Obamacare 2023 Rates for Montgomery County

Obamacare > Rates > Texas > Montgomery 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 Montgomery 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, 104 Plans and 2023 Rates for Montgomery County, Texas

Below, you’ll find a summary of the 104 plans for Montgomery County, Texas and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Oscar Insurance Company

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

Toc - Plan #1 Oscar Insurance Company

Bronze

(EPO) Bronze Simple (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 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

$293.75
$333.40
$375.40
$524.63
$797.22

$518.46
$558.11
$600.11
$749.34

$743.17
$782.82
$824.82
$974.05

$967.88
$1,007.53
$1,049.53
$1,198.76

$224.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$587.50
$666.80
$750.80
$1,049.26
$1,594.44

$812.21
$891.51
$975.51
$1,273.97

$1,036.92
$1,116.22
$1,200.22
$1,498.68

$1,261.63
$1,340.93
$1,424.93
$1,723.39

$224.71

Toc - Plan #2 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$7,750 $15,500 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$295.21
$335.06
$377.27
$527.23
$801.18

$521.04
$560.89
$603.10
$753.06

$746.87
$786.72
$828.93
$978.89

$972.70
$1,012.55
$1,054.76
$1,204.72

$225.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$590.42
$670.12
$754.54
$1,054.46
$1,602.36

$816.25
$895.95
$980.37
$1,280.29

$1,042.08
$1,121.78
$1,206.20
$1,506.12

$1,267.91
$1,347.61
$1,432.03
$1,731.95

$225.83

Toc - Plan #3 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$334.66
$379.83
$427.69
$597.69
$908.25

$590.67
$635.84
$683.70
$853.70

$846.68
$891.85
$939.71
$1,109.71

$1,102.69
$1,147.86
$1,195.72
$1,365.72

$256.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$669.32
$759.66
$855.38
$1,195.38
$1,816.50

$925.33
$1,015.67
$1,111.39
$1,451.39

$1,181.34
$1,271.68
$1,367.40
$1,707.40

$1,437.35
$1,527.69
$1,623.41
$1,963.41

$256.01

Toc - Plan #4 Oscar Insurance Company

Silver

(EPO) Silver Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,400 $10,800 Annual Deductible

$8,700 $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

$430.00
$488.04
$549.52
$767.96
$1,166.99

$758.94
$816.98
$878.46
$1,096.90

$1,087.88
$1,145.92
$1,207.40
$1,425.84

$1,416.82
$1,474.86
$1,536.34
$1,754.78

$328.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$860.00
$976.08
$1,099.04
$1,535.92
$2,333.98

$1,188.94
$1,305.02
$1,427.98
$1,864.86

$1,517.88
$1,633.96
$1,756.92
$2,193.80

$1,846.82
$1,962.90
$2,085.86
$2,522.74

$328.94

Toc - Plan #5 Oscar Insurance Company

Silver

(EPO) Silver Simple- Specialist Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$9,000 $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

$425.92
$483.40
$544.31
$760.67
$1,155.91

$751.74
$809.22
$870.13
$1,086.49

$1,077.56
$1,135.04
$1,195.95
$1,412.31

$1,403.38
$1,460.86
$1,521.77
$1,738.13

$325.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$851.84
$966.80
$1,088.62
$1,521.34
$2,311.82

$1,177.66
$1,292.62
$1,414.44
$1,847.16

$1,503.48
$1,618.44
$1,740.26
$2,172.98

$1,829.30
$1,944.26
$2,066.08
$2,498.80

$325.82

Toc - Plan #6 Oscar Insurance Company

Silver

(EPO) Silver Classic- PCP Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$430.48
$488.58
$550.14
$768.82
$1,168.29

$759.79
$817.89
$879.45
$1,098.13

$1,089.10
$1,147.20
$1,208.76
$1,427.44

$1,418.41
$1,476.51
$1,538.07
$1,756.75

$329.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$860.96
$977.16
$1,100.28
$1,537.64
$2,336.58

$1,190.27
$1,306.47
$1,429.59
$1,866.95

$1,519.58
$1,635.78
$1,758.90
$2,196.26

$1,848.89
$1,965.09
$2,088.21
$2,525.57

$329.31

Toc - Plan #7 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Elite- $0 Ded+Specialist Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $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

$333.47
$378.48
$426.16
$595.56
$905.01

$588.57
$633.58
$681.26
$850.66

$843.67
$888.68
$936.36
$1,105.76

$1,098.77
$1,143.78
$1,191.46
$1,360.86

$255.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$666.94
$756.96
$852.32
$1,191.12
$1,810.02

$922.04
$1,012.06
$1,107.42
$1,446.22

$1,177.14
$1,267.16
$1,362.52
$1,701.32

$1,432.24
$1,522.26
$1,617.62
$1,956.42

$255.10

Toc - Plan #8 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Simple- HSA (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,200 $10,400 Annual Deductible

$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$308.94
$350.64
$394.82
$551.76
$838.45

$545.27
$586.97
$631.15
$788.09

$781.60
$823.30
$867.48
$1,024.42

$1,017.93
$1,059.63
$1,103.81
$1,260.75

$236.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$617.88
$701.28
$789.64
$1,103.52
$1,676.90

$854.21
$937.61
$1,025.97
$1,339.85

$1,090.54
$1,173.94
$1,262.30
$1,576.18

$1,326.87
$1,410.27
$1,498.63
$1,812.51

$236.33

Toc - Plan #9 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Classic- $4700 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$4,700 $9,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$313.85
$356.21
$401.09
$560.52
$851.76

$553.94
$596.30
$641.18
$800.61

$794.03
$836.39
$881.27
$1,040.70

$1,034.12
$1,076.48
$1,121.36
$1,280.79

$240.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$627.70
$712.42
$802.18
$1,121.04
$1,703.52

$867.79
$952.51
$1,042.27
$1,361.13

$1,107.88
$1,192.60
$1,282.36
$1,601.22

$1,347.97
$1,432.69
$1,522.45
$1,841.31

$240.09

Toc - Plan #10 Oscar Insurance Company

Silver

(EPO) Silver Simple- PCP Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 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

$419.34
$475.94
$535.91
$748.93
$1,138.07

$740.13
$796.73
$856.70
$1,069.72

$1,060.92
$1,117.52
$1,177.49
$1,390.51

$1,381.71
$1,438.31
$1,498.28
$1,711.30

$320.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$838.68
$951.88
$1,071.82
$1,497.86
$2,276.14

$1,159.47
$1,272.67
$1,392.61
$1,818.65

$1,480.26
$1,593.46
$1,713.40
$2,139.44

$1,801.05
$1,914.25
$2,034.19
$2,460.23

$320.79

Toc - Plan #11 Oscar Insurance Company

Silver

(EPO) Silver Elite- $0 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$438.46
$497.64
$560.33
$783.07
$1,189.94

$773.87
$833.05
$895.74
$1,118.48

$1,109.28
$1,168.46
$1,231.15
$1,453.89

$1,444.69
$1,503.87
$1,566.56
$1,789.30

$335.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$876.92
$995.28
$1,120.66
$1,566.14
$2,379.88

$1,212.33
$1,330.69
$1,456.07
$1,901.55

$1,547.74
$1,666.10
$1,791.48
$2,236.96

$1,883.15
$2,001.51
$2,126.89
$2,572.37

$335.41

Toc - Plan #12 Oscar Insurance Company

Silver

(EPO) Silver Simple- For Diabetes (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$6,450 $12,900 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$427.95
$485.71
$546.90
$764.30
$1,161.42

$755.32
$813.08
$874.27
$1,091.67

$1,082.69
$1,140.45
$1,201.64
$1,419.04

$1,410.06
$1,467.82
$1,529.01
$1,746.41

$327.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$855.90
$971.42
$1,093.80
$1,528.60
$2,322.84

$1,183.27
$1,298.79
$1,421.17
$1,855.97

$1,510.64
$1,626.16
$1,748.54
$2,183.34

$1,838.01
$1,953.53
$2,075.91
$2,510.71

$327.37

Toc - Plan #13 Oscar Insurance Company

Expanded Bronze

(EPO) Bronze Classic- Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $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

$299.95
$340.43
$383.32
$535.69
$814.03

$529.40
$569.88
$612.77
$765.14

$758.85
$799.33
$842.22
$994.59

$988.30
$1,028.78
$1,071.67
$1,224.04

$229.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$599.90
$680.86
$766.64
$1,071.38
$1,628.06

$829.35
$910.31
$996.09
$1,300.83

$1,058.80
$1,139.76
$1,225.54
$1,530.28

$1,288.25
$1,369.21
$1,454.99
$1,759.73

$229.45

Toc - Plan #14 Oscar Insurance Company

Bronze

(EPO) Bronze Simple- Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

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

$282.07
$320.14
$360.47
$503.76
$765.51

$497.85
$535.92
$576.25
$719.54

$713.63
$751.70
$792.03
$935.32

$929.41
$967.48
$1,007.81
$1,151.10

$215.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$564.14
$640.28
$720.94
$1,007.52
$1,531.02

$779.92
$856.06
$936.72
$1,223.30

$995.70
$1,071.84
$1,152.50
$1,439.08

$1,211.48
$1,287.62
$1,368.28
$1,654.86

$215.78

Toc - Plan #15 Oscar Insurance Company

Silver

(EPO) Silver Classic- Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,800 $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

$419.75
$476.41
$536.43
$749.66
$1,139.19

$740.85
$797.51
$857.53
$1,070.76

$1,061.95
$1,118.61
$1,178.63
$1,391.86

$1,383.05
$1,439.71
$1,499.73
$1,712.96

$321.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$839.50
$952.82
$1,072.86
$1,499.32
$2,278.38

$1,160.60
$1,273.92
$1,393.96
$1,820.42

$1,481.70
$1,595.02
$1,715.06
$2,141.52

$1,802.80
$1,916.12
$2,036.16
$2,462.62

$321.10

Toc - Plan #16 Oscar Insurance Company

Gold

(EPO) Gold Classic- Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$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

$381.96
$433.52
$488.13
$682.17
$1,036.62

$674.15
$725.71
$780.32
$974.36

$966.34
$1,017.90
$1,072.51
$1,266.55

$1,258.53
$1,310.09
$1,364.70
$1,558.74

$292.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$763.92
$867.04
$976.26
$1,364.34
$2,073.24

$1,056.11
$1,159.23
$1,268.45
$1,656.53

$1,348.30
$1,451.42
$1,560.64
$1,948.72

$1,640.49
$1,743.61
$1,852.83
$2,240.91

$292.19

Community Health Choice

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

Toc - Plan #17 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 #18 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 #19 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 #20 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 #21 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 #22 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 #23 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 #24 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 #25 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 #26 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

Ambetter from Superior HealthPlan

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

Toc - Plan #27 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

$427.34
$485.02
$546.12
$763.21
$1,159.77

$754.25
$811.93
$873.03
$1,090.12

$1,081.16
$1,138.84
$1,199.94
$1,417.03

$1,408.07
$1,465.75
$1,526.85
$1,743.94

$326.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$854.68
$970.04
$1,092.24
$1,526.42
$2,319.54

$1,181.59
$1,296.95
$1,419.15
$1,853.33

$1,508.50
$1,623.86
$1,746.06
$2,180.24

$1,835.41
$1,950.77
$2,072.97
$2,507.15

$326.91

Toc - Plan #28 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

$393.36
$446.46
$502.71
$702.53
$1,067.56

$694.28
$747.38
$803.63
$1,003.45

$995.20
$1,048.30
$1,104.55
$1,304.37

$1,296.12
$1,349.22
$1,405.47
$1,605.29

$300.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$786.72
$892.92
$1,005.42
$1,405.06
$2,135.12

$1,087.64
$1,193.84
$1,306.34
$1,705.98

$1,388.56
$1,494.76
$1,607.26
$2,006.90

$1,689.48
$1,795.68
$1,908.18
$2,307.82

$300.92

Toc - Plan #29 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

$423.06
$480.17
$540.66
$755.57
$1,148.17

$746.70
$803.81
$864.30
$1,079.21

$1,070.34
$1,127.45
$1,187.94
$1,402.85

$1,393.98
$1,451.09
$1,511.58
$1,726.49

$323.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$846.12
$960.34
$1,081.32
$1,511.14
$2,296.34

$1,169.76
$1,283.98
$1,404.96
$1,834.78

$1,493.40
$1,607.62
$1,728.60
$2,158.42

$1,817.04
$1,931.26
$2,052.24
$2,482.06

$323.64

Toc - Plan #30 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

$421.48
$478.37
$538.64
$752.75
$1,143.88

$743.91
$800.80
$861.07
$1,075.18

$1,066.34
$1,123.23
$1,183.50
$1,397.61

$1,388.77
$1,445.66
$1,505.93
$1,720.04

$322.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$842.96
$956.74
$1,077.28
$1,505.50
$2,287.76

$1,165.39
$1,279.17
$1,399.71
$1,827.93

$1,487.82
$1,601.60
$1,722.14
$2,150.36

$1,810.25
$1,924.03
$2,044.57
$2,472.79

$322.43

Toc - Plan #31 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

$382.81
$434.48
$489.22
$683.68
$1,038.92

$675.65
$727.32
$782.06
$976.52

$968.49
$1,020.16
$1,074.90
$1,269.36

$1,261.33
$1,313.00
$1,367.74
$1,562.20

$292.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.62
$868.96
$978.44
$1,367.36
$2,077.84

$1,058.46
$1,161.80
$1,271.28
$1,660.20

$1,351.30
$1,454.64
$1,564.12
$1,953.04

$1,644.14
$1,747.48
$1,856.96
$2,245.88

$292.84

Toc - Plan #32 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

$380.50
$431.86
$486.27
$679.56
$1,032.66

$671.58
$722.94
$777.35
$970.64

$962.66
$1,014.02
$1,068.43
$1,261.72

$1,253.74
$1,305.10
$1,359.51
$1,552.80

$291.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$761.00
$863.72
$972.54
$1,359.12
$2,065.32

$1,052.08
$1,154.80
$1,263.62
$1,650.20

$1,343.16
$1,445.88
$1,554.70
$1,941.28

$1,634.24
$1,736.96
$1,845.78
$2,232.36

$291.08

Toc - Plan #33 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

$421.18
$478.03
$538.26
$752.22
$1,143.06

$743.38
$800.23
$860.46
$1,074.42

$1,065.58
$1,122.43
$1,182.66
$1,396.62

$1,387.78
$1,444.63
$1,504.86
$1,718.82

$322.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$842.36
$956.06
$1,076.52
$1,504.44
$2,286.12

$1,164.56
$1,278.26
$1,398.72
$1,826.64

$1,486.76
$1,600.46
$1,720.92
$2,148.84

$1,808.96
$1,922.66
$2,043.12
$2,471.04

$322.20

Toc - Plan #34 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

$379.78
$431.03
$485.34
$678.26
$1,030.68

$670.30
$721.55
$775.86
$968.78

$960.82
$1,012.07
$1,066.38
$1,259.30

$1,251.34
$1,302.59
$1,356.90
$1,549.82

$290.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$759.56
$862.06
$970.68
$1,356.52
$2,061.36

$1,050.08
$1,152.58
$1,261.20
$1,647.04

$1,340.60
$1,443.10
$1,551.72
$1,937.56

$1,631.12
$1,733.62
$1,842.24
$2,228.08

$290.52

Toc - Plan #35 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

$409.73
$465.03
$523.62
$731.75
$1,111.97

$723.16
$778.46
$837.05
$1,045.18

$1,036.59
$1,091.89
$1,150.48
$1,358.61

$1,350.02
$1,405.32
$1,463.91
$1,672.04

$313.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$819.46
$930.06
$1,047.24
$1,463.50
$2,223.94

$1,132.89
$1,243.49
$1,360.67
$1,776.93

$1,446.32
$1,556.92
$1,674.10
$2,090.36

$1,759.75
$1,870.35
$1,987.53
$2,403.79

$313.43

Toc - Plan #36 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

$445.11
$505.19
$568.84
$794.95
$1,208.00

$785.61
$845.69
$909.34
$1,135.45

$1,126.11
$1,186.19
$1,249.84
$1,475.95

$1,466.61
$1,526.69
$1,590.34
$1,816.45

$340.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$890.22
$1,010.38
$1,137.68
$1,589.90
$2,416.00

$1,230.72
$1,350.88
$1,478.18
$1,930.40

$1,571.22
$1,691.38
$1,818.68
$2,270.90

$1,911.72
$2,031.88
$2,159.18
$2,611.40

$340.50

Toc - Plan #37 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

$439.01
$498.27
$561.05
$784.06
$1,191.45

$774.85
$834.11
$896.89
$1,119.90

$1,110.69
$1,169.95
$1,232.73
$1,455.74

$1,446.53
$1,505.79
$1,568.57
$1,791.58

$335.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$878.02
$996.54
$1,122.10
$1,568.12
$2,382.90

$1,213.86
$1,332.38
$1,457.94
$1,903.96

$1,549.70
$1,668.22
$1,793.78
$2,239.80

$1,885.54
$2,004.06
$2,129.62
$2,575.64

$335.84

Toc - Plan #38 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

$398.73
$452.55
$509.57
$712.12
$1,082.13

$703.75
$757.57
$814.59
$1,017.14

$1,008.77
$1,062.59
$1,119.61
$1,322.16

$1,313.79
$1,367.61
$1,424.63
$1,627.18

$305.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$797.46
$905.10
$1,019.14
$1,424.24
$2,164.26

$1,102.48
$1,210.12
$1,324.16
$1,729.26

$1,407.50
$1,515.14
$1,629.18
$2,034.28

$1,712.52
$1,820.16
$1,934.20
$2,339.30

$305.02

Toc - Plan #39 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

$440.66
$500.14
$563.15
$787.00
$1,195.92

$777.76
$837.24
$900.25
$1,124.10

$1,114.86
$1,174.34
$1,237.35
$1,461.20

$1,451.96
$1,511.44
$1,574.45
$1,798.30

$337.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$881.32
$1,000.28
$1,126.30
$1,574.00
$2,391.84

$1,218.42
$1,337.38
$1,463.40
$1,911.10

$1,555.52
$1,674.48
$1,800.50
$2,248.20

$1,892.62
$2,011.58
$2,137.60
$2,585.30

$337.10

Toc - Plan #40 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

$396.33
$449.82
$506.49
$707.82
$1,075.61

$699.51
$753.00
$809.67
$1,011.00

$1,002.69
$1,056.18
$1,112.85
$1,314.18

$1,305.87
$1,359.36
$1,416.03
$1,617.36

$303.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$792.66
$899.64
$1,012.98
$1,415.64
$2,151.22

$1,095.84
$1,202.82
$1,316.16
$1,718.82

$1,399.02
$1,506.00
$1,619.34
$2,022.00

$1,702.20
$1,809.18
$1,922.52
$2,325.18

$303.18

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 #41 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

$375.67
$426.39
$480.11
$670.95
$1,019.58

$663.06
$713.78
$767.50
$958.34

$950.45
$1,001.17
$1,054.89
$1,245.73

$1,237.84
$1,288.56
$1,342.28
$1,533.12

$287.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$751.34
$852.78
$960.22
$1,341.90
$2,039.16

$1,038.73
$1,140.17
$1,247.61
$1,629.29

$1,326.12
$1,427.56
$1,535.00
$1,916.68

$1,613.51
$1,714.95
$1,822.39
$2,204.07

$287.39

Toc - Plan #42 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

$386.71
$438.91
$494.21
$690.66
$1,049.52

$682.54
$734.74
$790.04
$986.49

$978.37
$1,030.57
$1,085.87
$1,282.32

$1,274.20
$1,326.40
$1,381.70
$1,578.15

$295.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$773.42
$877.82
$988.42
$1,381.32
$2,099.04

$1,069.25
$1,173.65
$1,284.25
$1,677.15

$1,365.08
$1,469.48
$1,580.08
$1,972.98

$1,660.91
$1,765.31
$1,875.91
$2,268.81

$295.83

Toc - Plan #43 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

$451.82
$512.82
$577.43
$806.96
$1,226.25

$797.46
$858.46
$923.07
$1,152.60

$1,143.10
$1,204.10
$1,268.71
$1,498.24

$1,488.74
$1,549.74
$1,614.35
$1,843.88

$345.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$903.64
$1,025.64
$1,154.86
$1,613.92
$2,452.50

$1,249.28
$1,371.28
$1,500.50
$1,959.56

$1,594.92
$1,716.92
$1,846.14
$2,305.20

$1,940.56
$2,062.56
$2,191.78
$2,650.84

$345.64

Toc - Plan #44 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

$307.43
$348.94
$392.90
$549.08
$834.38

$542.62
$584.13
$628.09
$784.27

$777.81
$819.32
$863.28
$1,019.46

$1,013.00
$1,054.51
$1,098.47
$1,254.65

$235.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$614.86
$697.88
$785.80
$1,098.16
$1,668.76

$850.05
$933.07
$1,020.99
$1,333.35

$1,085.24
$1,168.26
$1,256.18
$1,568.54

$1,320.43
$1,403.45
$1,491.37
$1,803.73

$235.19

Toc - Plan #45 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

$319.74
$362.90
$408.63
$571.05
$867.77

$564.34
$607.50
$653.23
$815.65

$808.94
$852.10
$897.83
$1,060.25

$1,053.54
$1,096.70
$1,142.43
$1,304.85

$244.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$639.48
$725.80
$817.26
$1,142.10
$1,735.54

$884.08
$970.40
$1,061.86
$1,386.70

$1,128.68
$1,215.00
$1,306.46
$1,631.30

$1,373.28
$1,459.60
$1,551.06
$1,875.90

$244.60

Toc - Plan #46 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

$305.84
$347.13
$390.87
$546.23
$830.06

$539.81
$581.10
$624.84
$780.20

$773.78
$815.07
$858.81
$1,014.17

$1,007.75
$1,049.04
$1,092.78
$1,248.14

$233.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$611.68
$694.26
$781.74
$1,092.46
$1,660.12

$845.65
$928.23
$1,015.71
$1,326.43

$1,079.62
$1,162.20
$1,249.68
$1,560.40

$1,313.59
$1,396.17
$1,483.65
$1,794.37

$233.97

Toc - Plan #47 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

$275.13
$312.28
$351.62
$491.39
$746.71

$485.61
$522.76
$562.10
$701.87

$696.09
$733.24
$772.58
$912.35

$906.57
$943.72
$983.06
$1,122.83

$210.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$550.26
$624.56
$703.24
$982.78
$1,493.42

$760.74
$835.04
$913.72
$1,193.26

$971.22
$1,045.52
$1,124.20
$1,403.74

$1,181.70
$1,256.00
$1,334.68
$1,614.22

$210.48

Toc - Plan #48 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

$320.17
$363.40
$409.18
$571.83
$868.95

$565.10
$608.33
$654.11
$816.76

$810.03
$853.26
$899.04
$1,061.69

$1,054.96
$1,098.19
$1,143.97
$1,306.62

$244.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$640.34
$726.80
$818.36
$1,143.66
$1,737.90

$885.27
$971.73
$1,063.29
$1,388.59

$1,130.20
$1,216.66
$1,308.22
$1,633.52

$1,375.13
$1,461.59
$1,553.15
$1,878.45

$244.93

Toc - Plan #49 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

$380.78
$432.18
$486.63
$680.07
$1,033.43

$672.07
$723.47
$777.92
$971.36

$963.36
$1,014.76
$1,069.21
$1,262.65

$1,254.65
$1,306.05
$1,360.50
$1,553.94

$291.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$761.56
$864.36
$973.26
$1,360.14
$2,066.86

$1,052.85
$1,155.65
$1,264.55
$1,651.43

$1,344.14
$1,446.94
$1,555.84
$1,942.72

$1,635.43
$1,738.23
$1,847.13
$2,234.01

$291.29

Toc - Plan #50 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

$454.09
$515.39
$580.33
$811.00
$1,232.40

$801.47
$862.77
$927.71
$1,158.38

$1,148.85
$1,210.15
$1,275.09
$1,505.76

$1,496.23
$1,557.53
$1,622.47
$1,853.14

$347.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$908.18
$1,030.78
$1,160.66
$1,622.00
$2,464.80

$1,255.56
$1,378.16
$1,508.04
$1,969.38

$1,602.94
$1,725.54
$1,855.42
$2,316.76

$1,950.32
$2,072.92
$2,202.80
$2,664.14

$347.38

Toc - Plan #51 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

$299.14
$339.52
$382.30
$534.26
$811.86

$527.98
$568.36
$611.14
$763.10

$756.82
$797.20
$839.98
$991.94

$985.66
$1,026.04
$1,068.82
$1,220.78

$228.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$598.28
$679.04
$764.60
$1,068.52
$1,623.72

$827.12
$907.88
$993.44
$1,297.36

$1,055.96
$1,136.72
$1,222.28
$1,526.20

$1,284.80
$1,365.56
$1,451.12
$1,755.04

$228.84

Toc - Plan #52 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

$319.12
$362.20
$407.83
$569.94
$866.08

$563.24
$606.32
$651.95
$814.06

$807.36
$850.44
$896.07
$1,058.18

$1,051.48
$1,094.56
$1,140.19
$1,302.30

$244.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$638.24
$724.40
$815.66
$1,139.88
$1,732.16

$882.36
$968.52
$1,059.78
$1,384.00

$1,126.48
$1,212.64
$1,303.90
$1,628.12

$1,370.60
$1,456.76
$1,548.02
$1,872.24

$244.12

Toc - Plan #53 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

$442.87
$502.66
$565.99
$790.96
$1,201.94

$781.66
$841.45
$904.78
$1,129.75

$1,120.45
$1,180.24
$1,243.57
$1,468.54

$1,459.24
$1,519.03
$1,582.36
$1,807.33

$338.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$885.74
$1,005.32
$1,131.98
$1,581.92
$2,403.88

$1,224.53
$1,344.11
$1,470.77
$1,920.71

$1,563.32
$1,682.90
$1,809.56
$2,259.50

$1,902.11
$2,021.69
$2,148.35
$2,598.29

$338.79

Toc - Plan #54 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

$529.86
$601.39
$677.16
$946.32
$1,438.03

$935.20
$1,006.73
$1,082.50
$1,351.66

$1,340.54
$1,412.07
$1,487.84
$1,757.00

$1,745.88
$1,817.41
$1,893.18
$2,162.34

$405.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,059.72
$1,202.78
$1,354.32
$1,892.64
$2,876.06

$1,465.06
$1,608.12
$1,759.66
$2,297.98

$1,870.40
$2,013.46
$2,165.00
$2,703.32

$2,275.74
$2,418.80
$2,570.34
$3,108.66

$405.34

Toc - Plan #55 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

$534.90
$607.11
$683.60
$955.33
$1,451.71

$944.10
$1,016.31
$1,092.80
$1,364.53

$1,353.30
$1,425.51
$1,502.00
$1,773.73

$1,762.50
$1,834.71
$1,911.20
$2,182.93

$409.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,069.80
$1,214.22
$1,367.20
$1,910.66
$2,903.42

$1,479.00
$1,623.42
$1,776.40
$2,319.86

$1,888.20
$2,032.62
$2,185.60
$2,729.06

$2,297.40
$2,441.82
$2,594.80
$3,138.26

$409.20

Toc - Plan #56 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

$363.27
$412.31
$464.26
$648.80
$985.92

$641.17
$690.21
$742.16
$926.70

$919.07
$968.11
$1,020.06
$1,204.60

$1,196.97
$1,246.01
$1,297.96
$1,482.50

$277.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$726.54
$824.62
$928.52
$1,297.60
$1,971.84

$1,004.44
$1,102.52
$1,206.42
$1,575.50

$1,282.34
$1,380.42
$1,484.32
$1,853.40

$1,560.24
$1,658.32
$1,762.22
$2,131.30

$277.90

Toc - Plan #57 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

$346.38
$393.14
$442.67
$618.63
$940.07

$611.36
$658.12
$707.65
$883.61

$876.34
$923.10
$972.63
$1,148.59

$1,141.32
$1,188.08
$1,237.61
$1,413.57

$264.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$692.76
$786.28
$885.34
$1,237.26
$1,880.14

$957.74
$1,051.26
$1,150.32
$1,502.24

$1,222.72
$1,316.24
$1,415.30
$1,767.22

$1,487.70
$1,581.22
$1,680.28
$2,032.20

$264.98

Toc - Plan #58 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

$441.16
$500.71
$563.80
$787.90
$1,197.30

$778.64
$838.19
$901.28
$1,125.38

$1,116.12
$1,175.67
$1,238.76
$1,462.86

$1,453.60
$1,513.15
$1,576.24
$1,800.34

$337.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$882.32
$1,001.42
$1,127.60
$1,575.80
$2,394.60

$1,219.80
$1,338.90
$1,465.08
$1,913.28

$1,557.28
$1,676.38
$1,802.56
$2,250.76

$1,894.76
$2,013.86
$2,140.04
$2,588.24

$337.48

Toc - Plan #59 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

$526.67
$597.76
$673.08
$940.62
$1,429.37

$929.57
$1,000.66
$1,075.98
$1,343.52

$1,332.47
$1,403.56
$1,478.88
$1,746.42

$1,735.37
$1,806.46
$1,881.78
$2,149.32

$402.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,053.34
$1,195.52
$1,346.16
$1,881.24
$2,858.74

$1,456.24
$1,598.42
$1,749.06
$2,284.14

$1,859.14
$2,001.32
$2,151.96
$2,687.04

$2,262.04
$2,404.22
$2,554.86
$3,089.94

$402.90

Toc - Plan #60 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

$347.81
$394.76
$444.50
$621.18
$943.95

$613.88
$660.83
$710.57
$887.25

$879.95
$926.90
$976.64
$1,153.32

$1,146.02
$1,192.97
$1,242.71
$1,419.39

$266.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$695.62
$789.52
$889.00
$1,242.36
$1,887.90

$961.69
$1,055.59
$1,155.07
$1,508.43

$1,227.76
$1,321.66
$1,421.14
$1,774.50

$1,493.83
$1,587.73
$1,687.21
$2,040.57

$266.07

Toc - Plan #61 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

$370.20
$420.18
$473.12
$661.18
$1,004.72

$653.40
$703.38
$756.32
$944.38

$936.60
$986.58
$1,039.52
$1,227.58

$1,219.80
$1,269.78
$1,322.72
$1,510.78

$283.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$740.40
$840.36
$946.24
$1,322.36
$2,009.44

$1,023.60
$1,123.56
$1,229.44
$1,605.56

$1,306.80
$1,406.76
$1,512.64
$1,888.76

$1,590.00
$1,689.96
$1,795.84
$2,171.96

$283.20

UnitedHealthcare

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

Toc - Plan #62 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

$357.50
$405.76
$456.88
$638.49
$970.25

$630.99
$679.25
$730.37
$911.98

$904.48
$952.74
$1,003.86
$1,185.47

$1,177.97
$1,226.23
$1,277.35
$1,458.96

$273.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.00
$811.52
$913.76
$1,276.98
$1,940.50

$988.49
$1,085.01
$1,187.25
$1,550.47

$1,261.98
$1,358.50
$1,460.74
$1,823.96

$1,535.47
$1,631.99
$1,734.23
$2,097.45

$273.49

Toc - Plan #63 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

$406.00
$460.81
$518.87
$725.12
$1,101.89

$716.59
$771.40
$829.46
$1,035.71

$1,027.18
$1,081.99
$1,140.05
$1,346.30

$1,337.77
$1,392.58
$1,450.64
$1,656.89

$310.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$812.00
$921.62
$1,037.74
$1,450.24
$2,203.78

$1,122.59
$1,232.21
$1,348.33
$1,760.83

$1,433.18
$1,542.80
$1,658.92
$2,071.42

$1,743.77
$1,853.39
$1,969.51
$2,382.01

$310.59

Toc - Plan #64 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

$411.33
$466.86
$525.68
$734.64
$1,116.36

$726.00
$781.53
$840.35
$1,049.31

$1,040.67
$1,096.20
$1,155.02
$1,363.98

$1,355.34
$1,410.87
$1,469.69
$1,678.65

$314.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$822.66
$933.72
$1,051.36
$1,469.28
$2,232.72

$1,137.33
$1,248.39
$1,366.03
$1,783.95

$1,452.00
$1,563.06
$1,680.70
$2,098.62

$1,766.67
$1,877.73
$1,995.37
$2,413.29

$314.67

Toc - Plan #65 UnitedHealthcare

Silver

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

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

$394.73
$448.02
$504.47
$704.99
$1,071.30

$696.70
$749.99
$806.44
$1,006.96

$998.67
$1,051.96
$1,108.41
$1,308.93

$1,300.64
$1,353.93
$1,410.38
$1,610.90

$301.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$789.46
$896.04
$1,008.94
$1,409.98
$2,142.60

$1,091.43
$1,198.01
$1,310.91
$1,711.95

$1,393.40
$1,499.98
$1,612.88
$2,013.92

$1,695.37
$1,801.95
$1,914.85
$2,315.89

$301.97

Toc - Plan #66 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

$290.02
$329.17
$370.64
$517.97
$787.11

$511.88
$551.03
$592.50
$739.83

$733.74
$772.89
$814.36
$961.69

$955.60
$994.75
$1,036.22
$1,183.55

$221.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$580.04
$658.34
$741.28
$1,035.94
$1,574.22

$801.90
$880.20
$963.14
$1,257.80

$1,023.76
$1,102.06
$1,185.00
$1,479.66

$1,245.62
$1,323.92
$1,406.86
$1,701.52

$221.86

Toc - Plan #67 UnitedHealthcare

Expanded Bronze

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

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

$283.23
$321.47
$361.97
$505.86
$768.70

$499.90
$538.14
$578.64
$722.53

$716.57
$754.81
$795.31
$939.20

$933.24
$971.48
$1,011.98
$1,155.87

$216.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$566.46
$642.94
$723.94
$1,011.72
$1,537.40

$783.13
$859.61
$940.61
$1,228.39

$999.80
$1,076.28
$1,157.28
$1,445.06

$1,216.47
$1,292.95
$1,373.95
$1,661.73

$216.67

Toc - Plan #68 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

$360.89
$409.61
$461.22
$644.55
$979.46

$636.97
$685.69
$737.30
$920.63

$913.05
$961.77
$1,013.38
$1,196.71

$1,189.13
$1,237.85
$1,289.46
$1,472.79

$276.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$721.78
$819.22
$922.44
$1,289.10
$1,958.92

$997.86
$1,095.30
$1,198.52
$1,565.18

$1,273.94
$1,371.38
$1,474.60
$1,841.26

$1,550.02
$1,647.46
$1,750.68
$2,117.34

$276.08

Toc - Plan #69 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

$282.70
$320.87
$361.29
$504.91
$767.25

$498.97
$537.14
$577.56
$721.18

$715.24
$753.41
$793.83
$937.45

$931.51
$969.68
$1,010.10
$1,153.72

$216.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$565.40
$641.74
$722.58
$1,009.82
$1,534.50

$781.67
$858.01
$938.85
$1,226.09

$997.94
$1,074.28
$1,155.12
$1,442.36

$1,214.21
$1,290.55
$1,371.39
$1,658.63

$216.27

Toc - Plan #70 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

$289.77
$328.89
$370.33
$517.53
$786.44

$511.45
$550.57
$592.01
$739.21

$733.13
$772.25
$813.69
$960.89

$954.81
$993.93
$1,035.37
$1,182.57

$221.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$579.54
$657.78
$740.66
$1,035.06
$1,572.88

$801.22
$879.46
$962.34
$1,256.74

$1,022.90
$1,101.14
$1,184.02
$1,478.42

$1,244.58
$1,322.82
$1,405.70
$1,700.10

$221.68

Toc - Plan #71 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

$274.34
$311.38
$350.61
$489.97
$744.56

$484.21
$521.25
$560.48
$699.84

$694.08
$731.12
$770.35
$909.71

$903.95
$940.99
$980.22
$1,119.58

$209.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$548.68
$622.76
$701.22
$979.94
$1,489.12

$758.55
$832.63
$911.09
$1,189.81

$968.42
$1,042.50
$1,120.96
$1,399.68

$1,178.29
$1,252.37
$1,330.83
$1,609.55

$209.87

Toc - Plan #72 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

$405.23
$459.94
$517.89
$723.74
$1,099.80

$715.23
$769.94
$827.89
$1,033.74

$1,025.23
$1,079.94
$1,137.89
$1,343.74

$1,335.23
$1,389.94
$1,447.89
$1,653.74

$310.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$810.46
$919.88
$1,035.78
$1,447.48
$2,199.60

$1,120.46
$1,229.88
$1,345.78
$1,757.48

$1,430.46
$1,539.88
$1,655.78
$2,067.48

$1,740.46
$1,849.88
$1,965.78
$2,377.48

$310.00

Toc - Plan #73 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

$423.04
$480.15
$540.64
$755.54
$1,148.12

$746.66
$803.77
$864.26
$1,079.16

$1,070.28
$1,127.39
$1,187.88
$1,402.78

$1,393.90
$1,451.01
$1,511.50
$1,726.40

$323.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$846.08
$960.30
$1,081.28
$1,511.08
$2,296.24

$1,169.70
$1,283.92
$1,404.90
$1,834.70

$1,493.32
$1,607.54
$1,728.52
$2,158.32

$1,816.94
$1,931.16
$2,052.14
$2,481.94

$323.62

Toc - Plan #74 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

$422.20
$479.20
$539.57
$754.05
$1,145.85

$745.18
$802.18
$862.55
$1,077.03

$1,068.16
$1,125.16
$1,185.53
$1,400.01

$1,391.14
$1,448.14
$1,508.51
$1,722.99

$322.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$844.40
$958.40
$1,079.14
$1,508.10
$2,291.70

$1,167.38
$1,281.38
$1,402.12
$1,831.08

$1,490.36
$1,604.36
$1,725.10
$2,154.06

$1,813.34
$1,927.34
$2,048.08
$2,477.04

$322.98

Toc - Plan #75 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

$406.38
$461.24
$519.35
$725.79
$1,102.91

$717.26
$772.12
$830.23
$1,036.67

$1,028.14
$1,083.00
$1,141.11
$1,347.55

$1,339.02
$1,393.88
$1,451.99
$1,658.43

$310.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$812.76
$922.48
$1,038.70
$1,451.58
$2,205.82

$1,123.64
$1,233.36
$1,349.58
$1,762.46

$1,434.52
$1,544.24
$1,660.46
$2,073.34

$1,745.40
$1,855.12
$1,971.34
$2,384.22

$310.88

Toc - Plan #76 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

$357.00
$405.19
$456.24
$637.60
$968.89

$630.10
$678.29
$729.34
$910.70

$903.20
$951.39
$1,002.44
$1,183.80

$1,176.30
$1,224.49
$1,275.54
$1,456.90

$273.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$714.00
$810.38
$912.48
$1,275.20
$1,937.78

$987.10
$1,083.48
$1,185.58
$1,548.30

$1,260.20
$1,356.58
$1,458.68
$1,821.40

$1,533.30
$1,629.68
$1,731.78
$2,094.50

$273.10

Toc - Plan #77 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

$356.61
$404.75
$455.74
$636.90
$967.83

$629.41
$677.55
$728.54
$909.70

$902.21
$950.35
$1,001.34
$1,182.50

$1,175.01
$1,223.15
$1,274.14
$1,455.30

$272.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$713.22
$809.50
$911.48
$1,273.80
$1,935.66

$986.02
$1,082.30
$1,184.28
$1,546.60

$1,258.82
$1,355.10
$1,457.08
$1,819.40

$1,531.62
$1,627.90
$1,729.88
$2,092.20

$272.80

Toc - Plan #78 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

$374.41
$424.95
$478.49
$668.69
$1,016.15

$660.83
$711.37
$764.91
$955.11

$947.25
$997.79
$1,051.33
$1,241.53

$1,233.67
$1,284.21
$1,337.75
$1,527.95

$286.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$748.82
$849.90
$956.98
$1,337.38
$2,032.30

$1,035.24
$1,136.32
$1,243.40
$1,623.80

$1,321.66
$1,422.74
$1,529.82
$1,910.22

$1,608.08
$1,709.16
$1,816.24
$2,196.64

$286.42

Toc - Plan #79 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

$366.26
$415.70
$468.08
$654.14
$994.03

$646.45
$695.89
$748.27
$934.33

$926.64
$976.08
$1,028.46
$1,214.52

$1,206.83
$1,256.27
$1,308.65
$1,494.71

$280.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$732.52
$831.40
$936.16
$1,308.28
$1,988.06

$1,012.71
$1,111.59
$1,216.35
$1,588.47

$1,292.90
$1,391.78
$1,496.54
$1,868.66

$1,573.09
$1,671.97
$1,776.73
$2,148.85

$280.19

Molina Healthcare

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

Toc - Plan #80 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

$445.04
$505.12
$568.77
$794.85
$1,207.85

$785.50
$845.58
$909.23
$1,135.31

$1,125.96
$1,186.04
$1,249.69
$1,475.77

$1,466.42
$1,526.50
$1,590.15
$1,816.23

$340.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$890.08
$1,010.24
$1,137.54
$1,589.70
$2,415.70

$1,230.54
$1,350.70
$1,478.00
$1,930.16

$1,571.00
$1,691.16
$1,818.46
$2,270.62

$1,911.46
$2,031.62
$2,158.92
$2,611.08

$340.46

Toc - Plan #81 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

$382.61
$434.26
$488.97
$683.34
$1,038.40

$675.30
$726.95
$781.66
$976.03

$967.99
$1,019.64
$1,074.35
$1,268.72

$1,260.68
$1,312.33
$1,367.04
$1,561.41

$292.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.22
$868.52
$977.94
$1,366.68
$2,076.80

$1,057.91
$1,161.21
$1,270.63
$1,659.37

$1,350.60
$1,453.90
$1,563.32
$1,952.06

$1,643.29
$1,746.59
$1,856.01
$2,244.75

$292.69

Toc - Plan #82 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

$441.69
$501.32
$564.48
$788.86
$1,198.75

$779.58
$839.21
$902.37
$1,126.75

$1,117.47
$1,177.10
$1,240.26
$1,464.64

$1,455.36
$1,514.99
$1,578.15
$1,802.53

$337.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$883.38
$1,002.64
$1,128.96
$1,577.72
$2,397.50

$1,221.27
$1,340.53
$1,466.85
$1,915.61

$1,559.16
$1,678.42
$1,804.74
$2,253.50

$1,897.05
$2,016.31
$2,142.63
$2,591.39

$337.89

Toc - Plan #83 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

$382.56
$434.21
$488.92
$683.26
$1,038.28

$675.22
$726.87
$781.58
$975.92

$967.88
$1,019.53
$1,074.24
$1,268.58

$1,260.54
$1,312.19
$1,366.90
$1,561.24

$292.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.12
$868.42
$977.84
$1,366.52
$2,076.56

$1,057.78
$1,161.08
$1,270.50
$1,659.18

$1,350.44
$1,453.74
$1,563.16
$1,951.84

$1,643.10
$1,746.40
$1,855.82
$2,244.50

$292.66

Toc - Plan #84 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

$434.66
$493.33
$555.49
$776.29
$1,179.65

$767.17
$825.84
$888.00
$1,108.80

$1,099.68
$1,158.35
$1,220.51
$1,441.31

$1,432.19
$1,490.86
$1,553.02
$1,773.82

$332.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$869.32
$986.66
$1,110.98
$1,552.58
$2,359.30

$1,201.83
$1,319.17
$1,443.49
$1,885.09

$1,534.34
$1,651.68
$1,776.00
$2,217.60

$1,866.85
$1,984.19
$2,108.51
$2,550.11

$332.51

Toc - Plan #85 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

$386.75
$438.97
$494.27
$690.74
$1,049.65

$682.62
$734.84
$790.14
$986.61

$978.49
$1,030.71
$1,086.01
$1,282.48

$1,274.36
$1,326.58
$1,381.88
$1,578.35

$295.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$773.50
$877.94
$988.54
$1,381.48
$2,099.30

$1,069.37
$1,173.81
$1,284.41
$1,677.35

$1,365.24
$1,469.68
$1,580.28
$1,973.22

$1,661.11
$1,765.55
$1,876.15
$2,269.09

$295.87

Toc - Plan #86 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

$447.21
$507.58
$571.53
$798.71
$1,213.72

$789.32
$849.69
$913.64
$1,140.82

$1,131.43
$1,191.80
$1,255.75
$1,482.93

$1,473.54
$1,533.91
$1,597.86
$1,825.04

$342.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$894.42
$1,015.16
$1,143.06
$1,597.42
$2,427.44

$1,236.53
$1,357.27
$1,485.17
$1,939.53

$1,578.64
$1,699.38
$1,827.28
$2,281.64

$1,920.75
$2,041.49
$2,169.39
$2,623.75

$342.11

Aetna CVS Health

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

Toc - Plan #87 Aetna CVS Health

Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$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

$374.74
$425.33
$478.92
$669.29
$1,017.05

$661.42
$712.01
$765.60
$955.97

$948.10
$998.69
$1,052.28
$1,242.65

$1,234.78
$1,285.37
$1,338.96
$1,529.33

$286.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$749.48
$850.66
$957.84
$1,338.58
$2,034.10

$1,036.16
$1,137.34
$1,244.52
$1,625.26

$1,322.84
$1,424.02
$1,531.20
$1,911.94

$1,609.52
$1,710.70
$1,817.88
$2,198.62

$286.68

Toc - Plan #88 Aetna CVS Health

Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$4,700 $9,400 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

$355.63
$403.64
$454.50
$635.16
$965.19

$627.69
$675.70
$726.56
$907.22

$899.75
$947.76
$998.62
$1,179.28

$1,171.81
$1,219.82
$1,270.68
$1,451.34

$272.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$711.26
$807.28
$909.00
$1,270.32
$1,930.38

$983.32
$1,079.34
$1,181.06
$1,542.38

$1,255.38
$1,351.40
$1,453.12
$1,814.44

$1,527.44
$1,623.46
$1,725.18
$2,086.50

$272.06

Toc - Plan #89 Aetna CVS Health

Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$4,400 $8,800 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$356.72
$404.87
$455.88
$637.09
$968.13

$629.61
$677.76
$728.77
$909.98

$902.50
$950.65
$1,001.66
$1,182.87

$1,175.39
$1,223.54
$1,274.55
$1,455.76

$272.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$713.44
$809.74
$911.76
$1,274.18
$1,936.26

$986.33
$1,082.63
$1,184.65
$1,547.07

$1,259.22
$1,355.52
$1,457.54
$1,819.96

$1,532.11
$1,628.41
$1,730.43
$2,092.85

$272.89

Toc - Plan #90 Aetna CVS Health

Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

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

$254.75
$289.14
$325.57
$454.99
$691.40

$449.63
$484.02
$520.45
$649.87

$644.51
$678.90
$715.33
$844.75

$839.39
$873.78
$910.21
$1,039.63

$194.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$509.50
$578.28
$651.14
$909.98
$1,382.80

$704.38
$773.16
$846.02
$1,104.86

$899.26
$968.04
$1,040.90
$1,299.74

$1,094.14
$1,162.92
$1,235.78
$1,494.62

$194.88

Toc - Plan #91 Aetna CVS Health

Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

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

$345.38
$392.01
$441.40
$616.85
$937.37

$609.60
$656.23
$705.62
$881.07

$873.82
$920.45
$969.84
$1,145.29

$1,138.04
$1,184.67
$1,234.06
$1,409.51

$264.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$690.76
$784.02
$882.80
$1,233.70
$1,874.74

$954.98
$1,048.24
$1,147.02
$1,497.92

$1,219.20
$1,312.46
$1,411.24
$1,762.14

$1,483.42
$1,576.68
$1,675.46
$2,026.36

$264.22

Toc - Plan #92 Aetna CVS Health

Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$5,900 $11,800 Annual Deductible

$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

$362.98
$411.99
$463.89
$648.29
$985.14

$640.66
$689.67
$741.57
$925.97

$918.34
$967.35
$1,019.25
$1,203.65

$1,196.02
$1,245.03
$1,296.93
$1,481.33

$277.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$725.96
$823.98
$927.78
$1,296.58
$1,970.28

$1,003.64
$1,101.66
$1,205.46
$1,574.26

$1,281.32
$1,379.34
$1,483.14
$1,851.94

$1,559.00
$1,657.02
$1,760.82
$2,129.62

$277.68

Toc - Plan #93 Aetna CVS Health

Silver

(HMO) Silver 4: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,950 $17,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$454.60
$515.98
$580.98
$811.92
$1,233.80

$802.37
$863.75
$928.75
$1,159.69

$1,150.14
$1,211.52
$1,276.52
$1,507.46

$1,497.91
$1,559.29
$1,624.29
$1,855.23

$347.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$909.20
$1,031.96
$1,161.96
$1,623.84
$2,467.60

$1,256.97
$1,379.73
$1,509.73
$1,971.61

$1,604.74
$1,727.50
$1,857.50
$2,319.38

$1,952.51
$2,075.27
$2,205.27
$2,667.15

$347.77

Toc - Plan #94 Aetna CVS Health

Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

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

$351.93
$399.44
$449.77
$628.55
$955.14

$621.16
$668.67
$719.00
$897.78

$890.39
$937.90
$988.23
$1,167.01

$1,159.62
$1,207.13
$1,257.46
$1,436.24

$269.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$703.86
$798.88
$899.54
$1,257.10
$1,910.28

$973.09
$1,068.11
$1,168.77
$1,526.33

$1,242.32
$1,337.34
$1,438.00
$1,795.56

$1,511.55
$1,606.57
$1,707.23
$2,064.79

$269.23

Ambetter from Superior HealthPlan

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

Toc - Plan #95 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

$427.42
$485.11
$546.23
$763.35
$1,159.99

$754.39
$812.08
$873.20
$1,090.32

$1,081.36
$1,139.05
$1,200.17
$1,417.29

$1,408.33
$1,466.02
$1,527.14
$1,744.26

$326.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$854.84
$970.22
$1,092.46
$1,526.70
$2,319.98

$1,181.81
$1,297.19
$1,419.43
$1,853.67

$1,508.78
$1,624.16
$1,746.40
$2,180.64

$1,835.75
$1,951.13
$2,073.37
$2,507.61

$326.97

Toc - Plan #96 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

$401.94
$456.19
$513.67
$717.85
$1,090.84

$709.42
$763.67
$821.15
$1,025.33

$1,016.90
$1,071.15
$1,128.63
$1,332.81

$1,324.38
$1,378.63
$1,436.11
$1,640.29

$307.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$803.88
$912.38
$1,027.34
$1,435.70
$2,181.68

$1,111.36
$1,219.86
$1,334.82
$1,743.18

$1,418.84
$1,527.34
$1,642.30
$2,050.66

$1,726.32
$1,834.82
$1,949.78
$2,358.14

$307.48

Toc - Plan #97 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

$441.47
$501.06
$564.19
$788.45
$1,198.12

$779.19
$838.78
$901.91
$1,126.17

$1,116.91
$1,176.50
$1,239.63
$1,463.89

$1,454.63
$1,514.22
$1,577.35
$1,801.61

$337.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$882.94
$1,002.12
$1,128.38
$1,576.90
$2,396.24

$1,220.66
$1,339.84
$1,466.10
$1,914.62

$1,558.38
$1,677.56
$1,803.82
$2,252.34

$1,896.10
$2,015.28
$2,141.54
$2,590.06

$337.72

Toc - Plan #98 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

$398.10
$451.84
$508.76
$711.00
$1,080.43

$702.64
$756.38
$813.30
$1,015.54

$1,007.18
$1,060.92
$1,117.84
$1,320.08

$1,311.72
$1,365.46
$1,422.38
$1,624.62

$304.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$796.20
$903.68
$1,017.52
$1,422.00
$2,160.86

$1,100.74
$1,208.22
$1,322.06
$1,726.54

$1,405.28
$1,512.76
$1,626.60
$2,031.08

$1,709.82
$1,817.30
$1,931.14
$2,335.62

$304.54

Toc - Plan #99 Ambetter from Superior HealthPlan

Silver

(HMO) Complete VALUE 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

$359.06
$407.52
$458.86
$641.26
$974.46

$633.73
$682.19
$733.53
$915.93

$908.40
$956.86
$1,008.20
$1,190.60

$1,183.07
$1,231.53
$1,282.87
$1,465.27

$274.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$718.12
$815.04
$917.72
$1,282.52
$1,948.92

$992.79
$1,089.71
$1,192.39
$1,557.19

$1,267.46
$1,364.38
$1,467.06
$1,831.86

$1,542.13
$1,639.05
$1,741.73
$2,106.53

$274.67

Toc - Plan #100 Ambetter from Superior HealthPlan

Silver

(HMO) Clear VALUE 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

$355.46
$403.44
$454.27
$634.84
$964.70

$627.38
$675.36
$726.19
$906.76

$899.30
$947.28
$998.11
$1,178.68

$1,171.22
$1,219.20
$1,270.03
$1,450.60

$271.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$710.92
$806.88
$908.54
$1,269.68
$1,929.40

$982.84
$1,078.80
$1,180.46
$1,541.60

$1,254.76
$1,350.72
$1,452.38
$1,813.52

$1,526.68
$1,622.64
$1,724.30
$2,085.44

$271.92

Toc - Plan #101 Ambetter from Superior HealthPlan

Silver

(HMO) Focused VALUE 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

$354.13
$401.93
$452.57
$632.46
$961.09

$625.03
$672.83
$723.47
$903.36

$895.93
$943.73
$994.37
$1,174.26

$1,166.83
$1,214.63
$1,265.27
$1,445.16

$270.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$708.26
$803.86
$905.14
$1,264.92
$1,922.18

$979.16
$1,074.76
$1,176.04
$1,535.82

$1,250.06
$1,345.66
$1,446.94
$1,806.72

$1,520.96
$1,616.56
$1,717.84
$2,077.62

$270.90

Toc - Plan #102 Ambetter from Superior HealthPlan

Gold

(HMO) Everyday VALUE 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

$321.67
$365.08
$411.08
$574.48
$872.98

$567.74
$611.15
$657.15
$820.55

$813.81
$857.22
$903.22
$1,066.62

$1,059.88
$1,103.29
$1,149.29
$1,312.69

$246.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$643.34
$730.16
$822.16
$1,148.96
$1,745.96

$889.41
$976.23
$1,068.23
$1,395.03

$1,135.48
$1,222.30
$1,314.30
$1,641.10

$1,381.55
$1,468.37
$1,560.37
$1,887.17

$246.07

Toc - Plan #103 Ambetter from Superior HealthPlan

Silver

(HMO) CMS Standard Silver VALUE

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

$353.89
$401.65
$452.26
$632.03
$960.43

$624.61
$672.37
$722.98
$902.75

$895.33
$943.09
$993.70
$1,173.47

$1,166.05
$1,213.81
$1,264.42
$1,444.19

$270.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$707.78
$803.30
$904.52
$1,264.06
$1,920.86

$978.50
$1,074.02
$1,175.24
$1,534.78

$1,249.22
$1,344.74
$1,445.96
$1,805.50

$1,519.94
$1,615.46
$1,716.68
$2,076.22

$270.72

Toc - Plan #104 Ambetter from Superior HealthPlan

Gold

(HMO) CMS Standard Gold VALUE

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

$319.12
$362.19
$407.83
$569.94
$866.07

$563.24
$606.31
$651.95
$814.06

$807.36
$850.43
$896.07
$1,058.18

$1,051.48
$1,094.55
$1,140.19
$1,302.30

$244.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$638.24
$724.38
$815.66
$1,139.88
$1,732.14

$882.36
$968.50
$1,059.78
$1,384.00

$1,126.48
$1,212.62
$1,303.90
$1,628.12

$1,370.60
$1,456.74
$1,548.02
$1,872.24

$244.12

‡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 Montgomery County here.

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

Currently, there are 104 plans offered in Rating Area 10.

Top

2023 Obamacare Plans for Montgomery County, TX

Plan Browser: 104 Plans

Oscar Insurance Company

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

1. Bronze Bronze Simple (Choice)

2. Expanded Bronze Bronze Classic (Choice)

3. Expanded Bronze Bronze Elite- $0 Ded+PCP Saver (Choice)

4. Silver Silver Classic (Choice)

5. Silver Silver Simple- Specialist Saver (Choice)

6. Silver Silver Classic- PCP Saver (Choice)

7. Expanded Bronze Bronze Elite- $0 Ded+Specialist Saver (Choice)

8. Expanded Bronze Bronze Simple- HSA (Choice)

9. Expanded Bronze Bronze Classic- $4700 Ded (Choice)

10. Silver Silver Simple- PCP Saver (Choice)

11. Silver Silver Elite- $0 Ded (Choice)

12. Silver Silver Simple- For Diabetes (Choice)

13. Expanded Bronze Bronze Classic- Standard (Choice)

14. Bronze Bronze Simple- Standard (Choice)

15. Silver Silver Classic- Standard (Choice)

16. Gold Gold Classic- Standard (Choice)

Community Health Choice

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

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

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

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

20. Expanded Bronze Community Premier Virtual Bronze 011 (Unlimited Free 24/7 Virtual Visits)

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

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

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

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

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

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

Ambetter from Superior HealthPlan

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

27. Silver Complete Silver

28. Gold Complete Gold

29. Silver Clear Silver

30. Silver Focused Silver

31. Gold Everyday Gold

32. Gold Clear Gold

33. Silver CMS Standard Silver

34. Gold CMS Standard Gold

35. Gold Complete Gold + Vision + Adult Dental

36. Silver Complete Silver + Vision + Adult Dental

37. Silver Focused Silver + Vision + Adult Dental

38. Gold Everyday Gold + Vision + Adult Dental

39. Silver Clear Silver + Vision + Adult Dental

40. Gold Clear Gold + Vision + Adult Dental

Blue Cross and Blue Shield of Texas

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

41. Gold Blue Advantage Gold HMO? 206

42. Gold Blue Advantage Gold HMO? 603

43. Silver Blue Advantage Silver HMO? 205

44. Expanded Bronze Blue Advantage Bronze HMO? 204

45. Expanded Bronze Blue Advantage Bronze HMO? 302

46. Bronze Blue Advantage Bronze HMO? 301

47. Catastrophic Blue Advantage Security HMO? 200

48. Expanded Bronze Blue Advantage Bronze HMO? 702

49. Gold Blue Advantage Gold HMO? 706

50. Silver Blue Advantage Silver HMO? 705

51. Bronze Blue Advantage Bronze HMO? 704

52. Expanded Bronze Blue Advantage Bronze HMO? 707

53. Gold Blue Advantage Plus Gold? 203

54. Silver Blue Advantage Plus Silver? 202

55. Silver Blue Advantage Plus Silver? 605

56. Expanded Bronze Blue Advantage Plus Bronze? 303

57. Bronze Blue Advantage Plus Bronze? 305

58. Gold Blue Advantage Plus Gold? 706

59. Silver Blue Advantage Plus Silver? 705

60. Bronze Blue Advantage Plus Bronze? 704

61. Expanded Bronze Blue Advantage Plus Bronze? 707

UnitedHealthcare

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

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

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

64. Silver UHC Silver Value HSA

65. Silver UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en espa�ol)

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

67. Expanded Bronze UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en espa�ol)

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

69. Bronze UHC Bronze Essential ($3 T1 Preferred Rx)

70. Expanded Bronze UHC Bronze Standard $7,500 Deductible

71. Bronze UHC Bronze Standard $9,100 Deductible

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

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

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

75. Silver UHC Silver Standard

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

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

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

79. Gold UHC Gold Standard

Molina Healthcare

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

80. Silver Molina Silver 3 250

81. Gold Confident Care Gold 1

82. Silver Constant Care Silver 1 250

83. Gold Confident Care Gold 8

84. Silver Constant Care Silver 8 250

85. Gold Confident Care Gold 1 + Vision

86. Silver Constant Care Silver 1 250 + Vision

Aetna CVS Health

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

87. Gold Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

88. Silver Silver 2: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

89. Silver Silver 1: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

90. Expanded Bronze Bronze S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

91. Gold Gold S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

92. Silver Silver 3: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

93. Silver Silver 4: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

94. Silver Silver S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Ambetter from Superior HealthPlan

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

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

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

97. Silver CMS Standard Virtual Access Basic Silver

98. Gold CMS Standard Virtual Access Basic Gold

99. Silver Complete VALUE Silver

100. Silver Clear VALUE Silver

101. Silver Focused VALUE Silver

102. Gold Everyday VALUE Gold

103. Silver CMS Standard Silver VALUE

104. Gold CMS Standard Gold VALUE

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

Obamacare Providers, 104 Plans and 2023 Rates for Montgomery County, Texas

You may also be interested in:

Do I Qualify For a Tax Credit to Pay My Premiums?

How do I sign up in Texas?

Using a Broker to Help You Sign Up

Obamacare Rates and Providers for Other Years

How To Sign Up for Obamacare in Texas for 2023

Where's the Texas Health Care Exchange?

Texas Medicaid Expansion: Do I Qualify for Medicaid Under the ACA?

Texas Has Not Expanded Medicaid

The Medicaid Coverage Gap

Get Help Finding a Health Insurance Plan in Texas

Get Help From Texas's Health Insurance Exchange

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More Information

Oscar Insurance Company

(EPO) Bronze Simple (Choice)

Annual Out of Pocket Expenses:

Individual Family $8,500 $17,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze Classic (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Bronze Elite- $0 Ded+PCP Saver (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Silver Classic (Choice)

Annual Out of Pocket Expenses:

Individual Family $5,400 $10,800 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Silver Simple- Specialist Saver (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Silver Classic- PCP Saver (Choice)

Annual Out of Pocket Expenses:

Individual Family $6,000 $12,000 Annual Deductible $8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze Elite- $0 Ded+Specialist Saver (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Bronze Simple- HSA (Choice)

Annual Out of Pocket Expenses:

Individual Family $5,200 $10,400 Annual Deductible $7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze Classic- $4700 Ded (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Silver Simple- PCP Saver (Choice)

Annual Out of Pocket Expenses:

Individual Family $5,500 $11,000 Annual Deductible $8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Silver Elite- $0 Ded (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) Silver Simple- For Diabetes (Choice)

Annual Out of Pocket Expenses:

Individual Family $6,450 $12,900 Annual Deductible $8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) Bronze Classic- Standard (Choice)

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:

(EPO) Bronze Simple- Standard (Choice)

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:

(EPO) Silver Classic- Standard (Choice)

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:

(EPO) Gold Classic- Standard (Choice)

Annual Out of Pocket Expenses:

Individual Family $2,000 $4,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$8,500 $17,000 Annual Deductible

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

Individual Family

$7,750 $15,500 Annual Deductible

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

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$5,400 $10,800 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,500 $13,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$8,650 $17,300 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$5,200 $10,400 Annual Deductible

$7,450 $14,900 Maximum Out of Pocket Per Year

Individual Family

$4,700 $9,400 Annual Deductible

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

Individual Family

$5,500 $11,000 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$6,450 $12,900 Annual Deductible

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

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,700 $15,400 Annual Deductible

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

Individual Family

$3,300 $6,600 Annual Deductible

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

Individual Family

$1,600 $3,200 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$3,000 $6,000 Annual Deductible

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

Individual Family

$8,500 $17,000 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

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

Individual Family

$1,450 $2,900 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$5,400 $10,800 Annual Deductible

$5,400 $10,800 Maximum Out of Pocket Per Year

Individual Family

$6,100 $12,200 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$750 $1,500 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$900 $1,800 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year