
$770.90
$910.36 		$904.60
$941.66
$980.92
$1,120.38 		$210.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.08
$623.20
$701.72
$980.64
$1,490.18 		$759.10
$833.22
$911.74
$1,190.66 		$969.12
$1,043.24
$1,121.76
$1,400.68 		$1,179.14
$1,253.26
$1,331.78
$1,610.70 		$210.02
Toc - Plan #55 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Balanced Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$274.54
$311.60
$350.86
$490.32
$745.09 		$484.56
$521.62
$560.88
$700.34 		$694.58
$731.64
$770.90
$910.36 		$904.60
$941.66
$980.92
$1,120.38 		$210.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.08
$623.20
$701.72
$980.64
$1,490.18 		$759.10
$833.22
$911.74
$1,190.66 		$969.12
$1,043.24
$1,121.76
$1,400.68 		$1,179.14
$1,253.26
$1,331.78
$1,610.70 		$210.02
Toc - Plan #56 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care No Deductible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$276.21
$313.50
$353.00
$493.31
$749.64 		$487.51
$524.80
$564.30
$704.61 		$698.81
$736.10
$775.60
$915.91 		$910.11
$947.40
$986.90
$1,127.21 		$211.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552.42
$627.00
$706.00
$986.62
$1,499.28 		$763.72
$838.30
$917.30
$1,197.92 		$975.02
$1,049.60
$1,128.60
$1,409.22 		$1,186.32
$1,260.90
$1,339.90
$1,620.52 		$211.30
Toc - Plan #57 US Health and Life
Silver

(EPO) Ascension Personalized Care Balanced Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$415.96
$472.12
$531.60
$742.91
$1,128.92 		$734.17
$790.33
$849.81
$1,061.12 		$1,052.38
$1,108.54
$1,168.02
$1,379.33 		$1,370.59
$1,426.75
$1,486.23
$1,697.54 		$318.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.92
$944.24
$1,063.20
$1,485.82
$2,257.84 		$1,150.13
$1,262.45
$1,381.41
$1,804.03 		$1,468.34
$1,580.66
$1,699.62
$2,122.24 		$1,786.55
$1,898.87
$2,017.83
$2,440.45 		$318.21
Toc - Plan #58 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
$9,100 $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 		$420.75
$477.55
$537.71
$751.45
$1,141.91 		$742.62
$799.42
$859.58
$1,073.32 		$1,064.49
$1,121.29
$1,181.45
$1,395.19 		$1,386.36
$1,443.16
$1,503.32
$1,717.06 		$321.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.50
$955.10
$1,075.42
$1,502.90
$2,283.82 		$1,163.37
$1,276.97
$1,397.29
$1,824.77 		$1,485.24
$1,598.84
$1,719.16
$2,146.64 		$1,807.11
$1,920.71
$2,041.03
$2,468.51 		$321.87
Toc - Plan #59 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
$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 		$415.41
$471.49
$530.89
$741.92
$1,127.42 		$733.20
$789.28
$848.68
$1,059.71 		$1,050.99
$1,107.07
$1,166.47
$1,377.50 		$1,368.78
$1,424.86
$1,484.26
$1,695.29 		$317.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.82
$942.98
$1,061.78
$1,483.84
$2,254.84 		$1,148.61
$1,260.77
$1,379.57
$1,801.63 		$1,466.40
$1,578.56
$1,697.36
$2,119.42 		$1,784.19
$1,896.35
$2,015.15
$2,437.21 		$317.79
Toc - Plan #60 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
$9,000 $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 		$274.11
$311.11
$350.31
$489.56
$743.93 		$483.80
$520.80
$560.00
$699.25 		$693.49
$730.49
$769.69
$908.94 		$903.18
$940.18
$979.38
$1,118.63 		$209.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.22
$622.22
$700.62
$979.12
$1,487.86 		$757.91
$831.91
$910.31
$1,188.81 		$967.60
$1,041.60
$1,120.00
$1,398.50 		$1,177.29
$1,251.29
$1,329.69
$1,608.19 		$209.69
Toc - Plan #61 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
$5,800 $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 		$415.96
$472.12
$531.60
$742.91
$1,128.92 		$734.17
$790.33
$849.81
$1,061.12 		$1,052.38
$1,108.54
$1,168.02
$1,379.33 		$1,370.59
$1,426.75
$1,486.23
$1,697.54 		$318.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.92
$944.24
$1,063.20
$1,485.82
$2,257.84 		$1,150.13
$1,262.45
$1,381.41
$1,804.03 		$1,468.34
$1,580.66
$1,699.62
$2,122.24 		$1,786.55
$1,898.87
$2,017.83
$2,440.45 		$318.21
Toc - Plan #62 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
$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 		$359.54
$408.08
$459.50
$642.15
$975.80 		$634.59
$683.13
$734.55
$917.20 		$909.64
$958.18
$1,009.60
$1,192.25 		$1,184.69
$1,233.23
$1,284.65
$1,467.30 		$275.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.08
$816.16
$919.00
$1,284.30
$1,951.60 		$994.13
$1,091.21
$1,194.05
$1,559.35 		$1,269.18
$1,366.26
$1,469.10
$1,834.40 		$1,544.23
$1,641.31
$1,744.15
$2,109.45 		$275.05

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #63 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 		$404.18
$458.74
$516.53
$721.85
$1,096.92 		$713.37
$767.93
$825.72
$1,031.04 		$1,022.56
$1,077.12
$1,134.91
$1,340.23 		$1,331.75
$1,386.31
$1,444.10
$1,649.42 		$309.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.36
$917.48
$1,033.06
$1,443.70
$2,193.84 		$1,117.55
$1,226.67
$1,342.25
$1,752.89 		$1,426.74
$1,535.86
$1,651.44
$2,062.08 		$1,735.93
$1,845.05
$1,960.63
$2,371.27 		$309.19
Toc - Plan #64 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 		$380.09
$431.39
$485.74
$678.82
$1,031.53 		$670.85
$722.15
$776.50
$969.58 		$961.61
$1,012.91
$1,067.26
$1,260.34 		$1,252.37
$1,303.67
$1,358.02
$1,551.10 		$290.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.18
$862.78
$971.48
$1,357.64
$2,063.06 		$1,050.94
$1,153.54
$1,262.24
$1,648.40 		$1,341.70
$1,444.30
$1,553.00
$1,939.16 		$1,632.46
$1,735.06
$1,843.76
$2,229.92 		$290.76
Toc - Plan #65 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 		$417.47
$473.82
$533.51
$745.58
$1,132.99 		$736.83
$793.18
$852.87
$1,064.94 		$1,056.19
$1,112.54
$1,172.23
$1,384.30 		$1,375.55
$1,431.90
$1,491.59
$1,703.66 		$319.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.94
$947.64
$1,067.02
$1,491.16
$2,265.98 		$1,154.30
$1,267.00
$1,386.38
$1,810.52 		$1,473.66
$1,586.36
$1,705.74
$2,129.88 		$1,793.02
$1,905.72
$2,025.10
$2,449.24 		$319.36
Toc - Plan #66 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 		$376.46
$427.27
$481.10
$672.34
$1,021.69 		$664.44
$715.25
$769.08
$960.32 		$952.42
$1,003.23
$1,057.06
$1,248.30 		$1,240.40
$1,291.21
$1,345.04
$1,536.28 		$287.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.92
$854.54
$962.20
$1,344.68
$2,043.38 		$1,040.90
$1,142.52
$1,250.18
$1,632.66 		$1,328.88
$1,430.50
$1,538.16
$1,920.64 		$1,616.86
$1,718.48
$1,826.14
$2,208.62 		$287.98

‡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 Limestone County here.

Limestone County is in “Rating Area 26” of Texas.

Currently, there are 66 plans offered in Rating Area 26.

Top

2023 Obamacare Plans for Limestone County, TX

Plan Browser: 66 Plans
scroll down for more