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Florida Blue (BlueCross BlueShield FL)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771

Toc - Plan #1 Florida Blue (BlueCross BlueShield FL)

Silver

(EPO) BlueOptions Silver 1423 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,950 $11,900 Annual Deductible

$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$844.65
$958.68
$1,079.46
$1,508.54
$2,292.38

$1,490.81
$1,604.84
$1,725.62
$2,154.70

$2,136.97
$2,251.00
$2,371.78
$2,800.86

$2,783.13
$2,897.16
$3,017.94
$3,447.02

$646.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,689.30
$1,917.36
$2,158.92
$3,017.08
$4,584.76

$2,335.46
$2,563.52
$2,805.08
$3,663.24

$2,981.62
$3,209.68
$3,451.24
$4,309.40

$3,627.78
$3,855.84
$4,097.40
$4,955.56

$646.16

Toc - Plan #2 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueOptions Bronze 1419 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 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

$546.46
$620.23
$698.38
$975.98
$1,483.09

$964.50
$1,038.27
$1,116.42
$1,394.02

$1,382.54
$1,456.31
$1,534.46
$1,812.06

$1,800.58
$1,874.35
$1,952.50
$2,230.10

$418.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,092.92
$1,240.46
$1,396.76
$1,951.96
$2,966.18

$1,510.96
$1,658.50
$1,814.80
$2,370.00

$1,929.00
$2,076.54
$2,232.84
$2,788.04

$2,347.04
$2,494.58
$2,650.88
$3,206.08

$418.04

Toc - Plan #3 Florida Blue (BlueCross BlueShield FL)

Silver

(EPO) BlueOptions Silver 1431 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$849.29
$963.94
$1,085.39
$1,516.83
$2,304.97

$1,499.00
$1,613.65
$1,735.10
$2,166.54

$2,148.71
$2,263.36
$2,384.81
$2,816.25

$2,798.42
$2,913.07
$3,034.52
$3,465.96

$649.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,698.58
$1,927.88
$2,170.78
$3,033.66
$4,609.94

$2,348.29
$2,577.59
$2,820.49
$3,683.37

$2,998.00
$3,227.30
$3,470.20
$4,333.08

$3,647.71
$3,877.01
$4,119.91
$4,982.79

$649.71

Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)

Platinum

(EPO) BlueOptions Platinum 1418 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$4,000 $8,000 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

$1,068.77
$1,213.05
$1,365.89
$1,908.82
$2,900.64

$1,886.38
$2,030.66
$2,183.50
$2,726.43

$2,703.99
$2,848.27
$3,001.11
$3,544.04

$3,521.60
$3,665.88
$3,818.72
$4,361.65

$817.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$2,137.54
$2,426.10
$2,731.78
$3,817.64
$5,801.28

$2,955.15
$3,243.71
$3,549.39
$4,635.25

$3,772.76
$4,061.32
$4,367.00
$5,452.86

$4,590.37
$4,878.93
$5,184.61
$6,270.47

$817.61

Toc - Plan #5 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueOptions Bronze 1416 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$7,400 $14,800 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

$569.21
$646.05
$727.45
$1,016.61
$1,544.84

$1,004.66
$1,081.50
$1,162.90
$1,452.06

$1,440.11
$1,516.95
$1,598.35
$1,887.51

$1,875.56
$1,952.40
$2,033.80
$2,322.96

$435.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,138.42
$1,292.10
$1,454.90
$2,033.22
$3,089.68

$1,573.87
$1,727.55
$1,890.35
$2,468.67

$2,009.32
$2,163.00
$2,325.80
$2,904.12

$2,444.77
$2,598.45
$2,761.25
$3,339.57

$435.45

Toc - Plan #6 Florida Blue (BlueCross BlueShield FL)

Platinum

(EPO) BlueOptions Platinum 1424 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$2,000 $4,000 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

$1,119.88
$1,271.06
$1,431.21
$2,000.11
$3,039.35

$1,976.59
$2,127.77
$2,287.92
$2,856.82

$2,833.30
$2,984.48
$3,144.63
$3,713.53

$3,690.01
$3,841.19
$4,001.34
$4,570.24

$856.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$2,239.76
$2,542.12
$2,862.42
$4,000.22
$6,078.70

$3,096.47
$3,398.83
$3,719.13
$4,856.93

$3,953.18
$4,255.54
$4,575.84
$5,713.64

$4,809.89
$5,112.25
$5,432.55
$6,570.35

$856.71

Toc - Plan #7 Florida Blue (BlueCross BlueShield FL)

Silver

(EPO) BlueOptions Silver 1410 ($0 Virtual Visits / $0 Lab / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$7,900 $15,800 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

$792.84
$899.87
$1,013.25
$1,416.01
$2,151.77

$1,399.36
$1,506.39
$1,619.77
$2,022.53

$2,005.88
$2,112.91
$2,226.29
$2,629.05

$2,612.40
$2,719.43
$2,832.81
$3,235.57

$606.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,585.68
$1,799.74
$2,026.50
$2,832.02
$4,303.54

$2,192.20
$2,406.26
$2,633.02
$3,438.54

$2,798.72
$3,012.78
$3,239.54
$4,045.06

$3,405.24
$3,619.30
$3,846.06
$4,651.58

$606.52

Toc - Plan #8 Florida Blue (BlueCross BlueShield FL)

Gold

(EPO) BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 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

$917.89
$1,041.81
$1,173.06
$1,639.35
$2,491.15

$1,620.08
$1,744.00
$1,875.25
$2,341.54

$2,322.27
$2,446.19
$2,577.44
$3,043.73

$3,024.46
$3,148.38
$3,279.63
$3,745.92

$702.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,835.78
$2,083.62
$2,346.12
$3,278.70
$4,982.30

$2,537.97
$2,785.81
$3,048.31
$3,980.89

$3,240.16
$3,488.00
$3,750.50
$4,683.08

$3,942.35
$4,190.19
$4,452.69
$5,385.27

$702.19

Toc - Plan #9 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueOptions Bronze (HSA) 1705 (Rewards $$$ / $4 Condition Care Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$553.35
$628.05
$707.18
$988.28
$1,501.79

$976.66
$1,051.36
$1,130.49
$1,411.59

$1,399.97
$1,474.67
$1,553.80
$1,834.90

$1,823.28
$1,897.98
$1,977.11
$2,258.21

$423.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,106.70
$1,256.10
$1,414.36
$1,976.56
$3,003.58

$1,530.01
$1,679.41
$1,837.67
$2,399.87

$1,953.32
$2,102.72
$2,260.98
$2,823.18

$2,376.63
$2,526.03
$2,684.29
$3,246.49

$423.31

Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)

Gold

(EPO) BlueOptions Gold 1805 ($0 Virtual Visits / $20 Labs / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 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

$888.04
$1,007.93
$1,134.92
$1,586.04
$2,410.14

$1,567.39
$1,687.28
$1,814.27
$2,265.39

$2,246.74
$2,366.63
$2,493.62
$2,944.74

$2,926.09
$3,045.98
$3,172.97
$3,624.09

$679.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,776.08
$2,015.86
$2,269.84
$3,172.08
$4,820.28

$2,455.43
$2,695.21
$2,949.19
$3,851.43

$3,134.78
$3,374.56
$3,628.54
$4,530.78

$3,814.13
$4,053.91
$4,307.89
$5,210.13

$679.35

Toc - Plan #11 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueOptions Bronze 2119 ($0 Deductible / $0 Virtual Visits / $50 PCP Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

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

$602.84
$684.22
$770.43
$1,076.67
$1,636.11

$1,064.01
$1,145.39
$1,231.60
$1,537.84

$1,525.18
$1,606.56
$1,692.77
$1,999.01

$1,986.35
$2,067.73
$2,153.94
$2,460.18

$461.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,205.68
$1,368.44
$1,540.86
$2,153.34
$3,272.22

$1,666.85
$1,829.61
$2,002.03
$2,614.51

$2,128.02
$2,290.78
$2,463.20
$3,075.68

$2,589.19
$2,751.95
$2,924.37
$3,536.85

$461.17

Toc - Plan #12 Florida Blue (BlueCross BlueShield FL)

Bronze

(EPO) BlueOptions Bronze 2301S (Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$522.31
$592.82
$667.51
$932.85
$1,417.55

$921.88
$992.39
$1,067.08
$1,332.42

$1,321.45
$1,391.96
$1,466.65
$1,731.99

$1,721.02
$1,791.53
$1,866.22
$2,131.56

$399.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,044.62
$1,185.64
$1,335.02
$1,865.70
$2,835.10

$1,444.19
$1,585.21
$1,734.59
$2,265.27

$1,843.76
$1,984.78
$2,134.16
$2,664.84

$2,243.33
$2,384.35
$2,533.73
$3,064.41

$399.57

Toc - Plan #13 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueOptions Bronze 2302S (Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$561.49
$637.29
$717.58
$1,002.82
$1,523.88

$991.03
$1,066.83
$1,147.12
$1,432.36

$1,420.57
$1,496.37
$1,576.66
$1,861.90

$1,850.11
$1,925.91
$2,006.20
$2,291.44

$429.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,122.98
$1,274.58
$1,435.16
$2,005.64
$3,047.76

$1,552.52
$1,704.12
$1,864.70
$2,435.18

$1,982.06
$2,133.66
$2,294.24
$2,864.72

$2,411.60
$2,563.20
$2,723.78
$3,294.26

$429.54

Toc - Plan #14 Florida Blue (BlueCross BlueShield FL)

Silver

(EPO) BlueOptions Silver 2303S ($40 PCP Visits / Multilingual Available/ Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$836.02
$948.88
$1,068.43
$1,493.13
$2,268.96

$1,475.58
$1,588.44
$1,707.99
$2,132.69

$2,115.14
$2,228.00
$2,347.55
$2,772.25

$2,754.70
$2,867.56
$2,987.11
$3,411.81

$639.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,672.04
$1,897.76
$2,136.86
$2,986.26
$4,537.92

$2,311.60
$2,537.32
$2,776.42
$3,625.82

$2,951.16
$3,176.88
$3,415.98
$4,265.38

$3,590.72
$3,816.44
$4,055.54
$4,904.94

$639.56

Toc - Plan #15 Florida Blue (BlueCross BlueShield FL)

Gold

(EPO) BlueOptions Gold 2304S ($30 PCP Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$853.29
$968.48
$1,090.50
$1,523.98
$2,315.83

$1,506.06
$1,621.25
$1,743.27
$2,176.75

$2,158.83
$2,274.02
$2,396.04
$2,829.52

$2,811.60
$2,926.79
$3,048.81
$3,482.29

$652.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,706.58
$1,936.96
$2,181.00
$3,047.96
$4,631.66

$2,359.35
$2,589.73
$2,833.77
$3,700.73

$3,012.12
$3,242.50
$3,486.54
$4,353.50

$3,664.89
$3,895.27
$4,139.31
$5,006.27

$652.77

Toc - Plan #16 Florida Blue (BlueCross BlueShield FL)

Platinum

(EPO) BlueOptions Platinum 2305S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$3,000 $6,000 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

$1,117.07
$1,267.87
$1,427.62
$1,995.09
$3,031.73

$1,971.63
$2,122.43
$2,282.18
$2,849.65

$2,826.19
$2,976.99
$3,136.74
$3,704.21

$3,680.75
$3,831.55
$3,991.30
$4,558.77

$854.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$2,234.14
$2,535.74
$2,855.24
$3,990.18
$6,063.46

$3,088.70
$3,390.30
$3,709.80
$4,844.74

$3,943.26
$4,244.86
$4,564.36
$5,699.30

$4,797.82
$5,099.42
$5,418.92
$6,553.86

$854.56

Toc - Plan #17 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueOptions Bronze 2319 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

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

$590.98
$670.76
$755.27
$1,055.49
$1,603.92

$1,043.08
$1,122.86
$1,207.37
$1,507.59

$1,495.18
$1,574.96
$1,659.47
$1,959.69

$1,947.28
$2,027.06
$2,111.57
$2,411.79

$452.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,181.96
$1,341.52
$1,510.54
$2,110.98
$3,207.84

$1,634.06
$1,793.62
$1,962.64
$2,563.08

$2,086.16
$2,245.72
$2,414.74
$3,015.18

$2,538.26
$2,697.82
$2,866.84
$3,467.28

$452.10

Toc - Plan #18 Florida Blue (BlueCross BlueShield FL)

Silver

(EPO) BlueSelect Silver 1456 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,950 $11,900 Annual Deductible

$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$552.32
$626.88
$705.86
$986.44
$1,499.00

$974.84
$1,049.40
$1,128.38
$1,408.96

$1,397.36
$1,471.92
$1,550.90
$1,831.48

$1,819.88
$1,894.44
$1,973.42
$2,254.00

$422.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,104.64
$1,253.76
$1,411.72
$1,972.88
$2,998.00

$1,527.16
$1,676.28
$1,834.24
$2,395.40

$1,949.68
$2,098.80
$2,256.76
$2,817.92

$2,372.20
$2,521.32
$2,679.28
$3,240.44

$422.52

Toc - Plan #19 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueSelect Bronze 1452 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 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

$415.87
$472.01
$531.48
$742.74
$1,128.67

$734.01
$790.15
$849.62
$1,060.88

$1,052.15
$1,108.29
$1,167.76
$1,379.02

$1,370.29
$1,426.43
$1,485.90
$1,697.16

$318.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$831.74
$944.02
$1,062.96
$1,485.48
$2,257.34

$1,149.88
$1,262.16
$1,381.10
$1,803.62

$1,468.02
$1,580.30
$1,699.24
$2,121.76

$1,786.16
$1,898.44
$2,017.38
$2,439.90

$318.14

Toc - Plan #20 Florida Blue (BlueCross BlueShield FL)

Silver

(EPO) BlueSelect Silver 1464 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$550.61
$624.94
$703.68
$983.39
$1,494.36

$971.83
$1,046.16
$1,124.90
$1,404.61

$1,393.05
$1,467.38
$1,546.12
$1,825.83

$1,814.27
$1,888.60
$1,967.34
$2,247.05

$421.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,101.22
$1,249.88
$1,407.36
$1,966.78
$2,988.72

$1,522.44
$1,671.10
$1,828.58
$2,388.00

$1,943.66
$2,092.32
$2,249.80
$2,809.22

$2,364.88
$2,513.54
$2,671.02
$3,230.44

$421.22

Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)

Platinum

(EPO) BlueSelect Platinum 1451 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$4,000 $8,000 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

$698.66
$792.98
$892.89
$1,247.81
$1,896.16

$1,233.13
$1,327.45
$1,427.36
$1,782.28

$1,767.60
$1,861.92
$1,961.83
$2,316.75

$2,302.07
$2,396.39
$2,496.30
$2,851.22

$534.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,397.32
$1,585.96
$1,785.78
$2,495.62
$3,792.32

$1,931.79
$2,120.43
$2,320.25
$3,030.09

$2,466.26
$2,654.90
$2,854.72
$3,564.56

$3,000.73
$3,189.37
$3,389.19
$4,099.03

$534.47

Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$7,400 $14,800 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

$429.58
$487.57
$549.00
$767.23
$1,165.88

$758.21
$816.20
$877.63
$1,095.86

$1,086.84
$1,144.83
$1,206.26
$1,424.49

$1,415.47
$1,473.46
$1,534.89
$1,753.12

$328.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$859.16
$975.14
$1,098.00
$1,534.46
$2,331.76

$1,187.79
$1,303.77
$1,426.63
$1,863.09

$1,516.42
$1,632.40
$1,755.26
$2,191.72

$1,845.05
$1,961.03
$2,083.89
$2,520.35

$328.63

Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)

Platinum

(EPO) BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$2,000 $4,000 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

$731.13
$829.83
$934.38
$1,305.80
$1,984.29

$1,290.44
$1,389.14
$1,493.69
$1,865.11

$1,849.75
$1,948.45
$2,053.00
$2,424.42

$2,409.06
$2,507.76
$2,612.31
$2,983.73

$559.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,462.26
$1,659.66
$1,868.76
$2,611.60
$3,968.58

$2,021.57
$2,218.97
$2,428.07
$3,170.91

$2,580.88
$2,778.28
$2,987.38
$3,730.22

$3,140.19
$3,337.59
$3,546.69
$4,289.53

$559.31

Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)

Silver

(EPO) BlueSelect Silver 1443 ($0 Virtual Visits / $0 Labs / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$7,900 $15,800 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

$516.87
$586.65
$660.56
$923.13
$1,402.79

$912.28
$982.06
$1,055.97
$1,318.54

$1,307.69
$1,377.47
$1,451.38
$1,713.95

$1,703.10
$1,772.88
$1,846.79
$2,109.36

$395.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,033.74
$1,173.30
$1,321.12
$1,846.26
$2,805.58

$1,429.15
$1,568.71
$1,716.53
$2,241.67

$1,824.56
$1,964.12
$2,111.94
$2,637.08

$2,219.97
$2,359.53
$2,507.35
$3,032.49

$395.41

Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)

Gold

(EPO) BlueSelect Gold 1535 ($0 Virtual Visits / $20 PCP Visit / $15 Generic Meds / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 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

$609.86
$692.19
$779.40
$1,089.21
$1,655.16

$1,076.40
$1,158.73
$1,245.94
$1,555.75

$1,542.94
$1,625.27
$1,712.48
$2,022.29

$2,009.48
$2,091.81
$2,179.02
$2,488.83

$466.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,219.72
$1,384.38
$1,558.80
$2,178.42
$3,310.32

$1,686.26
$1,850.92
$2,025.34
$2,644.96

$2,152.80
$2,317.46
$2,491.88
$3,111.50

$2,619.34
$2,784.00
$2,958.42
$3,578.04

$466.54

Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$420.35
$477.10
$537.21
$750.75
$1,140.83

$741.92
$798.67
$858.78
$1,072.32

$1,063.49
$1,120.24
$1,180.35
$1,393.89

$1,385.06
$1,441.81
$1,501.92
$1,715.46

$321.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$840.70
$954.20
$1,074.42
$1,501.50
$2,281.66

$1,162.27
$1,275.77
$1,395.99
$1,823.07

$1,483.84
$1,597.34
$1,717.56
$2,144.64

$1,805.41
$1,918.91
$2,039.13
$2,466.21

$321.57

Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)

Gold

(EPO) BlueSelect Gold 1835 ($0 Virtual Visits / $20 Labs / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 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

$589.99
$669.64
$754.01
$1,053.72
$1,601.23

$1,041.33
$1,120.98
$1,205.35
$1,505.06

$1,492.67
$1,572.32
$1,656.69
$1,956.40

$1,944.01
$2,023.66
$2,108.03
$2,407.74

$451.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,179.98
$1,339.28
$1,508.02
$2,107.44
$3,202.46

$1,631.32
$1,790.62
$1,959.36
$2,558.78

$2,082.66
$2,241.96
$2,410.70
$3,010.12

$2,534.00
$2,693.30
$2,862.04
$3,461.46

$451.34

Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueSelect Bronze 2139 ($0 Deductible / $0 Virtual Visits / $50 PCP Visit / $30 Generic Meds / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

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

$455.15
$516.60
$581.68
$812.90
$1,235.28

$803.34
$864.79
$929.87
$1,161.09

$1,151.53
$1,212.98
$1,278.06
$1,509.28

$1,499.72
$1,561.17
$1,626.25
$1,857.47

$348.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$910.30
$1,033.20
$1,163.36
$1,625.80
$2,470.56

$1,258.49
$1,381.39
$1,511.55
$1,973.99

$1,606.68
$1,729.58
$1,859.74
$2,322.18

$1,954.87
$2,077.77
$2,207.93
$2,670.37

$348.19

Toc - Plan #29 Florida Blue (BlueCross BlueShield FL)

Bronze

(EPO) BlueSelect Bronze 2341S (Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$394.49
$447.75
$504.16
$704.56
$1,070.65

$696.27
$749.53
$805.94
$1,006.34

$998.05
$1,051.31
$1,107.72
$1,308.12

$1,299.83
$1,353.09
$1,409.50
$1,609.90

$301.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$788.98
$895.50
$1,008.32
$1,409.12
$2,141.30

$1,090.76
$1,197.28
$1,310.10
$1,710.90

$1,392.54
$1,499.06
$1,611.88
$2,012.68

$1,694.32
$1,800.84
$1,913.66
$2,314.46

$301.78

Toc - Plan #30 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueSelect Bronze 2342S (Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$424.13
$481.39
$542.04
$757.50
$1,151.09

$748.59
$805.85
$866.50
$1,081.96

$1,073.05
$1,130.31
$1,190.96
$1,406.42

$1,397.51
$1,454.77
$1,515.42
$1,730.88

$324.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$848.26
$962.78
$1,084.08
$1,515.00
$2,302.18

$1,172.72
$1,287.24
$1,408.54
$1,839.46

$1,497.18
$1,611.70
$1,733.00
$2,163.92

$1,821.64
$1,936.16
$2,057.46
$2,488.38

$324.46

Toc - Plan #31 Florida Blue (BlueCross BlueShield FL)

Silver

(EPO) BlueSelect Silver 2343S ($40 PCP Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$545.06
$618.64
$696.59
$973.48
$1,479.29

$962.03
$1,035.61
$1,113.56
$1,390.45

$1,379.00
$1,452.58
$1,530.53
$1,807.42

$1,795.97
$1,869.55
$1,947.50
$2,224.39

$416.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,090.12
$1,237.28
$1,393.18
$1,946.96
$2,958.58

$1,507.09
$1,654.25
$1,810.15
$2,363.93

$1,924.06
$2,071.22
$2,227.12
$2,780.90

$2,341.03
$2,488.19
$2,644.09
$3,197.87

$416.97

Toc - Plan #32 Florida Blue (BlueCross BlueShield FL)

Gold

(EPO) BlueSelect Gold 2344S ($30 PCP Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$567.00
$643.55
$724.63
$1,012.66
$1,538.84

$1,000.76
$1,077.31
$1,158.39
$1,446.42

$1,434.52
$1,511.07
$1,592.15
$1,880.18

$1,868.28
$1,944.83
$2,025.91
$2,313.94

$433.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,134.00
$1,287.10
$1,449.26
$2,025.32
$3,077.68

$1,567.76
$1,720.86
$1,883.02
$2,459.08

$2,001.52
$2,154.62
$2,316.78
$2,892.84

$2,435.28
$2,588.38
$2,750.54
$3,326.60

$433.76

Toc - Plan #33 Florida Blue (BlueCross BlueShield FL)

Platinum

(EPO) BlueSelect Platinum 2345S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$3,000 $6,000 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

$729.26
$827.71
$931.99
$1,302.46
$1,979.21

$1,287.14
$1,385.59
$1,489.87
$1,860.34

$1,845.02
$1,943.47
$2,047.75
$2,418.22

$2,402.90
$2,501.35
$2,605.63
$2,976.10

$557.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,458.52
$1,655.42
$1,863.98
$2,604.92
$3,958.42

$2,016.40
$2,213.30
$2,421.86
$3,162.80

$2,574.28
$2,771.18
$2,979.74
$3,720.68

$3,132.16
$3,329.06
$3,537.62
$4,278.56

$557.88

Toc - Plan #34 Florida Blue (BlueCross BlueShield FL)

Expanded Bronze

(EPO) BlueSelect Bronze 2339 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

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

$446.37
$506.63
$570.46
$797.22
$1,211.45

$787.84
$848.10
$911.93
$1,138.69

$1,129.31
$1,189.57
$1,253.40
$1,480.16

$1,470.78
$1,531.04
$1,594.87
$1,821.63

$341.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$892.74
$1,013.26
$1,140.92
$1,594.44
$2,422.90

$1,234.21
$1,354.73
$1,482.39
$1,935.91

$1,575.68
$1,696.20
$1,823.86
$2,277.38

$1,917.15
$2,037.67
$2,165.33
$2,618.85

$341.47

Aetna CVS Health

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

Toc - Plan #35 Aetna CVS Health

Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$394.15
$447.37
$503.73
$703.96
$1,069.74

$695.68
$748.90
$805.26
$1,005.49

$997.21
$1,050.43
$1,106.79
$1,307.02

$1,298.74
$1,351.96
$1,408.32
$1,608.55

$301.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$788.30
$894.74
$1,007.46
$1,407.92
$2,139.48

$1,089.83
$1,196.27
$1,308.99
$1,709.45

$1,391.36
$1,497.80
$1,610.52
$2,010.98

$1,692.89
$1,799.33
$1,912.05
$2,312.51

$301.53

Toc - Plan #36 Aetna CVS Health

Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$365.06
$414.34
$466.55
$652.00
$990.77

$644.33
$693.61
$745.82
$931.27

$923.60
$972.88
$1,025.09
$1,210.54

$1,202.87
$1,252.15
$1,304.36
$1,489.81

$279.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$730.12
$828.68
$933.10
$1,304.00
$1,981.54

$1,009.39
$1,107.95
$1,212.37
$1,583.27

$1,288.66
$1,387.22
$1,491.64
$1,862.54

$1,567.93
$1,666.49
$1,770.91
$2,141.81

$279.27

Toc - Plan #37 Aetna CVS Health

Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$299.59
$340.03
$382.87
$535.06
$813.07

$528.77
$569.21
$612.05
$764.24

$757.95
$798.39
$841.23
$993.42

$987.13
$1,027.57
$1,070.41
$1,222.60

$229.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$599.18
$680.06
$765.74
$1,070.12
$1,626.14

$828.36
$909.24
$994.92
$1,299.30

$1,057.54
$1,138.42
$1,224.10
$1,528.48

$1,286.72
$1,367.60
$1,453.28
$1,757.66

$229.18

Toc - Plan #38 Aetna CVS Health

Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$4,425 $8,850 Annual Deductible

$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$391.39
$444.22
$500.19
$699.02
$1,062.22

$690.80
$743.63
$799.60
$998.43

$990.21
$1,043.04
$1,099.01
$1,297.84

$1,289.62
$1,342.45
$1,398.42
$1,597.25

$299.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$782.78
$888.44
$1,000.38
$1,398.04
$2,124.44

$1,082.19
$1,187.85
$1,299.79
$1,697.45

$1,381.60
$1,487.26
$1,599.20
$1,996.86

$1,681.01
$1,786.67
$1,898.61
$2,296.27

$299.41

Toc - Plan #39 Aetna CVS Health

Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$418.35
$474.83
$534.65
$747.18
$1,135.41

$738.39
$794.87
$854.69
$1,067.22

$1,058.43
$1,114.91
$1,174.73
$1,387.26

$1,378.47
$1,434.95
$1,494.77
$1,707.30

$320.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$836.70
$949.66
$1,069.30
$1,494.36
$2,270.82

$1,156.74
$1,269.70
$1,389.34
$1,814.40

$1,476.78
$1,589.74
$1,709.38
$2,134.44

$1,796.82
$1,909.78
$2,029.42
$2,454.48

$320.04

Toc - Plan #40 Aetna CVS Health

Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$379.79
$431.06
$485.37
$678.30
$1,030.75

$670.33
$721.60
$775.91
$968.84

$960.87
$1,012.14
$1,066.45
$1,259.38

$1,251.41
$1,302.68
$1,356.99
$1,549.92

$290.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$759.58
$862.12
$970.74
$1,356.60
$2,061.50

$1,050.12
$1,152.66
$1,261.28
$1,647.14

$1,340.66
$1,443.20
$1,551.82
$1,937.68

$1,631.20
$1,733.74
$1,842.36
$2,228.22

$290.54

Toc - Plan #41 Aetna CVS Health

Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$444.96
$505.03
$568.66
$794.70
$1,207.63

$785.36
$845.43
$909.06
$1,135.10

$1,125.76
$1,185.83
$1,249.46
$1,475.50

$1,466.16
$1,526.23
$1,589.86
$1,815.90

$340.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$889.92
$1,010.06
$1,137.32
$1,589.40
$2,415.26

$1,230.32
$1,350.46
$1,477.72
$1,929.80

$1,570.72
$1,690.86
$1,818.12
$2,270.20

$1,911.12
$2,031.26
$2,158.52
$2,610.60

$340.40

AvMed

Local: 1-800-477-8768 | Toll Free:

Toc - Plan #42 AvMed

Gold

(HMO) AvMed Entrust Gold 125 (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$4,700 $9,400 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

$499.58
$567.02
$638.46
$892.24
$1,355.85

$881.76
$949.20
$1,020.64
$1,274.42

$1,263.94
$1,331.38
$1,402.82
$1,656.60

$1,646.12
$1,713.56
$1,785.00
$2,038.78

$382.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$999.16
$1,134.04
$1,276.92
$1,784.48
$2,711.70

$1,381.34
$1,516.22
$1,659.10
$2,166.66

$1,763.52
$1,898.40
$2,041.28
$2,548.84

$2,145.70
$2,280.58
$2,423.46
$2,931.02

$382.18

Toc - Plan #43 AvMed

Silver

(HMO) AvMed Entrust Silver 300 (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$7,650 $15,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$487.53
$553.34
$623.06
$870.72
$1,323.14

$860.49
$926.30
$996.02
$1,243.68

$1,233.45
$1,299.26
$1,368.98
$1,616.64

$1,606.41
$1,672.22
$1,741.94
$1,989.60

$372.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$975.06
$1,106.68
$1,246.12
$1,741.44
$2,646.28

$1,348.02
$1,479.64
$1,619.08
$2,114.40

$1,720.98
$1,852.60
$1,992.04
$2,487.36

$2,093.94
$2,225.56
$2,365.00
$2,860.32

$372.96

Toc - Plan #44 AvMed

Silver

(HMO) AvMed Entrust Silver 350 (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$469.23
$532.58
$599.68
$838.05
$1,273.49

$828.19
$891.54
$958.64
$1,197.01

$1,187.15
$1,250.50
$1,317.60
$1,555.97

$1,546.11
$1,609.46
$1,676.56
$1,914.93

$358.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$938.46
$1,065.16
$1,199.36
$1,676.10
$2,546.98

$1,297.42
$1,424.12
$1,558.32
$2,035.06

$1,656.38
$1,783.08
$1,917.28
$2,394.02

$2,015.34
$2,142.04
$2,276.24
$2,752.98

$358.96

Toc - Plan #45 AvMed

Silver

(HMO) AvMed Entrust Silver 500 (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 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

$466.49
$529.47
$596.17
$833.15
$1,266.06

$823.36
$886.34
$953.04
$1,190.02

$1,180.23
$1,243.21
$1,309.91
$1,546.89

$1,537.10
$1,600.08
$1,666.78
$1,903.76

$356.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$932.98
$1,058.94
$1,192.34
$1,666.30
$2,532.12

$1,289.85
$1,415.81
$1,549.21
$2,023.17

$1,646.72
$1,772.68
$1,906.08
$2,380.04

$2,003.59
$2,129.55
$2,262.95
$2,736.91

$356.87

Toc - Plan #46 AvMed

Silver

(HMO) AvMed Entrust Silver 550 (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$463.68
$526.28
$592.59
$828.14
$1,258.43

$818.40
$881.00
$947.31
$1,182.86

$1,173.12
$1,235.72
$1,302.03
$1,537.58

$1,527.84
$1,590.44
$1,656.75
$1,892.30

$354.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$927.36
$1,052.56
$1,185.18
$1,656.28
$2,516.86

$1,282.08
$1,407.28
$1,539.90
$2,011.00

$1,636.80
$1,762.00
$1,894.62
$2,365.72

$1,991.52
$2,116.72
$2,249.34
$2,720.44

$354.72

Toc - Plan #47 AvMed

Expanded Bronze

(HMO) AvMed Entrust Bronze 600 (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$7,900 $15,800 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

$382.70
$434.36
$489.09
$683.50
$1,038.64

$675.46
$727.12
$781.85
$976.26

$968.22
$1,019.88
$1,074.61
$1,269.02

$1,260.98
$1,312.64
$1,367.37
$1,561.78

$292.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.40
$868.72
$978.18
$1,367.00
$2,077.28

$1,058.16
$1,161.48
$1,270.94
$1,659.76

$1,350.92
$1,454.24
$1,563.70
$1,952.52

$1,643.68
$1,747.00
$1,856.46
$2,245.28

$292.76

Toc - Plan #48 AvMed

Expanded Bronze

(HMO) AvMed Entrust Bronze 650 (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$8,200 $16,400 Annual Deductible

$8,200 $16,400 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

$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 #49 AvMed

Catastrophic

(HMO) AvMed Entrust Catastrophic 100 (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$302.30
$343.11
$386.34
$539.91
$820.45

$533.56
$574.37
$617.60
$771.17

$764.82
$805.63
$848.86
$1,002.43

$996.08
$1,036.89
$1,080.12
$1,233.69

$231.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$604.60
$686.22
$772.68
$1,079.82
$1,640.90

$835.86
$917.48
$1,003.94
$1,311.08

$1,067.12
$1,148.74
$1,235.20
$1,542.34

$1,298.38
$1,380.00
$1,466.46
$1,773.60

$231.26

Toc - Plan #50 AvMed

Gold

(HMO) AvMed Entrust Gold Standard (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$496.21
$563.20
$634.16
$886.23
$1,346.71

$875.81
$942.80
$1,013.76
$1,265.83

$1,255.41
$1,322.40
$1,393.36
$1,645.43

$1,635.01
$1,702.00
$1,772.96
$2,025.03

$379.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$992.42
$1,126.40
$1,268.32
$1,772.46
$2,693.42

$1,372.02
$1,506.00
$1,647.92
$2,152.06

$1,751.62
$1,885.60
$2,027.52
$2,531.66

$2,131.22
$2,265.20
$2,407.12
$2,911.26

$379.60

Toc - Plan #51 AvMed

Silver

(HMO) AvMed Entrust Silver Standard (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$449.91
$510.65
$574.99
$803.55
$1,221.07

$794.09
$854.83
$919.17
$1,147.73

$1,138.27
$1,199.01
$1,263.35
$1,491.91

$1,482.45
$1,543.19
$1,607.53
$1,836.09

$344.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$899.82
$1,021.30
$1,149.98
$1,607.10
$2,442.14

$1,244.00
$1,365.48
$1,494.16
$1,951.28

$1,588.18
$1,709.66
$1,838.34
$2,295.46

$1,932.36
$2,053.84
$2,182.52
$2,639.64

$344.18

Toc - Plan #52 AvMed

Expanded Bronze

(HMO) AvMed Entrust Expanded Bronze Standard (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$380.12
$431.44
$485.80
$678.90
$1,031.65

$670.91
$722.23
$776.59
$969.69

$961.70
$1,013.02
$1,067.38
$1,260.48

$1,252.49
$1,303.81
$1,358.17
$1,551.27

$290.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$760.24
$862.88
$971.60
$1,357.80
$2,063.30

$1,051.03
$1,153.67
$1,262.39
$1,648.59

$1,341.82
$1,444.46
$1,553.18
$1,939.38

$1,632.61
$1,735.25
$1,843.97
$2,230.17

$290.79

Toc - Plan #53 AvMed

Gold

(HMO) AvMed Entrust Gold 125 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$504.42
$572.52
$644.65
$900.90
$1,369.00

$890.30
$958.40
$1,030.53
$1,286.78

$1,276.18
$1,344.28
$1,416.41
$1,672.66

$1,662.06
$1,730.16
$1,802.29
$2,058.54

$385.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,008.84
$1,145.04
$1,289.30
$1,801.80
$2,738.00

$1,394.72
$1,530.92
$1,675.18
$2,187.68

$1,780.60
$1,916.80
$2,061.06
$2,573.56

$2,166.48
$2,302.68
$2,446.94
$2,959.44

$385.88

Toc - Plan #54 AvMed

Silver

(HMO) AvMed Entrust Silver 300 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$7,650 $15,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$492.35
$558.82
$629.22
$879.34
$1,336.24

$869.00
$935.47
$1,005.87
$1,255.99

$1,245.65
$1,312.12
$1,382.52
$1,632.64

$1,622.30
$1,688.77
$1,759.17
$2,009.29

$376.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$984.70
$1,117.64
$1,258.44
$1,758.68
$2,672.48

$1,361.35
$1,494.29
$1,635.09
$2,135.33

$1,738.00
$1,870.94
$2,011.74
$2,511.98

$2,114.65
$2,247.59
$2,388.39
$2,888.63

$376.65

Toc - Plan #55 AvMed

Silver

(HMO) AvMed Entrust Silver 350 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$474.07
$538.06
$605.86
$846.68
$1,286.61

$836.73
$900.72
$968.52
$1,209.34

$1,199.39
$1,263.38
$1,331.18
$1,572.00

$1,562.05
$1,626.04
$1,693.84
$1,934.66

$362.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$948.14
$1,076.12
$1,211.72
$1,693.36
$2,573.22

$1,310.80
$1,438.78
$1,574.38
$2,056.02

$1,673.46
$1,801.44
$1,937.04
$2,418.68

$2,036.12
$2,164.10
$2,299.70
$2,781.34

$362.66

Toc - Plan #56 AvMed

Silver

(HMO) AvMed Entrust Silver 500 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 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

$471.30
$534.92
$602.32
$841.73
$1,279.10

$831.84
$895.46
$962.86
$1,202.27

$1,192.38
$1,256.00
$1,323.40
$1,562.81

$1,552.92
$1,616.54
$1,683.94
$1,923.35

$360.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$942.60
$1,069.84
$1,204.64
$1,683.46
$2,558.20

$1,303.14
$1,430.38
$1,565.18
$2,044.00

$1,663.68
$1,790.92
$1,925.72
$2,404.54

$2,024.22
$2,151.46
$2,286.26
$2,765.08

$360.54

Toc - Plan #57 AvMed

Silver

(HMO) AvMed Entrust Silver 550 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$468.51
$531.76
$598.75
$836.75
$1,271.53

$826.92
$890.17
$957.16
$1,195.16

$1,185.33
$1,248.58
$1,315.57
$1,553.57

$1,543.74
$1,606.99
$1,673.98
$1,911.98

$358.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$937.02
$1,063.52
$1,197.50
$1,673.50
$2,543.06

$1,295.43
$1,421.93
$1,555.91
$2,031.91

$1,653.84
$1,780.34
$1,914.32
$2,390.32

$2,012.25
$2,138.75
$2,272.73
$2,748.73

$358.41

Toc - Plan #58 AvMed

Expanded Bronze

(HMO) AvMed Entrust Bronze 625 Dental+Vision (2023)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,350 $16,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$474.52
$538.58
$606.43
$847.49
$1,287.84

$837.53
$901.59
$969.44
$1,210.50

$1,200.54
$1,264.60
$1,332.45
$1,573.51

$1,563.55
$1,627.61
$1,695.46
$1,936.52

$363.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$949.04
$1,077.16
$1,212.86
$1,694.98
$2,575.68

$1,312.05
$1,440.17
$1,575.87
$2,057.99

$1,675.06
$1,803.18
$1,938.88
$2,421.00

$2,038.07
$2,166.19
$2,301.89
$2,784.01

$363.01

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770

Toc - Plan #59 Ambetter from Sunshine Health

Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$8,600 $17,200 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$320.91
$364.22
$410.11
$573.13
$870.93

$566.40
$609.71
$655.60
$818.62

$811.89
$855.20
$901.09
$1,064.11

$1,057.38
$1,100.69
$1,146.58
$1,309.60

$245.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$641.82
$728.44
$820.22
$1,146.26
$1,741.86

$887.31
$973.93
$1,065.71
$1,391.75

$1,132.80
$1,219.42
$1,311.20
$1,637.24

$1,378.29
$1,464.91
$1,556.69
$1,882.73

$245.49

Toc - Plan #60 Ambetter from Sunshine Health

Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

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

$430.39
$488.48
$550.03
$768.66
$1,168.06

$759.63
$817.72
$879.27
$1,097.90

$1,088.87
$1,146.96
$1,208.51
$1,427.14

$1,418.11
$1,476.20
$1,537.75
$1,756.38

$329.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$860.78
$976.96
$1,100.06
$1,537.32
$2,336.12

$1,190.02
$1,306.20
$1,429.30
$1,866.56

$1,519.26
$1,635.44
$1,758.54
$2,195.80

$1,848.50
$1,964.68
$2,087.78
$2,525.04

$329.24

Toc - Plan #61 Ambetter from Sunshine Health

Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$353.42
$401.12
$451.66
$631.19
$959.15

$623.78
$671.48
$722.02
$901.55

$894.14
$941.84
$992.38
$1,171.91

$1,164.50
$1,212.20
$1,262.74
$1,442.27

$270.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$706.84
$802.24
$903.32
$1,262.38
$1,918.30

$977.20
$1,072.60
$1,173.68
$1,532.74

$1,247.56
$1,342.96
$1,444.04
$1,803.10

$1,517.92
$1,613.32
$1,714.40
$2,073.46

$270.36

Toc - Plan #62 Ambetter from Sunshine Health

Silver

(EPO) Everyday SIlver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$434.99
$493.70
$555.90
$776.87
$1,180.53

$767.75
$826.46
$888.66
$1,109.63

$1,100.51
$1,159.22
$1,221.42
$1,442.39

$1,433.27
$1,491.98
$1,554.18
$1,775.15

$332.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$869.98
$987.40
$1,111.80
$1,553.74
$2,361.06

$1,202.74
$1,320.16
$1,444.56
$1,886.50

$1,535.50
$1,652.92
$1,777.32
$2,219.26

$1,868.26
$1,985.68
$2,110.08
$2,552.02

$332.76

Toc - Plan #63 Ambetter from Sunshine Health

Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$8,300 $16,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$345.05
$391.62
$440.96
$616.25
$936.45

$609.01
$655.58
$704.92
$880.21

$872.97
$919.54
$968.88
$1,144.17

$1,136.93
$1,183.50
$1,232.84
$1,408.13

$263.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$690.10
$783.24
$881.92
$1,232.50
$1,872.90

$954.06
$1,047.20
$1,145.88
$1,496.46

$1,218.02
$1,311.16
$1,409.84
$1,760.42

$1,481.98
$1,575.12
$1,673.80
$2,024.38

$263.96

Toc - Plan #64 Ambetter from Sunshine Health

Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$395.46
$448.84
$505.38
$706.27
$1,073.25

$697.98
$751.36
$807.90
$1,008.79

$1,000.50
$1,053.88
$1,110.42
$1,311.31

$1,303.02
$1,356.40
$1,412.94
$1,613.83

$302.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$790.92
$897.68
$1,010.76
$1,412.54
$2,146.50

$1,093.44
$1,200.20
$1,313.28
$1,715.06

$1,395.96
$1,502.72
$1,615.80
$2,017.58

$1,698.48
$1,805.24
$1,918.32
$2,320.10

$302.52

Toc - Plan #65 Ambetter from Sunshine Health

Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

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

$429.79
$487.80
$549.25
$767.58
$1,166.41

$758.57
$816.58
$878.03
$1,096.36

$1,087.35
$1,145.36
$1,206.81
$1,425.14

$1,416.13
$1,474.14
$1,535.59
$1,753.92

$328.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$859.58
$975.60
$1,098.50
$1,535.16
$2,332.82

$1,188.36
$1,304.38
$1,427.28
$1,863.94

$1,517.14
$1,633.16
$1,756.06
$2,192.72

$1,845.92
$1,961.94
$2,084.84
$2,521.50

$328.78

Toc - Plan #66 Ambetter from Sunshine Health

Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$6,100 $12,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$433.43
$491.93
$553.91
$774.08
$1,176.29

$764.99
$823.49
$885.47
$1,105.64

$1,096.55
$1,155.05
$1,217.03
$1,437.20

$1,428.11
$1,486.61
$1,548.59
$1,768.76

$331.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$866.86
$983.86
$1,107.82
$1,548.16
$2,352.58

$1,198.42
$1,315.42
$1,439.38
$1,879.72

$1,529.98
$1,646.98
$1,770.94
$2,211.28

$1,861.54
$1,978.54
$2,102.50
$2,542.84

$331.56

Toc - Plan #67 Ambetter from Sunshine Health

Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

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

$410.72
$466.15
$524.88
$733.52
$1,114.66

$724.91
$780.34
$839.07
$1,047.71

$1,039.10
$1,094.53
$1,153.26
$1,361.90

$1,353.29
$1,408.72
$1,467.45
$1,676.09

$314.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$821.44
$932.30
$1,049.76
$1,467.04
$2,229.32

$1,135.63
$1,246.49
$1,363.95
$1,781.23

$1,449.82
$1,560.68
$1,678.14
$2,095.42

$1,764.01
$1,874.87
$1,992.33
$2,409.61

$314.19

Toc - Plan #68 Ambetter from Sunshine Health

Silver

(EPO) Enhanced SIlver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$3,850 $7,700 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$435.98
$494.83
$557.17
$778.65
$1,183.23

$769.50
$828.35
$890.69
$1,112.17

$1,103.02
$1,161.87
$1,224.21
$1,445.69

$1,436.54
$1,495.39
$1,557.73
$1,779.21

$333.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$871.96
$989.66
$1,114.34
$1,557.30
$2,366.46

$1,205.48
$1,323.18
$1,447.86
$1,890.82

$1,539.00
$1,656.70
$1,781.38
$2,224.34

$1,872.52
$1,990.22
$2,114.90
$2,557.86

$333.52

Toc - Plan #69 Ambetter from Sunshine Health

Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$0 $0 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

$477.90
$542.40
$610.74
$853.50
$1,296.98

$843.48
$907.98
$976.32
$1,219.08

$1,209.06
$1,273.56
$1,341.90
$1,584.66

$1,574.64
$1,639.14
$1,707.48
$1,950.24

$365.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$955.80
$1,084.80
$1,221.48
$1,707.00
$2,593.96

$1,321.38
$1,450.38
$1,587.06
$2,072.58

$1,686.96
$1,815.96
$1,952.64
$2,438.16

$2,052.54
$2,181.54
$2,318.22
$2,803.74

$365.58

Toc - Plan #70 Ambetter from Sunshine Health

Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$338.60
$384.29
$432.71
$604.71
$918.92

$597.62
$643.31
$691.73
$863.73

$856.64
$902.33
$950.75
$1,122.75

$1,115.66
$1,161.35
$1,209.77
$1,381.77

$259.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$677.20
$768.58
$865.42
$1,209.42
$1,837.84

$936.22
$1,027.60
$1,124.44
$1,468.44

$1,195.24
$1,286.62
$1,383.46
$1,727.46

$1,454.26
$1,545.64
$1,642.48
$1,986.48

$259.02

Toc - Plan #71 Ambetter from Sunshine Health

Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$429.53
$487.50
$548.92
$767.12
$1,165.71

$758.11
$816.08
$877.50
$1,095.70

$1,086.69
$1,144.66
$1,206.08
$1,424.28

$1,415.27
$1,473.24
$1,534.66
$1,752.86

$328.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$859.06
$975.00
$1,097.84
$1,534.24
$2,331.42

$1,187.64
$1,303.58
$1,426.42
$1,862.82

$1,516.22
$1,632.16
$1,755.00
$2,191.40

$1,844.80
$1,960.74
$2,083.58
$2,519.98

$328.58

Toc - Plan #72 Ambetter from Sunshine Health

Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$402.22
$456.51
$514.03
$718.35
$1,091.60

$709.91
$764.20
$821.72
$1,026.04

$1,017.60
$1,071.89
$1,129.41
$1,333.73

$1,325.29
$1,379.58
$1,437.10
$1,641.42

$307.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$804.44
$913.02
$1,028.06
$1,436.70
$2,183.20

$1,112.13
$1,220.71
$1,335.75
$1,744.39

$1,419.82
$1,528.40
$1,643.44
$2,052.08

$1,727.51
$1,836.09
$1,951.13
$2,359.77

$307.69

Toc - Plan #73 Ambetter from Sunshine Health

Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 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

$366.53
$416.00
$468.41
$654.60
$994.73

$646.92
$696.39
$748.80
$934.99

$927.31
$976.78
$1,029.19
$1,215.38

$1,207.70
$1,257.17
$1,309.58
$1,495.77

$280.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$733.06
$832.00
$936.82
$1,309.20
$1,989.46

$1,013.45
$1,112.39
$1,217.21
$1,589.59

$1,293.84
$1,392.78
$1,497.60
$1,869.98

$1,574.23
$1,673.17
$1,777.99
$2,150.37

$280.39

Toc - Plan #74 Ambetter from Sunshine Health

Silver

(EPO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$451.12
$512.01
$576.52
$805.69
$1,224.32

$796.22
$857.11
$921.62
$1,150.79

$1,141.32
$1,202.21
$1,266.72
$1,495.89

$1,486.42
$1,547.31
$1,611.82
$1,840.99

$345.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$902.24
$1,024.02
$1,153.04
$1,611.38
$2,448.64

$1,247.34
$1,369.12
$1,498.14
$1,956.48

$1,592.44
$1,714.22
$1,843.24
$2,301.58

$1,937.54
$2,059.32
$2,188.34
$2,646.68

$345.10

Toc - Plan #75 Ambetter from Sunshine Health

Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

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

$446.36
$506.60
$570.43
$797.18
$1,211.39

$787.82
$848.06
$911.89
$1,138.64

$1,129.28
$1,189.52
$1,253.35
$1,480.10

$1,470.74
$1,530.98
$1,594.81
$1,821.56

$341.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$892.72
$1,013.20
$1,140.86
$1,594.36
$2,422.78

$1,234.18
$1,354.66
$1,482.32
$1,935.82

$1,575.64
$1,696.12
$1,823.78
$2,277.28

$1,917.10
$2,037.58
$2,165.24
$2,618.74

$341.46

Toc - Plan #76 Ambetter from Sunshine Health

Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$8,600 $17,200 Annual Deductible

$8,600 $17,200 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

$332.82
$377.73
$425.33
$594.39
$903.23

$587.42
$632.33
$679.93
$848.99

$842.02
$886.93
$934.53
$1,103.59

$1,096.62
$1,141.53
$1,189.13
$1,358.19

$254.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$665.64
$755.46
$850.66
$1,188.78
$1,806.46

$920.24
$1,010.06
$1,105.26
$1,443.38

$1,174.84
$1,264.66
$1,359.86
$1,697.98

$1,429.44
$1,519.26
$1,614.46
$1,952.58

$254.60

Toc - Plan #77 Ambetter from Sunshine Health

Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

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

$445.73
$505.89
$569.63
$796.05
$1,209.68

$786.70
$846.86
$910.60
$1,137.02

$1,127.67
$1,187.83
$1,251.57
$1,477.99

$1,468.64
$1,528.80
$1,592.54
$1,818.96

$340.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$891.46
$1,011.78
$1,139.26
$1,592.10
$2,419.36

$1,232.43
$1,352.75
$1,480.23
$1,933.07

$1,573.40
$1,693.72
$1,821.20
$2,274.04

$1,914.37
$2,034.69
$2,162.17
$2,615.01

$340.97

Toc - Plan #78 Ambetter from Sunshine Health

Silver

(EPO) Enhanced Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$3,850 $7,700 Annual Deductible

$8,600 $17,200 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

$452.16
$513.19
$577.84
$807.53
$1,227.12

$798.05
$859.08
$923.73
$1,153.42

$1,143.94
$1,204.97
$1,269.62
$1,499.31

$1,489.83
$1,550.86
$1,615.51
$1,845.20

$345.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$904.32
$1,026.38
$1,155.68
$1,615.06
$2,454.24

$1,250.21
$1,372.27
$1,501.57
$1,960.95

$1,596.10
$1,718.16
$1,847.46
$2,306.84

$1,941.99
$2,064.05
$2,193.35
$2,652.73

$345.89

Toc - Plan #79 Ambetter from Sunshine Health

Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$0 $0 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

$495.62
$562.52
$633.39
$885.16
$1,345.09

$874.76
$941.66
$1,012.53
$1,264.30

$1,253.90
$1,320.80
$1,391.67
$1,643.44

$1,633.04
$1,699.94
$1,770.81
$2,022.58

$379.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$991.24
$1,125.04
$1,266.78
$1,770.32
$2,690.18

$1,370.38
$1,504.18
$1,645.92
$2,149.46

$1,749.52
$1,883.32
$2,025.06
$2,528.60

$2,128.66
$2,262.46
$2,404.20
$2,907.74

$379.14

Toc - Plan #80 Ambetter from Sunshine Health

Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$8,300 $16,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$357.85
$406.15
$457.32
$639.11
$971.18

$631.60
$679.90
$731.07
$912.86

$905.35
$953.65
$1,004.82
$1,186.61

$1,179.10
$1,227.40
$1,278.57
$1,460.36

$273.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.70
$812.30
$914.64
$1,278.22
$1,942.36

$989.45
$1,086.05
$1,188.39
$1,551.97

$1,263.20
$1,359.80
$1,462.14
$1,825.72

$1,536.95
$1,633.55
$1,735.89
$2,099.47

$273.75

Toc - Plan #81 Ambetter from Sunshine Health

Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$0 $0 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

$410.13
$465.48
$524.13
$732.47
$1,113.06

$723.87
$779.22
$837.87
$1,046.21

$1,037.61
$1,092.96
$1,151.61
$1,359.95

$1,351.35
$1,406.70
$1,465.35
$1,673.69

$313.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$820.26
$930.96
$1,048.26
$1,464.94
$2,226.12

$1,134.00
$1,244.70
$1,362.00
$1,778.68

$1,447.74
$1,558.44
$1,675.74
$2,092.42

$1,761.48
$1,872.18
$1,989.48
$2,406.16

$313.74

Toc - Plan #82 Ambetter from Sunshine Health

Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family

$6,100 $12,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$449.50
$510.18
$574.45
$802.80
$1,219.93

$793.36
$854.04
$918.31
$1,146.66

$1,137.22
$1,197.90
$1,262.17
$1,490.52

$1,481.08
$1,541.76
$1,606.03
$1,834.38

$343.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$899.00
$1,020.36
$1,148.90
$1,605.60
$2,439.86

$1,242.86
$1,364.22
$1,492.76
$1,949.46

$1,586.72
$1,708.08
$1,836.62
$2,293.32

$1,930.58
$2,051.94
$2,180.48
$2,637.18

$343.86

Toc - Plan #83 Ambetter from Sunshine Health

Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1169

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

$425.95
$483.44
$544.35
$760.73
$1,156.00

$751.79
$809.28
$870.19
$1,086.57

$1,077.63
$1,135.12
$1,196.03
$1,412.41

$1,403.47
$1,460.96
$1,521.87
$1,738.25

$325.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$851.90
$966.88
$1,088.70
$1,521.46
$2,312.00

$1,177.74
$1,292.72
$1,414.54
$1,847.30

$1,503.58
$1,618.56
$1,740.38
$2,173.14

$1,829.42
$1,944.40
$2,066.22
$2,498.98

$325.84

Florida Blue HMO (a BlueCross BlueShield FL company)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771

Toc - Plan #84 Florida Blue HMO (a BlueCross BlueShield FL company)

Platinum

(HMO) BlueCare Platinum 2151 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$2,000 $4,000 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

$807.18
$916.15
$1,031.58
$1,441.62
$2,190.69

$1,424.67
$1,533.64
$1,649.07
$2,059.11

$2,042.16
$2,151.13
$2,266.56
$2,676.60

$2,659.65
$2,768.62
$2,884.05
$3,294.09

$617.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,614.36
$1,832.30
$2,063.16
$2,883.24
$4,381.38

$2,231.85
$2,449.79
$2,680.65
$3,500.73

$2,849.34
$3,067.28
$3,298.14
$4,118.22

$3,466.83
$3,684.77
$3,915.63
$4,735.71

$617.49

Toc - Plan #85 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) BlueCare Bronze 2153 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$7,400 $14,800 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

$474.53
$538.59
$606.45
$847.51
$1,287.87

$837.55
$901.61
$969.47
$1,210.53

$1,200.57
$1,264.63
$1,332.49
$1,573.55

$1,563.59
$1,627.65
$1,695.51
$1,936.57

$363.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$949.06
$1,077.18
$1,212.90
$1,695.02
$2,575.74

$1,312.08
$1,440.20
$1,575.92
$2,058.04

$1,675.10
$1,803.22
$1,938.94
$2,421.06

$2,038.12
$2,166.24
$2,301.96
$2,784.08

$363.02

Toc - Plan #86 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) BlueCare Bronze 2154 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 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

$447.70
$508.14
$572.16
$799.59
$1,215.06

$790.19
$850.63
$914.65
$1,142.08

$1,132.68
$1,193.12
$1,257.14
$1,484.57

$1,475.17
$1,535.61
$1,599.63
$1,827.06

$342.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$895.40
$1,016.28
$1,144.32
$1,599.18
$2,430.12

$1,237.89
$1,358.77
$1,486.81
$1,941.67

$1,580.38
$1,701.26
$1,829.30
$2,284.16

$1,922.87
$2,043.75
$2,171.79
$2,626.65

$342.49

Toc - Plan #87 Florida Blue HMO (a BlueCross BlueShield FL company)

Gold

(HMO) BlueCare Gold 2156 ($0 Virtual Visits / $20 PCP Visit / $15 Generic Meds / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 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

$712.20
$808.35
$910.19
$1,271.99
$1,932.91

$1,257.03
$1,353.18
$1,455.02
$1,816.82

$1,801.86
$1,898.01
$1,999.85
$2,361.65

$2,346.69
$2,442.84
$2,544.68
$2,906.48

$544.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,424.40
$1,616.70
$1,820.38
$2,543.98
$3,865.82

$1,969.23
$2,161.53
$2,365.21
$3,088.81

$2,514.06
$2,706.36
$2,910.04
$3,633.64

$3,058.89
$3,251.19
$3,454.87
$4,178.47

$544.83

Toc - Plan #88 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) BlueCare Silver 2157 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,900 $11,800 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

$586.55
$665.73
$749.61
$1,047.58
$1,591.90

$1,035.26
$1,114.44
$1,198.32
$1,496.29

$1,483.97
$1,563.15
$1,647.03
$1,945.00

$1,932.68
$2,011.86
$2,095.74
$2,393.71

$448.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,173.10
$1,331.46
$1,499.22
$2,095.16
$3,183.80

$1,621.81
$1,780.17
$1,947.93
$2,543.87

$2,070.52
$2,228.88
$2,396.64
$2,992.58

$2,519.23
$2,677.59
$2,845.35
$3,441.29

$448.71

Toc - Plan #89 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) BlueCare Bronze 2159 ($0 Deductible / $0 Virtual Visits / $50 PCP Visit / $30 Generic Meds / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$514.98
$584.50
$658.14
$919.75
$1,397.66

$908.94
$978.46
$1,052.10
$1,313.71

$1,302.90
$1,372.42
$1,446.06
$1,707.67

$1,696.86
$1,766.38
$1,840.02
$2,101.63

$393.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,029.96
$1,169.00
$1,316.28
$1,839.50
$2,795.32

$1,423.92
$1,562.96
$1,710.24
$2,233.46

$1,817.88
$1,956.92
$2,104.20
$2,627.42

$2,211.84
$2,350.88
$2,498.16
$3,021.38

$393.96

Toc - Plan #90 Florida Blue HMO (a BlueCross BlueShield FL company)

Bronze

(HMO) BlueCare Bronze 2351S (Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$422.74
$479.81
$540.26
$755.01
$1,147.32

$746.14
$803.21
$863.66
$1,078.41

$1,069.54
$1,126.61
$1,187.06
$1,401.81

$1,392.94
$1,450.01
$1,510.46
$1,725.21

$323.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$845.48
$959.62
$1,080.52
$1,510.02
$2,294.64

$1,168.88
$1,283.02
$1,403.92
$1,833.42

$1,492.28
$1,606.42
$1,727.32
$2,156.82

$1,815.68
$1,929.82
$2,050.72
$2,480.22

$323.40

Toc - Plan #91 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) BlueCare Bronze 2352S (Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$465.74
$528.61
$595.22
$831.81
$1,264.02

$822.03
$884.90
$951.51
$1,188.10

$1,178.32
$1,241.19
$1,307.80
$1,544.39

$1,534.61
$1,597.48
$1,664.09
$1,900.68

$356.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$931.48
$1,057.22
$1,190.44
$1,663.62
$2,528.04

$1,287.77
$1,413.51
$1,546.73
$2,019.91

$1,644.06
$1,769.80
$1,903.02
$2,376.20

$2,000.35
$2,126.09
$2,259.31
$2,732.49

$356.29

Toc - Plan #92 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) BlueCare Silver 2353S ($40 PCP Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$626.13
$710.66
$800.19
$1,118.27
$1,699.32

$1,105.12
$1,189.65
$1,279.18
$1,597.26

$1,584.11
$1,668.64
$1,758.17
$2,076.25

$2,063.10
$2,147.63
$2,237.16
$2,555.24

$478.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,252.26
$1,421.32
$1,600.38
$2,236.54
$3,398.64

$1,731.25
$1,900.31
$2,079.37
$2,715.53

$2,210.24
$2,379.30
$2,558.36
$3,194.52

$2,689.23
$2,858.29
$3,037.35
$3,673.51

$478.99

Toc - Plan #93 Florida Blue HMO (a BlueCross BlueShield FL company)

Gold

(HMO) BlueCare Gold 2354S ($30 PCP Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$645.51
$732.65
$824.96
$1,152.88
$1,751.91

$1,139.33
$1,226.47
$1,318.78
$1,646.70

$1,633.15
$1,720.29
$1,812.60
$2,140.52

$2,126.97
$2,214.11
$2,306.42
$2,634.34

$493.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,291.02
$1,465.30
$1,649.92
$2,305.76
$3,503.82

$1,784.84
$1,959.12
$2,143.74
$2,799.58

$2,278.66
$2,452.94
$2,637.56
$3,293.40

$2,772.48
$2,946.76
$3,131.38
$3,787.22

$493.82

Toc - Plan #94 Florida Blue HMO (a BlueCross BlueShield FL company)

Platinum

(HMO) BlueCare Platinum 2355S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$3,000 $6,000 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

$804.96
$913.63
$1,028.74
$1,437.66
$2,184.66

$1,420.75
$1,529.42
$1,644.53
$2,053.45

$2,036.54
$2,145.21
$2,260.32
$2,669.24

$2,652.33
$2,761.00
$2,876.11
$3,285.03

$615.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,609.92
$1,827.26
$2,057.48
$2,875.32
$4,369.32

$2,225.71
$2,443.05
$2,673.27
$3,491.11

$2,841.50
$3,058.84
$3,289.06
$4,106.90

$3,457.29
$3,674.63
$3,904.85
$4,722.69

$615.79

Toc - Plan #95 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) BlueCare Bronze 2359 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$0 Not Applicable 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

$498.00
$565.23
$636.44
$889.43
$1,351.57

$878.97
$946.20
$1,017.41
$1,270.40

$1,259.94
$1,327.17
$1,398.38
$1,651.37

$1,640.91
$1,708.14
$1,779.35
$2,032.34

$380.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$996.00
$1,130.46
$1,272.88
$1,778.86
$2,703.14

$1,376.97
$1,511.43
$1,653.85
$2,159.83

$1,757.94
$1,892.40
$2,034.82
$2,540.80

$2,138.91
$2,273.37
$2,415.79
$2,921.77

$380.97

Toc - Plan #96 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$330.50
$375.12
$422.38
$590.27
$896.98

$583.33
$627.95
$675.21
$843.10

$836.16
$880.78
$928.04
$1,095.93

$1,088.99
$1,133.61
$1,180.87
$1,348.76

$252.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$661.00
$750.24
$844.76
$1,180.54
$1,793.96

$913.83
$1,003.07
$1,097.59
$1,433.37

$1,166.66
$1,255.90
$1,350.42
$1,686.20

$1,419.49
$1,508.73
$1,603.25
$1,939.03

$252.83

Toc - Plan #97 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Bronze 1602 ($0 Virtual Visits / $20 Labs / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$311.13
$353.13
$397.62
$555.68
$844.41

$549.14
$591.14
$635.63
$793.69

$787.15
$829.15
$873.64
$1,031.70

$1,025.16
$1,067.16
$1,111.65
$1,269.71

$238.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$622.26
$706.26
$795.24
$1,111.36
$1,688.82

$860.27
$944.27
$1,033.25
$1,349.37

$1,098.28
$1,182.28
$1,271.26
$1,587.38

$1,336.29
$1,420.29
$1,509.27
$1,825.39

$238.01

Toc - Plan #98 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 1603 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,900 $11,800 Annual Deductible

$7,200 $14,400 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

$407.03
$461.98
$520.18
$726.96
$1,104.68

$718.41
$773.36
$831.56
$1,038.34

$1,029.79
$1,084.74
$1,142.94
$1,349.72

$1,341.17
$1,396.12
$1,454.32
$1,661.10

$311.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$814.06
$923.96
$1,040.36
$1,453.92
$2,209.36

$1,125.44
$1,235.34
$1,351.74
$1,765.30

$1,436.82
$1,546.72
$1,663.12
$2,076.68

$1,748.20
$1,858.10
$1,974.50
$2,388.06

$311.38

Toc - Plan #99 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 1604 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 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

$387.99
$440.37
$495.85
$692.95
$1,053.00

$684.80
$737.18
$792.66
$989.76

$981.61
$1,033.99
$1,089.47
$1,286.57

$1,278.42
$1,330.80
$1,386.28
$1,583.38

$296.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$775.98
$880.74
$991.70
$1,385.90
$2,106.00

$1,072.79
$1,177.55
$1,288.51
$1,682.71

$1,369.60
$1,474.36
$1,585.32
$1,979.52

$1,666.41
$1,771.17
$1,882.13
$2,276.33

$296.81

Toc - Plan #100 Florida Blue HMO (a BlueCross BlueShield FL company)

Gold

(HMO) myBlue Gold 1605 ($0 Virtual Visits / $0 Labs / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$940 $1,880 Annual Deductible

$4,700 $9,400 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

$460.79
$523.00
$588.89
$822.97
$1,250.58

$813.29
$875.50
$941.39
$1,175.47

$1,165.79
$1,228.00
$1,293.89
$1,527.97

$1,518.29
$1,580.50
$1,646.39
$1,880.47

$352.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$921.58
$1,046.00
$1,177.78
$1,645.94
$2,501.16

$1,274.08
$1,398.50
$1,530.28
$1,998.44

$1,626.58
$1,751.00
$1,882.78
$2,350.94

$1,979.08
$2,103.50
$2,235.28
$2,703.44

$352.50

Toc - Plan #101 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 1710 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,700 $13,400 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

$413.53
$469.36
$528.49
$738.56
$1,122.32

$729.88
$785.71
$844.84
$1,054.91

$1,046.23
$1,102.06
$1,161.19
$1,371.26

$1,362.58
$1,418.41
$1,477.54
$1,687.61

$316.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$827.06
$938.72
$1,056.98
$1,477.12
$2,244.64

$1,143.41
$1,255.07
$1,373.33
$1,793.47

$1,459.76
$1,571.42
$1,689.68
$2,109.82

$1,776.11
$1,887.77
$2,006.03
$2,426.17

$316.35

Toc - Plan #102 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 2017 ($0 Virtual Visits / $20 Labs / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$384.87
$436.83
$491.86
$687.38
$1,044.54

$679.30
$731.26
$786.29
$981.81

$973.73
$1,025.69
$1,080.72
$1,276.24

$1,268.16
$1,320.12
$1,375.15
$1,570.67

$294.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$769.74
$873.66
$983.72
$1,374.76
$2,089.08

$1,064.17
$1,168.09
$1,278.15
$1,669.19

$1,358.60
$1,462.52
$1,572.58
$1,963.62

$1,653.03
$1,756.95
$1,867.01
$2,258.05

$294.43

Toc - Plan #103 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 2127 ($0 Virtual Visits / $25 Generic Meds / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$7,600 $15,200 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

$383.41
$435.17
$490.00
$684.77
$1,040.57

$676.72
$728.48
$783.31
$978.08

$970.03
$1,021.79
$1,076.62
$1,271.39

$1,263.34
$1,315.10
$1,369.93
$1,564.70

$293.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$766.82
$870.34
$980.00
$1,369.54
$2,081.14

$1,060.13
$1,163.65
$1,273.31
$1,662.85

$1,353.44
$1,456.96
$1,566.62
$1,956.16

$1,646.75
$1,750.27
$1,859.93
$2,249.47

$293.31

Toc - Plan #104 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Deductible / $0 Virtual Visits / $35 PCP Visit / $80 Specialist Visits / $25 Generic Meds / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

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

$357.54
$405.81
$456.94
$638.57
$970.36

$631.06
$679.33
$730.46
$912.09

$904.58
$952.85
$1,003.98
$1,185.61

$1,178.10
$1,226.37
$1,277.50
$1,459.13

$273.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.08
$811.62
$913.88
$1,277.14
$1,940.72

$988.60
$1,085.14
$1,187.40
$1,550.66

$1,262.12
$1,358.66
$1,460.92
$1,824.18

$1,535.64
$1,632.18
$1,734.44
$2,097.70

$273.52

Toc - Plan #105 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Bronze 2126 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$8,200 $16,400 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

$330.89
$375.56
$422.88
$590.97
$898.04

$584.02
$628.69
$676.01
$844.10

$837.15
$881.82
$929.14
$1,097.23

$1,090.28
$1,134.95
$1,182.27
$1,350.36

$253.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$661.78
$751.12
$845.76
$1,181.94
$1,796.08

$914.91
$1,004.25
$1,098.89
$1,435.07

$1,168.04
$1,257.38
$1,352.02
$1,688.20

$1,421.17
$1,510.51
$1,605.15
$1,941.33

$253.13

Toc - Plan #106 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 2237 ($0 Virtual Visits / $80 PCP Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$4,100 $8,200 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

$376.70
$427.55
$481.42
$672.79
$1,022.36

$664.88
$715.73
$769.60
$960.97

$953.06
$1,003.91
$1,057.78
$1,249.15

$1,241.24
$1,292.09
$1,345.96
$1,537.33

$288.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$753.40
$855.10
$962.84
$1,345.58
$2,044.72

$1,041.58
$1,143.28
$1,251.02
$1,633.76

$1,329.76
$1,431.46
$1,539.20
$1,921.94

$1,617.94
$1,719.64
$1,827.38
$2,210.12

$288.18

Toc - Plan #107 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Bronze 2219 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$2,400 $4,800 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

$323.40
$367.06
$413.31
$577.59
$877.71

$570.80
$614.46
$660.71
$824.99

$818.20
$861.86
$908.11
$1,072.39

$1,065.60
$1,109.26
$1,155.51
$1,319.79

$247.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$646.80
$734.12
$826.62
$1,155.18
$1,755.42

$894.20
$981.52
$1,074.02
$1,402.58

$1,141.60
$1,228.92
$1,321.42
$1,649.98

$1,389.00
$1,476.32
$1,568.82
$1,897.38

$247.40

Toc - Plan #108 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Bronze 2266 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$2,700 $5,400 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

$324.09
$367.84
$414.19
$578.82
$879.58

$572.02
$615.77
$662.12
$826.75

$819.95
$863.70
$910.05
$1,074.68

$1,067.88
$1,111.63
$1,157.98
$1,322.61

$247.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$648.18
$735.68
$828.38
$1,157.64
$1,759.16

$896.11
$983.61
$1,076.31
$1,405.57

$1,144.04
$1,231.54
$1,324.24
$1,653.50

$1,391.97
$1,479.47
$1,572.17
$1,901.43

$247.93

Toc - Plan #109 Florida Blue HMO (a BlueCross BlueShield FL company)

Bronze

(HMO) myBlue Bronze 2311S (Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$294.45
$334.20
$376.31
$525.89
$799.14

$519.70
$559.45
$601.56
$751.14

$744.95
$784.70
$826.81
$976.39

$970.20
$1,009.95
$1,052.06
$1,201.64

$225.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$588.90
$668.40
$752.62
$1,051.78
$1,598.28

$814.15
$893.65
$977.87
$1,277.03

$1,039.40
$1,118.90
$1,203.12
$1,502.28

$1,264.65
$1,344.15
$1,428.37
$1,727.53

$225.25

Toc - Plan #110 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Bronze 2312S (Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$315.88
$358.52
$403.69
$564.16
$857.30

$557.53
$600.17
$645.34
$805.81

$799.18
$841.82
$886.99
$1,047.46

$1,040.83
$1,083.47
$1,128.64
$1,289.11

$241.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$631.76
$717.04
$807.38
$1,128.32
$1,714.60

$873.41
$958.69
$1,049.03
$1,369.97

$1,115.06
$1,200.34
$1,290.68
$1,611.62

$1,356.71
$1,441.99
$1,532.33
$1,853.27

$241.65

Toc - Plan #111 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Bronze 2329 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

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

$346.20
$392.94
$442.44
$618.31
$939.59

$611.04
$657.78
$707.28
$883.15

$875.88
$922.62
$972.12
$1,147.99

$1,140.72
$1,187.46
$1,236.96
$1,412.83

$264.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$692.40
$785.88
$884.88
$1,236.62
$1,879.18

$957.24
$1,050.72
$1,149.72
$1,501.46

$1,222.08
$1,315.56
$1,414.56
$1,766.30

$1,486.92
$1,580.40
$1,679.40
$2,031.14

$264.84

Toc - Plan #112 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Connected Care Silver 2230 ($0 Primary Care Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Disponible en Espa�ol / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 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

$373.34
$423.74
$477.13
$666.79
$1,013.24

$658.95
$709.35
$762.74
$952.40

$944.56
$994.96
$1,048.35
$1,238.01

$1,230.17
$1,280.57
$1,333.96
$1,523.62

$285.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$746.68
$847.48
$954.26
$1,333.58
$2,026.48

$1,032.29
$1,133.09
$1,239.87
$1,619.19

$1,317.90
$1,418.70
$1,525.48
$1,904.80

$1,603.51
$1,704.31
$1,811.09
$2,190.41

$285.61

Toc - Plan #113 Florida Blue HMO (a BlueCross BlueShield FL company)

Expanded Bronze

(HMO) myBlue Connected Care Bronze 2231 ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Disponible en Espa�ol / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$306.24
$347.58
$391.37
$546.94
$831.14

$540.51
$581.85
$625.64
$781.21

$774.78
$816.12
$859.91
$1,015.48

$1,009.05
$1,050.39
$1,094.18
$1,249.75

$234.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$612.48
$695.16
$782.74
$1,093.88
$1,662.28

$846.75
$929.43
$1,017.01
$1,328.15

$1,081.02
$1,163.70
$1,251.28
$1,562.42

$1,315.29
$1,397.97
$1,485.55
$1,796.69

$234.27

Toc - Plan #114 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Connected Care Silver 2332 ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Disponible en Espa�ol / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$361.56
$410.37
$462.07
$645.75
$981.27

$638.15
$686.96
$738.66
$922.34

$914.74
$963.55
$1,015.25
$1,198.93

$1,191.33
$1,240.14
$1,291.84
$1,475.52

$276.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$723.12
$820.74
$924.14
$1,291.50
$1,962.54

$999.71
$1,097.33
$1,200.73
$1,568.09

$1,276.30
$1,373.92
$1,477.32
$1,844.68

$1,552.89
$1,650.51
$1,753.91
$2,121.27

$276.59

Toc - Plan #115 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 2337 ($0 Virtual Visits / $20 Labs / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 Annual Deductible

$8,300 $16,600 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

$364.64
$413.87
$466.01
$651.25
$989.63

$643.59
$692.82
$744.96
$930.20

$922.54
$971.77
$1,023.91
$1,209.15

$1,201.49
$1,250.72
$1,302.86
$1,488.10

$278.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$729.28
$827.74
$932.02
$1,302.50
$1,979.26

$1,008.23
$1,106.69
$1,210.97
$1,581.45

$1,287.18
$1,385.64
$1,489.92
$1,860.40

$1,566.13
$1,664.59
$1,768.87
$2,139.35

$278.95

Toc - Plan #116 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 2313S ($40 PCP Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$379.18
$430.37
$484.59
$677.22
$1,029.09

$669.25
$720.44
$774.66
$967.29

$959.32
$1,010.51
$1,064.73
$1,257.36

$1,249.39
$1,300.58
$1,354.80
$1,547.43

$290.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$758.36
$860.74
$969.18
$1,354.44
$2,058.18

$1,048.43
$1,150.81
$1,259.25
$1,644.51

$1,338.50
$1,440.88
$1,549.32
$1,934.58

$1,628.57
$1,730.95
$1,839.39
$2,224.65

$290.07

Toc - Plan #117 Florida Blue HMO (a BlueCross BlueShield FL company)

Gold

(HMO) myBlue Gold 2314S ($30 PCP Visits / Multilingual Available / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$436.16
$495.04
$557.41
$778.98
$1,183.74

$769.82
$828.70
$891.07
$1,112.64

$1,103.48
$1,162.36
$1,224.73
$1,446.30

$1,437.14
$1,496.02
$1,558.39
$1,779.96

$333.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$872.32
$990.08
$1,114.82
$1,557.96
$2,367.48

$1,205.98
$1,323.74
$1,448.48
$1,891.62

$1,539.64
$1,657.40
$1,782.14
$2,225.28

$1,873.30
$1,991.06
$2,115.80
$2,558.94

$333.66

Toc - Plan #118 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 2237D ($0 Virtual Visits / $80 PCP Visits / Adult Dental / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$4,100 $8,200 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

$384.36
$436.25
$491.21
$686.47
$1,043.15

$678.40
$730.29
$785.25
$980.51

$972.44
$1,024.33
$1,079.29
$1,274.55

$1,266.48
$1,318.37
$1,373.33
$1,568.59

$294.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$768.72
$872.50
$982.42
$1,372.94
$2,086.30

$1,062.76
$1,166.54
$1,276.46
$1,666.98

$1,356.80
$1,460.58
$1,570.50
$1,961.02

$1,650.84
$1,754.62
$1,864.54
$2,255.06

$294.04

Toc - Plan #119 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Connected Care Silver 2332D ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / Adult Dental / 24x7 Provider Access / Disponible en Espa�ol / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$369.20
$419.04
$471.84
$659.39
$1,002.01

$651.64
$701.48
$754.28
$941.83

$934.08
$983.92
$1,036.72
$1,224.27

$1,216.52
$1,266.36
$1,319.16
$1,506.71

$282.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$738.40
$838.08
$943.68
$1,318.78
$2,004.02

$1,020.84
$1,120.52
$1,226.12
$1,601.22

$1,303.28
$1,402.96
$1,508.56
$1,883.66

$1,585.72
$1,685.40
$1,791.00
$2,166.10

$282.44

Toc - Plan #120 Florida Blue HMO (a BlueCross BlueShield FL company)

Silver

(HMO) myBlue Silver 2337D ($0 Virtual Visits / Adult Dental / $20 Labs / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 Annual Deductible

$8,300 $16,600 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

$372.27
$422.53
$475.76
$664.87
$1,010.34

$657.06
$707.32
$760.55
$949.66

$941.85
$992.11
$1,045.34
$1,234.45

$1,226.64
$1,276.90
$1,330.13
$1,519.24

$284.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$744.54
$845.06
$951.52
$1,329.74
$2,020.68

$1,029.33
$1,129.85
$1,236.31
$1,614.53

$1,314.12
$1,414.64
$1,521.10
$1,899.32

$1,598.91
$1,699.43
$1,805.89
$2,184.11

$284.79

Oscar Insurance Company of Florida

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

Toc - Plan #121 Oscar Insurance Company of Florida

Silver

(EPO) Silver Simple

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 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

$374.38
$424.91
$478.44
$668.62
$1,016.04

$660.77
$711.30
$764.83
$955.01

$947.16
$997.69
$1,051.22
$1,241.40

$1,233.55
$1,284.08
$1,337.61
$1,527.79

$286.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$748.76
$849.82
$956.88
$1,337.24
$2,032.08

$1,035.15
$1,136.21
$1,243.27
$1,623.63

$1,321.54
$1,422.60
$1,529.66
$1,910.02

$1,607.93
$1,708.99
$1,816.05
$2,196.41

$286.39

Toc - Plan #122 Oscar Insurance Company of Florida

Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

$292.03
$331.44
$373.20
$521.54
$792.53

$515.42
$554.83
$596.59
$744.93

$738.81
$778.22
$819.98
$968.32

$962.20
$1,001.61
$1,043.37
$1,191.71

$223.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$584.06
$662.88
$746.40
$1,043.08
$1,585.06

$807.45
$886.27
$969.79
$1,266.47

$1,030.84
$1,109.66
$1,193.18
$1,489.86

$1,254.23
$1,333.05
$1,416.57
$1,713.25

$223.39

Toc - Plan #123 Oscar Insurance Company of Florida

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

$284.14
$322.49
$363.12
$507.45
$771.12

$501.50
$539.85
$580.48
$724.81

$718.86
$757.21
$797.84
$942.17

$936.22
$974.57
$1,015.20
$1,159.53

$217.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$568.28
$644.98
$726.24
$1,014.90
$1,542.24

$785.64
$862.34
$943.60
$1,232.26

$1,003.00
$1,079.70
$1,160.96
$1,449.62

$1,220.36
$1,297.06
$1,378.32
$1,666.98

$217.36

Toc - Plan #124 Oscar Insurance Company of Florida

Expanded Bronze

(EPO) Bronze Elite- Deductible+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

$9,100 $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

$344.84
$391.38
$440.69
$615.86
$935.86

$608.63
$655.17
$704.48
$879.65

$872.42
$918.96
$968.27
$1,143.44

$1,136.21
$1,182.75
$1,232.06
$1,407.23

$263.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$689.68
$782.76
$881.38
$1,231.72
$1,871.72

$953.47
$1,046.55
$1,145.17
$1,495.51

$1,217.26
$1,310.34
$1,408.96
$1,759.30

$1,481.05
$1,574.13
$1,672.75
$2,023.09

$263.79

Toc - Plan #125 Oscar Insurance Company of Florida

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

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$382.86
$434.53
$489.28
$683.77
$1,039.05

$675.74
$727.41
$782.16
$976.65

$968.62
$1,020.29
$1,075.04
$1,269.53

$1,261.50
$1,313.17
$1,367.92
$1,562.41

$292.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.72
$869.06
$978.56
$1,367.54
$2,078.10

$1,058.60
$1,161.94
$1,271.44
$1,660.42

$1,351.48
$1,454.82
$1,564.32
$1,953.30

$1,644.36
$1,747.70
$1,857.20
$2,246.18

$292.88

Toc - Plan #126 Oscar Insurance Company of Florida

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

$9,000 $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

$380.64
$432.01
$486.44
$679.80
$1,033.02

$671.82
$723.19
$777.62
$970.98

$963.00
$1,014.37
$1,068.80
$1,262.16

$1,254.18
$1,305.55
$1,359.98
$1,553.34

$291.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$761.28
$864.02
$972.88
$1,359.60
$2,066.04

$1,052.46
$1,155.20
$1,264.06
$1,650.78

$1,343.64
$1,446.38
$1,555.24
$1,941.96

$1,634.82
$1,737.56
$1,846.42
$2,233.14

$291.18

Toc - Plan #127 Oscar Insurance Company of Florida

Silver

(EPO) Silver Classic- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$383.42
$435.17
$489.99
$684.76
$1,040.56

$676.73
$728.48
$783.30
$978.07

$970.04
$1,021.79
$1,076.61
$1,271.38

$1,263.35
$1,315.10
$1,369.92
$1,564.69

$293.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$766.84
$870.34
$979.98
$1,369.52
$2,081.12

$1,060.15
$1,163.65
$1,273.29
$1,662.83

$1,353.46
$1,456.96
$1,566.60
$1,956.14

$1,646.77
$1,750.27
$1,859.91
$2,249.45

$293.31

Toc - Plan #128 Oscar Insurance Company of Florida

Catastrophic

(EPO) Secure

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$218.35
$247.81
$279.04
$389.95
$592.57

$385.38
$414.84
$446.07
$556.98

$552.41
$581.87
$613.10
$724.01

$719.44
$748.90
$780.13
$891.04

$167.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$436.70
$495.62
$558.08
$779.90
$1,185.14

$603.73
$662.65
$725.11
$946.93

$770.76
$829.68
$892.14
$1,113.96

$937.79
$996.71
$1,059.17
$1,280.99

$167.03

Toc - Plan #129 Oscar Insurance Company of Florida

Expanded Bronze

(EPO) Bronze Elite- Deductible+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

$9,100 $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

$344.39
$390.87
$440.11
$615.06
$934.64

$607.84
$654.32
$703.56
$878.51

$871.29
$917.77
$967.01
$1,141.96

$1,134.74
$1,181.22
$1,230.46
$1,405.41

$263.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$688.78
$781.74
$880.22
$1,230.12
$1,869.28

$952.23
$1,045.19
$1,143.67
$1,493.57

$1,215.68
$1,308.64
$1,407.12
$1,757.02

$1,479.13
$1,572.09
$1,670.57
$2,020.47

$263.45

Toc - Plan #130 Oscar Insurance Company of Florida

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

$405.86
$460.64
$518.68
$724.85
$1,101.48

$716.34
$771.12
$829.16
$1,035.33

$1,026.82
$1,081.60
$1,139.64
$1,345.81

$1,337.30
$1,392.08
$1,450.12
$1,656.29

$310.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$811.72
$921.28
$1,037.36
$1,449.70
$2,202.96

$1,122.20
$1,231.76
$1,347.84
$1,760.18

$1,432.68
$1,542.24
$1,658.32
$2,070.66

$1,743.16
$1,852.72
$1,968.80
$2,381.14

$310.48

Toc - Plan #131 Oscar Insurance Company of Florida

Expanded Bronze

(EPO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,200 $10,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$302.45
$343.27
$386.52
$540.16
$820.83

$533.82
$574.64
$617.89
$771.53

$765.19
$806.01
$849.26
$1,002.90

$996.56
$1,037.38
$1,080.63
$1,234.27

$231.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$604.90
$686.54
$773.04
$1,080.32
$1,641.66

$836.27
$917.91
$1,004.41
$1,311.69

$1,067.64
$1,149.28
$1,235.78
$1,543.06

$1,299.01
$1,380.65
$1,467.15
$1,774.43

$231.37

Toc - Plan #132 Oscar Insurance Company of Florida

Silver

(EPO) Silver Elite

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$387.87
$440.22
$495.68
$692.72
$1,052.65

$684.58
$736.93
$792.39
$989.43

$981.29
$1,033.64
$1,089.10
$1,286.14

$1,278.00
$1,330.35
$1,385.81
$1,582.85

$296.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$775.74
$880.44
$991.36
$1,385.44
$2,105.30

$1,072.45
$1,177.15
$1,288.07
$1,682.15

$1,369.16
$1,473.86
$1,584.78
$1,978.86

$1,665.87
$1,770.57
$1,881.49
$2,275.57

$296.71

Toc - Plan #133 Oscar Insurance Company of Florida

Silver

(EPO) Silver Classic- Deductible Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,000 $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

$390.66
$443.38
$499.25
$697.69
$1,060.21

$689.50
$742.22
$798.09
$996.53

$988.34
$1,041.06
$1,096.93
$1,295.37

$1,287.18
$1,339.90
$1,395.77
$1,594.21

$298.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$781.32
$886.76
$998.50
$1,395.38
$2,120.42

$1,080.16
$1,185.60
$1,297.34
$1,694.22

$1,379.00
$1,484.44
$1,596.18
$1,993.06

$1,677.84
$1,783.28
$1,895.02
$2,291.90

$298.84

Toc - Plan #134 Oscar Insurance Company of Florida

Expanded Bronze

(EPO) Bronze Classic- PCP Saver Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$300.82
$341.42
$384.43
$537.25
$816.40

$530.94
$571.54
$614.55
$767.37

$761.06
$801.66
$844.67
$997.49

$991.18
$1,031.78
$1,074.79
$1,227.61

$230.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$601.64
$682.84
$768.86
$1,074.50
$1,632.80

$831.76
$912.96
$998.98
$1,304.62

$1,061.88
$1,143.08
$1,229.10
$1,534.74

$1,292.00
$1,373.20
$1,459.22
$1,764.86

$230.12

Toc - Plan #135 Oscar Insurance Company of Florida

Expanded Bronze

(EPO) Bronze Classic- Deductible Saver

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

$310.53
$352.44
$396.85
$554.59
$842.75

$548.08
$589.99
$634.40
$792.14

$785.63
$827.54
$871.95
$1,029.69

$1,023.18
$1,065.09
$1,109.50
$1,267.24

$237.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$621.06
$704.88
$793.70
$1,109.18
$1,685.50

$858.61
$942.43
$1,031.25
$1,346.73

$1,096.16
$1,179.98
$1,268.80
$1,584.28

$1,333.71
$1,417.53
$1,506.35
$1,821.83

$237.55

Toc - Plan #136 Oscar Insurance Company of Florida

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

$5,500 $11,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$367.87
$417.52
$470.13
$657.00
$998.38

$649.28
$698.93
$751.54
$938.41

$930.69
$980.34
$1,032.95
$1,219.82

$1,212.10
$1,261.75
$1,314.36
$1,501.23

$281.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$735.74
$835.04
$940.26
$1,314.00
$1,996.76

$1,017.15
$1,116.45
$1,221.67
$1,595.41

$1,298.56
$1,397.86
$1,503.08
$1,876.82

$1,579.97
$1,679.27
$1,784.49
$2,158.23

$281.41

Toc - Plan #137 Oscar Insurance Company of Florida

Silver

(EPO) Silver Elite- PCP Saver Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 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

$392.33
$445.28
$501.38
$700.68
$1,064.75

$692.45
$745.40
$801.50
$1,000.80

$992.57
$1,045.52
$1,101.62
$1,300.92

$1,292.69
$1,345.64
$1,401.74
$1,601.04

$300.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$784.66
$890.56
$1,002.76
$1,401.36
$2,129.50

$1,084.78
$1,190.68
$1,302.88
$1,701.48

$1,384.90
$1,490.80
$1,603.00
$2,001.60

$1,685.02
$1,790.92
$1,903.12
$2,301.72

$300.12

Toc - Plan #138 Oscar Insurance Company of Florida

Silver

(EPO) Silver Elite- Deductible 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

$383.42
$435.17
$489.99
$684.76
$1,040.56

$676.73
$728.48
$783.30
$978.07

$970.04
$1,021.79
$1,076.61
$1,271.38

$1,263.35
$1,315.10
$1,369.92
$1,564.69

$293.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$766.84
$870.34
$979.98
$1,369.52
$2,081.12

$1,060.15
$1,163.65
$1,273.29
$1,662.83

$1,353.46
$1,456.96
$1,566.60
$1,956.14

$1,646.77
$1,750.27
$1,859.91
$2,249.45

$293.31

Toc - Plan #139 Oscar Insurance Company of Florida

Gold

(EPO) Gold Elite- Deductible 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

$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

$444.38
$504.36
$567.91
$793.65
$1,206.03

$784.33
$844.31
$907.86
$1,133.60

$1,124.28
$1,184.26
$1,247.81
$1,473.55

$1,464.23
$1,524.21
$1,587.76
$1,813.50

$339.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$888.76
$1,008.72
$1,135.82
$1,587.30
$2,412.06

$1,228.71
$1,348.67
$1,475.77
$1,927.25

$1,568.66
$1,688.62
$1,815.72
$2,267.20

$1,908.61
$2,028.57
$2,155.67
$2,607.15

$339.95

Toc - Plan #140 Oscar Insurance Company of Florida

Gold

(EPO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$500 $1,000 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

$416.08
$472.24
$531.74
$743.10
$1,129.22

$734.38
$790.54
$850.04
$1,061.40

$1,052.68
$1,108.84
$1,168.34
$1,379.70

$1,370.98
$1,427.14
$1,486.64
$1,698.00

$318.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$832.16
$944.48
$1,063.48
$1,486.20
$2,258.44

$1,150.46
$1,262.78
$1,381.78
$1,804.50

$1,468.76
$1,581.08
$1,700.08
$2,122.80

$1,787.06
$1,899.38
$2,018.38
$2,441.10

$318.30

Toc - Plan #141 Oscar Insurance Company of Florida

Expanded Bronze

(EPO) Bronze Elite- Deductible 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

$335.88
$381.21
$429.24
$599.86
$911.55

$592.82
$638.15
$686.18
$856.80

$849.76
$895.09
$943.12
$1,113.74

$1,106.70
$1,152.03
$1,200.06
$1,370.68

$256.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$671.76
$762.42
$858.48
$1,199.72
$1,823.10

$928.70
$1,019.36
$1,115.42
$1,456.66

$1,185.64
$1,276.30
$1,372.36
$1,713.60

$1,442.58
$1,533.24
$1,629.30
$1,970.54

$256.94

Toc - Plan #142 Oscar Insurance Company of Florida

Silver

(EPO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$6,450 $12,900 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$381.75
$433.27
$487.86
$681.78
$1,036.04

$673.78
$725.30
$779.89
$973.81

$965.81
$1,017.33
$1,071.92
$1,265.84

$1,257.84
$1,309.36
$1,363.95
$1,557.87

$292.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$763.50
$866.54
$975.72
$1,363.56
$2,072.08

$1,055.53
$1,158.57
$1,267.75
$1,655.59

$1,347.56
$1,450.60
$1,559.78
$1,947.62

$1,639.59
$1,742.63
$1,851.81
$2,239.65

$292.03

Toc - Plan #143 Oscar Insurance Company of Florida

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

$9,000 $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

$307.00
$348.43
$392.33
$548.28
$833.16

$541.84
$583.27
$627.17
$783.12

$776.68
$818.11
$862.01
$1,017.96

$1,011.52
$1,052.95
$1,096.85
$1,252.80

$234.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$614.00
$696.86
$784.66
$1,096.56
$1,666.32

$848.84
$931.70
$1,019.50
$1,331.40

$1,083.68
$1,166.54
$1,254.34
$1,566.24

$1,318.52
$1,401.38
$1,489.18
$1,801.08

$234.84

Toc - Plan #144 Oscar Insurance Company of Florida

Bronze

(EPO) Bronze Simple- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$271.05
$307.63
$346.39
$484.08
$735.61

$478.40
$514.98
$553.74
$691.43

$685.75
$722.33
$761.09
$898.78

$893.10
$929.68
$968.44
$1,106.13

$207.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$542.10
$615.26
$692.78
$968.16
$1,471.22

$749.45
$822.61
$900.13
$1,175.51

$956.80
$1,029.96
$1,107.48
$1,382.86

$1,164.15
$1,237.31
$1,314.83
$1,590.21

$207.35

Toc - Plan #145 Oscar Insurance Company of Florida

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

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$377.86
$428.86
$482.89
$674.84
$1,025.48

$666.91
$717.91
$771.94
$963.89

$955.96
$1,006.96
$1,060.99
$1,252.94

$1,245.01
$1,296.01
$1,350.04
$1,541.99

$289.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$755.72
$857.72
$965.78
$1,349.68
$2,050.96

$1,044.77
$1,146.77
$1,254.83
$1,638.73

$1,333.82
$1,435.82
$1,543.88
$1,927.78

$1,622.87
$1,724.87
$1,832.93
$2,216.83

$289.05

Toc - Plan #146 Oscar Insurance Company of Florida

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

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$387.05
$439.29
$494.63
$691.25
$1,050.42

$683.13
$735.37
$790.71
$987.33

$979.21
$1,031.45
$1,086.79
$1,283.41

$1,275.29
$1,327.53
$1,382.87
$1,579.49

$296.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$774.10
$878.58
$989.26
$1,382.50
$2,100.84

$1,070.18
$1,174.66
$1,285.34
$1,678.58

$1,366.26
$1,470.74
$1,581.42
$1,974.66

$1,662.34
$1,766.82
$1,877.50
$2,270.74

$296.08

Cigna Healthcare

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

Toc - Plan #147 Cigna Healthcare

Bronze

(EPO) Cigna Connect 8700

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$319.77
$362.93
$408.66
$571.10
$867.84

$564.39
$607.55
$653.28
$815.72

$809.01
$852.17
$897.90
$1,060.34

$1,053.63
$1,096.79
$1,142.52
$1,304.96

$244.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$639.54
$725.86
$817.32
$1,142.20
$1,735.68

$884.16
$970.48
$1,061.94
$1,386.82

$1,128.78
$1,215.10
$1,306.56
$1,631.44

$1,373.40
$1,459.72
$1,551.18
$1,876.06

$244.62

Toc - Plan #148 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 7300

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,300 $14,600 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

$332.12
$376.95
$424.45
$593.16
$901.37

$586.19
$631.02
$678.52
$847.23

$840.26
$885.09
$932.59
$1,101.30

$1,094.33
$1,139.16
$1,186.66
$1,355.37

$254.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$664.24
$753.90
$848.90
$1,186.32
$1,802.74

$918.31
$1,007.97
$1,102.97
$1,440.39

$1,172.38
$1,262.04
$1,357.04
$1,694.46

$1,426.45
$1,516.11
$1,611.11
$1,948.53

$254.07

Toc - Plan #149 Cigna Healthcare

Expanded Bronze

(EPO) Cigna Connect 8200

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$8,200 $16,400 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

$332.25
$377.10
$424.61
$593.40
$901.72

$586.42
$631.27
$678.78
$847.57

$840.59
$885.44
$932.95
$1,101.74

$1,094.76
$1,139.61
$1,187.12
$1,355.91

$254.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$664.50
$754.20
$849.22
$1,186.80
$1,803.44

$918.67
$1,008.37
$1,103.39
$1,440.97

$1,172.84
$1,262.54
$1,357.56
$1,695.14

$1,427.01
$1,516.71
$1,611.73
$1,949.31

$254.17

Toc - Plan #150 Cigna Healthcare

Silver

(EPO) Cigna Connect 4400

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$4,400 $8,800 Annual Deductible

$9,050 $18,100 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

$381.74
$433.28
$487.86
$681.79
$1,036.05

$673.77
$725.31
$779.89
$973.82

$965.80
$1,017.34
$1,071.92
$1,265.85

$1,257.83
$1,309.37
$1,363.95
$1,557.88

$292.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$763.48
$866.56
$975.72
$1,363.58
$2,072.10

$1,055.51
$1,158.59
$1,267.75
$1,655.61

$1,347.54
$1,450.62
$1,559.78
$1,947.64

$1,639.57
$1,742.65
$1,851.81
$2,239.67

$292.03

Toc - Plan #151 Cigna Healthcare

Silver

(EPO) Cigna Connect 4500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 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

$385.70
$437.77
$492.92
$688.85
$1,046.78

$680.76
$732.83
$787.98
$983.91

$975.82
$1,027.89
$1,083.04
$1,278.97

$1,270.88
$1,322.95
$1,378.10
$1,574.03

$295.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$771.40
$875.54
$985.84
$1,377.70
$2,093.56

$1,066.46
$1,170.60
$1,280.90
$1,672.76

$1,361.52
$1,465.66
$1,575.96
$1,967.82

$1,656.58
$1,760.72
$1,871.02
$2,262.88

$295.06

Toc - Plan #152 Cigna Healthcare

Silver

(EPO) Cigna Connect 8900

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$8,900 $17,800 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

$388.73
$441.21
$496.80
$694.27
$1,055.01

$686.11
$738.59
$794.18
$991.65

$983.49
$1,035.97
$1,091.56
$1,289.03

$1,280.87
$1,333.35
$1,388.94
$1,586.41

$297.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$777.46
$882.42
$993.60
$1,388.54
$2,110.02

$1,074.84
$1,179.80
$1,290.98
$1,685.92

$1,372.22
$1,477.18
$1,588.36
$1,983.30

$1,669.60
$1,774.56
$1,885.74
$2,280.68

$297.38

Toc - Plan #153 Cigna Healthcare

Silver

(EPO) Cigna Connect 3500

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

$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

$389.35
$441.91
$497.58
$695.37
$1,056.68

$687.20
$739.76
$795.43
$993.22

$985.05
$1,037.61
$1,093.28
$1,291.07

$1,282.90
$1,335.46
$1,391.13
$1,588.92

$297.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$778.70
$883.82
$995.16
$1,390.74
$2,113.36

$1,076.55
$1,181.67
$1,293.01
$1,688.59

$1,374.40
$1,479.52
$1,590.86
$1,986.44

$1,672.25
$1,777.37
$1,888.71
$2,284.29

$297.85

Toc - Plan #154 Cigna Healthcare

Gold

(EPO) Cigna Connect 1950

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$1,950 $3,900 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

$463.41
$525.97
$592.23
$827.65
$1,257.69

$817.92
$880.48
$946.74
$1,182.16

$1,172.43
$1,234.99
$1,301.25
$1,536.67

$1,526.94
$1,589.50
$1,655.76
$1,891.18

$354.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$926.82
$1,051.94
$1,184.46
$1,655.30
$2,515.38

$1,281.33
$1,406.45
$1,538.97
$2,009.81

$1,635.84
$1,760.96
$1,893.48
$2,364.32

$1,990.35
$2,115.47
$2,247.99
$2,718.83

$354.51

Florida Obamacare 2023 Rates

Obamacare Rates and Providers for Other Years

How To Sign Up for Obamacare in Florida for 2023

Where's the Florida Health Care Exchange?

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

Florida Has Not Expanded Medicaid

The Medicaid Coverage Gap

Get Help Finding a Health Insurance Plan in Florida

Get Help From Florida's Health Insurance Exchange

Get Help From a Licensed Insurance Broker

More Information

Florida Blue (BlueCross BlueShield FL)

(EPO) BlueOptions Silver 1423 ($0 Virtual Visits / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $5,950 $11,900 Annual Deductible $7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Bronze 1419 ($0 Virtual Visits / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $6,900 $13,800 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Silver 1431 ($0 Virtual Visits / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $6,000 $12,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Platinum 1418 ($0 Virtual Visits / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $1,000 $2,000 Annual Deductible $4,000 $8,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Bronze 1416 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $7,400 $14,800 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Platinum 1424 ($0 Virtual Visits / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $0 $0 Annual Deductible $2,000 $4,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Silver 1410 ($0 Virtual Visits / $0 Lab / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $6,000 $12,000 Annual Deductible $7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $0 $0 Annual Deductible $5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Bronze (HSA) 1705 (Rewards $$$ / $4 Condition Care Rx)

Annual Out of Pocket Expenses:

Individual Family $6,850 $13,700 Annual Deductible $6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Gold 1805 ($0 Virtual Visits / $20 Labs / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $1,500 $3,000 Annual Deductible $5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Bronze 2119 ($0 Deductible / $0 Virtual Visits / $50 PCP Visits / Rewards $$$)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) BlueOptions Bronze 2301S (Multilingual Available / Rewards $$$)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) BlueOptions Bronze 2302S (Multilingual Available / Rewards $$$)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) BlueOptions Silver 2303S ($40 PCP Visits / Multilingual Available/ Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $5,800 $11,600 Annual Deductible $8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Gold 2304S ($30 PCP Visits / Multilingual Available / Rewards $$$)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(EPO) BlueOptions Platinum 2305S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

Annual Out of Pocket Expenses:

Individual Family $0 $0 Annual Deductible $3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(EPO) BlueOptions Bronze 2319 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

Individual Family

$5,950 $11,900 Annual Deductible

$7,150 $14,300 Maximum Out of Pocket Per Year

Individual Family

$6,900 $13,800 Annual Deductible

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

Individual Family

$6,000 $12,000 Annual Deductible

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

Individual Family

$1,000 $2,000 Annual Deductible

$4,000 $8,000 Maximum Out of Pocket Per Year

Individual Family

$7,400 $14,800 Annual Deductible

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

Individual Family

$0 $0 Annual Deductible

$2,000 $4,000 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$7,900 $15,800 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$7,500 $15,000 Annual Deductible

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

Individual Family

$5,800 $11,600 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

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

Individual Family

$0 $0 Annual Deductible

$3,000 $6,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$5,950 $11,900 Annual Deductible

$7,150 $14,300 Maximum Out of Pocket Per Year

Individual Family

$6,900 $13,800 Annual Deductible

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

Individual Family

$6,000 $12,000 Annual Deductible

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

Individual Family

$1,000 $2,000 Annual Deductible

$4,000 $8,000 Maximum Out of Pocket Per Year

Individual Family

$7,400 $14,800 Annual Deductible

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

Individual Family

$0 $0 Annual Deductible

$2,000 $4,000 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$7,900 $15,800 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Individual Family

$6,850 $13,700 Annual Deductible

$6,850 $13,700 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$7,500 $15,000 Annual Deductible

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

Individual Family

$5,800 $11,600 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

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

Individual Family

$0 $0 Annual Deductible

$3,000 $6,000 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

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