Rockwall County, Texas Obamacare 2024 Rates

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

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

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

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

Obamacare Providers, 112 Plans and 2024 Rates for Rockwall County, Texas

Below, you’ll find a summary of the 112 plans for Rockwall County, Texas and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

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Oscar Insurance Company

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

Toc - Plan #1 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322.32
$365.82
$411.91
$575.65
$874.75
$568.89
$612.39
$658.48
$822.22
$815.46
$858.96
$905.05
$1,068.79
$1,062.03
$1,105.53
$1,151.62
$1,315.36
$246.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$644.64
$731.64
$823.82
$1,151.30
$1,749.50
$891.21
$978.21
$1,070.39
$1,397.87
$1,137.78
$1,224.78
$1,316.96
$1,644.44
$1,384.35
$1,471.35
$1,563.53
$1,891.01
$246.57
Toc - Plan #2 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite + PCP Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.56
$386.53
$435.23
$608.23
$924.27
$601.08
$647.05
$695.75
$868.75
$861.60
$907.57
$956.27
$1,129.27
$1,122.12
$1,168.09
$1,216.79
$1,389.79
$260.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$681.12
$773.06
$870.46
$1,216.46
$1,848.54
$941.64
$1,033.58
$1,130.98
$1,476.98
$1,202.16
$1,294.10
$1,391.50
$1,737.50
$1,462.68
$1,554.62
$1,652.02
$1,998.02
$260.52
Toc - Plan #3 Oscar Insurance Company
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$443.66
$503.55
$566.99
$792.36
$1,204.07
$783.05
$842.94
$906.38
$1,131.75
$1,122.44
$1,182.33
$1,245.77
$1,471.14
$1,461.83
$1,521.72
$1,585.16
$1,810.53
$339.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$887.32
$1,007.10
$1,133.98
$1,584.72
$2,408.14
$1,226.71
$1,346.49
$1,473.37
$1,924.11
$1,566.10
$1,685.88
$1,812.76
$2,263.50
$1,905.49
$2,025.27
$2,152.15
$2,602.89
$339.39
Toc - Plan #4 Oscar Insurance Company
Silver

(EPO) Silver Simple Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$438.89
$498.13
$560.89
$783.85
$1,191.13
$774.64
$833.88
$896.64
$1,119.60
$1,110.39
$1,169.63
$1,232.39
$1,455.35
$1,446.14
$1,505.38
$1,568.14
$1,791.10
$335.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$877.78
$996.26
$1,121.78
$1,567.70
$2,382.26
$1,213.53
$1,332.01
$1,457.53
$1,903.45
$1,549.28
$1,667.76
$1,793.28
$2,239.20
$1,885.03
$2,003.51
$2,129.03
$2,574.95
$335.75
Toc - Plan #5 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite + Specialist Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.67
$387.79
$436.64
$610.21
$927.27
$603.04
$649.16
$698.01
$871.58
$864.41
$910.53
$959.38
$1,132.95
$1,125.78
$1,171.90
$1,220.75
$1,394.32
$261.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.34
$775.58
$873.28
$1,220.42
$1,854.54
$944.71
$1,036.95
$1,134.65
$1,481.79
$1,206.08
$1,298.32
$1,396.02
$1,743.16
$1,467.45
$1,559.69
$1,657.39
$2,004.53
$261.37
Toc - Plan #6 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic 4700

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$327.85
$372.10
$418.98
$585.53
$889.77
$578.65
$622.90
$669.78
$836.33
$829.45
$873.70
$920.58
$1,087.13
$1,080.25
$1,124.50
$1,171.38
$1,337.93
$250.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$655.70
$744.20
$837.96
$1,171.06
$1,779.54
$906.50
$995.00
$1,088.76
$1,421.86
$1,157.30
$1,245.80
$1,339.56
$1,672.66
$1,408.10
$1,496.60
$1,590.36
$1,923.46
$250.80
Toc - Plan #7 Oscar Insurance Company
Silver

(EPO) Silver Simple PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$437.21
$496.22
$558.74
$780.84
$1,186.56
$771.67
$830.68
$893.20
$1,115.30
$1,106.13
$1,165.14
$1,227.66
$1,449.76
$1,440.59
$1,499.60
$1,562.12
$1,784.22
$334.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.42
$992.44
$1,117.48
$1,561.68
$2,373.12
$1,208.88
$1,326.90
$1,451.94
$1,896.14
$1,543.34
$1,661.36
$1,786.40
$2,230.60
$1,877.80
$1,995.82
$2,120.86
$2,565.06
$334.46
Toc - Plan #8 Oscar Insurance Company
Silver

(EPO) Silver Elite Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$460.97
$523.19
$589.10
$823.27
$1,251.04
$813.60
$875.82
$941.73
$1,175.90
$1,166.23
$1,228.45
$1,294.36
$1,528.53
$1,518.86
$1,581.08
$1,646.99
$1,881.16
$352.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$921.94
$1,046.38
$1,178.20
$1,646.54
$2,502.08
$1,274.57
$1,399.01
$1,530.83
$1,999.17
$1,627.20
$1,751.64
$1,883.46
$2,351.80
$1,979.83
$2,104.27
$2,236.09
$2,704.43
$352.63
Toc - Plan #9 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.75
$365.17
$411.18
$574.63
$873.20
$567.88
$611.30
$657.31
$820.76
$814.01
$857.43
$903.44
$1,066.89
$1,060.14
$1,103.56
$1,149.57
$1,313.02
$246.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.50
$730.34
$822.36
$1,149.26
$1,746.40
$889.63
$976.47
$1,068.49
$1,395.39
$1,135.76
$1,222.60
$1,314.62
$1,641.52
$1,381.89
$1,468.73
$1,560.75
$1,887.65
$246.13
Toc - Plan #10 Oscar Insurance Company
Silver

(EPO) Silver Classic Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$432.15
$490.48
$552.28
$771.81
$1,172.83
$762.74
$821.07
$882.87
$1,102.40
$1,093.33
$1,151.66
$1,213.46
$1,432.99
$1,423.92
$1,482.25
$1,544.05
$1,763.58
$330.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$864.30
$980.96
$1,104.56
$1,543.62
$2,345.66
$1,194.89
$1,311.55
$1,435.15
$1,874.21
$1,525.48
$1,642.14
$1,765.74
$2,204.80
$1,856.07
$1,972.73
$2,096.33
$2,535.39
$330.59
Toc - Plan #11 Oscar Insurance Company
Gold

(EPO) Gold Classic Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.01
$422.22
$475.41
$664.39
$1,009.60
$656.59
$706.80
$759.99
$948.97
$941.17
$991.38
$1,044.57
$1,233.55
$1,225.75
$1,275.96
$1,329.15
$1,518.13
$284.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.02
$844.44
$950.82
$1,328.78
$2,019.20
$1,028.60
$1,129.02
$1,235.40
$1,613.36
$1,313.18
$1,413.60
$1,519.98
$1,897.94
$1,597.76
$1,698.18
$1,804.56
$2,182.52
$284.58
Toc - Plan #12 Oscar Insurance Company
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.81
$435.61
$490.50
$685.47
$1,041.64
$677.42
$729.22
$784.11
$979.08
$971.03
$1,022.83
$1,077.72
$1,272.69
$1,264.64
$1,316.44
$1,371.33
$1,566.30
$293.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.62
$871.22
$981.00
$1,370.94
$2,083.28
$1,061.23
$1,164.83
$1,274.61
$1,664.55
$1,354.84
$1,458.44
$1,568.22
$1,958.16
$1,648.45
$1,752.05
$1,861.83
$2,251.77
$293.61
Toc - Plan #13 Oscar Insurance Company
Gold

(EPO) Gold Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.72
$450.27
$507.00
$708.53
$1,076.67
$700.20
$753.75
$810.48
$1,012.01
$1,003.68
$1,057.23
$1,113.96
$1,315.49
$1,307.16
$1,360.71
$1,417.44
$1,618.97
$303.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793.44
$900.54
$1,014.00
$1,417.06
$2,153.34
$1,096.92
$1,204.02
$1,317.48
$1,720.54
$1,400.40
$1,507.50
$1,620.96
$2,024.02
$1,703.88
$1,810.98
$1,924.44
$2,327.50
$303.48

ADVERTISEMENT

Ambetter from Superior HealthPlan

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

Toc - Plan #14 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
$516.30
$585.99
$659.82
$922.09
$1,401.21
$911.26
$980.95
$1,054.78
$1,317.05
$1,306.22
$1,375.91
$1,449.74
$1,712.01
$1,701.18
$1,770.87
$1,844.70
$2,106.97
$394.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,032.60
$1,171.98
$1,319.64
$1,844.18
$2,802.42
$1,427.56
$1,566.94
$1,714.60
$2,239.14
$1,822.52
$1,961.90
$2,109.56
$2,634.10
$2,217.48
$2,356.86
$2,504.52
$3,029.06
$394.96
Toc - Plan #15 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
$467.97
$531.14
$598.05
$835.78
$1,270.04
$825.96
$889.13
$956.04
$1,193.77
$1,183.95
$1,247.12
$1,314.03
$1,551.76
$1,541.94
$1,605.11
$1,672.02
$1,909.75
$357.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$935.94
$1,062.28
$1,196.10
$1,671.56
$2,540.08
$1,293.93
$1,420.27
$1,554.09
$2,029.55
$1,651.92
$1,778.26
$1,912.08
$2,387.54
$2,009.91
$2,136.25
$2,270.07
$2,745.53
$357.99
Toc - Plan #16 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
$507.96
$576.52
$649.16
$907.19
$1,378.57
$896.54
$965.10
$1,037.74
$1,295.77
$1,285.12
$1,353.68
$1,426.32
$1,684.35
$1,673.70
$1,742.26
$1,814.90
$2,072.93
$388.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,015.92
$1,153.04
$1,298.32
$1,814.38
$2,757.14
$1,404.50
$1,541.62
$1,686.90
$2,202.96
$1,793.08
$1,930.20
$2,075.48
$2,591.54
$2,181.66
$2,318.78
$2,464.06
$2,980.12
$388.58
Toc - Plan #17 Ambetter from Superior HealthPlan
Silver

(EPO) Focused Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$511.09
$580.08
$653.16
$912.79
$1,387.08
$902.07
$971.06
$1,044.14
$1,303.77
$1,293.05
$1,362.04
$1,435.12
$1,694.75
$1,684.03
$1,753.02
$1,826.10
$2,085.73
$390.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,022.18
$1,160.16
$1,306.32
$1,825.58
$2,774.16
$1,413.16
$1,551.14
$1,697.30
$2,216.56
$1,804.14
$1,942.12
$2,088.28
$2,607.54
$2,195.12
$2,333.10
$2,479.26
$2,998.52
$390.98
Toc - Plan #18 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
$455.94
$517.48
$582.68
$814.29
$1,237.39
$804.73
$866.27
$931.47
$1,163.08
$1,153.52
$1,215.06
$1,280.26
$1,511.87
$1,502.31
$1,563.85
$1,629.05
$1,860.66
$348.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$911.88
$1,034.96
$1,165.36
$1,628.58
$2,474.78
$1,260.67
$1,383.75
$1,514.15
$1,977.37
$1,609.46
$1,732.54
$1,862.94
$2,326.16
$1,958.25
$2,081.33
$2,211.73
$2,674.95
$348.79
Toc - Plan #19 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
$452.20
$513.23
$577.90
$807.61
$1,227.24
$798.12
$859.15
$923.82
$1,153.53
$1,144.04
$1,205.07
$1,269.74
$1,499.45
$1,489.96
$1,550.99
$1,615.66
$1,845.37
$345.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$904.40
$1,026.46
$1,155.80
$1,615.22
$2,454.48
$1,250.32
$1,372.38
$1,501.72
$1,961.14
$1,596.24
$1,718.30
$1,847.64
$2,307.06
$1,942.16
$2,064.22
$2,193.56
$2,652.98
$345.92
Toc - Plan #20 Ambetter from Superior HealthPlan
Silver

(EPO) Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$505.53
$573.77
$646.06
$902.86
$1,371.98
$892.25
$960.49
$1,032.78
$1,289.58
$1,278.97
$1,347.21
$1,419.50
$1,676.30
$1,665.69
$1,733.93
$1,806.22
$2,063.02
$386.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,011.06
$1,147.54
$1,292.12
$1,805.72
$2,743.96
$1,397.78
$1,534.26
$1,678.84
$2,192.44
$1,784.50
$1,920.98
$2,065.56
$2,579.16
$2,171.22
$2,307.70
$2,452.28
$2,965.88
$386.72
Toc - Plan #21 Ambetter from Superior HealthPlan
Gold

(EPO) Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$457.46
$519.20
$584.62
$817.00
$1,241.51
$807.41
$869.15
$934.57
$1,166.95
$1,157.36
$1,219.10
$1,284.52
$1,516.90
$1,507.31
$1,569.05
$1,634.47
$1,866.85
$349.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$914.92
$1,038.40
$1,169.24
$1,634.00
$2,483.02
$1,264.87
$1,388.35
$1,519.19
$1,983.95
$1,614.82
$1,738.30
$1,869.14
$2,333.90
$1,964.77
$2,088.25
$2,219.09
$2,683.85
$349.95
Toc - Plan #22 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
$486.13
$551.74
$621.26
$868.20
$1,319.32
$858.01
$923.62
$993.14
$1,240.08
$1,229.89
$1,295.50
$1,365.02
$1,611.96
$1,601.77
$1,667.38
$1,736.90
$1,983.84
$371.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$972.26
$1,103.48
$1,242.52
$1,736.40
$2,638.64
$1,344.14
$1,475.36
$1,614.40
$2,108.28
$1,716.02
$1,847.24
$1,986.28
$2,480.16
$2,087.90
$2,219.12
$2,358.16
$2,852.04
$371.88
Toc - Plan #23 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
$536.33
$608.72
$685.41
$957.86
$1,455.57
$946.61
$1,019.00
$1,095.69
$1,368.14
$1,356.89
$1,429.28
$1,505.97
$1,778.42
$1,767.17
$1,839.56
$1,916.25
$2,188.70
$410.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,072.66
$1,217.44
$1,370.82
$1,915.72
$2,911.14
$1,482.94
$1,627.72
$1,781.10
$2,326.00
$1,893.22
$2,038.00
$2,191.38
$2,736.28
$2,303.50
$2,448.28
$2,601.66
$3,146.56
$410.28
Toc - Plan #24 Ambetter from Superior HealthPlan
Silver

(EPO) Standard Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$525.14
$596.03
$671.12
$937.89
$1,425.21
$926.87
$997.76
$1,072.85
$1,339.62
$1,328.60
$1,399.49
$1,474.58
$1,741.35
$1,730.33
$1,801.22
$1,876.31
$2,143.08
$401.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,050.28
$1,192.06
$1,342.24
$1,875.78
$2,850.42
$1,452.01
$1,593.79
$1,743.97
$2,277.51
$1,853.74
$1,995.52
$2,145.70
$2,679.24
$2,255.47
$2,397.25
$2,547.43
$3,080.97
$401.73
Toc - Plan #25 Ambetter from Superior HealthPlan
Gold

(EPO) Standard Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$475.20
$539.34
$607.30
$848.69
$1,289.67
$838.72
$902.86
$970.82
$1,212.21
$1,202.24
$1,266.38
$1,334.34
$1,575.73
$1,565.76
$1,629.90
$1,697.86
$1,939.25
$363.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$950.40
$1,078.68
$1,214.60
$1,697.38
$2,579.34
$1,313.92
$1,442.20
$1,578.12
$2,060.90
$1,677.44
$1,805.72
$1,941.64
$2,424.42
$2,040.96
$2,169.24
$2,305.16
$2,787.94
$363.52
Toc - Plan #26 Ambetter from Superior HealthPlan
Silver

(EPO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$530.92
$602.58
$678.50
$948.20
$1,440.89
$937.07
$1,008.73
$1,084.65
$1,354.35
$1,343.22
$1,414.88
$1,490.80
$1,760.50
$1,749.37
$1,821.03
$1,896.95
$2,166.65
$406.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,061.84
$1,205.16
$1,357.00
$1,896.40
$2,881.78
$1,467.99
$1,611.31
$1,763.15
$2,302.55
$1,874.14
$2,017.46
$2,169.30
$2,708.70
$2,280.29
$2,423.61
$2,575.45
$3,114.85
$406.15
Toc - Plan #27 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
$473.63
$537.56
$605.28
$845.88
$1,285.40
$835.95
$899.88
$967.60
$1,208.20
$1,198.27
$1,262.20
$1,329.92
$1,570.52
$1,560.59
$1,624.52
$1,692.24
$1,932.84
$362.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$947.26
$1,075.12
$1,210.56
$1,691.76
$2,570.80
$1,309.58
$1,437.44
$1,572.88
$2,054.08
$1,671.90
$1,799.76
$1,935.20
$2,416.40
$2,034.22
$2,162.08
$2,297.52
$2,778.72
$362.32
Toc - Plan #28 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
$527.66
$598.89
$674.34
$942.39
$1,432.05
$931.32
$1,002.55
$1,078.00
$1,346.05
$1,334.98
$1,406.21
$1,481.66
$1,749.71
$1,738.64
$1,809.87
$1,885.32
$2,153.37
$403.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,055.32
$1,197.78
$1,348.68
$1,884.78
$2,864.10
$1,458.98
$1,601.44
$1,752.34
$2,288.44
$1,862.64
$2,005.10
$2,156.00
$2,692.10
$2,266.30
$2,408.76
$2,559.66
$3,095.76
$403.66
Toc - Plan #29 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
$469.74
$533.15
$600.32
$838.94
$1,274.85
$829.08
$892.49
$959.66
$1,198.28
$1,188.42
$1,251.83
$1,319.00
$1,557.62
$1,547.76
$1,611.17
$1,678.34
$1,916.96
$359.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$939.48
$1,066.30
$1,200.64
$1,677.88
$2,549.70
$1,298.82
$1,425.64
$1,559.98
$2,037.22
$1,658.16
$1,784.98
$1,919.32
$2,396.56
$2,017.50
$2,144.32
$2,278.66
$2,755.90
$359.34

ADVERTISEMENT

Blue Cross and Blue Shield of Texas

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

Toc - Plan #30 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 206

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.03
$451.77
$508.69
$710.89
$1,080.26
$702.53
$756.27
$813.19
$1,015.39
$1,007.03
$1,060.77
$1,117.69
$1,319.89
$1,311.53
$1,365.27
$1,422.19
$1,624.39
$304.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.06
$903.54
$1,017.38
$1,421.78
$2,160.52
$1,100.56
$1,208.04
$1,321.88
$1,726.28
$1,405.06
$1,512.54
$1,626.38
$2,030.78
$1,709.56
$1,817.04
$1,930.88
$2,335.28
$304.50
Toc - Plan #31 Blue Cross and Blue Shield of Texas
Catastrophic

(HMO) Blue Advantage Security HMO? 200

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$294.83
$334.63
$376.80
$526.57
$800.17
$520.38
$560.18
$602.35
$752.12
$745.93
$785.73
$827.90
$977.67
$971.48
$1,011.28
$1,053.45
$1,203.22
$225.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$589.66
$669.26
$753.60
$1,053.14
$1,600.34
$815.21
$894.81
$979.15
$1,278.69
$1,040.76
$1,120.36
$1,204.70
$1,504.24
$1,266.31
$1,345.91
$1,430.25
$1,729.79
$225.55
Toc - Plan #32 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 205

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$472.65
$536.46
$604.04
$844.15
$1,282.77
$834.23
$898.04
$965.62
$1,205.73
$1,195.81
$1,259.62
$1,327.20
$1,567.31
$1,557.39
$1,621.20
$1,688.78
$1,928.89
$361.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$945.30
$1,072.92
$1,208.08
$1,688.30
$2,565.54
$1,306.88
$1,434.50
$1,569.66
$2,049.88
$1,668.46
$1,796.08
$1,931.24
$2,411.46
$2,030.04
$2,157.66
$2,292.82
$2,773.04
$361.58
Toc - Plan #33 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 204

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$330.15
$374.72
$421.93
$589.65
$896.03
$582.71
$627.28
$674.49
$842.21
$835.27
$879.84
$927.05
$1,094.77
$1,087.83
$1,132.40
$1,179.61
$1,347.33
$252.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$660.30
$749.44
$843.86
$1,179.30
$1,792.06
$912.86
$1,002.00
$1,096.42
$1,431.86
$1,165.42
$1,254.56
$1,348.98
$1,684.42
$1,417.98
$1,507.12
$1,601.54
$1,936.98
$252.56
Toc - Plan #34 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 302

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.72
$387.85
$436.72
$610.31
$927.43
$603.14
$649.27
$698.14
$871.73
$864.56
$910.69
$959.56
$1,133.15
$1,125.98
$1,172.11
$1,220.98
$1,394.57
$261.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.44
$775.70
$873.44
$1,220.62
$1,854.86
$944.86
$1,037.12
$1,134.86
$1,482.04
$1,206.28
$1,298.54
$1,396.28
$1,743.46
$1,467.70
$1,559.96
$1,657.70
$2,004.88
$261.42
Toc - Plan #35 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO? 301

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$325.23
$369.14
$415.64
$580.86
$882.67
$574.03
$617.94
$664.44
$829.66
$822.83
$866.74
$913.24
$1,078.46
$1,071.63
$1,115.54
$1,162.04
$1,327.26
$248.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$650.46
$738.28
$831.28
$1,161.72
$1,765.34
$899.26
$987.08
$1,080.08
$1,410.52
$1,148.06
$1,235.88
$1,328.88
$1,659.32
$1,396.86
$1,484.68
$1,577.68
$1,908.12
$248.80
Toc - Plan #36 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 603

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.00
$466.49
$525.26
$734.05
$1,115.46
$725.42
$780.91
$839.68
$1,048.47
$1,039.84
$1,095.33
$1,154.10
$1,362.89
$1,354.26
$1,409.75
$1,468.52
$1,677.31
$314.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.00
$932.98
$1,050.52
$1,468.10
$2,230.92
$1,136.42
$1,247.40
$1,364.94
$1,782.52
$1,450.84
$1,561.82
$1,679.36
$2,096.94
$1,765.26
$1,876.24
$1,993.78
$2,411.36
$314.42
Toc - Plan #37 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 706

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.29
$463.40
$521.79
$729.20
$1,108.09
$720.63
$775.74
$834.13
$1,041.54
$1,032.97
$1,088.08
$1,146.47
$1,353.88
$1,345.31
$1,400.42
$1,458.81
$1,666.22
$312.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$816.58
$926.80
$1,043.58
$1,458.40
$2,216.18
$1,128.92
$1,239.14
$1,355.92
$1,770.74
$1,441.26
$1,551.48
$1,668.26
$2,083.08
$1,753.60
$1,863.82
$1,980.60
$2,395.42
$312.34
Toc - Plan #38 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 705

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$472.69
$536.51
$604.10
$844.23
$1,282.89
$834.30
$898.12
$965.71
$1,205.84
$1,195.91
$1,259.73
$1,327.32
$1,567.45
$1,557.52
$1,621.34
$1,688.93
$1,929.06
$361.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$945.38
$1,073.02
$1,208.20
$1,688.46
$2,565.78
$1,306.99
$1,434.63
$1,569.81
$2,050.07
$1,668.60
$1,796.24
$1,931.42
$2,411.68
$2,030.21
$2,157.85
$2,293.03
$2,773.29
$361.61
Toc - Plan #39 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 707

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$329.03
$373.45
$420.50
$587.65
$892.99
$580.74
$625.16
$672.21
$839.36
$832.45
$876.87
$923.92
$1,091.07
$1,084.16
$1,128.58
$1,175.63
$1,342.78
$251.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$658.06
$746.90
$841.00
$1,175.30
$1,785.98
$909.77
$998.61
$1,092.71
$1,427.01
$1,161.48
$1,250.32
$1,344.42
$1,678.72
$1,413.19
$1,502.03
$1,596.13
$1,930.43
$251.71
Toc - Plan #40 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 801

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$470.69
$534.23
$601.54
$840.65
$1,277.45
$830.77
$894.31
$961.62
$1,200.73
$1,190.85
$1,254.39
$1,321.70
$1,560.81
$1,550.93
$1,614.47
$1,681.78
$1,920.89
$360.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$941.38
$1,068.46
$1,203.08
$1,681.30
$2,554.90
$1,301.46
$1,428.54
$1,563.16
$2,041.38
$1,661.54
$1,788.62
$1,923.24
$2,401.46
$2,021.62
$2,148.70
$2,283.32
$2,761.54
$360.08
Toc - Plan #41 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) MyBlue Health Bronze? 402

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$263.47
$299.04
$336.72
$470.56
$715.07
$465.03
$500.60
$538.28
$672.12
$666.59
$702.16
$739.84
$873.68
$868.15
$903.72
$941.40
$1,075.24
$201.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$526.94
$598.08
$673.44
$941.12
$1,430.14
$728.50
$799.64
$875.00
$1,142.68
$930.06
$1,001.20
$1,076.56
$1,344.24
$1,131.62
$1,202.76
$1,278.12
$1,545.80
$201.56
Toc - Plan #42 Blue Cross and Blue Shield of Texas
Gold

(HMO) MyBlue Health Gold? 403

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.87
$363.05
$408.79
$571.28
$868.12
$564.57
$607.75
$653.49
$815.98
$809.27
$852.45
$898.19
$1,060.68
$1,053.97
$1,097.15
$1,142.89
$1,305.38
$244.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$639.74
$726.10
$817.58
$1,142.56
$1,736.24
$884.44
$970.80
$1,062.28
$1,387.26
$1,129.14
$1,215.50
$1,306.98
$1,631.96
$1,373.84
$1,460.20
$1,551.68
$1,876.66
$244.70
Toc - Plan #43 Blue Cross and Blue Shield of Texas
Silver

(HMO) MyBlue Health Silver? 405

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

Annual Out of Pocket Expenses:

Individual Family
$2,250 $4,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.62
$437.67
$492.82
$688.71
$1,046.56
$680.62
$732.67
$787.82
$983.71
$975.62
$1,027.67
$1,082.82
$1,278.71
$1,270.62
$1,322.67
$1,377.82
$1,573.71
$295.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.24
$875.34
$985.64
$1,377.42
$2,093.12
$1,066.24
$1,170.34
$1,280.64
$1,672.42
$1,361.24
$1,465.34
$1,575.64
$1,967.42
$1,656.24
$1,760.34
$1,870.64
$2,262.42
$295.00
Toc - Plan #44 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) MyBlue Health Bronze? 806

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$265.72
$301.60
$339.59
$474.58
$721.17
$469.00
$504.88
$542.87
$677.86
$672.28
$708.16
$746.15
$881.14
$875.56
$911.44
$949.43
$1,084.42
$203.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$531.44
$603.20
$679.18
$949.16
$1,442.34
$734.72
$806.48
$882.46
$1,152.44
$938.00
$1,009.76
$1,085.74
$1,355.72
$1,141.28
$1,213.04
$1,289.02
$1,559.00
$203.28
Toc - Plan #45 Blue Cross and Blue Shield of Texas
Gold

(HMO) MyBlue Health Gold? 808

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.91
$377.85
$425.46
$594.57
$903.51
$587.58
$632.52
$680.13
$849.24
$842.25
$887.19
$934.80
$1,103.91
$1,096.92
$1,141.86
$1,189.47
$1,358.58
$254.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.82
$755.70
$850.92
$1,189.14
$1,807.02
$920.49
$1,010.37
$1,105.59
$1,443.81
$1,175.16
$1,265.04
$1,360.26
$1,698.48
$1,429.83
$1,519.71
$1,614.93
$1,953.15
$254.67
Toc - Plan #46 Blue Cross and Blue Shield of Texas
Silver

(HMO) MyBlue Health Silver? 807

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.87
$435.69
$490.58
$685.59
$1,041.82
$677.53
$729.35
$784.24
$979.25
$971.19
$1,023.01
$1,077.90
$1,272.91
$1,264.85
$1,316.67
$1,371.56
$1,566.57
$293.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.74
$871.38
$981.16
$1,371.18
$2,083.64
$1,061.40
$1,165.04
$1,274.82
$1,664.84
$1,355.06
$1,458.70
$1,568.48
$1,958.50
$1,648.72
$1,752.36
$1,862.14
$2,252.16
$293.66
Toc - Plan #47 Blue Cross and Blue Shield of Texas
Expanded Bronze

(POS) Blue Advantage Plus Bronze? 303

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.99
$410.86
$462.62
$646.51
$982.44
$638.91
$687.78
$739.54
$923.43
$915.83
$964.70
$1,016.46
$1,200.35
$1,192.75
$1,241.62
$1,293.38
$1,477.27
$276.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.98
$821.72
$925.24
$1,293.02
$1,964.88
$1,000.90
$1,098.64
$1,202.16
$1,569.94
$1,277.82
$1,375.56
$1,479.08
$1,846.86
$1,554.74
$1,652.48
$1,756.00
$2,123.78
$276.92
Toc - Plan #48 Blue Cross and Blue Shield of Texas
Bronze

(POS) Blue Advantage Plus Bronze? 305

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.17
$389.50
$438.58
$612.91
$931.37
$605.70
$652.03
$701.11
$875.44
$868.23
$914.56
$963.64
$1,137.97
$1,130.76
$1,177.09
$1,226.17
$1,400.50
$262.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.34
$779.00
$877.16
$1,225.82
$1,862.74
$948.87
$1,041.53
$1,139.69
$1,488.35
$1,211.40
$1,304.06
$1,402.22
$1,750.88
$1,473.93
$1,566.59
$1,664.75
$2,013.41
$262.53
Toc - Plan #49 Blue Cross and Blue Shield of Texas
Expanded Bronze

(POS) Blue Advantage Plus Bronze? 707

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$352.23
$399.78
$450.15
$629.08
$955.95
$621.69
$669.24
$719.61
$898.54
$891.15
$938.70
$989.07
$1,168.00
$1,160.61
$1,208.16
$1,258.53
$1,437.46
$269.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704.46
$799.56
$900.30
$1,258.16
$1,911.90
$973.92
$1,069.02
$1,169.76
$1,527.62
$1,243.38
$1,338.48
$1,439.22
$1,797.08
$1,512.84
$1,607.94
$1,708.68
$2,066.54
$269.46
Toc - Plan #50 Blue Cross and Blue Shield of Texas
Gold

(POS) Blue Advantage Plus Gold? 203

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.66
$492.21
$554.22
$774.52
$1,176.96
$765.41
$823.96
$885.97
$1,106.27
$1,097.16
$1,155.71
$1,217.72
$1,438.02
$1,428.91
$1,487.46
$1,549.47
$1,769.77
$331.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.32
$984.42
$1,108.44
$1,549.04
$2,353.92
$1,199.07
$1,316.17
$1,440.19
$1,880.79
$1,530.82
$1,647.92
$1,771.94
$2,212.54
$1,862.57
$1,979.67
$2,103.69
$2,544.29
$331.75
Toc - Plan #51 Blue Cross and Blue Shield of Texas
Gold

(POS) Blue Advantage Plus Gold? 706

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$436.88
$495.86
$558.33
$780.26
$1,185.68
$771.09
$830.07
$892.54
$1,114.47
$1,105.30
$1,164.28
$1,226.75
$1,448.68
$1,439.51
$1,498.49
$1,560.96
$1,782.89
$334.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.76
$991.72
$1,116.66
$1,560.52
$2,371.36
$1,207.97
$1,325.93
$1,450.87
$1,894.73
$1,542.18
$1,660.14
$1,785.08
$2,228.94
$1,876.39
$1,994.35
$2,119.29
$2,563.15
$334.21
Toc - Plan #52 Blue Cross and Blue Shield of Texas
Silver

(POS) Blue Advantage Plus Silver? 202

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$511.30
$580.33
$653.44
$913.18
$1,387.67
$902.44
$971.47
$1,044.58
$1,304.32
$1,293.58
$1,362.61
$1,435.72
$1,695.46
$1,684.72
$1,753.75
$1,826.86
$2,086.60
$391.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,022.60
$1,160.66
$1,306.88
$1,826.36
$2,775.34
$1,413.74
$1,551.80
$1,698.02
$2,217.50
$1,804.88
$1,942.94
$2,089.16
$2,608.64
$2,196.02
$2,334.08
$2,480.30
$2,999.78
$391.14
Toc - Plan #53 Blue Cross and Blue Shield of Texas
Silver

(POS) Blue Advantage Plus Silver? 605

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$518.58
$588.59
$662.75
$926.19
$1,407.44
$915.30
$985.31
$1,059.47
$1,322.91
$1,312.02
$1,382.03
$1,456.19
$1,719.63
$1,708.74
$1,778.75
$1,852.91
$2,116.35
$396.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,037.16
$1,177.18
$1,325.50
$1,852.38
$2,814.88
$1,433.88
$1,573.90
$1,722.22
$2,249.10
$1,830.60
$1,970.62
$2,118.94
$2,645.82
$2,227.32
$2,367.34
$2,515.66
$3,042.54
$396.72
Toc - Plan #54 Blue Cross and Blue Shield of Texas
Silver

(POS) Blue Advantage Plus Silver? 705

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$505.81
$574.10
$646.43
$903.38
$1,372.77
$892.76
$961.05
$1,033.38
$1,290.33
$1,279.71
$1,348.00
$1,420.33
$1,677.28
$1,666.66
$1,734.95
$1,807.28
$2,064.23
$386.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,011.62
$1,148.20
$1,292.86
$1,806.76
$2,745.54
$1,398.57
$1,535.15
$1,679.81
$2,193.71
$1,785.52
$1,922.10
$2,066.76
$2,580.66
$2,172.47
$2,309.05
$2,453.71
$2,967.61
$386.95
Toc - Plan #55 Blue Cross and Blue Shield of Texas
Gold

(POS) Blue Advantage Plus Gold? 803

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.18
$483.72
$544.66
$761.16
$1,156.66
$752.21
$809.75
$870.69
$1,087.19
$1,078.24
$1,135.78
$1,196.72
$1,413.22
$1,404.27
$1,461.81
$1,522.75
$1,739.25
$326.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.36
$967.44
$1,089.32
$1,522.32
$2,313.32
$1,178.39
$1,293.47
$1,415.35
$1,848.35
$1,504.42
$1,619.50
$1,741.38
$2,174.38
$1,830.45
$1,945.53
$2,067.41
$2,500.41
$326.03

ADVERTISEMENT

UnitedHealthcare

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

Toc - Plan #56 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$421.98
$478.94
$539.29
$753.65
$1,145.24
$744.79
$801.75
$862.10
$1,076.46
$1,067.60
$1,124.56
$1,184.91
$1,399.27
$1,390.41
$1,447.37
$1,507.72
$1,722.08
$322.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$843.96
$957.88
$1,078.58
$1,507.30
$2,290.48
$1,166.77
$1,280.69
$1,401.39
$1,830.11
$1,489.58
$1,603.50
$1,724.20
$2,152.92
$1,812.39
$1,926.31
$2,047.01
$2,475.73
$322.81
Toc - Plan #57 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$297.15
$337.26
$379.75
$530.70
$806.45
$524.47
$564.58
$607.07
$758.02
$751.79
$791.90
$834.39
$985.34
$979.11
$1,019.22
$1,061.71
$1,212.66
$227.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$594.30
$674.52
$759.50
$1,061.40
$1,612.90
$821.62
$901.84
$986.82
$1,288.72
$1,048.94
$1,129.16
$1,214.14
$1,516.04
$1,276.26
$1,356.48
$1,441.46
$1,743.36
$227.32
Toc - Plan #58 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$300.96
$341.59
$384.62
$537.51
$816.79
$531.19
$571.82
$614.85
$767.74
$761.42
$802.05
$845.08
$997.97
$991.65
$1,032.28
$1,075.31
$1,228.20
$230.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$601.92
$683.18
$769.24
$1,075.02
$1,633.58
$832.15
$913.41
$999.47
$1,305.25
$1,062.38
$1,143.64
$1,229.70
$1,535.48
$1,292.61
$1,373.87
$1,459.93
$1,765.71
$230.23
Toc - Plan #59 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.37
$419.24
$472.06
$659.70
$1,002.48
$651.94
$701.81
$754.63
$942.27
$934.51
$984.38
$1,037.20
$1,224.84
$1,217.08
$1,266.95
$1,319.77
$1,507.41
$282.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.74
$838.48
$944.12
$1,319.40
$2,004.96
$1,021.31
$1,121.05
$1,226.69
$1,601.97
$1,303.88
$1,403.62
$1,509.26
$1,884.54
$1,586.45
$1,686.19
$1,791.83
$2,167.11
$282.57
Toc - Plan #60 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$301.62
$342.34
$385.48
$538.70
$818.61
$532.36
$573.08
$616.22
$769.44
$763.10
$803.82
$846.96
$1,000.18
$993.84
$1,034.56
$1,077.70
$1,230.92
$230.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$603.24
$684.68
$770.96
$1,077.40
$1,637.22
$833.98
$915.42
$1,001.70
$1,308.14
$1,064.72
$1,146.16
$1,232.44
$1,538.88
$1,295.46
$1,376.90
$1,463.18
$1,769.62
$230.74
Toc - Plan #61 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $5 Tier 2 Rx, $0 Insulin)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$438.74
$497.97
$560.71
$783.59
$1,190.75
$774.38
$833.61
$896.35
$1,119.23
$1,110.02
$1,169.25
$1,231.99
$1,454.87
$1,445.66
$1,504.89
$1,567.63
$1,790.51
$335.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$877.48
$995.94
$1,121.42
$1,567.18
$2,381.50
$1,213.12
$1,331.58
$1,457.06
$1,902.82
$1,548.76
$1,667.22
$1,792.70
$2,238.46
$1,884.40
$2,002.86
$2,128.34
$2,574.10
$335.64
Toc - Plan #62 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$421.89
$478.84
$539.17
$753.49
$1,145.01
$744.64
$801.59
$861.92
$1,076.24
$1,067.39
$1,124.34
$1,184.67
$1,398.99
$1,390.14
$1,447.09
$1,507.42
$1,721.74
$322.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$843.78
$957.68
$1,078.34
$1,506.98
$2,290.02
$1,166.53
$1,280.43
$1,401.09
$1,829.73
$1,489.28
$1,603.18
$1,723.84
$2,152.48
$1,812.03
$1,925.93
$2,046.59
$2,475.23
$322.75
Toc - Plan #63 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.13
$433.72
$488.36
$682.49
$1,037.10
$674.46
$726.05
$780.69
$974.82
$966.79
$1,018.38
$1,073.02
$1,267.15
$1,259.12
$1,310.71
$1,365.35
$1,559.48
$292.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.26
$867.44
$976.72
$1,364.98
$2,074.20
$1,056.59
$1,159.77
$1,269.05
$1,657.31
$1,348.92
$1,452.10
$1,561.38
$1,949.64
$1,641.25
$1,744.43
$1,853.71
$2,241.97
$292.33
Toc - Plan #64 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.91
$466.38
$525.14
$733.88
$1,115.20
$725.25
$780.72
$839.48
$1,048.22
$1,039.59
$1,095.06
$1,153.82
$1,362.56
$1,353.93
$1,409.40
$1,468.16
$1,676.90
$314.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.82
$932.76
$1,050.28
$1,467.76
$2,230.40
$1,136.16
$1,247.10
$1,364.62
$1,782.10
$1,450.50
$1,561.44
$1,678.96
$2,096.44
$1,764.84
$1,875.78
$1,993.30
$2,410.78
$314.34
Toc - Plan #65 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.17
$474.62
$534.42
$746.85
$1,134.91
$738.07
$794.52
$854.32
$1,066.75
$1,057.97
$1,114.42
$1,174.22
$1,386.65
$1,377.87
$1,434.32
$1,494.12
$1,706.55
$319.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.34
$949.24
$1,068.84
$1,493.70
$2,269.82
$1,156.24
$1,269.14
$1,388.74
$1,813.60
$1,476.14
$1,589.04
$1,708.64
$2,133.50
$1,796.04
$1,908.94
$2,028.54
$2,453.40
$319.90
Toc - Plan #66 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.35
$409.00
$460.53
$643.59
$978.00
$636.02
$684.67
$736.20
$919.26
$911.69
$960.34
$1,011.87
$1,194.93
$1,187.36
$1,236.01
$1,287.54
$1,470.60
$275.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.70
$818.00
$921.06
$1,287.18
$1,956.00
$996.37
$1,093.67
$1,196.73
$1,562.85
$1,272.04
$1,369.34
$1,472.40
$1,838.52
$1,547.71
$1,645.01
$1,748.07
$2,114.19
$275.67
Toc - Plan #67 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.62
$422.93
$476.21
$665.50
$1,011.30
$657.68
$707.99
$761.27
$950.56
$942.74
$993.05
$1,046.33
$1,235.62
$1,227.80
$1,278.11
$1,331.39
$1,520.68
$285.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$745.24
$845.86
$952.42
$1,331.00
$2,022.60
$1,030.30
$1,130.92
$1,237.48
$1,616.06
$1,315.36
$1,415.98
$1,522.54
$1,901.12
$1,600.42
$1,701.04
$1,807.60
$2,186.18
$285.06
Toc - Plan #68 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370.28
$420.27
$473.22
$661.32
$1,004.95
$653.55
$703.54
$756.49
$944.59
$936.82
$986.81
$1,039.76
$1,227.86
$1,220.09
$1,270.08
$1,323.03
$1,511.13
$283.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.56
$840.54
$946.44
$1,322.64
$2,009.90
$1,023.83
$1,123.81
$1,229.71
$1,605.91
$1,307.10
$1,407.08
$1,512.98
$1,889.18
$1,590.37
$1,690.35
$1,796.25
$2,172.45
$283.27
Toc - Plan #69 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Insulin)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$318.04
$360.97
$406.45
$568.02
$863.16
$561.34
$604.27
$649.75
$811.32
$804.64
$847.57
$893.05
$1,054.62
$1,047.94
$1,090.87
$1,136.35
$1,297.92
$243.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636.08
$721.94
$812.90
$1,136.04
$1,726.32
$879.38
$965.24
$1,056.20
$1,379.34
$1,122.68
$1,208.54
$1,299.50
$1,622.64
$1,365.98
$1,451.84
$1,542.80
$1,865.94
$243.30
Toc - Plan #70 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$298.08
$338.32
$380.95
$532.37
$808.99
$526.11
$566.35
$608.98
$760.40
$754.14
$794.38
$837.01
$988.43
$982.17
$1,022.41
$1,065.04
$1,216.46
$228.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.16
$676.64
$761.90
$1,064.74
$1,617.98
$824.19
$904.67
$989.93
$1,292.77
$1,052.22
$1,132.70
$1,217.96
$1,520.80
$1,280.25
$1,360.73
$1,445.99
$1,748.83
$228.03
Toc - Plan #71 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$436.76
$495.73
$558.18
$780.06
$1,185.37
$770.88
$829.85
$892.30
$1,114.18
$1,105.00
$1,163.97
$1,226.42
$1,448.30
$1,439.12
$1,498.09
$1,560.54
$1,782.42
$334.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.52
$991.46
$1,116.36
$1,560.12
$2,370.74
$1,207.64
$1,325.58
$1,450.48
$1,894.24
$1,541.76
$1,659.70
$1,784.60
$2,228.36
$1,875.88
$1,993.82
$2,118.72
$2,562.48
$334.12
Toc - Plan #72 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.22
$444.03
$499.97
$698.71
$1,061.76
$690.50
$743.31
$799.25
$997.99
$989.78
$1,042.59
$1,098.53
$1,297.27
$1,289.06
$1,341.87
$1,397.81
$1,596.55
$299.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782.44
$888.06
$999.94
$1,397.42
$2,123.52
$1,081.72
$1,187.34
$1,299.22
$1,696.70
$1,381.00
$1,486.62
$1,598.50
$1,995.98
$1,680.28
$1,785.90
$1,897.78
$2,295.26
$299.28

ADVERTISEMENT

Baylor Scott and White Health Plan

Local: 1-844-633-5325 | Toll Free: 1-844-633-5325 | TTY: 1-800-735-2989

Toc - Plan #73 Baylor Scott and White Health Plan
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.45
$401.17
$451.71
$631.26
$959.27
$623.84
$671.56
$722.10
$901.65
$894.23
$941.95
$992.49
$1,172.04
$1,164.62
$1,212.34
$1,262.88
$1,442.43
$270.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.90
$802.34
$903.42
$1,262.52
$1,918.54
$977.29
$1,072.73
$1,173.81
$1,532.91
$1,247.68
$1,343.12
$1,444.20
$1,803.30
$1,518.07
$1,613.51
$1,714.59
$2,073.69
$270.39
Toc - Plan #74 Baylor Scott and White Health Plan
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$349.29
$396.45
$446.40
$623.84
$947.98
$616.50
$663.66
$713.61
$891.05
$883.71
$930.87
$980.82
$1,158.26
$1,150.92
$1,198.08
$1,248.03
$1,425.47
$267.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.58
$792.90
$892.80
$1,247.68
$1,895.96
$965.79
$1,060.11
$1,160.01
$1,514.89
$1,233.00
$1,327.32
$1,427.22
$1,782.10
$1,500.21
$1,594.53
$1,694.43
$2,049.31
$267.21
Toc - Plan #75 Baylor Scott and White Health Plan
Gold

(HMO) BSW Elite Gold HMO 004 (Two free PCP visits, $0 Pediatric PCP visits)

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

Annual Out of Pocket Expenses:

Individual Family
$1,100 $2,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.05
$389.37
$438.42
$612.70
$931.05
$605.49
$651.81
$700.86
$875.14
$867.93
$914.25
$963.30
$1,137.58
$1,130.37
$1,176.69
$1,225.74
$1,400.02
$262.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.10
$778.74
$876.84
$1,225.40
$1,862.10
$948.54
$1,041.18
$1,139.28
$1,487.84
$1,210.98
$1,303.62
$1,401.72
$1,750.28
$1,473.42
$1,566.06
$1,664.16
$2,012.72
$262.44
Toc - Plan #76 Baylor Scott and White Health Plan
Silver

(HMO) BSW Prime Silver HMO 005

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

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.45
$403.43
$454.26
$634.83
$964.69
$627.37
$675.35
$726.18
$906.75
$899.29
$947.27
$998.10
$1,178.67
$1,171.21
$1,219.19
$1,270.02
$1,450.59
$271.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.90
$806.86
$908.52
$1,269.66
$1,929.38
$982.82
$1,078.78
$1,180.44
$1,541.58
$1,254.74
$1,350.70
$1,452.36
$1,813.50
$1,526.66
$1,622.62
$1,724.28
$2,085.42
$271.92
Toc - Plan #77 Baylor Scott and White Health Plan
Expanded Bronze

(HMO) BSW Savers Bronze HMO H S A 006

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.94
$331.36
$373.10
$521.41
$792.34
$515.28
$554.70
$596.44
$744.75
$738.62
$778.04
$819.78
$968.09
$961.96
$1,001.38
$1,043.12
$1,191.43
$223.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$583.88
$662.72
$746.20
$1,042.82
$1,584.68
$807.22
$886.06
$969.54
$1,266.16
$1,030.56
$1,109.40
$1,192.88
$1,489.50
$1,253.90
$1,332.74
$1,416.22
$1,712.84
$223.34
Toc - Plan #78 Baylor Scott and White Health Plan
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$274.85
$311.96
$351.26
$490.88
$745.95
$485.11
$522.22
$561.52
$701.14
$695.37
$732.48
$771.78
$911.40
$905.63
$942.74
$982.04
$1,121.66
$210.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$549.70
$623.92
$702.52
$981.76
$1,491.90
$759.96
$834.18
$912.78
$1,192.02
$970.22
$1,044.44
$1,123.04
$1,402.28
$1,180.48
$1,254.70
$1,333.30
$1,612.54
$210.26
Toc - Plan #79 Baylor Scott and White Health Plan
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$342.97
$389.27
$438.32
$612.55
$930.83
$605.34
$651.64
$700.69
$874.92
$867.71
$914.01
$963.06
$1,137.29
$1,130.08
$1,176.38
$1,225.43
$1,399.66
$262.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.94
$778.54
$876.64
$1,225.10
$1,861.66
$948.31
$1,040.91
$1,139.01
$1,487.47
$1,210.68
$1,303.28
$1,401.38
$1,749.84
$1,473.05
$1,565.65
$1,663.75
$2,012.21
$262.37
Toc - Plan #80 Baylor Scott and White Health Plan
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$283.29
$321.54
$362.05
$505.96
$768.86
$500.01
$538.26
$578.77
$722.68
$716.73
$754.98
$795.49
$939.40
$933.45
$971.70
$1,012.21
$1,156.12
$216.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$566.58
$643.08
$724.10
$1,011.92
$1,537.72
$783.30
$859.80
$940.82
$1,228.64
$1,000.02
$1,076.52
$1,157.54
$1,445.36
$1,216.74
$1,293.24
$1,374.26
$1,662.08
$216.72
Toc - Plan #81 Baylor Scott and White Health Plan
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$9,300 $18,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.23
$386.16
$434.81
$607.65
$923.38
$600.50
$646.43
$695.08
$867.92
$860.77
$906.70
$955.35
$1,128.19
$1,121.04
$1,166.97
$1,215.62
$1,388.46
$260.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.46
$772.32
$869.62
$1,215.30
$1,846.76
$940.73
$1,032.59
$1,129.89
$1,475.57
$1,201.00
$1,292.86
$1,390.16
$1,735.84
$1,461.27
$1,553.13
$1,650.43
$1,996.11
$260.27

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #82 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.61
$409.29
$460.85
$644.04
$978.68
$636.47
$685.15
$736.71
$919.90
$912.33
$961.01
$1,012.57
$1,195.76
$1,188.19
$1,236.87
$1,288.43
$1,471.62
$275.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.22
$818.58
$921.70
$1,288.08
$1,957.36
$997.08
$1,094.44
$1,197.56
$1,563.94
$1,272.94
$1,370.30
$1,473.42
$1,839.80
$1,548.80
$1,646.16
$1,749.28
$2,115.66
$275.86
Toc - Plan #83 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$401.39
$455.58
$512.97
$716.88
$1,089.36
$708.45
$762.64
$820.03
$1,023.94
$1,015.51
$1,069.70
$1,127.09
$1,331.00
$1,322.57
$1,376.76
$1,434.15
$1,638.06
$307.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802.78
$911.16
$1,025.94
$1,433.76
$2,178.72
$1,109.84
$1,218.22
$1,333.00
$1,740.82
$1,416.90
$1,525.28
$1,640.06
$2,047.88
$1,723.96
$1,832.34
$1,947.12
$2,354.94
$307.06
Toc - Plan #84 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389.44
$442.01
$497.70
$695.53
$1,056.92
$687.36
$739.93
$795.62
$993.45
$985.28
$1,037.85
$1,093.54
$1,291.37
$1,283.20
$1,335.77
$1,391.46
$1,589.29
$297.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.88
$884.02
$995.40
$1,391.06
$2,113.84
$1,076.80
$1,181.94
$1,293.32
$1,688.98
$1,374.72
$1,479.86
$1,591.24
$1,986.90
$1,672.64
$1,777.78
$1,889.16
$2,284.82
$297.92
Toc - Plan #85 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$359.45
$407.98
$459.38
$641.98
$975.55
$634.43
$682.96
$734.36
$916.96
$909.41
$957.94
$1,009.34
$1,191.94
$1,184.39
$1,232.92
$1,284.32
$1,466.92
$274.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$718.90
$815.96
$918.76
$1,283.96
$1,951.10
$993.88
$1,090.94
$1,193.74
$1,558.94
$1,268.86
$1,365.92
$1,468.72
$1,833.92
$1,543.84
$1,640.90
$1,743.70
$2,108.90
$274.98
Toc - Plan #86 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364.45
$413.65
$465.77
$650.91
$989.11
$643.26
$692.46
$744.58
$929.72
$922.07
$971.27
$1,023.39
$1,208.53
$1,200.88
$1,250.08
$1,302.20
$1,487.34
$278.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$728.90
$827.30
$931.54
$1,301.82
$1,978.22
$1,007.71
$1,106.11
$1,210.35
$1,580.63
$1,286.52
$1,384.92
$1,489.16
$1,859.44
$1,565.33
$1,663.73
$1,767.97
$2,138.25
$278.81
Toc - Plan #87 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.98
$441.50
$497.12
$694.72
$1,055.69
$686.55
$739.07
$794.69
$992.29
$984.12
$1,036.64
$1,092.26
$1,289.86
$1,281.69
$1,334.21
$1,389.83
$1,587.43
$297.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.96
$883.00
$994.24
$1,389.44
$2,111.38
$1,075.53
$1,180.57
$1,291.81
$1,687.01
$1,373.10
$1,478.14
$1,589.38
$1,984.58
$1,670.67
$1,775.71
$1,886.95
$2,282.15
$297.57
Toc - Plan #88 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$397.55
$451.22
$508.07
$710.02
$1,078.94
$701.68
$755.35
$812.20
$1,014.15
$1,005.81
$1,059.48
$1,116.33
$1,318.28
$1,309.94
$1,363.61
$1,420.46
$1,622.41
$304.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.10
$902.44
$1,016.14
$1,420.04
$2,157.88
$1,099.23
$1,206.57
$1,320.27
$1,724.17
$1,403.36
$1,510.70
$1,624.40
$2,028.30
$1,707.49
$1,814.83
$1,928.53
$2,332.43
$304.13
Toc - Plan #89 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.00
$451.73
$508.64
$710.83
$1,080.17
$702.47
$756.20
$813.11
$1,015.30
$1,006.94
$1,060.67
$1,117.58
$1,319.77
$1,311.41
$1,365.14
$1,422.05
$1,624.24
$304.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.00
$903.46
$1,017.28
$1,421.66
$2,160.34
$1,100.47
$1,207.93
$1,321.75
$1,726.13
$1,404.94
$1,512.40
$1,626.22
$2,030.60
$1,709.41
$1,816.87
$1,930.69
$2,335.07
$304.47

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

Toc - Plan #90 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 5500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.04
$343.95
$387.28
$541.22
$822.44
$534.86
$575.77
$619.10
$773.04
$766.68
$807.59
$850.92
$1,004.86
$998.50
$1,039.41
$1,082.74
$1,236.68
$231.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$606.08
$687.90
$774.56
$1,082.44
$1,644.88
$837.90
$919.72
$1,006.38
$1,314.26
$1,069.72
$1,151.54
$1,238.20
$1,546.08
$1,301.54
$1,383.36
$1,470.02
$1,777.90
$231.82
Toc - Plan #91 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 6500 Indiv Med Deductible Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.72
$344.72
$388.15
$542.44
$824.29
$536.06
$577.06
$620.49
$774.78
$768.40
$809.40
$852.83
$1,007.12
$1,000.74
$1,041.74
$1,085.17
$1,239.46
$232.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$607.44
$689.44
$776.30
$1,084.88
$1,648.58
$839.78
$921.78
$1,008.64
$1,317.22
$1,072.12
$1,154.12
$1,240.98
$1,549.56
$1,304.46
$1,386.46
$1,473.32
$1,781.90
$232.34
Toc - Plan #92 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 8500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304.63
$345.75
$389.31
$544.07
$826.76
$537.67
$578.79
$622.35
$777.11
$770.71
$811.83
$855.39
$1,010.15
$1,003.75
$1,044.87
$1,088.43
$1,243.19
$233.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$609.26
$691.50
$778.62
$1,088.14
$1,653.52
$842.30
$924.54
$1,011.66
$1,321.18
$1,075.34
$1,157.58
$1,244.70
$1,554.22
$1,308.38
$1,390.62
$1,477.74
$1,787.26
$233.04
Toc - Plan #93 Cigna Healthcare
Silver

(HMO) Connect Silver 5000 Indiv Med Deductible Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$443.97
$503.90
$567.39
$792.92
$1,204.93
$783.60
$843.53
$907.02
$1,132.55
$1,123.23
$1,183.16
$1,246.65
$1,472.18
$1,462.86
$1,522.79
$1,586.28
$1,811.81
$339.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$887.94
$1,007.80
$1,134.78
$1,585.84
$2,409.86
$1,227.57
$1,347.43
$1,474.41
$1,925.47
$1,567.20
$1,687.06
$1,814.04
$2,265.10
$1,906.83
$2,026.69
$2,153.67
$2,604.73
$339.63
Toc - Plan #94 Cigna Healthcare
Silver

(HMO) Connect Silver 4000 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$438.65
$497.87
$560.59
$783.43
$1,190.49
$774.22
$833.44
$896.16
$1,119.00
$1,109.79
$1,169.01
$1,231.73
$1,454.57
$1,445.36
$1,504.58
$1,567.30
$1,790.14
$335.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$877.30
$995.74
$1,121.18
$1,566.86
$2,380.98
$1,212.87
$1,331.31
$1,456.75
$1,902.43
$1,548.44
$1,666.88
$1,792.32
$2,238.00
$1,884.01
$2,002.45
$2,127.89
$2,573.57
$335.57
Toc - Plan #95 Cigna Healthcare
Silver

(HMO) Connect Silver 7000 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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
$449.42
$510.09
$574.36
$802.66
$1,219.73
$793.23
$853.90
$918.17
$1,146.47
$1,137.04
$1,197.71
$1,261.98
$1,490.28
$1,480.85
$1,541.52
$1,605.79
$1,834.09
$343.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$898.84
$1,020.18
$1,148.72
$1,605.32
$2,439.46
$1,242.65
$1,363.99
$1,492.53
$1,949.13
$1,586.46
$1,707.80
$1,836.34
$2,292.94
$1,930.27
$2,051.61
$2,180.15
$2,636.75
$343.81
Toc - Plan #96 Cigna Healthcare
Silver

(HMO) Connect Silver 3000 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$443.24
$503.08
$566.46
$791.63
$1,202.95
$782.32
$842.16
$905.54
$1,130.71
$1,121.40
$1,181.24
$1,244.62
$1,469.79
$1,460.48
$1,520.32
$1,583.70
$1,808.87
$339.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.48
$1,006.16
$1,132.92
$1,583.26
$2,405.90
$1,225.56
$1,345.24
$1,472.00
$1,922.34
$1,564.64
$1,684.32
$1,811.08
$2,261.42
$1,903.72
$2,023.40
$2,150.16
$2,600.50
$339.08
Toc - Plan #97 Cigna Healthcare
Gold

(HMO) Connect Gold 3500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$5,700 $11,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.48
$427.30
$481.14
$672.39
$1,021.76
$664.49
$715.31
$769.15
$960.40
$952.50
$1,003.32
$1,057.16
$1,248.41
$1,240.51
$1,291.33
$1,345.17
$1,536.42
$288.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.96
$854.60
$962.28
$1,344.78
$2,043.52
$1,040.97
$1,142.61
$1,250.29
$1,632.79
$1,328.98
$1,430.62
$1,538.30
$1,920.80
$1,616.99
$1,718.63
$1,826.31
$2,208.81
$288.01
Toc - Plan #98 Cigna Healthcare
Gold

(HMO) Connect Gold 2500 Indiv Med Deductible Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$7,700 $15,400 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
$375.21
$425.86
$479.51
$670.12
$1,018.31
$662.24
$712.89
$766.54
$957.15
$949.27
$999.92
$1,053.57
$1,244.18
$1,236.30
$1,286.95
$1,340.60
$1,531.21
$287.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.42
$851.72
$959.02
$1,340.24
$2,036.62
$1,037.45
$1,138.75
$1,246.05
$1,627.27
$1,324.48
$1,425.78
$1,533.08
$1,914.30
$1,611.51
$1,712.81
$1,820.11
$2,201.33
$287.03
Toc - Plan #99 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze CMS Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.13
$344.05
$387.40
$541.39
$822.69
$535.02
$575.94
$619.29
$773.28
$766.91
$807.83
$851.18
$1,005.17
$998.80
$1,039.72
$1,083.07
$1,237.06
$231.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$606.26
$688.10
$774.80
$1,082.78
$1,645.38
$838.15
$919.99
$1,006.69
$1,314.67
$1,070.04
$1,151.88
$1,238.58
$1,546.56
$1,301.93
$1,383.77
$1,470.47
$1,778.45
$231.89
Toc - Plan #100 Cigna Healthcare
Silver

(HMO) Connect Silver CMS Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$440.10
$499.52
$562.45
$786.03
$1,194.44
$776.78
$836.20
$899.13
$1,122.71
$1,113.46
$1,172.88
$1,235.81
$1,459.39
$1,450.14
$1,509.56
$1,572.49
$1,796.07
$336.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$880.20
$999.04
$1,124.90
$1,572.06
$2,388.88
$1,216.88
$1,335.72
$1,461.58
$1,908.74
$1,553.56
$1,672.40
$1,798.26
$2,245.42
$1,890.24
$2,009.08
$2,134.94
$2,582.10
$336.68
Toc - Plan #101 Cigna Healthcare
Gold

(HMO) Connect Gold CMS Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.71
$427.56
$481.43
$672.80
$1,022.38
$664.89
$715.74
$769.61
$960.98
$953.07
$1,003.92
$1,057.79
$1,249.16
$1,241.25
$1,292.10
$1,345.97
$1,537.34
$288.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.42
$855.12
$962.86
$1,345.60
$2,044.76
$1,041.60
$1,143.30
$1,251.04
$1,633.78
$1,329.78
$1,431.48
$1,539.22
$1,921.96
$1,617.96
$1,719.66
$1,827.40
$2,210.14
$288.18
Toc - Plan #102 Cigna Healthcare
Bronze

(HMO) Connect Bronze 9450 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$289.86
$328.99
$370.44
$517.69
$786.67
$511.60
$550.73
$592.18
$739.43
$733.34
$772.47
$813.92
$961.17
$955.08
$994.21
$1,035.66
$1,182.91
$221.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$579.72
$657.98
$740.88
$1,035.38
$1,573.34
$801.46
$879.72
$962.62
$1,257.12
$1,023.20
$1,101.46
$1,184.36
$1,478.86
$1,244.94
$1,323.20
$1,406.10
$1,700.60
$221.74

ADVERTISEMENT

Ambetter from Superior HealthPlan

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

Toc - Plan #103 Ambetter from Superior HealthPlan
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$518.65
$588.66
$662.83
$926.30
$1,407.60
$915.41
$985.42
$1,059.59
$1,323.06
$1,312.17
$1,382.18
$1,456.35
$1,719.82
$1,708.93
$1,778.94
$1,853.11
$2,116.58
$396.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,037.30
$1,177.32
$1,325.66
$1,852.60
$2,815.20
$1,434.06
$1,574.08
$1,722.42
$2,249.36
$1,830.82
$1,970.84
$2,119.18
$2,646.12
$2,227.58
$2,367.60
$2,515.94
$3,042.88
$396.76
Toc - Plan #104 Ambetter from Superior HealthPlan
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$478.34
$542.90
$611.30
$854.29
$1,298.18
$844.26
$908.82
$977.22
$1,220.21
$1,210.18
$1,274.74
$1,343.14
$1,586.13
$1,576.10
$1,640.66
$1,709.06
$1,952.05
$365.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$956.68
$1,085.80
$1,222.60
$1,708.58
$2,596.36
$1,322.60
$1,451.72
$1,588.52
$2,074.50
$1,688.52
$1,817.64
$1,954.44
$2,440.42
$2,054.44
$2,183.56
$2,320.36
$2,806.34
$365.92
Toc - Plan #105 Ambetter from Superior HealthPlan
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$518.00
$587.91
$661.98
$925.12
$1,405.81
$914.26
$984.17
$1,058.24
$1,321.38
$1,310.52
$1,380.43
$1,454.50
$1,717.64
$1,706.78
$1,776.69
$1,850.76
$2,113.90
$396.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,036.00
$1,175.82
$1,323.96
$1,850.24
$2,811.62
$1,432.26
$1,572.08
$1,720.22
$2,246.50
$1,828.52
$1,968.34
$2,116.48
$2,642.76
$2,224.78
$2,364.60
$2,512.74
$3,039.02
$396.26
Toc - Plan #106 Ambetter from Superior HealthPlan
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$468.71
$531.97
$598.99
$837.09
$1,272.04
$827.26
$890.52
$957.54
$1,195.64
$1,185.81
$1,249.07
$1,316.09
$1,554.19
$1,544.36
$1,607.62
$1,674.64
$1,912.74
$358.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$937.42
$1,063.94
$1,197.98
$1,674.18
$2,544.08
$1,295.97
$1,422.49
$1,556.53
$2,032.73
$1,654.52
$1,781.04
$1,915.08
$2,391.28
$2,013.07
$2,139.59
$2,273.63
$2,749.83
$358.55
Toc - Plan #107 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
$402.80
$457.17
$514.76
$719.38
$1,093.17
$710.93
$765.30
$822.89
$1,027.51
$1,019.06
$1,073.43
$1,131.02
$1,335.64
$1,327.19
$1,381.56
$1,439.15
$1,643.77
$308.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.60
$914.34
$1,029.52
$1,438.76
$2,186.34
$1,113.73
$1,222.47
$1,337.65
$1,746.89
$1,421.86
$1,530.60
$1,645.78
$2,055.02
$1,729.99
$1,838.73
$1,953.91
$2,363.15
$308.13
Toc - Plan #108 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
$396.29
$449.78
$506.45
$707.76
$1,075.51
$699.45
$752.94
$809.61
$1,010.92
$1,002.61
$1,056.10
$1,112.77
$1,314.08
$1,305.77
$1,359.26
$1,415.93
$1,617.24
$303.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.58
$899.56
$1,012.90
$1,415.52
$2,151.02
$1,095.74
$1,202.72
$1,316.06
$1,718.68
$1,398.90
$1,505.88
$1,619.22
$2,021.84
$1,702.06
$1,809.04
$1,922.38
$2,325.00
$303.16
Toc - Plan #109 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
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.71
$452.52
$509.54
$712.08
$1,082.07
$703.72
$757.53
$814.55
$1,017.09
$1,008.73
$1,062.54
$1,119.56
$1,322.10
$1,313.74
$1,367.55
$1,424.57
$1,627.11
$305.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$797.42
$905.04
$1,019.08
$1,424.16
$2,164.14
$1,102.43
$1,210.05
$1,324.09
$1,729.17
$1,407.44
$1,515.06
$1,629.10
$2,034.18
$1,712.45
$1,820.07
$1,934.11
$2,339.19
$305.01
Toc - Plan #110 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
$355.71
$403.72
$454.58
$635.28
$965.37
$627.82
$675.83
$726.69
$907.39
$899.93
$947.94
$998.80
$1,179.50
$1,172.04
$1,220.05
$1,270.91
$1,451.61
$272.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.42
$807.44
$909.16
$1,270.56
$1,930.74
$983.53
$1,079.55
$1,181.27
$1,542.67
$1,255.64
$1,351.66
$1,453.38
$1,814.78
$1,527.75
$1,623.77
$1,725.49
$2,086.89
$272.11
Toc - Plan #111 Ambetter from Superior HealthPlan
Silver

(HMO) Standard Silver VALUE

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.36
$447.58
$503.98
$704.30
$1,070.26
$696.04
$749.26
$805.66
$1,005.98
$997.72
$1,050.94
$1,107.34
$1,307.66
$1,299.40
$1,352.62
$1,409.02
$1,609.34
$301.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.72
$895.16
$1,007.96
$1,408.60
$2,140.52
$1,090.40
$1,196.84
$1,309.64
$1,710.28
$1,392.08
$1,498.52
$1,611.32
$2,011.96
$1,693.76
$1,800.20
$1,913.00
$2,313.64
$301.68
Toc - Plan #112 Ambetter from Superior HealthPlan
Gold

(HMO) Standard Gold VALUE

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.85
$405.02
$456.05
$637.32
$968.47
$629.83
$678.00
$729.03
$910.30
$902.81
$950.98
$1,002.01
$1,183.28
$1,175.79
$1,223.96
$1,274.99
$1,456.26
$272.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.70
$810.04
$912.10
$1,274.64
$1,936.94
$986.68
$1,083.02
$1,185.08
$1,547.62
$1,259.66
$1,356.00
$1,458.06
$1,820.60
$1,532.64
$1,628.98
$1,731.04
$2,093.58
$272.98

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Rockwall County here.

Rockwall County is in “Rating Area 8” of Texas.

Currently, there are 112 plans offered in Rating Area 8.

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2024 Obamacare Plans for Rockwall County, TX

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