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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)
Bronze

(EPO) BlueSelect Bronze 24L01-01 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$460.39
$522.54
$588.38
$822.26
$1,249.50 		$812.59
$874.74
$940.58
$1,174.46 		$1,164.79
$1,226.94
$1,292.78
$1,526.66 		$1,516.99
$1,579.14
$1,644.98
$1,878.86 		$352.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$920.78
$1,045.08
$1,176.76
$1,644.52
$2,499.00 		$1,272.98
$1,397.28
$1,528.96
$1,996.72 		$1,625.18
$1,749.48
$1,881.16
$2,348.92 		$1,977.38
$2,101.68
$2,233.36
$2,701.12 		$352.20
Toc - Plan #2 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
$2,800 $5,600 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 		$624.67
$709.00
$798.33
$1,115.66
$1,695.35 		$1,102.54
$1,186.87
$1,276.20
$1,593.53 		$1,580.41
$1,664.74
$1,754.07
$2,071.40 		$2,058.28
$2,142.61
$2,231.94
$2,549.27 		$477.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,249.34
$1,418.00
$1,596.66
$2,231.32
$3,390.70 		$1,727.21
$1,895.87
$2,074.53
$2,709.19 		$2,205.08
$2,373.74
$2,552.40
$3,187.06 		$2,682.95
$2,851.61
$3,030.27
$3,664.93 		$477.87
Toc - Plan #3 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 		$819.96
$930.65
$1,047.91
$1,464.45
$2,225.37 		$1,447.23
$1,557.92
$1,675.18
$2,091.72 		$2,074.50
$2,185.19
$2,302.45
$2,718.99 		$2,701.77
$2,812.46
$2,929.72
$3,346.26 		$627.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,639.92
$1,861.30
$2,095.82
$2,928.90
$4,450.74 		$2,267.19
$2,488.57
$2,723.09
$3,556.17 		$2,894.46
$3,115.84
$3,350.36
$4,183.44 		$3,521.73
$3,743.11
$3,977.63
$4,810.71 		$627.27
Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$492.03
$558.45
$628.81
$878.77
$1,335.37 		$868.43
$934.85
$1,005.21
$1,255.17 		$1,244.83
$1,311.25
$1,381.61
$1,631.57 		$1,621.23
$1,687.65
$1,758.01
$2,007.97 		$376.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$984.06
$1,116.90
$1,257.62
$1,757.54
$2,670.74 		$1,360.46
$1,493.30
$1,634.02
$2,133.94 		$1,736.86
$1,869.70
$2,010.42
$2,510.34 		$2,113.26
$2,246.10
$2,386.82
$2,886.74 		$376.40
Toc - Plan #5 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 		$851.98
$967.00
$1,088.83
$1,521.64
$2,312.27 		$1,503.74
$1,618.76
$1,740.59
$2,173.40 		$2,155.50
$2,270.52
$2,392.35
$2,825.16 		$2,807.26
$2,922.28
$3,044.11
$3,476.92 		$651.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,703.96
$1,934.00
$2,177.66
$3,043.28
$4,624.54 		$2,355.72
$2,585.76
$2,829.42
$3,695.04 		$3,007.48
$3,237.52
$3,481.18
$4,346.80 		$3,659.24
$3,889.28
$4,132.94
$4,998.56 		$651.76
Toc - Plan #6 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
$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 		$584.71
$663.65
$747.26
$1,044.29
$1,586.90 		$1,032.01
$1,110.95
$1,194.56
$1,491.59 		$1,479.31
$1,558.25
$1,641.86
$1,938.89 		$1,926.61
$2,005.55
$2,089.16
$2,386.19 		$447.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,169.42
$1,327.30
$1,494.52
$2,088.58
$3,173.80 		$1,616.72
$1,774.60
$1,941.82
$2,535.88 		$2,064.02
$2,221.90
$2,389.12
$2,983.18 		$2,511.32
$2,669.20
$2,836.42
$3,430.48 		$447.30
Toc - Plan #7 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
$6,250 $12,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$704.59
$799.71
$900.47
$1,258.40
$1,912.26 		$1,243.60
$1,338.72
$1,439.48
$1,797.41 		$1,782.61
$1,877.73
$1,978.49
$2,336.42 		$2,321.62
$2,416.74
$2,517.50
$2,875.43 		$539.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,409.18
$1,599.42
$1,800.94
$2,516.80
$3,824.52 		$1,948.19
$2,138.43
$2,339.95
$3,055.81 		$2,487.20
$2,677.44
$2,878.96
$3,594.82 		$3,026.21
$3,216.45
$3,417.97
$4,133.83 		$539.01
Toc - Plan #8 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
$7,050 $14,100 Annual Deductible
$7,050 $14,100 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 		$479.13
$543.81
$612.33
$855.73
$1,300.36 		$845.66
$910.34
$978.86
$1,222.26 		$1,212.19
$1,276.87
$1,345.39
$1,588.79 		$1,578.72
$1,643.40
$1,711.92
$1,955.32 		$366.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.26
$1,087.62
$1,224.66
$1,711.46
$2,600.72 		$1,324.79
$1,454.15
$1,591.19
$2,077.99 		$1,691.32
$1,820.68
$1,957.72
$2,444.52 		$2,057.85
$2,187.21
$2,324.25
$2,811.05 		$366.53
Toc - Plan #9 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
$5,900 $11,800 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 		$684.20
$776.57
$874.41
$1,221.98
$1,856.92 		$1,207.61
$1,299.98
$1,397.82
$1,745.39 		$1,731.02
$1,823.39
$1,921.23
$2,268.80 		$2,254.43
$2,346.80
$2,444.64
$2,792.21 		$523.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,368.40
$1,553.14
$1,748.82
$2,443.96
$3,713.84 		$1,891.81
$2,076.55
$2,272.23
$2,967.37 		$2,415.22
$2,599.96
$2,795.64
$3,490.78 		$2,938.63
$3,123.37
$3,319.05
$4,014.19 		$523.41
Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2139 ($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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$515.28
$584.84
$658.53
$920.29
$1,398.47 		$909.47
$979.03
$1,052.72
$1,314.48 		$1,303.66
$1,373.22
$1,446.91
$1,708.67 		$1,697.85
$1,767.41
$1,841.10
$2,102.86 		$394.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,030.56
$1,169.68
$1,317.06
$1,840.58
$2,796.94 		$1,424.75
$1,563.87
$1,711.25
$2,234.77 		$1,818.94
$1,958.06
$2,105.44
$2,628.96 		$2,213.13
$2,352.25
$2,499.63
$3,023.15 		$394.19
Toc - Plan #11 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$483.01
$548.22
$617.29
$862.66
$1,310.89 		$852.51
$917.72
$986.79
$1,232.16 		$1,222.01
$1,287.22
$1,356.29
$1,601.66 		$1,591.51
$1,656.72
$1,725.79
$1,971.16 		$369.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$966.02
$1,096.44
$1,234.58
$1,725.32
$2,621.78 		$1,335.52
$1,465.94
$1,604.08
$2,094.82 		$1,705.02
$1,835.44
$1,973.58
$2,464.32 		$2,074.52
$2,204.94
$2,343.08
$2,833.82 		$369.50
Toc - Plan #12 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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$607.39
$689.39
$776.24
$1,084.80
$1,648.46 		$1,072.04
$1,154.04
$1,240.89
$1,549.45 		$1,536.69
$1,618.69
$1,705.54
$2,014.10 		$2,001.34
$2,083.34
$2,170.19
$2,478.75 		$464.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,214.78
$1,378.78
$1,552.48
$2,169.60
$3,296.92 		$1,679.43
$1,843.43
$2,017.13
$2,634.25 		$2,144.08
$2,308.08
$2,481.78
$3,098.90 		$2,608.73
$2,772.73
$2,946.43
$3,563.55 		$464.65
Toc - Plan #13 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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$667.04
$757.09
$852.48
$1,191.33
$1,810.35 		$1,177.33
$1,267.38
$1,362.77
$1,701.62 		$1,687.62
$1,777.67
$1,873.06
$2,211.91 		$2,197.91
$2,287.96
$2,383.35
$2,722.20 		$510.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,334.08
$1,514.18
$1,704.96
$2,382.66
$3,620.70 		$1,844.37
$2,024.47
$2,215.25
$2,892.95 		$2,354.66
$2,534.76
$2,725.54
$3,403.24 		$2,864.95
$3,045.05
$3,235.83
$3,913.53 		$510.29
Toc - Plan #14 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
$3,200 $6,400 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 		$847.28
$961.66
$1,082.82
$1,513.24
$2,299.52 		$1,495.45
$1,609.83
$1,730.99
$2,161.41 		$2,143.62
$2,258.00
$2,379.16
$2,809.58 		$2,791.79
$2,906.17
$3,027.33
$3,457.75 		$648.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,694.56
$1,923.32
$2,165.64
$3,026.48
$4,599.04 		$2,342.73
$2,571.49
$2,813.81
$3,674.65 		$2,990.90
$3,219.66
$3,461.98
$4,322.82 		$3,639.07
$3,867.83
$4,110.15
$4,970.99 		$648.17
Toc - Plan #15 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-03 ($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
$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 		$917.52
$1,041.39
$1,172.59
$1,638.69
$2,490.15 		$1,619.42
$1,743.29
$1,874.49
$2,340.59 		$2,321.32
$2,445.19
$2,576.39
$3,042.49 		$3,023.22
$3,147.09
$3,278.29
$3,744.39 		$701.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,835.04
$2,082.78
$2,345.18
$3,277.38
$4,980.30 		$2,536.94
$2,784.68
$3,047.08
$3,979.28 		$3,238.84
$3,486.58
$3,748.98
$4,681.18 		$3,940.74
$4,188.48
$4,450.88
$5,383.08 		$701.90
Toc - Plan #16 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-04 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$655.79
$744.32
$838.10
$1,171.24
$1,779.81 		$1,157.47
$1,246.00
$1,339.78
$1,672.92 		$1,659.15
$1,747.68
$1,841.46
$2,174.60 		$2,160.83
$2,249.36
$2,343.14
$2,676.28 		$501.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,311.58
$1,488.64
$1,676.20
$2,342.48
$3,559.62 		$1,813.26
$1,990.32
$2,177.88
$2,844.16 		$2,314.94
$2,492.00
$2,679.56
$3,345.84 		$2,816.62
$2,993.68
$3,181.24
$3,847.52 		$501.68
Toc - Plan #17 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-05 ($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 		$1,238.03
$1,405.16
$1,582.20
$2,211.12
$3,360.01 		$2,185.12
$2,352.25
$2,529.29
$3,158.21 		$3,132.21
$3,299.34
$3,476.38
$4,105.30 		$4,079.30
$4,246.43
$4,423.47
$5,052.39 		$947.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,476.06
$2,810.32
$3,164.40
$4,422.24
$6,720.02 		$3,423.15
$3,757.41
$4,111.49
$5,369.33 		$4,370.24
$4,704.50
$5,058.58
$6,316.42 		$5,317.33
$5,651.59
$6,005.67
$7,263.51 		$947.09
Toc - Plan #18 Florida Blue (BlueCross BlueShield FL)
Bronze

(PPO) BlueOptions Bronze 24J01-06 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$613.55
$696.38
$784.12
$1,095.80
$1,665.17 		$1,082.92
$1,165.75
$1,253.49
$1,565.17 		$1,552.29
$1,635.12
$1,722.86
$2,034.54 		$2,021.66
$2,104.49
$2,192.23
$2,503.91 		$469.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,227.10
$1,392.76
$1,568.24
$2,191.60
$3,330.34 		$1,696.47
$1,862.13
$2,037.61
$2,660.97 		$2,165.84
$2,331.50
$2,506.98
$3,130.34 		$2,635.21
$2,800.87
$2,976.35
$3,599.71 		$469.37
Toc - Plan #19 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-07 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$981.49
$1,113.99
$1,254.34
$1,752.94
$2,663.76 		$1,732.33
$1,864.83
$2,005.18
$2,503.78 		$2,483.17
$2,615.67
$2,756.02
$3,254.62 		$3,234.01
$3,366.51
$3,506.86
$4,005.46 		$750.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,962.98
$2,227.98
$2,508.68
$3,505.88
$5,327.52 		$2,713.82
$2,978.82
$3,259.52
$4,256.72 		$3,464.66
$3,729.66
$4,010.36
$5,007.56 		$4,215.50
$4,480.50
$4,761.20
$5,758.40 		$750.84
Toc - Plan #20 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-08 ($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 		$1,287.68
$1,461.52
$1,645.66
$2,299.80
$3,494.76 		$2,272.76
$2,446.60
$2,630.74
$3,284.88 		$3,257.84
$3,431.68
$3,615.82
$4,269.96 		$4,242.92
$4,416.76
$4,600.90
$5,255.04 		$985.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,575.36
$2,923.04
$3,291.32
$4,599.60
$6,989.52 		$3,560.44
$3,908.12
$4,276.40
$5,584.68 		$4,545.52
$4,893.20
$5,261.48
$6,569.76 		$5,530.60
$5,878.28
$6,246.56
$7,554.84 		$985.08
Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-09 ($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
$6,250 $12,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$1,056.56
$1,199.20
$1,350.28
$1,887.02
$2,867.50 		$1,864.83
$2,007.47
$2,158.55
$2,695.29 		$2,673.10
$2,815.74
$2,966.82
$3,503.56 		$3,481.37
$3,624.01
$3,775.09
$4,311.83 		$808.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,113.12
$2,398.40
$2,700.56
$3,774.04
$5,735.00 		$2,921.39
$3,206.67
$3,508.83
$4,582.31 		$3,729.66
$4,014.94
$4,317.10
$5,390.58 		$4,537.93
$4,823.21
$5,125.37
$6,198.85 		$808.27
Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze (HSA) 24J01-10 (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
$7,050 $14,100 Annual Deductible
$7,050 $14,100 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 		$637.89
$724.01
$815.22
$1,139.27
$1,731.23 		$1,125.88
$1,212.00
$1,303.21
$1,627.26 		$1,613.87
$1,699.99
$1,791.20
$2,115.25 		$2,101.86
$2,187.98
$2,279.19
$2,603.24 		$487.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,275.78
$1,448.02
$1,630.44
$2,278.54
$3,462.46 		$1,763.77
$1,936.01
$2,118.43
$2,766.53 		$2,251.76
$2,424.00
$2,606.42
$3,254.52 		$2,739.75
$2,911.99
$3,094.41
$3,742.51 		$487.99
Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-12 ($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
$5,900 $11,800 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 		$1,025.33
$1,163.75
$1,310.37
$1,831.24
$2,782.75 		$1,809.71
$1,948.13
$2,094.75
$2,615.62 		$2,594.09
$2,732.51
$2,879.13
$3,400.00 		$3,378.47
$3,516.89
$3,663.51
$4,184.38 		$784.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,050.66
$2,327.50
$2,620.74
$3,662.48
$5,565.50 		$2,835.04
$3,111.88
$3,405.12
$4,446.86 		$3,619.42
$3,896.26
$4,189.50
$5,231.24 		$4,403.80
$4,680.64
$4,973.88
$6,015.62 		$784.38
Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-17 ($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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$686.66
$779.36
$877.55
$1,226.37
$1,863.60 		$1,211.95
$1,304.65
$1,402.84
$1,751.66 		$1,737.24
$1,829.94
$1,928.13
$2,276.95 		$2,262.53
$2,355.23
$2,453.42
$2,802.24 		$525.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,373.32
$1,558.72
$1,755.10
$2,452.74
$3,727.20 		$1,898.61
$2,084.01
$2,280.39
$2,978.03 		$2,423.90
$2,609.30
$2,805.68
$3,503.32 		$2,949.19
$3,134.59
$3,330.97
$4,028.61 		$525.29
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-18S (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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$642.81
$729.59
$821.51
$1,148.06
$1,744.59 		$1,134.56
$1,221.34
$1,313.26
$1,639.81 		$1,626.31
$1,713.09
$1,805.01
$2,131.56 		$2,118.06
$2,204.84
$2,296.76
$2,623.31 		$491.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,285.62
$1,459.18
$1,643.02
$2,296.12
$3,489.18 		$1,777.37
$1,950.93
$2,134.77
$2,787.87 		$2,269.12
$2,442.68
$2,626.52
$3,279.62 		$2,760.87
$2,934.43
$3,118.27
$3,771.37 		$491.75
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-19S ($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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$953.57
$1,082.30
$1,218.66
$1,703.08
$2,587.99 		$1,683.05
$1,811.78
$1,948.14
$2,432.56 		$2,412.53
$2,541.26
$2,677.62
$3,162.04 		$3,142.01
$3,270.74
$3,407.10
$3,891.52 		$729.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,907.14
$2,164.60
$2,437.32
$3,406.16
$5,175.98 		$2,636.62
$2,894.08
$3,166.80
$4,135.64 		$3,366.10
$3,623.56
$3,896.28
$4,865.12 		$4,095.58
$4,353.04
$4,625.76
$5,594.60 		$729.48
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-20S ($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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$1,000.01
$1,135.01
$1,278.01
$1,786.02
$2,714.03 		$1,765.02
$1,900.02
$2,043.02
$2,551.03 		$2,530.03
$2,665.03
$2,808.03
$3,316.04 		$3,295.04
$3,430.04
$3,573.04
$4,081.05 		$765.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,000.02
$2,270.02
$2,556.02
$3,572.04
$5,428.06 		$2,765.03
$3,035.03
$3,321.03
$4,337.05 		$3,530.04
$3,800.04
$4,086.04
$5,102.06 		$4,295.05
$4,565.05
$4,851.05
$5,867.07 		$765.01
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-21S ($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
$3,200 $6,400 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 		$1,279.63
$1,452.38
$1,635.37
$2,285.42
$3,472.92 		$2,258.55
$2,431.30
$2,614.29
$3,264.34 		$3,237.47
$3,410.22
$3,593.21
$4,243.26 		$4,216.39
$4,389.14
$4,572.13
$5,222.18 		$978.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$2,559.26
$2,904.76
$3,270.74
$4,570.84
$6,945.84 		$3,538.18
$3,883.68
$4,249.66
$5,549.76 		$4,517.10
$4,862.60
$5,228.58
$6,528.68 		$5,496.02
$5,841.52
$6,207.50
$7,507.60 		$978.92

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #29 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$385.74
$437.81
$492.97
$688.93
$1,046.89 		$680.83
$732.90
$788.06
$984.02 		$975.92
$1,027.99
$1,083.15
$1,279.11 		$1,271.01
$1,323.08
$1,378.24
$1,574.20 		$295.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.48
$875.62
$985.94
$1,377.86
$2,093.78 		$1,066.57
$1,170.71
$1,281.03
$1,672.95 		$1,361.66
$1,465.80
$1,576.12
$1,968.04 		$1,656.75
$1,760.89
$1,871.21
$2,263.13 		$295.09
Toc - Plan #30 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$308.03
$349.61
$393.66
$550.14
$835.98 		$543.67
$585.25
$629.30
$785.78 		$779.31
$820.89
$864.94
$1,021.42 		$1,014.95
$1,056.53
$1,100.58
$1,257.06 		$235.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.06
$699.22
$787.32
$1,100.28
$1,671.96 		$851.70
$934.86
$1,022.96
$1,335.92 		$1,087.34
$1,170.50
$1,258.60
$1,571.56 		$1,322.98
$1,406.14
$1,494.24
$1,807.20 		$235.64
Toc - Plan #31 Aetna CVS Health
Silver

(HMO) Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$385.49
$437.53
$492.65
$688.48
$1,046.20 		$680.39
$732.43
$787.55
$983.38 		$975.29
$1,027.33
$1,082.45
$1,278.28 		$1,270.19
$1,322.23
$1,377.35
$1,573.18 		$294.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.98
$875.06
$985.30
$1,376.96
$2,092.40 		$1,065.88
$1,169.96
$1,280.20
$1,671.86 		$1,360.78
$1,464.86
$1,575.10
$1,966.76 		$1,655.68
$1,759.76
$1,870.00
$2,261.66 		$294.90
Toc - Plan #32 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.28
$467.94
$526.89
$736.33
$1,118.92 		$727.68
$783.34
$842.29
$1,051.73 		$1,043.08
$1,098.74
$1,157.69
$1,367.13 		$1,358.48
$1,414.14
$1,473.09
$1,682.53 		$315.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.56
$935.88
$1,053.78
$1,472.66
$2,237.84 		$1,139.96
$1,251.28
$1,369.18
$1,788.06 		$1,455.36
$1,566.68
$1,684.58
$2,103.46 		$1,770.76
$1,882.08
$1,999.98
$2,418.86 		$315.40
Toc - Plan #33 Aetna CVS Health
Silver

(HMO) Silver 6: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.61
$446.75
$503.04
$702.99
$1,068.26 		$694.73
$747.87
$804.16
$1,004.11 		$995.85
$1,048.99
$1,105.28
$1,305.23 		$1,296.97
$1,350.11
$1,406.40
$1,606.35 		$301.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.22
$893.50
$1,006.08
$1,405.98
$2,136.52 		$1,088.34
$1,194.62
$1,307.20
$1,707.10 		$1,389.46
$1,495.74
$1,608.32
$2,008.22 		$1,690.58
$1,796.86
$1,909.44
$2,309.34 		$301.12
Toc - Plan #34 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$339.22
$385.02
$433.53
$605.85
$920.64 		$598.73
$644.53
$693.04
$865.36 		$858.24
$904.04
$952.55
$1,124.87 		$1,117.75
$1,163.55
$1,212.06
$1,384.38 		$259.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.44
$770.04
$867.06
$1,211.70
$1,841.28 		$937.95
$1,029.55
$1,126.57
$1,471.21 		$1,197.46
$1,289.06
$1,386.08
$1,730.72 		$1,456.97
$1,548.57
$1,645.59
$1,990.23 		$259.51
Toc - Plan #35 Aetna CVS Health
Gold

(HMO) Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.62
$466.06
$524.78
$733.37
$1,114.43 		$724.75
$780.19
$838.91
$1,047.50 		$1,038.88
$1,094.32
$1,153.04
$1,361.63 		$1,353.01
$1,408.45
$1,467.17
$1,675.76 		$314.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.24
$932.12
$1,049.56
$1,466.74
$2,228.86 		$1,135.37
$1,246.25
$1,363.69
$1,780.87 		$1,449.50
$1,560.38
$1,677.82
$2,095.00 		$1,763.63
$1,874.51
$1,991.95
$2,409.13 		$314.13
Toc - Plan #36 Aetna CVS Health
Gold

(HMO) Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$416.10
$472.27
$531.77
$743.14
$1,129.27 		$734.41
$790.58
$850.08
$1,061.45 		$1,052.72
$1,108.89
$1,168.39
$1,379.76 		$1,371.03
$1,427.20
$1,486.70
$1,698.07 		$318.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.20
$944.54
$1,063.54
$1,486.28
$2,258.54 		$1,150.51
$1,262.85
$1,381.85
$1,804.59 		$1,468.82
$1,581.16
$1,700.16
$2,122.90 		$1,787.13
$1,899.47
$2,018.47
$2,441.21 		$318.31
Toc - Plan #37 Aetna CVS Health
Silver

(HMO) Silver 7: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.80
$446.96
$503.27
$703.32
$1,068.76 		$695.06
$748.22
$804.53
$1,004.58 		$996.32
$1,049.48
$1,105.79
$1,305.84 		$1,297.58
$1,350.74
$1,407.05
$1,607.10 		$301.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.60
$893.92
$1,006.54
$1,406.64
$2,137.52 		$1,088.86
$1,195.18
$1,307.80
$1,707.90 		$1,390.12
$1,496.44
$1,609.06
$2,009.16 		$1,691.38
$1,797.70
$1,910.32
$2,310.42 		$301.26

ADVERTISEMENT

AvMed

Local: 1-800-477-8768 | Toll Free: 

Toc - Plan #38 AvMed
Gold

(HMO) AvMed Entrust Gold 125 (2024)

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 		$517.85
$587.76
$661.81
$924.88
$1,405.44 		$914.00
$983.91
$1,057.96
$1,321.03 		$1,310.15
$1,380.06
$1,454.11
$1,717.18 		$1,706.30
$1,776.21
$1,850.26
$2,113.33 		$396.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,035.70
$1,175.52
$1,323.62
$1,849.76
$2,810.88 		$1,431.85
$1,571.67
$1,719.77
$2,245.91 		$1,828.00
$1,967.82
$2,115.92
$2,642.06 		$2,224.15
$2,363.97
$2,512.07
$3,038.21 		$396.15
Toc - Plan #39 AvMed
Silver

(HMO) AvMed Entrust Silver 300 (2024)

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 		$497.48
$564.64
$635.77
$888.49
$1,350.15 		$878.05
$945.21
$1,016.34
$1,269.06 		$1,258.62
$1,325.78
$1,396.91
$1,649.63 		$1,639.19
$1,706.35
$1,777.48
$2,030.20 		$380.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$994.96
$1,129.28
$1,271.54
$1,776.98
$2,700.30 		$1,375.53
$1,509.85
$1,652.11
$2,157.55 		$1,756.10
$1,890.42
$2,032.68
$2,538.12 		$2,136.67
$2,270.99
$2,413.25
$2,918.69 		$380.57
Toc - Plan #40 AvMed
Silver

(HMO) AvMed Entrust Silver 350 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$480.31
$545.16
$613.84
$857.84
$1,303.57 		$847.75
$912.60
$981.28
$1,225.28 		$1,215.19
$1,280.04
$1,348.72
$1,592.72 		$1,582.63
$1,647.48
$1,716.16
$1,960.16 		$367.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$960.62
$1,090.32
$1,227.68
$1,715.68
$2,607.14 		$1,328.06
$1,457.76
$1,595.12
$2,083.12 		$1,695.50
$1,825.20
$1,962.56
$2,450.56 		$2,062.94
$2,192.64
$2,330.00
$2,818.00 		$367.44
Toc - Plan #41 AvMed
Silver

(HMO) AvMed Entrust Silver 500 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$475.32
$539.49
$607.46
$848.93
$1,290.03 		$838.94
$903.11
$971.08
$1,212.55 		$1,202.56
$1,266.73
$1,334.70
$1,576.17 		$1,566.18
$1,630.35
$1,698.32
$1,939.79 		$363.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$950.64
$1,078.98
$1,214.92
$1,697.86
$2,580.06 		$1,314.26
$1,442.60
$1,578.54
$2,061.48 		$1,677.88
$1,806.22
$1,942.16
$2,425.10 		$2,041.50
$2,169.84
$2,305.78
$2,788.72 		$363.62
Toc - Plan #42 AvMed
Silver

(HMO) AvMed Entrust Silver 550 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$470.89
$534.46
$601.80
$841.01
$1,278.00 		$831.12
$894.69
$962.03
$1,201.24 		$1,191.35
$1,254.92
$1,322.26
$1,561.47 		$1,551.58
$1,615.15
$1,682.49
$1,921.70 		$360.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$941.78
$1,068.92
$1,203.60
$1,682.02
$2,556.00 		$1,302.01
$1,429.15
$1,563.83
$2,042.25 		$1,662.24
$1,789.38
$1,924.06
$2,402.48 		$2,022.47
$2,149.61
$2,284.29
$2,762.71 		$360.23
Toc - Plan #43 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 600 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.39
$446.49
$502.75
$702.59
$1,067.65 		$694.33
$747.43
$803.69
$1,003.53 		$995.27
$1,048.37
$1,104.63
$1,304.47 		$1,296.21
$1,349.31
$1,405.57
$1,605.41 		$300.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.78
$892.98
$1,005.50
$1,405.18
$2,135.30 		$1,087.72
$1,193.92
$1,306.44
$1,706.12 		$1,388.66
$1,494.86
$1,607.38
$2,007.06 		$1,689.60
$1,795.80
$1,908.32
$2,308.00 		$300.94
Toc - Plan #44 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 650 (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.25
$420.23
$473.18
$661.27
$1,004.86 		$653.49
$703.47
$756.42
$944.51 		$936.73
$986.71
$1,039.66
$1,227.75 		$1,219.97
$1,269.95
$1,322.90
$1,510.99 		$283.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.50
$840.46
$946.36
$1,322.54
$2,009.72 		$1,023.74
$1,123.70
$1,229.60
$1,605.78 		$1,306.98
$1,406.94
$1,512.84
$1,889.02 		$1,590.22
$1,690.18
$1,796.08
$2,172.26 		$283.24
Toc - Plan #45 AvMed
Gold

(HMO) AvMed Entrust Gold Standard (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$540.83
$613.84
$691.18
$965.92
$1,467.80 		$954.56
$1,027.57
$1,104.91
$1,379.65 		$1,368.29
$1,441.30
$1,518.64
$1,793.38 		$1,782.02
$1,855.03
$1,932.37
$2,207.11 		$413.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,081.66
$1,227.68
$1,382.36
$1,931.84
$2,935.60 		$1,495.39
$1,641.41
$1,796.09
$2,345.57 		$1,909.12
$2,055.14
$2,209.82
$2,759.30 		$2,322.85
$2,468.87
$2,623.55
$3,173.03 		$413.73
Toc - Plan #46 AvMed
Silver

(HMO) AvMed Entrust Silver Standard (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$461.03
$523.27
$589.20
$823.41
$1,251.25 		$813.72
$875.96
$941.89
$1,176.10 		$1,166.41
$1,228.65
$1,294.58
$1,528.79 		$1,519.10
$1,581.34
$1,647.27
$1,881.48 		$352.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.06
$1,046.54
$1,178.40
$1,646.82
$2,502.50 		$1,274.75
$1,399.23
$1,531.09
$1,999.51 		$1,627.44
$1,751.92
$1,883.78
$2,352.20 		$1,980.13
$2,104.61
$2,236.47
$2,704.89 		$352.69
Toc - Plan #47 AvMed
Expanded Bronze

(HMO) AvMed Entrust Expanded Bronze Standard (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$377.94
$428.96
$483.01
$675.00
$1,025.73 		$667.07
$718.09
$772.14
$964.13 		$956.20
$1,007.22
$1,061.27
$1,253.26 		$1,245.33
$1,296.35
$1,350.40
$1,542.39 		$289.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.88
$857.92
$966.02
$1,350.00
$2,051.46 		$1,045.01
$1,147.05
$1,255.15
$1,639.13 		$1,334.14
$1,436.18
$1,544.28
$1,928.26 		$1,623.27
$1,725.31
$1,833.41
$2,217.39 		$289.13
Toc - Plan #48 AvMed
Gold

(HMO) AvMed Entrust Gold 125 Dental+Vision (2024)

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 		$522.82
$593.40
$668.16
$933.75
$1,418.93 		$922.78
$993.36
$1,068.12
$1,333.71 		$1,322.74
$1,393.32
$1,468.08
$1,733.67 		$1,722.70
$1,793.28
$1,868.04
$2,133.63 		$399.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,045.64
$1,186.80
$1,336.32
$1,867.50
$2,837.86 		$1,445.60
$1,586.76
$1,736.28
$2,267.46 		$1,845.56
$1,986.72
$2,136.24
$2,667.42 		$2,245.52
$2,386.68
$2,536.20
$3,067.38 		$399.96
Toc - Plan #49 AvMed
Silver

(HMO) AvMed Entrust Silver 300 Dental+Vision (2024)

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 		$502.45
$570.28
$642.13
$897.37
$1,363.64 		$886.82
$954.65
$1,026.50
$1,281.74 		$1,271.19
$1,339.02
$1,410.87
$1,666.11 		$1,655.56
$1,723.39
$1,795.24
$2,050.48 		$384.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,004.90
$1,140.56
$1,284.26
$1,794.74
$2,727.28 		$1,389.27
$1,524.93
$1,668.63
$2,179.11 		$1,773.64
$1,909.30
$2,053.00
$2,563.48 		$2,158.01
$2,293.67
$2,437.37
$2,947.85 		$384.37
Toc - Plan #50 AvMed
Silver

(HMO) AvMed Entrust Silver 350 Dental+Vision (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$485.28
$550.80
$620.19
$866.71
$1,317.06 		$856.52
$922.04
$991.43
$1,237.95 		$1,227.76
$1,293.28
$1,362.67
$1,609.19 		$1,599.00
$1,664.52
$1,733.91
$1,980.43 		$371.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$970.56
$1,101.60
$1,240.38
$1,733.42
$2,634.12 		$1,341.80
$1,472.84
$1,611.62
$2,104.66 		$1,713.04
$1,844.08
$1,982.86
$2,475.90 		$2,084.28
$2,215.32
$2,354.10
$2,847.14 		$371.24
Toc - Plan #51 AvMed
Silver

(HMO) AvMed Entrust Silver 500 Dental+Vision (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$480.29
$545.13
$613.82
$857.80
$1,303.52 		$847.71
$912.55
$981.24
$1,225.22 		$1,215.13
$1,279.97
$1,348.66
$1,592.64 		$1,582.55
$1,647.39
$1,716.08
$1,960.06 		$367.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$960.58
$1,090.26
$1,227.64
$1,715.60
$2,607.04 		$1,328.00
$1,457.68
$1,595.06
$2,083.02 		$1,695.42
$1,825.10
$1,962.48
$2,450.44 		$2,062.84
$2,192.52
$2,329.90
$2,817.86 		$367.42
Toc - Plan #52 AvMed
Silver

(HMO) AvMed Entrust Silver 550 Dental+Vision (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$475.86
$540.10
$608.15
$849.89
$1,291.49 		$839.89
$904.13
$972.18
$1,213.92 		$1,203.92
$1,268.16
$1,336.21
$1,577.95 		$1,567.95
$1,632.19
$1,700.24
$1,941.98 		$364.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$951.72
$1,080.20
$1,216.30
$1,699.78
$2,582.98 		$1,315.75
$1,444.23
$1,580.33
$2,063.81 		$1,679.78
$1,808.26
$1,944.36
$2,427.84 		$2,043.81
$2,172.29
$2,308.39
$2,791.87 		$364.03
Toc - Plan #53 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 625 Dental+Vision (2024)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$472.42
$536.20
$603.76
$843.75
$1,282.16 		$833.82
$897.60
$965.16
$1,205.15 		$1,195.22
$1,259.00
$1,326.56
$1,566.55 		$1,556.62
$1,620.40
$1,687.96
$1,927.95 		$361.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$944.84
$1,072.40
$1,207.52
$1,687.50
$2,564.32 		$1,306.24
$1,433.80
$1,568.92
$2,048.90 		$1,667.64
$1,795.20
$1,930.32
$2,410.30 		$2,029.04
$2,156.60
$2,291.72
$2,771.70 		$361.40

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #54 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 		$426.09
$483.60
$544.53
$760.98
$1,156.39 		$752.04
$809.55
$870.48
$1,086.93 		$1,077.99
$1,135.50
$1,196.43
$1,412.88 		$1,403.94
$1,461.45
$1,522.38
$1,738.83 		$325.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.18
$967.20
$1,089.06
$1,521.96
$2,312.78 		$1,178.13
$1,293.15
$1,415.01
$1,847.91 		$1,504.08
$1,619.10
$1,740.96
$2,173.86 		$1,830.03
$1,945.05
$2,066.91
$2,499.81 		$325.95
Toc - Plan #55 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
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$351.97
$399.48
$449.81
$628.61
$955.23 		$621.22
$668.73
$719.06
$897.86 		$890.47
$937.98
$988.31
$1,167.11 		$1,159.72
$1,207.23
$1,257.56
$1,436.36 		$269.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$703.94
$798.96
$899.62
$1,257.22
$1,910.46 		$973.19
$1,068.21
$1,168.87
$1,526.47 		$1,242.44
$1,337.46
$1,438.12
$1,795.72 		$1,511.69
$1,606.71
$1,707.37
$2,064.97 		$269.25
Toc - Plan #56 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 		$444.24
$504.21
$567.73
$793.40
$1,205.65 		$784.08
$844.05
$907.57
$1,133.24 		$1,123.92
$1,183.89
$1,247.41
$1,473.08 		$1,463.76
$1,523.73
$1,587.25
$1,812.92 		$339.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.48
$1,008.42
$1,135.46
$1,586.80
$2,411.30 		$1,228.32
$1,348.26
$1,475.30
$1,926.64 		$1,568.16
$1,688.10
$1,815.14
$2,266.48 		$1,908.00
$2,027.94
$2,154.98
$2,606.32 		$339.84
Toc - Plan #57 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$347.19
$394.05
$443.69
$620.06
$942.24 		$612.78
$659.64
$709.28
$885.65 		$878.37
$925.23
$974.87
$1,151.24 		$1,143.96
$1,190.82
$1,240.46
$1,416.83 		$265.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.38
$788.10
$887.38
$1,240.12
$1,884.48 		$959.97
$1,053.69
$1,152.97
$1,505.71 		$1,225.56
$1,319.28
$1,418.56
$1,771.30 		$1,491.15
$1,584.87
$1,684.15
$2,036.89 		$265.59
Toc - Plan #58 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
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$398.63
$452.43
$509.43
$711.93
$1,081.84 		$703.57
$757.37
$814.37
$1,016.87 		$1,008.51
$1,062.31
$1,119.31
$1,321.81 		$1,313.45
$1,367.25
$1,424.25
$1,626.75 		$304.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.26
$904.86
$1,018.86
$1,423.86
$2,163.68 		$1,102.20
$1,209.80
$1,323.80
$1,728.80 		$1,407.14
$1,514.74
$1,628.74
$2,033.74 		$1,712.08
$1,819.68
$1,933.68
$2,338.68 		$304.94
Toc - Plan #59 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 		$432.65
$491.04
$552.91
$772.69
$1,174.17 		$763.62
$822.01
$883.88
$1,103.66 		$1,094.59
$1,152.98
$1,214.85
$1,434.63 		$1,425.56
$1,483.95
$1,545.82
$1,765.60 		$330.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$865.30
$982.08
$1,105.82
$1,545.38
$2,348.34 		$1,196.27
$1,313.05
$1,436.79
$1,876.35 		$1,527.24
$1,644.02
$1,767.76
$2,207.32 		$1,858.21
$1,974.99
$2,098.73
$2,538.29 		$330.97
Toc - Plan #60 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
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$440.36
$499.80
$562.77
$786.47
$1,195.12 		$777.23
$836.67
$899.64
$1,123.34 		$1,114.10
$1,173.54
$1,236.51
$1,460.21 		$1,450.97
$1,510.41
$1,573.38
$1,797.08 		$336.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.72
$999.60
$1,125.54
$1,572.94
$2,390.24 		$1,217.59
$1,336.47
$1,462.41
$1,909.81 		$1,554.46
$1,673.34
$1,799.28
$2,246.68 		$1,891.33
$2,010.21
$2,136.15
$2,583.55 		$336.87
Toc - Plan #61 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 		$407.29
$462.27
$520.51
$727.41
$1,105.37 		$718.86
$773.84
$832.08
$1,038.98 		$1,030.43
$1,085.41
$1,143.65
$1,350.55 		$1,342.00
$1,396.98
$1,455.22
$1,662.12 		$311.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.58
$924.54
$1,041.02
$1,454.82
$2,210.74 		$1,126.15
$1,236.11
$1,352.59
$1,766.39 		$1,437.72
$1,547.68
$1,664.16
$2,077.96 		$1,749.29
$1,859.25
$1,975.73
$2,389.53 		$311.57
Toc - Plan #62 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
$5,500 $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 		$468.52
$531.76
$598.75
$836.76
$1,271.53 		$826.93
$890.17
$957.16
$1,195.17 		$1,185.34
$1,248.58
$1,315.57
$1,553.58 		$1,543.75
$1,606.99
$1,673.98
$1,911.99 		$358.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$937.04
$1,063.52
$1,197.50
$1,673.52
$2,543.06 		$1,295.45
$1,421.93
$1,555.91
$2,031.93 		$1,653.86
$1,780.34
$1,914.32
$2,390.34 		$2,012.27
$2,138.75
$2,272.73
$2,748.75 		$358.41
Toc - Plan #63 Ambetter from Sunshine Health
Expanded Bronze

(EPO) 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.46
$386.41
$435.10
$608.05
$923.99 		$600.91
$646.86
$695.55
$868.50 		$861.36
$907.31
$956.00
$1,128.95 		$1,121.81
$1,167.76
$1,216.45
$1,389.40 		$260.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.92
$772.82
$870.20
$1,216.10
$1,847.98 		$941.37
$1,033.27
$1,130.65
$1,476.55 		$1,201.82
$1,293.72
$1,391.10
$1,737.00 		$1,462.27
$1,554.17
$1,651.55
$1,997.45 		$260.45
Toc - Plan #64 Ambetter from Sunshine Health
Silver

(EPO) Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$431.18
$489.38
$551.03
$770.07
$1,170.19 		$761.02
$819.22
$880.87
$1,099.91 		$1,090.86
$1,149.06
$1,210.71
$1,429.75 		$1,420.70
$1,478.90
$1,540.55
$1,759.59 		$329.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.36
$978.76
$1,102.06
$1,540.14
$2,340.38 		$1,192.20
$1,308.60
$1,431.90
$1,869.98 		$1,522.04
$1,638.44
$1,761.74
$2,199.82 		$1,851.88
$1,968.28
$2,091.58
$2,529.66 		$329.84
Toc - Plan #65 Ambetter from Sunshine Health
Gold

(EPO) Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$404.84
$459.48
$517.37
$723.02
$1,098.70 		$714.53
$769.17
$827.06
$1,032.71 		$1,024.22
$1,078.86
$1,136.75
$1,342.40 		$1,333.91
$1,388.55
$1,446.44
$1,652.09 		$309.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.68
$918.96
$1,034.74
$1,446.04
$2,197.40 		$1,119.37
$1,228.65
$1,344.43
$1,755.73 		$1,429.06
$1,538.34
$1,654.12
$2,065.42 		$1,738.75
$1,848.03
$1,963.81
$2,375.11 		$309.69
Toc - Plan #66 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
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.09
$413.23
$465.29
$650.24
$988.11 		$642.61
$691.75
$743.81
$928.76 		$921.13
$970.27
$1,022.33
$1,207.28 		$1,199.65
$1,248.79
$1,300.85
$1,485.80 		$278.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.18
$826.46
$930.58
$1,300.48
$1,976.22 		$1,006.70
$1,104.98
$1,209.10
$1,579.00 		$1,285.22
$1,383.50
$1,487.62
$1,857.52 		$1,563.74
$1,662.02
$1,766.14
$2,136.04 		$278.52
Toc - Plan #67 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 		$459.53
$521.56
$587.27
$820.71
$1,247.15 		$811.07
$873.10
$938.81
$1,172.25 		$1,162.61
$1,224.64
$1,290.35
$1,523.79 		$1,514.15
$1,576.18
$1,641.89
$1,875.33 		$351.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$919.06
$1,043.12
$1,174.54
$1,641.42
$2,494.30 		$1,270.60
$1,394.66
$1,526.08
$1,992.96 		$1,622.14
$1,746.20
$1,877.62
$2,344.50 		$1,973.68
$2,097.74
$2,229.16
$2,696.04 		$351.54
Toc - Plan #68 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 		$440.76
$500.25
$563.27
$787.17
$1,196.18 		$777.93
$837.42
$900.44
$1,124.34 		$1,115.10
$1,174.59
$1,237.61
$1,461.51 		$1,452.27
$1,511.76
$1,574.78
$1,798.68 		$337.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.52
$1,000.50
$1,126.54
$1,574.34
$2,392.36 		$1,218.69
$1,337.67
$1,463.71
$1,911.51 		$1,555.86
$1,674.84
$1,800.88
$2,248.68 		$1,893.03
$2,012.01
$2,138.05
$2,585.85 		$337.17
Toc - Plan #69 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 		$447.54
$507.94
$571.94
$799.28
$1,214.58 		$789.90
$850.30
$914.30
$1,141.64 		$1,132.26
$1,192.66
$1,256.66
$1,484.00 		$1,474.62
$1,535.02
$1,599.02
$1,826.36 		$342.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.08
$1,015.88
$1,143.88
$1,598.56
$2,429.16 		$1,237.44
$1,358.24
$1,486.24
$1,940.92 		$1,579.80
$1,700.60
$1,828.60
$2,283.28 		$1,922.16
$2,042.96
$2,170.96
$2,625.64 		$342.36
Toc - Plan #70 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
$5,500 $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 		$484.64
$550.06
$619.36
$865.56
$1,315.30 		$855.38
$920.80
$990.10
$1,236.30 		$1,226.12
$1,291.54
$1,360.84
$1,607.04 		$1,596.86
$1,662.28
$1,731.58
$1,977.78 		$370.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969.28
$1,100.12
$1,238.72
$1,731.12
$2,630.60 		$1,340.02
$1,470.86
$1,609.46
$2,101.86 		$1,710.76
$1,841.60
$1,980.20
$2,472.60 		$2,081.50
$2,212.34
$2,350.94
$2,843.34 		$370.74
Toc - Plan #71 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Standard Expanded Bronze + Vision + Adult Dental

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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.18
$399.71
$450.07
$628.97
$955.79 		$621.59
$669.12
$719.48
$898.38 		$891.00
$938.53
$988.89
$1,167.79 		$1,160.41
$1,207.94
$1,258.30
$1,437.20 		$269.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.36
$799.42
$900.14
$1,257.94
$1,911.58 		$973.77
$1,068.83
$1,169.55
$1,527.35 		$1,243.18
$1,338.24
$1,438.96
$1,796.76 		$1,512.59
$1,607.65
$1,708.37
$2,066.17 		$269.41
Toc - Plan #72 Ambetter from Sunshine Health
Silver

(EPO) Standard Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$446.02
$506.22
$570.00
$796.57
$1,210.47 		$787.22
$847.42
$911.20
$1,137.77 		$1,128.42
$1,188.62
$1,252.40
$1,478.97 		$1,469.62
$1,529.82
$1,593.60
$1,820.17 		$341.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.04
$1,012.44
$1,140.00
$1,593.14
$2,420.94 		$1,233.24
$1,353.64
$1,481.20
$1,934.34 		$1,574.44
$1,694.84
$1,822.40
$2,275.54 		$1,915.64
$2,036.04
$2,163.60
$2,616.74 		$341.20
Toc - Plan #73 Ambetter from Sunshine Health
Gold

(EPO) Standard Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.77
$475.29
$535.17
$747.90
$1,136.51 		$739.12
$795.64
$855.52
$1,068.25 		$1,059.47
$1,115.99
$1,175.87
$1,388.60 		$1,379.82
$1,436.34
$1,496.22
$1,708.95 		$320.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.54
$950.58
$1,070.34
$1,495.80
$2,273.02 		$1,157.89
$1,270.93
$1,390.69
$1,816.15 		$1,478.24
$1,591.28
$1,711.04
$2,136.50 		$1,798.59
$1,911.63
$2,031.39
$2,456.85 		$320.35
Toc - Plan #74 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.14
$407.61
$458.96
$641.40
$974.67 		$633.87
$682.34
$733.69
$916.13 		$908.60
$957.07
$1,008.42
$1,190.86 		$1,183.33
$1,231.80
$1,283.15
$1,465.59 		$274.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.28
$815.22
$917.92
$1,282.80
$1,949.34 		$993.01
$1,089.95
$1,192.65
$1,557.53 		$1,267.74
$1,364.68
$1,467.38
$1,832.26 		$1,542.47
$1,639.41
$1,742.11
$2,106.99 		$274.73
Toc - Plan #75 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
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.35
$468.00
$526.96
$736.43
$1,119.08 		$727.79
$783.44
$842.40
$1,051.87 		$1,043.23
$1,098.88
$1,157.84
$1,367.31 		$1,358.67
$1,414.32
$1,473.28
$1,682.75 		$315.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.70
$936.00
$1,053.92
$1,472.86
$2,238.16 		$1,140.14
$1,251.44
$1,369.36
$1,788.30 		$1,455.58
$1,566.88
$1,684.80
$2,103.74 		$1,771.02
$1,882.32
$2,000.24
$2,419.18 		$315.44
Toc - Plan #76 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
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$455.52
$517.00
$582.14
$813.54
$1,236.25 		$803.98
$865.46
$930.60
$1,162.00 		$1,152.44
$1,213.92
$1,279.06
$1,510.46 		$1,500.90
$1,562.38
$1,627.52
$1,858.92 		$348.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.04
$1,034.00
$1,164.28
$1,627.08
$2,472.50 		$1,259.50
$1,382.46
$1,512.74
$1,975.54 		$1,607.96
$1,730.92
$1,861.20
$2,324.00 		$1,956.42
$2,079.38
$2,209.66
$2,672.46 		$348.46
Toc - Plan #77 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 		$421.31
$478.18
$538.42
$752.44
$1,143.41 		$743.60
$800.47
$860.71
$1,074.73 		$1,065.89
$1,122.76
$1,183.00
$1,397.02 		$1,388.18
$1,445.05
$1,505.29
$1,719.31 		$322.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.62
$956.36
$1,076.84
$1,504.88
$2,286.82 		$1,164.91
$1,278.65
$1,399.13
$1,827.17 		$1,487.20
$1,600.94
$1,721.42
$2,149.46 		$1,809.49
$1,923.23
$2,043.71
$2,471.75 		$322.29

ADVERTISEMENT

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 #78 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 then $45 / 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$357.39
$405.64
$456.74
$638.30
$969.96 		$630.79
$679.04
$730.14
$911.70 		$904.19
$952.44
$1,003.54
$1,185.10 		$1,177.59
$1,225.84
$1,276.94
$1,458.50 		$273.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.78
$811.28
$913.48
$1,276.60
$1,939.92 		$988.18
$1,084.68
$1,186.88
$1,550.00 		$1,261.58
$1,358.08
$1,460.28
$1,823.40 		$1,534.98
$1,631.48
$1,733.68
$2,096.80 		$273.40
Toc - Plan #79 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 		$484.34
$549.73
$618.99
$865.03
$1,314.50 		$854.86
$920.25
$989.51
$1,235.55 		$1,225.38
$1,290.77
$1,360.03
$1,606.07 		$1,595.90
$1,661.29
$1,730.55
$1,976.59 		$370.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$968.68
$1,099.46
$1,237.98
$1,730.06
$2,629.00 		$1,339.20
$1,469.98
$1,608.50
$2,100.58 		$1,709.72
$1,840.50
$1,979.02
$2,471.10 		$2,080.24
$2,211.02
$2,349.54
$2,841.62 		$370.52
Toc - Plan #80 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2017 ($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
$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 		$414.26
$470.19
$529.42
$739.87
$1,124.30 		$731.17
$787.10
$846.33
$1,056.78 		$1,048.08
$1,104.01
$1,163.24
$1,373.69 		$1,364.99
$1,420.92
$1,480.15
$1,690.60 		$316.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.52
$940.38
$1,058.84
$1,479.74
$2,248.60 		$1,145.43
$1,257.29
$1,375.75
$1,796.65 		$1,462.34
$1,574.20
$1,692.66
$2,113.56 		$1,779.25
$1,891.11
$2,009.57
$2,430.47 		$316.91
Toc - Plan #81 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Virtual Visits / $35 PCP Visit / $75 Specialist Visits / $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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.15
$426.93
$480.72
$671.80
$1,020.87 		$663.90
$714.68
$768.47
$959.55 		$951.65
$1,002.43
$1,056.22
$1,247.30 		$1,239.40
$1,290.18
$1,343.97
$1,535.05 		$287.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.30
$853.86
$961.44
$1,343.60
$2,041.74 		$1,040.05
$1,141.61
$1,249.19
$1,631.35 		$1,327.80
$1,429.36
$1,536.94
$1,919.10 		$1,615.55
$1,717.11
$1,824.69
$2,206.85 		$287.75
Toc - Plan #82 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237 ($0 Virtual Visits / $60 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$392.94
$445.99
$502.18
$701.79
$1,066.44 		$693.54
$746.59
$802.78
$1,002.39 		$994.14
$1,047.19
$1,103.38
$1,302.99 		$1,294.74
$1,347.79
$1,403.98
$1,603.59 		$300.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.88
$891.98
$1,004.36
$1,403.58
$2,132.88 		$1,086.48
$1,192.58
$1,304.96
$1,704.18 		$1,387.08
$1,493.18
$1,605.56
$2,004.78 		$1,687.68
$1,793.78
$1,906.16
$2,305.38 		$300.60
Toc - Plan #83 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
$1,650 $3,300 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.89
$397.13
$447.16
$624.90
$949.60 		$617.56
$664.80
$714.83
$892.57 		$885.23
$932.47
$982.50
$1,160.24 		$1,152.90
$1,200.14
$1,250.17
$1,427.91 		$267.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$699.78
$794.26
$894.32
$1,249.80
$1,899.20 		$967.45
$1,061.93
$1,161.99
$1,517.47 		$1,235.12
$1,329.60
$1,429.66
$1,785.14 		$1,502.79
$1,597.27
$1,697.33
$2,052.81 		$267.67
Toc - Plan #84 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$338.81
$384.55
$433.00
$605.11
$919.53 		$598.00
$643.74
$692.19
$864.30 		$857.19
$902.93
$951.38
$1,123.49 		$1,116.38
$1,162.12
$1,210.57
$1,382.68 		$259.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677.62
$769.10
$866.00
$1,210.22
$1,839.06 		$936.81
$1,028.29
$1,125.19
$1,469.41 		$1,196.00
$1,287.48
$1,384.38
$1,728.60 		$1,455.19
$1,546.67
$1,643.57
$1,987.79 		$259.19
Toc - Plan #85 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2329 ($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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.38
$416.98
$469.51
$656.14
$997.07 		$648.43
$698.03
$750.56
$937.19 		$929.48
$979.08
$1,031.61
$1,218.24 		$1,210.53
$1,260.13
$1,312.66
$1,499.29 		$281.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.76
$833.96
$939.02
$1,312.28
$1,994.14 		$1,015.81
$1,115.01
$1,220.07
$1,593.33 		$1,296.86
$1,396.06
$1,501.12
$1,874.38 		$1,577.91
$1,677.11
$1,782.17
$2,155.43 		$281.05
Toc - Plan #86 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 / 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 		$388.12
$440.52
$496.02
$693.18
$1,053.36 		$685.03
$737.43
$792.93
$990.09 		$981.94
$1,034.34
$1,089.84
$1,287.00 		$1,278.85
$1,331.25
$1,386.75
$1,583.91 		$296.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.24
$881.04
$992.04
$1,386.36
$2,106.72 		$1,073.15
$1,177.95
$1,288.95
$1,683.27 		$1,370.06
$1,474.86
$1,585.86
$1,980.18 		$1,666.97
$1,771.77
$1,882.77
$2,277.09 		$296.91
Toc - Plan #87 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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.66
$470.64
$529.94
$740.58
$1,125.39 		$731.87
$787.85
$847.15
$1,057.79 		$1,049.08
$1,105.06
$1,164.36
$1,375.00 		$1,366.29
$1,422.27
$1,481.57
$1,692.21 		$317.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.32
$941.28
$1,059.88
$1,481.16
$2,250.78 		$1,146.53
$1,258.49
$1,377.09
$1,798.37 		$1,463.74
$1,575.70
$1,694.30
$2,115.58 		$1,780.95
$1,892.91
$2,011.51
$2,432.79 		$317.21
Toc - Plan #88 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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$477.55
$542.02
$610.31
$852.90
$1,296.07 		$842.88
$907.35
$975.64
$1,218.23 		$1,208.21
$1,272.68
$1,340.97
$1,583.56 		$1,573.54
$1,638.01
$1,706.30
$1,948.89 		$365.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$955.10
$1,084.04
$1,220.62
$1,705.80
$2,592.14 		$1,320.43
$1,449.37
$1,585.95
$2,071.13 		$1,685.76
$1,814.70
$1,951.28
$2,436.46 		$2,051.09
$2,180.03
$2,316.61
$2,801.79 		$365.33
Toc - Plan #89 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Connected Care Silver 24M03-70 ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$379.48
$430.71
$484.98
$677.75
$1,029.91 		$669.78
$721.01
$775.28
$968.05 		$960.08
$1,011.31
$1,065.58
$1,258.35 		$1,250.38
$1,301.61
$1,355.88
$1,548.65 		$290.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.96
$861.42
$969.96
$1,355.50
$2,059.82 		$1,049.26
$1,151.72
$1,260.26
$1,645.80 		$1,339.56
$1,442.02
$1,550.56
$1,936.10 		$1,629.86
$1,732.32
$1,840.86
$2,226.40 		$290.30
Toc - Plan #90 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237D ($0 Virtual Visits / $60 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$400.79
$454.90
$512.21
$715.81
$1,087.74 		$707.39
$761.50
$818.81
$1,022.41 		$1,013.99
$1,068.10
$1,125.41
$1,329.01 		$1,320.59
$1,374.70
$1,432.01
$1,635.61 		$306.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.58
$909.80
$1,024.42
$1,431.62
$2,175.48 		$1,108.18
$1,216.40
$1,331.02
$1,738.22 		$1,414.78
$1,523.00
$1,637.62
$2,044.82 		$1,721.38
$1,829.60
$1,944.22
$2,351.42 		$306.60
Toc - Plan #91 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 / 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 		$395.99
$449.45
$506.08
$707.24
$1,074.72 		$698.92
$752.38
$809.01
$1,010.17 		$1,001.85
$1,055.31
$1,111.94
$1,313.10 		$1,304.78
$1,358.24
$1,414.87
$1,616.03 		$302.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.98
$898.90
$1,012.16
$1,414.48
$2,149.44 		$1,094.91
$1,201.83
$1,315.09
$1,717.41 		$1,397.84
$1,504.76
$1,618.02
$2,020.34 		$1,700.77
$1,807.69
$1,920.95
$2,323.27 		$302.93
Toc - Plan #92 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Connected Care Silver 24M03-70D ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / Adult Dental / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$387.38
$439.68
$495.07
$691.86
$1,051.35 		$683.73
$736.03
$791.42
$988.21 		$980.08
$1,032.38
$1,087.77
$1,284.56 		$1,276.43
$1,328.73
$1,384.12
$1,580.91 		$296.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.76
$879.36
$990.14
$1,383.72
$2,102.70 		$1,071.11
$1,175.71
$1,286.49
$1,680.07 		$1,367.46
$1,472.06
$1,582.84
$1,976.42 		$1,663.81
$1,768.41
$1,879.19
$2,272.77 		$296.35
Toc - Plan #93 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K02-15 ($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 		$895.93
$1,016.88
$1,145.00
$1,600.13
$2,431.55 		$1,581.32
$1,702.27
$1,830.39
$2,285.52 		$2,266.71
$2,387.66
$2,515.78
$2,970.91 		$2,952.10
$3,073.05
$3,201.17
$3,656.30 		$685.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,791.86
$2,033.76
$2,290.00
$3,200.26
$4,863.10 		$2,477.25
$2,719.15
$2,975.39
$3,885.65 		$3,162.64
$3,404.54
$3,660.78
$4,571.04 		$3,848.03
$4,089.93
$4,346.17
$5,256.43 		$685.39
Toc - Plan #94 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K02-17 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$525.98
$596.99
$672.20
$939.40
$1,427.51 		$928.35
$999.36
$1,074.57
$1,341.77 		$1,330.72
$1,401.73
$1,476.94
$1,744.14 		$1,733.09
$1,804.10
$1,879.31
$2,146.51 		$402.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,051.96
$1,193.98
$1,344.40
$1,878.80
$2,855.02 		$1,454.33
$1,596.35
$1,746.77
$2,281.17 		$1,856.70
$1,998.72
$2,149.14
$2,683.54 		$2,259.07
$2,401.09
$2,551.51
$3,085.91 		$402.37
Toc - Plan #95 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(POS) BlueCare Bronze 24K02-18 ($0 Virtual Visits / Rewards $$$)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-352-2583

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$479.25
$543.95
$612.48
$855.94
$1,300.68 		$845.88
$910.58
$979.11
$1,222.57 		$1,212.51
$1,277.21
$1,345.74
$1,589.20 		$1,579.14
$1,643.84
$1,712.37
$1,955.83 		$366.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.50
$1,087.90
$1,224.96
$1,711.88
$2,601.36 		$1,325.13
$1,454.53
$1,591.59
$2,078.51 		$1,691.76
$1,821.16
$1,958.22
$2,445.14 		$2,058.39
$2,187.79
$2,324.85
$2,811.77 		$366.63
Toc - Plan #96 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K02-20 ($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
$6,250 $12,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$775.06
$879.69
$990.53
$1,384.26
$2,103.51 		$1,367.98
$1,472.61
$1,583.45
$1,977.18 		$1,960.90
$2,065.53
$2,176.37
$2,570.10 		$2,553.82
$2,658.45
$2,769.29
$3,163.02 		$592.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,550.12
$1,759.38
$1,981.06
$2,768.52
$4,207.02 		$2,143.04
$2,352.30
$2,573.98
$3,361.44 		$2,735.96
$2,945.22
$3,166.90
$3,954.36 		$3,328.88
$3,538.14
$3,759.82
$4,547.28 		$592.92
Toc - Plan #97 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K02-21 ($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
$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 		$615.26
$698.32
$786.30
$1,098.85
$1,669.82 		$1,085.93
$1,168.99
$1,256.97
$1,569.52 		$1,556.60
$1,639.66
$1,727.64
$2,040.19 		$2,027.27
$2,110.33
$2,198.31
$2,510.86 		$470.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,230.52
$1,396.64
$1,572.60
$2,197.70
$3,339.64 		$1,701.19
$1,867.31
$2,043.27
$2,668.37 		$2,171.86
$2,337.98
$2,513.94
$3,139.04 		$2,642.53
$2,808.65
$2,984.61
$3,609.71 		$470.67
Toc - Plan #98 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K02-23 ($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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$561.20
$636.96
$717.21
$1,002.30
$1,523.10 		$990.52
$1,066.28
$1,146.53
$1,431.62 		$1,419.84
$1,495.60
$1,575.85
$1,860.94 		$1,849.16
$1,924.92
$2,005.17
$2,290.26 		$429.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,122.40
$1,273.92
$1,434.42
$2,004.60
$3,046.20 		$1,551.72
$1,703.24
$1,863.74
$2,433.92 		$1,981.04
$2,132.56
$2,293.06
$2,863.24 		$2,410.36
$2,561.88
$2,722.38
$3,292.56 		$429.32
Toc - Plan #99 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K02-26S (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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$512.43
$581.61
$654.89
$915.20
$1,390.74 		$904.44
$973.62
$1,046.90
$1,307.21 		$1,296.45
$1,365.63
$1,438.91
$1,699.22 		$1,688.46
$1,757.64
$1,830.92
$2,091.23 		$392.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,024.86
$1,163.22
$1,309.78
$1,830.40
$2,781.48 		$1,416.87
$1,555.23
$1,701.79
$2,222.41 		$1,808.88
$1,947.24
$2,093.80
$2,614.42 		$2,200.89
$2,339.25
$2,485.81
$3,006.43 		$392.01
Toc - Plan #100 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K02-27S ($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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$651.58
$739.54
$832.72
$1,163.72
$1,768.39 		$1,150.04
$1,238.00
$1,331.18
$1,662.18 		$1,648.50
$1,736.46
$1,829.64
$2,160.64 		$2,146.96
$2,234.92
$2,328.10
$2,659.10 		$498.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,303.16
$1,479.08
$1,665.44
$2,327.44
$3,536.78 		$1,801.62
$1,977.54
$2,163.90
$2,825.90 		$2,300.08
$2,476.00
$2,662.36
$3,324.36 		$2,798.54
$2,974.46
$3,160.82
$3,822.82 		$498.46
Toc - Plan #101 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K02-28S ($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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$720.61
$817.89
$920.94
$1,287.01
$1,955.74 		$1,271.88
$1,369.16
$1,472.21
$1,838.28 		$1,823.15
$1,920.43
$2,023.48
$2,389.55 		$2,374.42
$2,471.70
$2,574.75
$2,940.82 		$551.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,441.22
$1,635.78
$1,841.88
$2,574.02
$3,911.48 		$1,992.49
$2,187.05
$2,393.15
$3,125.29 		$2,543.76
$2,738.32
$2,944.42
$3,676.56 		$3,095.03
$3,289.59
$3,495.69
$4,227.83 		$551.27
Toc - Plan #102 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K02-29S ($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
$3,200 $6,400 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 		$893.10
$1,013.67
$1,141.38
$1,595.08
$2,423.87 		$1,576.32
$1,696.89
$1,824.60
$2,278.30 		$2,259.54
$2,380.11
$2,507.82
$2,961.52 		$2,942.76
$3,063.33
$3,191.04
$3,644.74 		$683.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,786.20
$2,027.34
$2,282.76
$3,190.16
$4,847.74 		$2,469.42
$2,710.56
$2,965.98
$3,873.38 		$3,152.64
$3,393.78
$3,649.20
$4,556.60 		$3,835.86
$4,077.00
$4,332.42
$5,239.82 		$683.22

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #103 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 		$393.95
$447.12
$503.45
$703.58
$1,069.15 		$695.31
$748.48
$804.81
$1,004.94 		$996.67
$1,049.84
$1,106.17
$1,306.30 		$1,298.03
$1,351.20
$1,407.53
$1,607.66 		$301.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.90
$894.24
$1,006.90
$1,407.16
$2,138.30 		$1,089.26
$1,195.60
$1,308.26
$1,708.52 		$1,390.62
$1,496.96
$1,609.62
$2,009.88 		$1,691.98
$1,798.32
$1,910.98
$2,311.24 		$301.36
Toc - Plan #104 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 		$297.40
$337.54
$380.06
$531.14
$807.11 		$524.90
$565.04
$607.56
$758.64 		$752.40
$792.54
$835.06
$986.14 		$979.90
$1,020.04
$1,062.56
$1,213.64 		$227.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$594.80
$675.08
$760.12
$1,062.28
$1,614.22 		$822.30
$902.58
$987.62
$1,289.78 		$1,049.80
$1,130.08
$1,215.12
$1,517.28 		$1,277.30
$1,357.58
$1,442.62
$1,744.78 		$227.50
Toc - Plan #105 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite + PCP Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.46
$411.38
$463.21
$647.33
$983.69 		$639.73
$688.65
$740.48
$924.60 		$917.00
$965.92
$1,017.75
$1,201.87 		$1,194.27
$1,243.19
$1,295.02
$1,479.14 		$277.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.92
$822.76
$926.42
$1,294.66
$1,967.38 		$1,002.19
$1,100.03
$1,203.69
$1,571.93 		$1,279.46
$1,377.30
$1,480.96
$1,849.20 		$1,556.73
$1,654.57
$1,758.23
$2,126.47 		$277.27
Toc - Plan #106 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
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$243.10
$275.91
$310.67
$434.16
$659.75 		$429.07
$461.88
$496.64
$620.13 		$615.04
$647.85
$682.61
$806.10 		$801.01
$833.82
$868.58
$992.07 		$185.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.20
$551.82
$621.34
$868.32
$1,319.50 		$672.17
$737.79
$807.31
$1,054.29 		$858.14
$923.76
$993.28
$1,240.26 		$1,044.11
$1,109.73
$1,179.25
$1,426.23 		$185.97
Toc - Plan #107 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 		$406.05
$460.86
$518.92
$725.19
$1,102.00 		$716.67
$771.48
$829.54
$1,035.81 		$1,027.29
$1,082.10
$1,140.16
$1,346.43 		$1,337.91
$1,392.72
$1,450.78
$1,657.05 		$310.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.10
$921.72
$1,037.84
$1,450.38
$2,204.00 		$1,122.72
$1,232.34
$1,348.46
$1,761.00 		$1,433.34
$1,542.96
$1,659.08
$2,071.62 		$1,743.96
$1,853.58
$1,969.70
$2,382.24 		$310.62
Toc - Plan #108 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic 4700

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.74
$373.11
$420.11
$587.11
$892.17 		$580.22
$624.59
$671.59
$838.59 		$831.70
$876.07
$923.07
$1,090.07 		$1,083.18
$1,127.55
$1,174.55
$1,341.55 		$251.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.48
$746.22
$840.22
$1,174.22
$1,784.34 		$908.96
$997.70
$1,091.70
$1,425.70 		$1,160.44
$1,249.18
$1,343.18
$1,677.18 		$1,411.92
$1,500.66
$1,594.66
$1,928.66 		$251.48
Toc - Plan #109 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 		$387.96
$440.32
$495.80
$692.88
$1,052.89 		$684.74
$737.10
$792.58
$989.66 		$981.52
$1,033.88
$1,089.36
$1,286.44 		$1,278.30
$1,330.66
$1,386.14
$1,583.22 		$296.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.92
$880.64
$991.60
$1,385.76
$2,105.78 		$1,072.70
$1,177.42
$1,288.38
$1,682.54 		$1,369.48
$1,474.20
$1,585.16
$1,979.32 		$1,666.26
$1,770.98
$1,881.94
$2,276.10 		$296.78
Toc - Plan #110 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.08
$455.21
$512.56
$716.30
$1,088.49 		$707.89
$762.02
$819.37
$1,023.11 		$1,014.70
$1,068.83
$1,126.18
$1,329.92 		$1,321.51
$1,375.64
$1,432.99
$1,636.73 		$306.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.16
$910.42
$1,025.12
$1,432.60
$2,176.98 		$1,108.97
$1,217.23
$1,331.93
$1,739.41 		$1,415.78
$1,524.04
$1,638.74
$2,046.22 		$1,722.59
$1,830.85
$1,945.55
$2,353.03 		$306.81
Toc - Plan #111 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$356.88
$405.04
$456.07
$637.36
$968.53 		$629.88
$678.04
$729.07
$910.36 		$902.88
$951.04
$1,002.07
$1,183.36 		$1,175.88
$1,224.04
$1,275.07
$1,456.36 		$273.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.76
$810.08
$912.14
$1,274.72
$1,937.06 		$986.76
$1,083.08
$1,185.14
$1,547.72 		$1,259.76
$1,356.08
$1,458.14
$1,820.72 		$1,532.76
$1,629.08
$1,731.14
$2,093.72 		$273.00
Toc - Plan #112 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.52
$369.45
$416.00
$581.36
$883.43 		$574.54
$618.47
$665.02
$830.38 		$823.56
$867.49
$914.04
$1,079.40 		$1,072.58
$1,116.51
$1,163.06
$1,328.42 		$249.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.04
$738.90
$832.00
$1,162.72
$1,766.86 		$900.06
$987.92
$1,081.02
$1,411.74 		$1,149.08
$1,236.94
$1,330.04
$1,660.76 		$1,398.10
$1,485.96
$1,579.06
$1,909.78 		$249.02
Toc - Plan #113 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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.86
$449.29
$505.90
$707.00
$1,074.35 		$698.69
$752.12
$808.73
$1,009.83 		$1,001.52
$1,054.95
$1,111.56
$1,312.66 		$1,304.35
$1,357.78
$1,414.39
$1,615.49 		$302.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.72
$898.58
$1,011.80
$1,414.00
$2,148.70 		$1,094.55
$1,201.41
$1,314.63
$1,716.83 		$1,397.38
$1,504.24
$1,617.46
$2,019.66 		$1,700.21
$1,807.07
$1,920.29
$2,322.49 		$302.83
Toc - Plan #114 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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.82
$465.13
$523.73
$731.91
$1,112.21 		$723.32
$778.63
$837.23
$1,045.41 		$1,036.82
$1,092.13
$1,150.73
$1,358.91 		$1,350.32
$1,405.63
$1,464.23
$1,672.41 		$313.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.64
$930.26
$1,047.46
$1,463.82
$2,224.42 		$1,133.14
$1,243.76
$1,360.96
$1,777.32 		$1,446.64
$1,557.26
$1,674.46
$2,090.82 		$1,760.14
$1,870.76
$1,987.96
$2,404.32 		$313.50

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #115 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 8500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.02
$406.36
$457.56
$639.43
$971.68 		$631.91
$680.25
$731.45
$913.32 		$905.80
$954.14
$1,005.34
$1,187.21 		$1,179.69
$1,228.03
$1,279.23
$1,461.10 		$273.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.04
$812.72
$915.12
$1,278.86
$1,943.36 		$989.93
$1,086.61
$1,189.01
$1,552.75 		$1,263.82
$1,360.50
$1,462.90
$1,826.64 		$1,537.71
$1,634.39
$1,736.79
$2,100.53 		$273.89
Toc - Plan #116 Cigna Healthcare
Silver

(EPO) Connect Silver 4000 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,200 $18,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$482.64
$547.79
$616.81
$861.99
$1,309.88 		$851.86
$917.01
$986.03
$1,231.21 		$1,221.08
$1,286.23
$1,355.25
$1,600.43 		$1,590.30
$1,655.45
$1,724.47
$1,969.65 		$369.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$965.28
$1,095.58
$1,233.62
$1,723.98
$2,619.76 		$1,334.50
$1,464.80
$1,602.84
$2,093.20 		$1,703.72
$1,834.02
$1,972.06
$2,462.42 		$2,072.94
$2,203.24
$2,341.28
$2,831.64 		$369.22
Toc - Plan #117 Cigna Healthcare
Silver

(EPO) Connect Silver 5000 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,000 $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 		$478.79
$543.43
$611.89
$855.12
$1,299.43 		$845.06
$909.70
$978.16
$1,221.39 		$1,211.33
$1,275.97
$1,344.43
$1,587.66 		$1,577.60
$1,642.24
$1,710.70
$1,953.93 		$366.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.58
$1,086.86
$1,223.78
$1,710.24
$2,598.86 		$1,323.85
$1,453.13
$1,590.05
$2,076.51 		$1,690.12
$1,819.40
$1,956.32
$2,442.78 		$2,056.39
$2,185.67
$2,322.59
$2,809.05 		$366.27
Toc - Plan #118 Cigna Healthcare
Silver

(EPO) Connect Silver 9100 Indiv Med Deductible

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

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 		$488.28
$554.20
$624.02
$872.06
$1,325.19 		$861.81
$927.73
$997.55
$1,245.59 		$1,235.34
$1,301.26
$1,371.08
$1,619.12 		$1,608.87
$1,674.79
$1,744.61
$1,992.65 		$373.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$976.56
$1,108.40
$1,248.04
$1,744.12
$2,650.38 		$1,350.09
$1,481.93
$1,621.57
$2,117.65 		$1,723.62
$1,855.46
$1,995.10
$2,491.18 		$2,097.15
$2,228.99
$2,368.63
$2,864.71 		$373.53
Toc - Plan #119 Cigna Healthcare
Gold

(EPO) Connect Gold 2500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$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 		$497.19
$564.31
$635.40
$887.97
$1,349.36 		$877.54
$944.66
$1,015.75
$1,268.32 		$1,257.89
$1,325.01
$1,396.10
$1,648.67 		$1,638.24
$1,705.36
$1,776.45
$2,029.02 		$380.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$994.38
$1,128.62
$1,270.80
$1,775.94
$2,698.72 		$1,374.73
$1,508.97
$1,651.15
$2,156.29 		$1,755.08
$1,889.32
$2,031.50
$2,536.64 		$2,135.43
$2,269.67
$2,411.85
$2,916.99 		$380.35
Toc - Plan #120 Cigna Healthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.08
$406.42
$457.62
$639.53
$971.82 		$632.01
$680.35
$731.55
$913.46 		$905.94
$954.28
$1,005.48
$1,187.39 		$1,179.87
$1,228.21
$1,279.41
$1,461.32 		$273.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.16
$812.84
$915.24
$1,279.06
$1,943.64 		$990.09
$1,086.77
$1,189.17
$1,552.99 		$1,264.02
$1,360.70
$1,463.10
$1,826.92 		$1,537.95
$1,634.63
$1,737.03
$2,100.85 		$273.93
Toc - Plan #121 Cigna Healthcare
Silver

(EPO) Connect Silver 3000 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$477.73
$542.23
$610.55
$853.23
$1,296.57 		$843.20
$907.70
$976.02
$1,218.70 		$1,208.67
$1,273.17
$1,341.49
$1,584.17 		$1,574.14
$1,638.64
$1,706.96
$1,949.64 		$365.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$955.46
$1,084.46
$1,221.10
$1,706.46
$2,593.14 		$1,320.93
$1,449.93
$1,586.57
$2,071.93 		$1,686.40
$1,815.40
$1,952.04
$2,437.40 		$2,051.87
$2,180.87
$2,317.51
$2,802.87 		$365.47
Toc - Plan #122 Cigna Healthcare
Gold

(EPO) Connect Gold 500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$518.17
$588.12
$662.22
$925.44
$1,406.30 		$914.57
$984.52
$1,058.62
$1,321.84 		$1,310.97
$1,380.92
$1,455.02
$1,718.24 		$1,707.37
$1,777.32
$1,851.42
$2,114.64 		$396.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,036.34
$1,176.24
$1,324.44
$1,850.88
$2,812.60 		$1,432.74
$1,572.64
$1,720.84
$2,247.28 		$1,829.14
$1,969.04
$2,117.24
$2,643.68 		$2,225.54
$2,365.44
$2,513.64
$3,040.08 		$396.40
Toc - Plan #123 Cigna Healthcare
Gold

(EPO) Connect Gold CMS Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$502.67
$570.53
$642.41
$897.77
$1,364.24 		$887.21
$955.07
$1,026.95
$1,282.31 		$1,271.75
$1,339.61
$1,411.49
$1,666.85 		$1,656.29
$1,724.15
$1,796.03
$2,051.39 		$384.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,005.34
$1,141.06
$1,284.82
$1,795.54
$2,728.48 		$1,389.88
$1,525.60
$1,669.36
$2,180.08 		$1,774.42
$1,910.14
$2,053.90
$2,564.62 		$2,158.96
$2,294.68
$2,438.44
$2,949.16 		$384.54
Toc - Plan #124 Cigna Healthcare
Silver

(EPO) Connect Silver CMS Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$481.74
$546.78
$615.67
$860.39
$1,307.45 		$850.27
$915.31
$984.20
$1,228.92 		$1,218.80
$1,283.84
$1,352.73
$1,597.45 		$1,587.33
$1,652.37
$1,721.26
$1,965.98 		$368.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$963.48
$1,093.56
$1,231.34
$1,720.78
$2,614.90 		$1,332.01
$1,462.09
$1,599.87
$2,089.31 		$1,700.54
$1,830.62
$1,968.40
$2,457.84 		$2,069.07
$2,199.15
$2,336.93
$2,826.37 		$368.53
Toc - Plan #125 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze CMS Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.82
$408.39
$459.85
$642.63
$976.54 		$635.08
$683.65
$735.11
$917.89 		$910.34
$958.91
$1,010.37
$1,193.15 		$1,185.60
$1,234.17
$1,285.63
$1,468.41 		$275.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.64
$816.78
$919.70
$1,285.26
$1,953.08 		$994.90
$1,092.04
$1,194.96
$1,560.52 		$1,270.16
$1,367.30
$1,470.22
$1,835.78 		$1,545.42
$1,642.56
$1,745.48
$2,111.04 		$275.26
Toc - Plan #126 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 0 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.66
$446.80
$503.10
$703.07
$1,068.39 		$694.81
$747.95
$804.25
$1,004.22 		$995.96
$1,049.10
$1,105.40
$1,305.37 		$1,297.11
$1,350.25
$1,406.55
$1,606.52 		$301.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.32
$893.60
$1,006.20
$1,406.14
$2,136.78 		$1,088.47
$1,194.75
$1,307.35
$1,707.29 		$1,389.62
$1,495.90
$1,608.50
$2,008.44 		$1,690.77
$1,797.05
$1,909.65
$2,309.59 		$301.15
Toc - Plan #127 Cigna Healthcare
Expanded Bronze

(EPO) Connect Bronze 5500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.66
$412.76
$464.76
$649.51
$986.99 		$641.86
$690.96
$742.96
$927.71 		$920.06
$969.16
$1,021.16
$1,205.91 		$1,198.26
$1,247.36
$1,299.36
$1,484.11 		$278.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.32
$825.52
$929.52
$1,299.02
$1,973.98 		$1,005.52
$1,103.72
$1,207.72
$1,577.22 		$1,283.72
$1,381.92
$1,485.92
$1,855.42 		$1,561.92
$1,660.12
$1,764.12
$2,133.62 		$278.20

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-5716 | Toll Free: 1-888-560-5716 | TTY: 1-800-955-8771
Toc - Plan #128 Molina Healthcare
Gold

(HMO) Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$460.87
$523.08
$588.99
$823.11
$1,250.79 		$813.43
$875.64
$941.55
$1,175.67 		$1,165.99
$1,228.20
$1,294.11
$1,528.23 		$1,518.55
$1,580.76
$1,646.67
$1,880.79 		$352.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.74
$1,046.16
$1,177.98
$1,646.22
$2,501.58 		$1,274.30
$1,398.72
$1,530.54
$1,998.78 		$1,626.86
$1,751.28
$1,883.10
$2,351.34 		$1,979.42
$2,103.84
$2,235.66
$2,703.90 		$352.56
Toc - Plan #129 Molina Healthcare
Silver

(HMO) Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 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 		$391.93
$444.84
$500.88
$699.98
$1,063.69 		$691.75
$744.66
$800.70
$999.80 		$991.57
$1,044.48
$1,100.52
$1,299.62 		$1,291.39
$1,344.30
$1,400.34
$1,599.44 		$299.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783.86
$889.68
$1,001.76
$1,399.96
$2,127.38 		$1,083.68
$1,189.50
$1,301.58
$1,699.78 		$1,383.50
$1,489.32
$1,601.40
$1,999.60 		$1,683.32
$1,789.14
$1,901.22
$2,299.42 		$299.82
Toc - Plan #130 Molina Healthcare
Expanded Bronze

(HMO) Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.06
$412.07
$463.99
$648.43
$985.35 		$640.80
$689.81
$741.73
$926.17 		$918.54
$967.55
$1,019.47
$1,203.91 		$1,196.28
$1,245.29
$1,297.21
$1,481.65 		$277.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.12
$824.14
$927.98
$1,296.86
$1,970.70 		$1,003.86
$1,101.88
$1,205.72
$1,574.60 		$1,281.60
$1,379.62
$1,483.46
$1,852.34 		$1,559.34
$1,657.36
$1,761.20
$2,130.08 		$277.74
Toc - Plan #131 Molina Healthcare
Gold

(HMO) Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$471.27
$534.90
$602.29
$841.69
$1,279.04 		$831.79
$895.42
$962.81
$1,202.21 		$1,192.31
$1,255.94
$1,323.33
$1,562.73 		$1,552.83
$1,616.46
$1,683.85
$1,923.25 		$360.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942.54
$1,069.80
$1,204.58
$1,683.38
$2,558.08 		$1,303.06
$1,430.32
$1,565.10
$2,043.90 		$1,663.58
$1,790.84
$1,925.62
$2,404.42 		$2,024.10
$2,151.36
$2,286.14
$2,764.94 		$360.52
Toc - Plan #132 Molina Healthcare
Silver

(HMO) Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.14
$453.03
$510.11
$712.87
$1,083.28 		$704.49
$758.38
$815.46
$1,018.22 		$1,009.84
$1,063.73
$1,120.81
$1,323.57 		$1,315.19
$1,369.08
$1,426.16
$1,628.92 		$305.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.28
$906.06
$1,020.22
$1,425.74
$2,166.56 		$1,103.63
$1,211.41
$1,325.57
$1,731.09 		$1,408.98
$1,516.76
$1,630.92
$2,036.44 		$1,714.33
$1,822.11
$1,936.27
$2,341.79 		$305.35
Toc - Plan #133 Molina Healthcare
Expanded Bronze

(HMO) Bronze 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$312.15
$354.29
$398.93
$557.51
$847.19 		$550.95
$593.09
$637.73
$796.31 		$789.75
$831.89
$876.53
$1,035.11 		$1,028.55
$1,070.69
$1,115.33
$1,273.91 		$238.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.30
$708.58
$797.86
$1,115.02
$1,694.38 		$863.10
$947.38
$1,036.66
$1,353.82 		$1,101.90
$1,186.18
$1,275.46
$1,592.62 		$1,340.70
$1,424.98
$1,514.26
$1,831.42 		$238.80
Toc - Plan #134 Molina Healthcare
Silver

(HMO) Silver 12 with First 4 Primary Care Visits Free

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$390.36
$443.06
$498.88
$697.18
$1,059.44 		$688.99
$741.69
$797.51
$995.81 		$987.62
$1,040.32
$1,096.14
$1,294.44 		$1,286.25
$1,338.95
$1,394.77
$1,593.07 		$298.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.72
$886.12
$997.76
$1,394.36
$2,118.88 		$1,079.35
$1,184.75
$1,296.39
$1,692.99 		$1,377.98
$1,483.38
$1,595.02
$1,991.62 		$1,676.61
$1,782.01
$1,893.65
$2,290.25 		$298.63
Toc - Plan #135 Molina Healthcare
Gold

(HMO) Gold 1 with Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 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 		$463.91
$526.54
$592.88
$828.54
$1,259.05 		$818.80
$881.43
$947.77
$1,183.43 		$1,173.69
$1,236.32
$1,302.66
$1,538.32 		$1,528.58
$1,591.21
$1,657.55
$1,893.21 		$354.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.82
$1,053.08
$1,185.76
$1,657.08
$2,518.10 		$1,282.71
$1,407.97
$1,540.65
$2,011.97 		$1,637.60
$1,762.86
$1,895.54
$2,366.86 		$1,992.49
$2,117.75
$2,250.43
$2,721.75 		$354.89
Toc - Plan #136 Molina Healthcare
Silver

(HMO) Silver 1 with Adult Vision Services

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 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 		$394.85
$448.16
$504.62
$705.21
$1,071.63 		$696.91
$750.22
$806.68
$1,007.27 		$998.97
$1,052.28
$1,108.74
$1,309.33 		$1,301.03
$1,354.34
$1,410.80
$1,611.39 		$302.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.70
$896.32
$1,009.24
$1,410.42
$2,143.26 		$1,091.76
$1,198.38
$1,311.30
$1,712.48 		$1,393.82
$1,500.44
$1,613.36
$2,014.54 		$1,695.88
$1,802.50
$1,915.42
$2,316.60 		$302.06
Toc - Plan #137 Molina Healthcare
Silver

(HMO) Silver 9

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-5716

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$387.03
$439.28
$494.63
$691.24
$1,050.41 		$683.11
$735.36
$790.71
$987.32 		$979.19
$1,031.44
$1,086.79
$1,283.40 		$1,275.27
$1,327.52
$1,382.87
$1,579.48 		$296.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.06
$878.56
$989.26
$1,382.48
$2,100.82 		$1,070.14
$1,174.64
$1,285.34
$1,678.56 		$1,366.22
$1,470.72
$1,581.42
$1,974.64 		$1,662.30
$1,766.80
$1,877.50
$2,270.72 		$296.08

ADVERTISEMENT

AmeriHealth Caritas Next

Local: 1-833-999-3567 | Toll Free: 1-833-999-3567

Toc - Plan #138 AmeriHealth Caritas Next
Bronze

(HMO) AmeriHealth Caritas Next Bronze Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-999-3567

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.71
$327.69
$368.98
$515.64
$783.56 		$509.58
$548.56
$589.85
$736.51 		$730.45
$769.43
$810.72
$957.38 		$951.32
$990.30
$1,031.59
$1,178.25 		$220.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.42
$655.38
$737.96
$1,031.28
$1,567.12 		$798.29
$876.25
$958.83
$1,252.15 		$1,019.16
$1,097.12
$1,179.70
$1,473.02 		$1,240.03
$1,317.99
$1,400.57
$1,693.89 		$220.87
Toc - Plan #139 AmeriHealth Caritas Next
Expanded Bronze

(HMO) AmeriHealth Caritas Next Expanded Bronze Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-999-3567

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$310.92
$352.89
$397.35
$555.30
$843.82 		$548.77
$590.74
$635.20
$793.15 		$786.62
$828.59
$873.05
$1,031.00 		$1,024.47
$1,066.44
$1,110.90
$1,268.85 		$237.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.84
$705.78
$794.70
$1,110.60
$1,687.64 		$859.69
$943.63
$1,032.55
$1,348.45 		$1,097.54
$1,181.48
$1,270.40
$1,586.30 		$1,335.39
$1,419.33
$1,508.25
$1,824.15 		$237.85
Toc - Plan #140 AmeriHealth Caritas Next
Silver

(HMO) AmeriHealth Caritas Next Silver Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-999-3567

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.19
$434.92
$489.71
$684.37
$1,039.96 		$676.33
$728.06
$782.85
$977.51 		$969.47
$1,021.20
$1,075.99
$1,270.65 		$1,262.61
$1,314.34
$1,369.13
$1,563.79 		$293.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.38
$869.84
$979.42
$1,368.74
$2,079.92 		$1,059.52
$1,162.98
$1,272.56
$1,661.88 		$1,352.66
$1,456.12
$1,565.70
$1,955.02 		$1,645.80
$1,749.26
$1,858.84
$2,248.16 		$293.14
Toc - Plan #141 AmeriHealth Caritas Next
Gold

(HMO) AmeriHealth Caritas Next Gold Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-999-3567

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$437.25
$496.28
$558.80
$780.92
$1,186.68 		$771.75
$830.78
$893.30
$1,115.42 		$1,106.25
$1,165.28
$1,227.80
$1,449.92 		$1,440.75
$1,499.78
$1,562.30
$1,784.42 		$334.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.50
$992.56
$1,117.60
$1,561.84
$2,373.36 		$1,209.00
$1,327.06
$1,452.10
$1,896.34 		$1,543.50
$1,661.56
$1,786.60
$2,230.84 		$1,878.00
$1,996.06
$2,121.10
$2,565.34 		$334.50
Toc - Plan #142 AmeriHealth Caritas Next
Expanded Bronze

(HMO) AmeriHealth Caritas Next Expanded Bronze Premier + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-999-3567

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$318.03
$360.97
$406.45
$568.00
$863.13 		$561.33
$604.27
$649.75
$811.30 		$804.63
$847.57
$893.05
$1,054.60 		$1,047.93
$1,090.87
$1,136.35
$1,297.90 		$243.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.06
$721.94
$812.90
$1,136.00
$1,726.26 		$879.36
$965.24
$1,056.20
$1,379.30 		$1,122.66
$1,208.54
$1,299.50
$1,622.60 		$1,365.96
$1,451.84
$1,542.80
$1,865.90 		$243.30
Toc - Plan #143 AmeriHealth Caritas Next
Silver

(HMO) AmeriHealth Caritas Next Silver Premier + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-999-3567

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.56
$464.85
$523.41
$731.47
$1,111.53 		$722.87
$778.16
$836.72
$1,044.78 		$1,036.18
$1,091.47
$1,150.03
$1,358.09 		$1,349.49
$1,404.78
$1,463.34
$1,671.40 		$313.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.12
$929.70
$1,046.82
$1,462.94
$2,223.06 		$1,132.43
$1,243.01
$1,360.13
$1,776.25 		$1,445.74
$1,556.32
$1,673.44
$2,089.56 		$1,759.05
$1,869.63
$1,986.75
$2,402.87 		$313.31

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0405 | Toll Free: 1-888-200-0405 | TTY: 1-888-200-0405
Toc - Plan #144 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,900 $7,800 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 		$405.52
$460.27
$518.26
$724.26
$1,100.58 		$715.74
$770.49
$828.48
$1,034.48 		$1,025.96
$1,080.71
$1,138.70
$1,344.70 		$1,336.18
$1,390.93
$1,448.92
$1,654.92 		$310.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.04
$920.54
$1,036.52
$1,448.52
$2,201.16 		$1,121.26
$1,230.76
$1,346.74
$1,758.74 		$1,431.48
$1,540.98
$1,656.96
$2,068.96 		$1,741.70
$1,851.20
$1,967.18
$2,379.18 		$310.22
Toc - Plan #145 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.00
$368.87
$415.35
$580.44
$882.04 		$573.62
$617.49
$663.97
$829.06 		$822.24
$866.11
$912.59
$1,077.68 		$1,070.86
$1,114.73
$1,161.21
$1,326.30 		$248.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.00
$737.74
$830.70
$1,160.88
$1,764.08 		$898.62
$986.36
$1,079.32
$1,409.50 		$1,147.24
$1,234.98
$1,327.94
$1,658.12 		$1,395.86
$1,483.60
$1,576.56
$1,906.74 		$248.62
Toc - Plan #146 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.50
$369.44
$415.98
$581.34
$883.40 		$574.50
$618.44
$664.98
$830.34 		$823.50
$867.44
$913.98
$1,079.34 		$1,072.50
$1,116.44
$1,162.98
$1,328.34 		$249.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.00
$738.88
$831.96
$1,162.68
$1,766.80 		$900.00
$987.88
$1,080.96
$1,411.68 		$1,149.00
$1,236.88
$1,329.96
$1,660.68 		$1,398.00
$1,485.88
$1,578.96
$1,909.68 		$249.00
Toc - Plan #147 UnitedHealthcare
Gold

(HMO) UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$466.09
$529.02
$595.67
$832.44
$1,264.98 		$822.65
$885.58
$952.23
$1,189.00 		$1,179.21
$1,242.14
$1,308.79
$1,545.56 		$1,535.77
$1,598.70
$1,665.35
$1,902.12 		$356.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$932.18
$1,058.04
$1,191.34
$1,664.88
$2,529.96 		$1,288.74
$1,414.60
$1,547.90
$2,021.44 		$1,645.30
$1,771.16
$1,904.46
$2,378.00 		$2,001.86
$2,127.72
$2,261.02
$2,734.56 		$356.56
Toc - Plan #148 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$458.17
$520.02
$585.54
$818.28
$1,243.46 		$808.67
$870.52
$936.04
$1,168.78 		$1,159.17
$1,221.02
$1,286.54
$1,519.28 		$1,509.67
$1,571.52
$1,637.04
$1,869.78 		$350.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$916.34
$1,040.04
$1,171.08
$1,636.56
$2,486.92 		$1,266.84
$1,390.54
$1,521.58
$1,987.06 		$1,617.34
$1,741.04
$1,872.08
$2,337.56 		$1,967.84
$2,091.54
$2,222.58
$2,688.06 		$350.50
Toc - Plan #149 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$421.83
$478.78
$539.10
$753.39
$1,144.85 		$744.53
$801.48
$861.80
$1,076.09 		$1,067.23
$1,124.18
$1,184.50
$1,398.79 		$1,389.93
$1,446.88
$1,507.20
$1,721.49 		$322.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.66
$957.56
$1,078.20
$1,506.78
$2,289.70 		$1,166.36
$1,280.26
$1,400.90
$1,829.48 		$1,489.06
$1,602.96
$1,723.60
$2,152.18 		$1,811.76
$1,925.66
$2,046.30
$2,474.88 		$322.70
Toc - Plan #150 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.02
$455.16
$512.50
$716.22
$1,088.37 		$707.80
$761.94
$819.28
$1,023.00 		$1,014.58
$1,068.72
$1,126.06
$1,329.78 		$1,321.36
$1,375.50
$1,432.84
$1,636.56 		$306.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.04
$910.32
$1,025.00
$1,432.44
$2,176.74 		$1,108.82
$1,217.10
$1,331.78
$1,739.22 		$1,415.60
$1,523.88
$1,638.56
$2,046.00 		$1,722.38
$1,830.66
$1,945.34
$2,352.78 		$306.78
Toc - Plan #151 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($0 Virtual Urgent Care, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.23
$363.46
$409.26
$571.93
$869.11 		$565.21
$608.44
$654.24
$816.91 		$810.19
$853.42
$899.22
$1,061.89 		$1,055.17
$1,098.40
$1,144.20
$1,306.87 		$244.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.46
$726.92
$818.52
$1,143.86
$1,738.22 		$885.44
$971.90
$1,063.50
$1,388.84 		$1,130.42
$1,216.88
$1,308.48
$1,633.82 		$1,375.40
$1,461.86
$1,553.46
$1,878.80 		$244.98
Toc - Plan #152 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.97
$369.98
$416.59
$582.19
$884.69 		$575.34
$619.35
$665.96
$831.56 		$824.71
$868.72
$915.33
$1,080.93 		$1,074.08
$1,118.09
$1,164.70
$1,330.30 		$249.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.94
$739.96
$833.18
$1,164.38
$1,769.38 		$901.31
$989.33
$1,082.55
$1,413.75 		$1,150.68
$1,238.70
$1,331.92
$1,663.12 		$1,400.05
$1,488.07
$1,581.29
$1,912.49 		$249.37
Toc - Plan #153 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$341.83
$387.98
$436.86
$610.51
$927.72 		$603.33
$649.48
$698.36
$872.01 		$864.83
$910.98
$959.86
$1,133.51 		$1,126.33
$1,172.48
$1,221.36
$1,395.01 		$261.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.66
$775.96
$873.72
$1,221.02
$1,855.44 		$945.16
$1,037.46
$1,135.22
$1,482.52 		$1,206.66
$1,298.96
$1,396.72
$1,744.02 		$1,468.16
$1,560.46
$1,658.22
$2,005.52 		$261.50
Toc - Plan #154 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$404.63
$459.25
$517.11
$722.67
$1,098.16 		$714.17
$768.79
$826.65
$1,032.21 		$1,023.71
$1,078.33
$1,136.19
$1,341.75 		$1,333.25
$1,387.87
$1,445.73
$1,651.29 		$309.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.26
$918.50
$1,034.22
$1,445.34
$2,196.32 		$1,118.80
$1,228.04
$1,343.76
$1,754.88 		$1,428.34
$1,537.58
$1,653.30
$2,064.42 		$1,737.88
$1,847.12
$1,962.84
$2,373.96 		$309.54
Toc - Plan #155 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.20
$464.44
$522.95
$730.82
$1,110.56 		$722.23
$777.47
$835.98
$1,043.85 		$1,035.26
$1,090.50
$1,149.01
$1,356.88 		$1,348.29
$1,403.53
$1,462.04
$1,669.91 		$313.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.40
$928.88
$1,045.90
$1,461.64
$2,221.12 		$1,131.43
$1,241.91
$1,358.93
$1,774.67 		$1,444.46
$1,554.94
$1,671.96
$2,087.70 		$1,757.49
$1,867.97
$1,984.99
$2,400.73 		$313.03
Toc - Plan #156 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$455.60
$517.11
$582.26
$813.71
$1,236.51 		$804.14
$865.65
$930.80
$1,162.25 		$1,152.68
$1,214.19
$1,279.34
$1,510.79 		$1,501.22
$1,562.73
$1,627.88
$1,859.33 		$348.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.20
$1,034.22
$1,164.52
$1,627.42
$2,473.02 		$1,259.74
$1,382.76
$1,513.06
$1,975.96 		$1,608.28
$1,731.30
$1,861.60
$2,324.50 		$1,956.82
$2,079.84
$2,210.14
$2,673.04 		$348.54
Toc - Plan #157 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$456.83
$518.50
$583.83
$815.90
$1,239.84 		$806.31
$867.98
$933.31
$1,165.38 		$1,155.79
$1,217.46
$1,282.79
$1,514.86 		$1,505.27
$1,566.94
$1,632.27
$1,864.34 		$349.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$913.66
$1,037.00
$1,167.66
$1,631.80
$2,479.68 		$1,263.14
$1,386.48
$1,517.14
$1,981.28 		$1,612.62
$1,735.96
$1,866.62
$2,330.76 		$1,962.10
$2,085.44
$2,216.10
$2,680.24 		$349.48
Toc - Plan #158 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$483.00
$548.21
$617.28
$862.65
$1,310.87 		$852.50
$917.71
$986.78
$1,232.15 		$1,222.00
$1,287.21
$1,356.28
$1,601.65 		$1,591.50
$1,656.71
$1,725.78
$1,971.15 		$369.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$966.00
$1,096.42
$1,234.56
$1,725.30
$2,621.74 		$1,335.50
$1,465.92
$1,604.06
$2,094.80 		$1,705.00
$1,835.42
$1,973.56
$2,464.30 		$2,074.50
$2,204.92
$2,343.06
$2,833.80 		$369.50
Toc - Plan #159 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0405

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$427.18
$484.85
$545.93
$762.94
$1,159.36 		$753.97
$811.64
$872.72
$1,089.73 		$1,080.76
$1,138.43
$1,199.51
$1,416.52 		$1,407.55
$1,465.22
$1,526.30
$1,743.31 		$326.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.36
$969.70
$1,091.86
$1,525.88
$2,318.72 		$1,181.15
$1,296.49
$1,418.65
$1,852.67 		$1,507.94
$1,623.28
$1,745.44
$2,179.46 		$1,834.73
$1,950.07
$2,072.23
$2,506.25 		$326.79

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #160 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Elite SELECT Bronze with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408.64
$463.80
$522.23
$729.82
$1,109.03 		$721.24
$776.40
$834.83
$1,042.42 		$1,033.84
$1,089.00
$1,147.43
$1,355.02 		$1,346.44
$1,401.60
$1,460.03
$1,667.62 		$312.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817.28
$927.60
$1,044.46
$1,459.64
$2,218.06 		$1,129.88
$1,240.20
$1,357.06
$1,772.24 		$1,442.48
$1,552.80
$1,669.66
$2,084.84 		$1,755.08
$1,865.40
$1,982.26
$2,397.44 		$312.60
Toc - Plan #161 Ambetter from Sunshine Health
Silver

(HMO) Focused SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$451.43
$512.36
$576.91
$806.24
$1,225.15 		$796.77
$857.70
$922.25
$1,151.58 		$1,142.11
$1,203.04
$1,267.59
$1,496.92 		$1,487.45
$1,548.38
$1,612.93
$1,842.26 		$345.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902.86
$1,024.72
$1,153.82
$1,612.48
$2,450.30 		$1,248.20
$1,370.06
$1,499.16
$1,957.82 		$1,593.54
$1,715.40
$1,844.50
$2,303.16 		$1,938.88
$2,060.74
$2,189.84
$2,648.50 		$345.34
Toc - Plan #162 Ambetter from Sunshine Health
Gold

(HMO) Complete SELECT Gold with Select Providers

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 		$436.80
$495.76
$558.22
$780.11
$1,185.45 		$770.94
$829.90
$892.36
$1,114.25 		$1,105.08
$1,164.04
$1,226.50
$1,448.39 		$1,439.22
$1,498.18
$1,560.64
$1,782.53 		$334.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$873.60
$991.52
$1,116.44
$1,560.22
$2,370.90 		$1,207.74
$1,325.66
$1,450.58
$1,894.36 		$1,541.88
$1,659.80
$1,784.72
$2,228.50 		$1,876.02
$1,993.94
$2,118.86
$2,562.64 		$334.14
Toc - Plan #163 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Standard Expanded Bronze SELECT

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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.02
$396.12
$446.03
$623.33
$947.21 		$616.01
$663.11
$713.02
$890.32 		$883.00
$930.10
$980.01
$1,157.31 		$1,149.99
$1,197.09
$1,247.00
$1,424.30 		$266.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.04
$792.24
$892.06
$1,246.66
$1,894.42 		$965.03
$1,059.23
$1,159.05
$1,513.65 		$1,232.02
$1,326.22
$1,426.04
$1,780.64 		$1,499.01
$1,593.21
$1,693.03
$2,047.63 		$266.99
Toc - Plan #164 Ambetter from Sunshine Health
Silver

(HMO) Standard Silver SELECT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$442.02
$501.68
$564.88
$789.42
$1,199.60 		$780.15
$839.81
$903.01
$1,127.55 		$1,118.28
$1,177.94
$1,241.14
$1,465.68 		$1,456.41
$1,516.07
$1,579.27
$1,803.81 		$338.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.04
$1,003.36
$1,129.76
$1,578.84
$2,399.20 		$1,222.17
$1,341.49
$1,467.89
$1,916.97 		$1,560.30
$1,679.62
$1,806.02
$2,255.10 		$1,898.43
$2,017.75
$2,144.15
$2,593.23 		$338.13
Toc - Plan #165 Ambetter from Sunshine Health
Gold

(HMO) Standard Gold SELECT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$415.01
$471.02
$530.37
$741.19
$1,126.31 		$732.48
$788.49
$847.84
$1,058.66 		$1,049.95
$1,105.96
$1,165.31
$1,376.13 		$1,367.42
$1,423.43
$1,482.78
$1,693.60 		$317.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.02
$942.04
$1,060.74
$1,482.38
$2,252.62 		$1,147.49
$1,259.51
$1,378.21
$1,799.85 		$1,464.96
$1,576.98
$1,695.68
$2,117.32 		$1,782.43
$1,894.45
$2,013.15
$2,434.79 		$317.47
Toc - Plan #166 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Elite VALUE 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
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.12
$457.53
$515.17
$719.95
$1,094.04 		$711.50
$765.91
$823.55
$1,028.33 		$1,019.88
$1,074.29
$1,131.93
$1,336.71 		$1,328.26
$1,382.67
$1,440.31
$1,645.09 		$308.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.24
$915.06
$1,030.34
$1,439.90
$2,188.08 		$1,114.62
$1,223.44
$1,338.72
$1,748.28 		$1,423.00
$1,531.82
$1,647.10
$2,056.66 		$1,731.38
$1,840.20
$1,955.48
$2,365.04 		$308.38
Toc - Plan #167 Ambetter from Sunshine Health
Silver

(HMO) Complete VALUE Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1169

Annual Out of Pocket Expenses:

Individual Family