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Florida Obamacare 2023 Rates

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Florida Blue (BlueCross BlueShield FL)

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

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

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 Annual Deductible
$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$844.65
$958.68
$1,079.46
$1,508.54
$2,292.38
$1,490.81
$1,604.84
$1,725.62
$2,154.70
$2,136.97
$2,251.00
$2,371.78
$2,800.86
$2,783.13
$2,897.16
$3,017.94
$3,447.02
$646.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,689.30
$1,917.36
$2,158.92
$3,017.08
$4,584.76
$2,335.46
$2,563.52
$2,805.08
$3,663.24
$2,981.62
$3,209.68
$3,451.24
$4,309.40
$3,627.78
$3,855.84
$4,097.40
$4,955.56
$646.16
Toc - Plan #2 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$546.46
$620.23
$698.38
$975.98
$1,483.09
$964.50
$1,038.27
$1,116.42
$1,394.02
$1,382.54
$1,456.31
$1,534.46
$1,812.06
$1,800.58
$1,874.35
$1,952.50
$2,230.10
$418.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,092.92
$1,240.46
$1,396.76
$1,951.96
$2,966.18
$1,510.96
$1,658.50
$1,814.80
$2,370.00
$1,929.00
$2,076.54
$2,232.84
$2,788.04
$2,347.04
$2,494.58
$2,650.88
$3,206.08
$418.04
Toc - Plan #3 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$849.29
$963.94
$1,085.39
$1,516.83
$2,304.97
$1,499.00
$1,613.65
$1,735.10
$2,166.54
$2,148.71
$2,263.36
$2,384.81
$2,816.25
$2,798.42
$2,913.07
$3,034.52
$3,465.96
$649.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,698.58
$1,927.88
$2,170.78
$3,033.66
$4,609.94
$2,348.29
$2,577.59
$2,820.49
$3,683.37
$2,998.00
$3,227.30
$3,470.20
$4,333.08
$3,647.71
$3,877.01
$4,119.91
$4,982.79
$649.71
Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,000 $8,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$1,068.77
$1,213.05
$1,365.89
$1,908.82
$2,900.64
$1,886.38
$2,030.66
$2,183.50
$2,726.43
$2,703.99
$2,848.27
$3,001.11
$3,544.04
$3,521.60
$3,665.88
$3,818.72
$4,361.65
$817.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,137.54
$2,426.10
$2,731.78
$3,817.64
$5,801.28
$2,955.15
$3,243.71
$3,549.39
$4,635.25
$3,772.76
$4,061.32
$4,367.00
$5,452.86
$4,590.37
$4,878.93
$5,184.61
$6,270.47
$817.61
Toc - Plan #5 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$569.21
$646.05
$727.45
$1,016.61
$1,544.84
$1,004.66
$1,081.50
$1,162.90
$1,452.06
$1,440.11
$1,516.95
$1,598.35
$1,887.51
$1,875.56
$1,952.40
$2,033.80
$2,322.96
$435.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,138.42
$1,292.10
$1,454.90
$2,033.22
$3,089.68
$1,573.87
$1,727.55
$1,890.35
$2,468.67
$2,009.32
$2,163.00
$2,325.80
$2,904.12
$2,444.77
$2,598.45
$2,761.25
$3,339.57
$435.45
Toc - Plan #6 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$1,119.88
$1,271.06
$1,431.21
$2,000.11
$3,039.35
$1,976.59
$2,127.77
$2,287.92
$2,856.82
$2,833.30
$2,984.48
$3,144.63
$3,713.53
$3,690.01
$3,841.19
$4,001.34
$4,570.24
$856.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,239.76
$2,542.12
$2,862.42
$4,000.22
$6,078.70
$3,096.47
$3,398.83
$3,719.13
$4,856.93
$3,953.18
$4,255.54
$4,575.84
$5,713.64
$4,809.89
$5,112.25
$5,432.55
$6,570.35
$856.71
Toc - Plan #7 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$792.84
$899.87
$1,013.25
$1,416.01
$2,151.77
$1,399.36
$1,506.39
$1,619.77
$2,022.53
$2,005.88
$2,112.91
$2,226.29
$2,629.05
$2,612.40
$2,719.43
$2,832.81
$3,235.57
$606.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,585.68
$1,799.74
$2,026.50
$2,832.02
$4,303.54
$2,192.20
$2,406.26
$2,633.02
$3,438.54
$2,798.72
$3,012.78
$3,239.54
$4,045.06
$3,405.24
$3,619.30
$3,846.06
$4,651.58
$606.52
Toc - Plan #8 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$917.89
$1,041.81
$1,173.06
$1,639.35
$2,491.15
$1,620.08
$1,744.00
$1,875.25
$2,341.54
$2,322.27
$2,446.19
$2,577.44
$3,043.73
$3,024.46
$3,148.38
$3,279.63
$3,745.92
$702.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,835.78
$2,083.62
$2,346.12
$3,278.70
$4,982.30
$2,537.97
$2,785.81
$3,048.31
$3,980.89
$3,240.16
$3,488.00
$3,750.50
$4,683.08
$3,942.35
$4,190.19
$4,452.69
$5,385.27
$702.19
Toc - Plan #9 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$553.35
$628.05
$707.18
$988.28
$1,501.79
$976.66
$1,051.36
$1,130.49
$1,411.59
$1,399.97
$1,474.67
$1,553.80
$1,834.90
$1,823.28
$1,897.98
$1,977.11
$2,258.21
$423.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,106.70
$1,256.10
$1,414.36
$1,976.56
$3,003.58
$1,530.01
$1,679.41
$1,837.67
$2,399.87
$1,953.32
$2,102.72
$2,260.98
$2,823.18
$2,376.63
$2,526.03
$2,684.29
$3,246.49
$423.31
Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$888.04
$1,007.93
$1,134.92
$1,586.04
$2,410.14
$1,567.39
$1,687.28
$1,814.27
$2,265.39
$2,246.74
$2,366.63
$2,493.62
$2,944.74
$2,926.09
$3,045.98
$3,172.97
$3,624.09
$679.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,776.08
$2,015.86
$2,269.84
$3,172.08
$4,820.28
$2,455.43
$2,695.21
$2,949.19
$3,851.43
$3,134.78
$3,374.56
$3,628.54
$4,530.78
$3,814.13
$4,053.91
$4,307.89
$5,210.13
$679.35
Toc - Plan #11 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$602.84
$684.22
$770.43
$1,076.67
$1,636.11
$1,064.01
$1,145.39
$1,231.60
$1,537.84
$1,525.18
$1,606.56
$1,692.77
$1,999.01
$1,986.35
$2,067.73
$2,153.94
$2,460.18
$461.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,205.68
$1,368.44
$1,540.86
$2,153.34
$3,272.22
$1,666.85
$1,829.61
$2,002.03
$2,614.51
$2,128.02
$2,290.78
$2,463.20
$3,075.68
$2,589.19
$2,751.95
$2,924.37
$3,536.85
$461.17
Toc - Plan #12 Florida Blue (BlueCross BlueShield FL)
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$522.31
$592.82
$667.51
$932.85
$1,417.55
$921.88
$992.39
$1,067.08
$1,332.42
$1,321.45
$1,391.96
$1,466.65
$1,731.99
$1,721.02
$1,791.53
$1,866.22
$2,131.56
$399.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,044.62
$1,185.64
$1,335.02
$1,865.70
$2,835.10
$1,444.19
$1,585.21
$1,734.59
$2,265.27
$1,843.76
$1,984.78
$2,134.16
$2,664.84
$2,243.33
$2,384.35
$2,533.73
$3,064.41
$399.57
Toc - Plan #13 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$561.49
$637.29
$717.58
$1,002.82
$1,523.88
$991.03
$1,066.83
$1,147.12
$1,432.36
$1,420.57
$1,496.37
$1,576.66
$1,861.90
$1,850.11
$1,925.91
$2,006.20
$2,291.44
$429.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,122.98
$1,274.58
$1,435.16
$2,005.64
$3,047.76
$1,552.52
$1,704.12
$1,864.70
$2,435.18
$1,982.06
$2,133.66
$2,294.24
$2,864.72
$2,411.60
$2,563.20
$2,723.78
$3,294.26
$429.54
Toc - Plan #14 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$836.02
$948.88
$1,068.43
$1,493.13
$2,268.96
$1,475.58
$1,588.44
$1,707.99
$2,132.69
$2,115.14
$2,228.00
$2,347.55
$2,772.25
$2,754.70
$2,867.56
$2,987.11
$3,411.81
$639.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,672.04
$1,897.76
$2,136.86
$2,986.26
$4,537.92
$2,311.60
$2,537.32
$2,776.42
$3,625.82
$2,951.16
$3,176.88
$3,415.98
$4,265.38
$3,590.72
$3,816.44
$4,055.54
$4,904.94
$639.56
Toc - Plan #15 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$853.29
$968.48
$1,090.50
$1,523.98
$2,315.83
$1,506.06
$1,621.25
$1,743.27
$2,176.75
$2,158.83
$2,274.02
$2,396.04
$2,829.52
$2,811.60
$2,926.79
$3,048.81
$3,482.29
$652.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,706.58
$1,936.96
$2,181.00
$3,047.96
$4,631.66
$2,359.35
$2,589.73
$2,833.77
$3,700.73
$3,012.12
$3,242.50
$3,486.54
$4,353.50
$3,664.89
$3,895.27
$4,139.31
$5,006.27
$652.77
Toc - Plan #16 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$1,117.07
$1,267.87
$1,427.62
$1,995.09
$3,031.73
$1,971.63
$2,122.43
$2,282.18
$2,849.65
$2,826.19
$2,976.99
$3,136.74
$3,704.21
$3,680.75
$3,831.55
$3,991.30
$4,558.77
$854.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,234.14
$2,535.74
$2,855.24
$3,990.18
$6,063.46
$3,088.70
$3,390.30
$3,709.80
$4,844.74
$3,943.26
$4,244.86
$4,564.36
$5,699.30
$4,797.82
$5,099.42
$5,418.92
$6,553.86
$854.56
Toc - Plan #17 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$590.98
$670.76
$755.27
$1,055.49
$1,603.92
$1,043.08
$1,122.86
$1,207.37
$1,507.59
$1,495.18
$1,574.96
$1,659.47
$1,959.69
$1,947.28
$2,027.06
$2,111.57
$2,411.79
$452.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,181.96
$1,341.52
$1,510.54
$2,110.98
$3,207.84
$1,634.06
$1,793.62
$1,962.64
$2,563.08
$2,086.16
$2,245.72
$2,414.74
$3,015.18
$2,538.26
$2,697.82
$2,866.84
$3,467.28
$452.10
Toc - Plan #18 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 Annual Deductible
$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$552.32
$626.88
$705.86
$986.44
$1,499.00
$974.84
$1,049.40
$1,128.38
$1,408.96
$1,397.36
$1,471.92
$1,550.90
$1,831.48
$1,819.88
$1,894.44
$1,973.42
$2,254.00
$422.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,104.64
$1,253.76
$1,411.72
$1,972.88
$2,998.00
$1,527.16
$1,676.28
$1,834.24
$2,395.40
$1,949.68
$2,098.80
$2,256.76
$2,817.92
$2,372.20
$2,521.32
$2,679.28
$3,240.44
$422.52
Toc - Plan #19 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415.87
$472.01
$531.48
$742.74
$1,128.67
$734.01
$790.15
$849.62
$1,060.88
$1,052.15
$1,108.29
$1,167.76
$1,379.02
$1,370.29
$1,426.43
$1,485.90
$1,697.16
$318.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$831.74
$944.02
$1,062.96
$1,485.48
$2,257.34
$1,149.88
$1,262.16
$1,381.10
$1,803.62
$1,468.02
$1,580.30
$1,699.24
$2,121.76
$1,786.16
$1,898.44
$2,017.38
$2,439.90
$318.14
Toc - Plan #20 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$550.61
$624.94
$703.68
$983.39
$1,494.36
$971.83
$1,046.16
$1,124.90
$1,404.61
$1,393.05
$1,467.38
$1,546.12
$1,825.83
$1,814.27
$1,888.60
$1,967.34
$2,247.05
$421.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,101.22
$1,249.88
$1,407.36
$1,966.78
$2,988.72
$1,522.44
$1,671.10
$1,828.58
$2,388.00
$1,943.66
$2,092.32
$2,249.80
$2,809.22
$2,364.88
$2,513.54
$2,671.02
$3,230.44
$421.22
Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,000 $8,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$698.66
$792.98
$892.89
$1,247.81
$1,896.16
$1,233.13
$1,327.45
$1,427.36
$1,782.28
$1,767.60
$1,861.92
$1,961.83
$2,316.75
$2,302.07
$2,396.39
$2,496.30
$2,851.22
$534.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,397.32
$1,585.96
$1,785.78
$2,495.62
$3,792.32
$1,931.79
$2,120.43
$2,320.25
$3,030.09
$2,466.26
$2,654.90
$2,854.72
$3,564.56
$3,000.73
$3,189.37
$3,389.19
$4,099.03
$534.47
Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.58
$487.57
$549.00
$767.23
$1,165.88
$758.21
$816.20
$877.63
$1,095.86
$1,086.84
$1,144.83
$1,206.26
$1,424.49
$1,415.47
$1,473.46
$1,534.89
$1,753.12
$328.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.16
$975.14
$1,098.00
$1,534.46
$2,331.76
$1,187.79
$1,303.77
$1,426.63
$1,863.09
$1,516.42
$1,632.40
$1,755.26
$2,191.72
$1,845.05
$1,961.03
$2,083.89
$2,520.35
$328.63
Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$731.13
$829.83
$934.38
$1,305.80
$1,984.29
$1,290.44
$1,389.14
$1,493.69
$1,865.11
$1,849.75
$1,948.45
$2,053.00
$2,424.42
$2,409.06
$2,507.76
$2,612.31
$2,983.73
$559.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,462.26
$1,659.66
$1,868.76
$2,611.60
$3,968.58
$2,021.57
$2,218.97
$2,428.07
$3,170.91
$2,580.88
$2,778.28
$2,987.38
$3,730.22
$3,140.19
$3,337.59
$3,546.69
$4,289.53
$559.31
Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$516.87
$586.65
$660.56
$923.13
$1,402.79
$912.28
$982.06
$1,055.97
$1,318.54
$1,307.69
$1,377.47
$1,451.38
$1,713.95
$1,703.10
$1,772.88
$1,846.79
$2,109.36
$395.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,033.74
$1,173.30
$1,321.12
$1,846.26
$2,805.58
$1,429.15
$1,568.71
$1,716.53
$2,241.67
$1,824.56
$1,964.12
$2,111.94
$2,637.08
$2,219.97
$2,359.53
$2,507.35
$3,032.49
$395.41
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$609.86
$692.19
$779.40
$1,089.21
$1,655.16
$1,076.40
$1,158.73
$1,245.94
$1,555.75
$1,542.94
$1,625.27
$1,712.48
$2,022.29
$2,009.48
$2,091.81
$2,179.02
$2,488.83
$466.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,219.72
$1,384.38
$1,558.80
$2,178.42
$3,310.32
$1,686.26
$1,850.92
$2,025.34
$2,644.96
$2,152.80
$2,317.46
$2,491.88
$3,111.50
$2,619.34
$2,784.00
$2,958.42
$3,578.04
$466.54
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$420.35
$477.10
$537.21
$750.75
$1,140.83
$741.92
$798.67
$858.78
$1,072.32
$1,063.49
$1,120.24
$1,180.35
$1,393.89
$1,385.06
$1,441.81
$1,501.92
$1,715.46
$321.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$840.70
$954.20
$1,074.42
$1,501.50
$2,281.66
$1,162.27
$1,275.77
$1,395.99
$1,823.07
$1,483.84
$1,597.34
$1,717.56
$2,144.64
$1,805.41
$1,918.91
$2,039.13
$2,466.21
$321.57
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$589.99
$669.64
$754.01
$1,053.72
$1,601.23
$1,041.33
$1,120.98
$1,205.35
$1,505.06
$1,492.67
$1,572.32
$1,656.69
$1,956.40
$1,944.01
$2,023.66
$2,108.03
$2,407.74
$451.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,179.98
$1,339.28
$1,508.02
$2,107.44
$3,202.46
$1,631.32
$1,790.62
$1,959.36
$2,558.78
$2,082.66
$2,241.96
$2,410.70
$3,010.12
$2,534.00
$2,693.30
$2,862.04
$3,461.46
$451.34
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$455.15
$516.60
$581.68
$812.90
$1,235.28
$803.34
$864.79
$929.87
$1,161.09
$1,151.53
$1,212.98
$1,278.06
$1,509.28
$1,499.72
$1,561.17
$1,626.25
$1,857.47
$348.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$910.30
$1,033.20
$1,163.36
$1,625.80
$2,470.56
$1,258.49
$1,381.39
$1,511.55
$1,973.99
$1,606.68
$1,729.58
$1,859.74
$2,322.18
$1,954.87
$2,077.77
$2,207.93
$2,670.37
$348.19
Toc - Plan #29 Florida Blue (BlueCross BlueShield FL)
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.49
$447.75
$504.16
$704.56
$1,070.65
$696.27
$749.53
$805.94
$1,006.34
$998.05
$1,051.31
$1,107.72
$1,308.12
$1,299.83
$1,353.09
$1,409.50
$1,609.90
$301.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.98
$895.50
$1,008.32
$1,409.12
$2,141.30
$1,090.76
$1,197.28
$1,310.10
$1,710.90
$1,392.54
$1,499.06
$1,611.88
$2,012.68
$1,694.32
$1,800.84
$1,913.66
$2,314.46
$301.78
Toc - Plan #30 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$424.13
$481.39
$542.04
$757.50
$1,151.09
$748.59
$805.85
$866.50
$1,081.96
$1,073.05
$1,130.31
$1,190.96
$1,406.42
$1,397.51
$1,454.77
$1,515.42
$1,730.88
$324.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$848.26
$962.78
$1,084.08
$1,515.00
$2,302.18
$1,172.72
$1,287.24
$1,408.54
$1,839.46
$1,497.18
$1,611.70
$1,733.00
$2,163.92
$1,821.64
$1,936.16
$2,057.46
$2,488.38
$324.46
Toc - Plan #31 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$545.06
$618.64
$696.59
$973.48
$1,479.29
$962.03
$1,035.61
$1,113.56
$1,390.45
$1,379.00
$1,452.58
$1,530.53
$1,807.42
$1,795.97
$1,869.55
$1,947.50
$2,224.39
$416.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,090.12
$1,237.28
$1,393.18
$1,946.96
$2,958.58
$1,507.09
$1,654.25
$1,810.15
$2,363.93
$1,924.06
$2,071.22
$2,227.12
$2,780.90
$2,341.03
$2,488.19
$2,644.09
$3,197.87
$416.97
Toc - Plan #32 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$567.00
$643.55
$724.63
$1,012.66
$1,538.84
$1,000.76
$1,077.31
$1,158.39
$1,446.42
$1,434.52
$1,511.07
$1,592.15
$1,880.18
$1,868.28
$1,944.83
$2,025.91
$2,313.94
$433.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,134.00
$1,287.10
$1,449.26
$2,025.32
$3,077.68
$1,567.76
$1,720.86
$1,883.02
$2,459.08
$2,001.52
$2,154.62
$2,316.78
$2,892.84
$2,435.28
$2,588.38
$2,750.54
$3,326.60
$433.76
Toc - Plan #33 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$729.26
$827.71
$931.99
$1,302.46
$1,979.21
$1,287.14
$1,385.59
$1,489.87
$1,860.34
$1,845.02
$1,943.47
$2,047.75
$2,418.22
$2,402.90
$2,501.35
$2,605.63
$2,976.10
$557.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,458.52
$1,655.42
$1,863.98
$2,604.92
$3,958.42
$2,016.40
$2,213.30
$2,421.86
$3,162.80
$2,574.28
$2,771.18
$2,979.74
$3,720.68
$3,132.16
$3,329.06
$3,537.62
$4,278.56
$557.88
Toc - Plan #34 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$446.37
$506.63
$570.46
$797.22
$1,211.45
$787.84
$848.10
$911.93
$1,138.69
$1,129.31
$1,189.57
$1,253.40
$1,480.16
$1,470.78
$1,531.04
$1,594.87
$1,821.63
$341.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$892.74
$1,013.26
$1,140.92
$1,594.44
$2,422.90
$1,234.21
$1,354.73
$1,482.39
$1,935.91
$1,575.68
$1,696.20
$1,823.86
$2,277.38
$1,917.15
$2,037.67
$2,165.33
$2,618.85
$341.47

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #35 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.15
$447.37
$503.73
$703.96
$1,069.74
$695.68
$748.90
$805.26
$1,005.49
$997.21
$1,050.43
$1,106.79
$1,307.02
$1,298.74
$1,351.96
$1,408.32
$1,608.55
$301.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.30
$894.74
$1,007.46
$1,407.92
$2,139.48
$1,089.83
$1,196.27
$1,308.99
$1,709.45
$1,391.36
$1,497.80
$1,610.52
$2,010.98
$1,692.89
$1,799.33
$1,912.05
$2,312.51
$301.53
Toc - Plan #36 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$365.06
$414.34
$466.55
$652.00
$990.77
$644.33
$693.61
$745.82
$931.27
$923.60
$972.88
$1,025.09
$1,210.54
$1,202.87
$1,252.15
$1,304.36
$1,489.81
$279.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.12
$828.68
$933.10
$1,304.00
$1,981.54
$1,009.39
$1,107.95
$1,212.37
$1,583.27
$1,288.66
$1,387.22
$1,491.64
$1,862.54
$1,567.93
$1,666.49
$1,770.91
$2,141.81
$279.27
Toc - Plan #37 Aetna CVS Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$299.59
$340.03
$382.87
$535.06
$813.07
$528.77
$569.21
$612.05
$764.24
$757.95
$798.39
$841.23
$993.42
$987.13
$1,027.57
$1,070.41
$1,222.60
$229.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$599.18
$680.06
$765.74
$1,070.12
$1,626.14
$828.36
$909.24
$994.92
$1,299.30
$1,057.54
$1,138.42
$1,224.10
$1,528.48
$1,286.72
$1,367.60
$1,453.28
$1,757.66
$229.18
Toc - Plan #38 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$4,425 $8,850 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.39
$444.22
$500.19
$699.02
$1,062.22
$690.80
$743.63
$799.60
$998.43
$990.21
$1,043.04
$1,099.01
$1,297.84
$1,289.62
$1,342.45
$1,398.42
$1,597.25
$299.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782.78
$888.44
$1,000.38
$1,398.04
$2,124.44
$1,082.19
$1,187.85
$1,299.79
$1,697.45
$1,381.60
$1,487.26
$1,599.20
$1,996.86
$1,681.01
$1,786.67
$1,898.61
$2,296.27
$299.41
Toc - Plan #39 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.35
$474.83
$534.65
$747.18
$1,135.41
$738.39
$794.87
$854.69
$1,067.22
$1,058.43
$1,114.91
$1,174.73
$1,387.26
$1,378.47
$1,434.95
$1,494.77
$1,707.30
$320.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.70
$949.66
$1,069.30
$1,494.36
$2,270.82
$1,156.74
$1,269.70
$1,389.34
$1,814.40
$1,476.78
$1,589.74
$1,709.38
$2,134.44
$1,796.82
$1,909.78
$2,029.42
$2,454.48
$320.04
Toc - Plan #40 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$379.79
$431.06
$485.37
$678.30
$1,030.75
$670.33
$721.60
$775.91
$968.84
$960.87
$1,012.14
$1,066.45
$1,259.38
$1,251.41
$1,302.68
$1,356.99
$1,549.92
$290.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$759.58
$862.12
$970.74
$1,356.60
$2,061.50
$1,050.12
$1,152.66
$1,261.28
$1,647.14
$1,340.66
$1,443.20
$1,551.82
$1,937.68
$1,631.20
$1,733.74
$1,842.36
$2,228.22
$290.54
Toc - Plan #41 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.96
$505.03
$568.66
$794.70
$1,207.63
$785.36
$845.43
$909.06
$1,135.10
$1,125.76
$1,185.83
$1,249.46
$1,475.50
$1,466.16
$1,526.23
$1,589.86
$1,815.90
$340.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$889.92
$1,010.06
$1,137.32
$1,589.40
$2,415.26
$1,230.32
$1,350.46
$1,477.72
$1,929.80
$1,570.72
$1,690.86
$1,818.12
$2,270.20
$1,911.12
$2,031.26
$2,158.52
$2,610.60
$340.40

ADVERTISEMENT

AvMed

Local: 1-800-477-8768 | Toll Free: 

Toc - Plan #42 AvMed
Gold

(HMO) AvMed Entrust Gold 125 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$499.58
$567.02
$638.46
$892.24
$1,355.85
$881.76
$949.20
$1,020.64
$1,274.42
$1,263.94
$1,331.38
$1,402.82
$1,656.60
$1,646.12
$1,713.56
$1,785.00
$2,038.78
$382.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$999.16
$1,134.04
$1,276.92
$1,784.48
$2,711.70
$1,381.34
$1,516.22
$1,659.10
$2,166.66
$1,763.52
$1,898.40
$2,041.28
$2,548.84
$2,145.70
$2,280.58
$2,423.46
$2,931.02
$382.18
Toc - Plan #43 AvMed
Silver

(HMO) AvMed Entrust Silver 300 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,650 $15,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$487.53
$553.34
$623.06
$870.72
$1,323.14
$860.49
$926.30
$996.02
$1,243.68
$1,233.45
$1,299.26
$1,368.98
$1,616.64
$1,606.41
$1,672.22
$1,741.94
$1,989.60
$372.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$975.06
$1,106.68
$1,246.12
$1,741.44
$2,646.28
$1,348.02
$1,479.64
$1,619.08
$2,114.40
$1,720.98
$1,852.60
$1,992.04
$2,487.36
$2,093.94
$2,225.56
$2,365.00
$2,860.32
$372.96
Toc - Plan #44 AvMed
Silver

(HMO) AvMed Entrust Silver 350 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$469.23
$532.58
$599.68
$838.05
$1,273.49
$828.19
$891.54
$958.64
$1,197.01
$1,187.15
$1,250.50
$1,317.60
$1,555.97
$1,546.11
$1,609.46
$1,676.56
$1,914.93
$358.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$938.46
$1,065.16
$1,199.36
$1,676.10
$2,546.98
$1,297.42
$1,424.12
$1,558.32
$2,035.06
$1,656.38
$1,783.08
$1,917.28
$2,394.02
$2,015.34
$2,142.04
$2,276.24
$2,752.98
$358.96
Toc - Plan #45 AvMed
Silver

(HMO) AvMed Entrust Silver 500 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$466.49
$529.47
$596.17
$833.15
$1,266.06
$823.36
$886.34
$953.04
$1,190.02
$1,180.23
$1,243.21
$1,309.91
$1,546.89
$1,537.10
$1,600.08
$1,666.78
$1,903.76
$356.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$932.98
$1,058.94
$1,192.34
$1,666.30
$2,532.12
$1,289.85
$1,415.81
$1,549.21
$2,023.17
$1,646.72
$1,772.68
$1,906.08
$2,380.04
$2,003.59
$2,129.55
$2,262.95
$2,736.91
$356.87
Toc - Plan #46 AvMed
Silver

(HMO) AvMed Entrust Silver 550 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$463.68
$526.28
$592.59
$828.14
$1,258.43
$818.40
$881.00
$947.31
$1,182.86
$1,173.12
$1,235.72
$1,302.03
$1,537.58
$1,527.84
$1,590.44
$1,656.75
$1,892.30
$354.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$927.36
$1,052.56
$1,185.18
$1,656.28
$2,516.86
$1,282.08
$1,407.28
$1,539.90
$2,011.00
$1,636.80
$1,762.00
$1,894.62
$2,365.72
$1,991.52
$2,116.72
$2,249.34
$2,720.44
$354.72
Toc - Plan #47 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 600 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.70
$434.36
$489.09
$683.50
$1,038.64
$675.46
$727.12
$781.85
$976.26
$968.22
$1,019.88
$1,074.61
$1,269.02
$1,260.98
$1,312.64
$1,367.37
$1,561.78
$292.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.40
$868.72
$978.18
$1,367.00
$2,077.28
$1,058.16
$1,161.48
$1,270.94
$1,659.76
$1,350.92
$1,454.24
$1,563.70
$1,952.52
$1,643.68
$1,747.00
$1,856.46
$2,245.28
$292.76
Toc - Plan #48 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 650 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.37
$419.24
$472.06
$659.70
$1,002.48
$651.94
$701.81
$754.63
$942.27
$934.51
$984.38
$1,037.20
$1,224.84
$1,217.08
$1,266.95
$1,319.77
$1,507.41
$282.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.74
$838.48
$944.12
$1,319.40
$2,004.96
$1,021.31
$1,121.05
$1,226.69
$1,601.97
$1,303.88
$1,403.62
$1,509.26
$1,884.54
$1,586.45
$1,686.19
$1,791.83
$2,167.11
$282.57
Toc - Plan #49 AvMed
Catastrophic

(HMO) AvMed Entrust Catastrophic 100 (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$302.30
$343.11
$386.34
$539.91
$820.45
$533.56
$574.37
$617.60
$771.17
$764.82
$805.63
$848.86
$1,002.43
$996.08
$1,036.89
$1,080.12
$1,233.69
$231.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.60
$686.22
$772.68
$1,079.82
$1,640.90
$835.86
$917.48
$1,003.94
$1,311.08
$1,067.12
$1,148.74
$1,235.20
$1,542.34
$1,298.38
$1,380.00
$1,466.46
$1,773.60
$231.26
Toc - Plan #50 AvMed
Gold

(HMO) AvMed Entrust Gold Standard (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$496.21
$563.20
$634.16
$886.23
$1,346.71
$875.81
$942.80
$1,013.76
$1,265.83
$1,255.41
$1,322.40
$1,393.36
$1,645.43
$1,635.01
$1,702.00
$1,772.96
$2,025.03
$379.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$992.42
$1,126.40
$1,268.32
$1,772.46
$2,693.42
$1,372.02
$1,506.00
$1,647.92
$2,152.06
$1,751.62
$1,885.60
$2,027.52
$2,531.66
$2,131.22
$2,265.20
$2,407.12
$2,911.26
$379.60
Toc - Plan #51 AvMed
Silver

(HMO) AvMed Entrust Silver Standard (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$449.91
$510.65
$574.99
$803.55
$1,221.07
$794.09
$854.83
$919.17
$1,147.73
$1,138.27
$1,199.01
$1,263.35
$1,491.91
$1,482.45
$1,543.19
$1,607.53
$1,836.09
$344.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$899.82
$1,021.30
$1,149.98
$1,607.10
$2,442.14
$1,244.00
$1,365.48
$1,494.16
$1,951.28
$1,588.18
$1,709.66
$1,838.34
$2,295.46
$1,932.36
$2,053.84
$2,182.52
$2,639.64
$344.18
Toc - Plan #52 AvMed
Expanded Bronze

(HMO) AvMed Entrust Expanded Bronze Standard (2023)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.12
$431.44
$485.80
$678.90
$1,031.65
$670.91
$722.23
$776.59
$969.69
$961.70
$1,013.02
$1,067.38
$1,260.48
$1,252.49
$1,303.81
$1,358.17
$1,551.27
$290.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.24
$862.88
$971.60
$1,357.80
$2,063.30
$1,051.03
$1,153.67
$1,262.39
$1,648.59
$1,341.82
$1,444.46
$1,553.18
$1,939.38
$1,632.61
$1,735.25
$1,843.97
$2,230.17
$290.79
Toc - Plan #53 AvMed
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$504.42
$572.52
$644.65
$900.90
$1,369.00
$890.30
$958.40
$1,030.53
$1,286.78
$1,276.18
$1,344.28
$1,416.41
$1,672.66
$1,662.06
$1,730.16
$1,802.29
$2,058.54
$385.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,008.84
$1,145.04
$1,289.30
$1,801.80
$2,738.00
$1,394.72
$1,530.92
$1,675.18
$2,187.68
$1,780.60
$1,916.80
$2,061.06
$2,573.56
$2,166.48
$2,302.68
$2,446.94
$2,959.44
$385.88
Toc - Plan #54 AvMed
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,650 $15,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$492.35
$558.82
$629.22
$879.34
$1,336.24
$869.00
$935.47
$1,005.87
$1,255.99
$1,245.65
$1,312.12
$1,382.52
$1,632.64
$1,622.30
$1,688.77
$1,759.17
$2,009.29
$376.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$984.70
$1,117.64
$1,258.44
$1,758.68
$2,672.48
$1,361.35
$1,494.29
$1,635.09
$2,135.33
$1,738.00
$1,870.94
$2,011.74
$2,511.98
$2,114.65
$2,247.59
$2,388.39
$2,888.63
$376.65
Toc - Plan #55 AvMed
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$474.07
$538.06
$605.86
$846.68
$1,286.61
$836.73
$900.72
$968.52
$1,209.34
$1,199.39
$1,263.38
$1,331.18
$1,572.00
$1,562.05
$1,626.04
$1,693.84
$1,934.66
$362.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$948.14
$1,076.12
$1,211.72
$1,693.36
$2,573.22
$1,310.80
$1,438.78
$1,574.38
$2,056.02
$1,673.46
$1,801.44
$1,937.04
$2,418.68
$2,036.12
$2,164.10
$2,299.70
$2,781.34
$362.66
Toc - Plan #56 AvMed
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$471.30
$534.92
$602.32
$841.73
$1,279.10
$831.84
$895.46
$962.86
$1,202.27
$1,192.38
$1,256.00
$1,323.40
$1,562.81
$1,552.92
$1,616.54
$1,683.94
$1,923.35
$360.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$942.60
$1,069.84
$1,204.64
$1,683.46
$2,558.20
$1,303.14
$1,430.38
$1,565.18
$2,044.00
$1,663.68
$1,790.92
$1,925.72
$2,404.54
$2,024.22
$2,151.46
$2,286.26
$2,765.08
$360.54
Toc - Plan #57 AvMed
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$468.51
$531.76
$598.75
$836.75
$1,271.53
$826.92
$890.17
$957.16
$1,195.16
$1,185.33
$1,248.58
$1,315.57
$1,553.57
$1,543.74
$1,606.99
$1,673.98
$1,911.98
$358.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$937.02
$1,063.52
$1,197.50
$1,673.50
$2,543.06
$1,295.43
$1,421.93
$1,555.91
$2,031.91
$1,653.84
$1,780.34
$1,914.32
$2,390.32
$2,012.25
$2,138.75
$2,272.73
$2,748.73
$358.41
Toc - Plan #58 AvMed
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,350 $16,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$474.52
$538.58
$606.43
$847.49
$1,287.84
$837.53
$901.59
$969.44
$1,210.50
$1,200.54
$1,264.60
$1,332.45
$1,573.51
$1,563.55
$1,627.61
$1,695.46
$1,936.52
$363.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$949.04
$1,077.16
$1,212.86
$1,694.98
$2,575.68
$1,312.05
$1,440.17
$1,575.87
$2,057.99
$1,675.06
$1,803.18
$1,938.88
$2,421.00
$2,038.07
$2,166.19
$2,301.89
$2,784.01
$363.01

ADVERTISEMENT

Ambetter from Sunshine Health

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

Toc - Plan #59 Ambetter from Sunshine Health
Bronze

(EPO) Clear Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$320.91
$364.22
$410.11
$573.13
$870.93
$566.40
$609.71
$655.60
$818.62
$811.89
$855.20
$901.09
$1,064.11
$1,057.38
$1,100.69
$1,146.58
$1,309.60
$245.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.82
$728.44
$820.22
$1,146.26
$1,741.86
$887.31
$973.93
$1,065.71
$1,391.75
$1,132.80
$1,219.42
$1,311.20
$1,637.24
$1,378.29
$1,464.91
$1,556.69
$1,882.73
$245.49
Toc - Plan #60 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$430.39
$488.48
$550.03
$768.66
$1,168.06
$759.63
$817.72
$879.27
$1,097.90
$1,088.87
$1,146.96
$1,208.51
$1,427.14
$1,418.11
$1,476.20
$1,537.75
$1,756.38
$329.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$860.78
$976.96
$1,100.06
$1,537.32
$2,336.12
$1,190.02
$1,306.20
$1,429.30
$1,866.56
$1,519.26
$1,635.44
$1,758.54
$2,195.80
$1,848.50
$1,964.68
$2,087.78
$2,525.04
$329.24
Toc - Plan #61 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.42
$401.12
$451.66
$631.19
$959.15
$623.78
$671.48
$722.02
$901.55
$894.14
$941.84
$992.38
$1,171.91
$1,164.50
$1,212.20
$1,262.74
$1,442.27
$270.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.84
$802.24
$903.32
$1,262.38
$1,918.30
$977.20
$1,072.60
$1,173.68
$1,532.74
$1,247.56
$1,342.96
$1,444.04
$1,803.10
$1,517.92
$1,613.32
$1,714.40
$2,073.46
$270.36
Toc - Plan #62 Ambetter from Sunshine Health
Silver

(EPO) Everyday SIlver

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.99
$493.70
$555.90
$776.87
$1,180.53
$767.75
$826.46
$888.66
$1,109.63
$1,100.51
$1,159.22
$1,221.42
$1,442.39
$1,433.27
$1,491.98
$1,554.18
$1,775.15
$332.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869.98
$987.40
$1,111.80
$1,553.74
$2,361.06
$1,202.74
$1,320.16
$1,444.56
$1,886.50
$1,535.50
$1,652.92
$1,777.32
$2,219.26
$1,868.26
$1,985.68
$2,110.08
$2,552.02
$332.76
Toc - Plan #63 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$345.05
$391.62
$440.96
$616.25
$936.45
$609.01
$655.58
$704.92
$880.21
$872.97
$919.54
$968.88
$1,144.17
$1,136.93
$1,183.50
$1,232.84
$1,408.13
$263.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$690.10
$783.24
$881.92
$1,232.50
$1,872.90
$954.06
$1,047.20
$1,145.88
$1,496.46
$1,218.02
$1,311.16
$1,409.84
$1,760.42
$1,481.98
$1,575.12
$1,673.80
$2,024.38
$263.96
Toc - Plan #64 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.46
$448.84
$505.38
$706.27
$1,073.25
$697.98
$751.36
$807.90
$1,008.79
$1,000.50
$1,053.88
$1,110.42
$1,311.31
$1,303.02
$1,356.40
$1,412.94
$1,613.83
$302.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$790.92
$897.68
$1,010.76
$1,412.54
$2,146.50
$1,093.44
$1,200.20
$1,313.28
$1,715.06
$1,395.96
$1,502.72
$1,615.80
$2,017.58
$1,698.48
$1,805.24
$1,918.32
$2,320.10
$302.52
Toc - Plan #65 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.79
$487.80
$549.25
$767.58
$1,166.41
$758.57
$816.58
$878.03
$1,096.36
$1,087.35
$1,145.36
$1,206.81
$1,425.14
$1,416.13
$1,474.14
$1,535.59
$1,753.92
$328.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.58
$975.60
$1,098.50
$1,535.16
$2,332.82
$1,188.36
$1,304.38
$1,427.28
$1,863.94
$1,517.14
$1,633.16
$1,756.06
$2,192.72
$1,845.92
$1,961.94
$2,084.84
$2,521.50
$328.78
Toc - Plan #66 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.43
$491.93
$553.91
$774.08
$1,176.29
$764.99
$823.49
$885.47
$1,105.64
$1,096.55
$1,155.05
$1,217.03
$1,437.20
$1,428.11
$1,486.61
$1,548.59
$1,768.76
$331.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$866.86
$983.86
$1,107.82
$1,548.16
$2,352.58
$1,198.42
$1,315.42
$1,439.38
$1,879.72
$1,529.98
$1,646.98
$1,770.94
$2,211.28
$1,861.54
$1,978.54
$2,102.50
$2,542.84
$331.56
Toc - Plan #67 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.72
$466.15
$524.88
$733.52
$1,114.66
$724.91
$780.34
$839.07
$1,047.71
$1,039.10
$1,094.53
$1,153.26
$1,361.90
$1,353.29
$1,408.72
$1,467.45
$1,676.09
$314.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.44
$932.30
$1,049.76
$1,467.04
$2,229.32
$1,135.63
$1,246.49
$1,363.95
$1,781.23
$1,449.82
$1,560.68
$1,678.14
$2,095.42
$1,764.01
$1,874.87
$1,992.33
$2,409.61
$314.19
Toc - Plan #68 Ambetter from Sunshine Health
Silver

(EPO) Enhanced SIlver

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

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.98
$494.83
$557.17
$778.65
$1,183.23
$769.50
$828.35
$890.69
$1,112.17
$1,103.02
$1,161.87
$1,224.21
$1,445.69
$1,436.54
$1,495.39
$1,557.73
$1,779.21
$333.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871.96
$989.66
$1,114.34
$1,557.30
$2,366.46
$1,205.48
$1,323.18
$1,447.86
$1,890.82
$1,539.00
$1,656.70
$1,781.38
$2,224.34
$1,872.52
$1,990.22
$2,114.90
$2,557.86
$333.52
Toc - Plan #69 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$477.90
$542.40
$610.74
$853.50
$1,296.98
$843.48
$907.98
$976.32
$1,219.08
$1,209.06
$1,273.56
$1,341.90
$1,584.66
$1,574.64
$1,639.14
$1,707.48
$1,950.24
$365.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$955.80
$1,084.80
$1,221.48
$1,707.00
$2,593.96
$1,321.38
$1,450.38
$1,587.06
$2,072.58
$1,686.96
$1,815.96
$1,952.64
$2,438.16
$2,052.54
$2,181.54
$2,318.22
$2,803.74
$365.58
Toc - Plan #70 Ambetter from Sunshine Health
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$338.60
$384.29
$432.71
$604.71
$918.92
$597.62
$643.31
$691.73
$863.73
$856.64
$902.33
$950.75
$1,122.75
$1,115.66
$1,161.35
$1,209.77
$1,381.77
$259.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$677.20
$768.58
$865.42
$1,209.42
$1,837.84
$936.22
$1,027.60
$1,124.44
$1,468.44
$1,195.24
$1,286.62
$1,383.46
$1,727.46
$1,454.26
$1,545.64
$1,642.48
$1,986.48
$259.02
Toc - Plan #71 Ambetter from Sunshine Health
Silver

(EPO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.53
$487.50
$548.92
$767.12
$1,165.71
$758.11
$816.08
$877.50
$1,095.70
$1,086.69
$1,144.66
$1,206.08
$1,424.28
$1,415.27
$1,473.24
$1,534.66
$1,752.86
$328.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.06
$975.00
$1,097.84
$1,534.24
$2,331.42
$1,187.64
$1,303.58
$1,426.42
$1,862.82
$1,516.22
$1,632.16
$1,755.00
$2,191.40
$1,844.80
$1,960.74
$2,083.58
$2,519.98
$328.58
Toc - Plan #72 Ambetter from Sunshine Health
Gold

(EPO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$402.22
$456.51
$514.03
$718.35
$1,091.60
$709.91
$764.20
$821.72
$1,026.04
$1,017.60
$1,071.89
$1,129.41
$1,333.73
$1,325.29
$1,379.58
$1,437.10
$1,641.42
$307.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$804.44
$913.02
$1,028.06
$1,436.70
$2,183.20
$1,112.13
$1,220.71
$1,335.75
$1,744.39
$1,419.82
$1,528.40
$1,643.44
$2,052.08
$1,727.51
$1,836.09
$1,951.13
$2,359.77
$307.69
Toc - Plan #73 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.53
$416.00
$468.41
$654.60
$994.73
$646.92
$696.39
$748.80
$934.99
$927.31
$976.78
$1,029.19
$1,215.38
$1,207.70
$1,257.17
$1,309.58
$1,495.77
$280.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.06
$832.00
$936.82
$1,309.20
$1,989.46
$1,013.45
$1,112.39
$1,217.21
$1,589.59
$1,293.84
$1,392.78
$1,497.60
$1,869.98
$1,574.23
$1,673.17
$1,777.99
$2,150.37
$280.39
Toc - Plan #74 Ambetter from Sunshine Health
Silver

(EPO) Everyday Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$451.12
$512.01
$576.52
$805.69
$1,224.32
$796.22
$857.11
$921.62
$1,150.79
$1,141.32
$1,202.21
$1,266.72
$1,495.89
$1,486.42
$1,547.31
$1,611.82
$1,840.99
$345.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$902.24
$1,024.02
$1,153.04
$1,611.38
$2,448.64
$1,247.34
$1,369.12
$1,498.14
$1,956.48
$1,592.44
$1,714.22
$1,843.24
$2,301.58
$1,937.54
$2,059.32
$2,188.34
$2,646.68
$345.10
Toc - Plan #75 Ambetter from Sunshine Health
Gold

(EPO) Complete Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$446.36
$506.60
$570.43
$797.18
$1,211.39
$787.82
$848.06
$911.89
$1,138.64
$1,129.28
$1,189.52
$1,253.35
$1,480.10
$1,470.74
$1,530.98
$1,594.81
$1,821.56
$341.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$892.72
$1,013.20
$1,140.86
$1,594.36
$2,422.78
$1,234.18
$1,354.66
$1,482.32
$1,935.82
$1,575.64
$1,696.12
$1,823.78
$2,277.28
$1,917.10
$2,037.58
$2,165.24
$2,618.74
$341.46
Toc - Plan #76 Ambetter from Sunshine Health
Bronze

(EPO) Clear Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.82
$377.73
$425.33
$594.39
$903.23
$587.42
$632.33
$679.93
$848.99
$842.02
$886.93
$934.53
$1,103.59
$1,096.62
$1,141.53
$1,189.13
$1,358.19
$254.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.64
$755.46
$850.66
$1,188.78
$1,806.46
$920.24
$1,010.06
$1,105.26
$1,443.38
$1,174.84
$1,264.66
$1,359.86
$1,697.98
$1,429.44
$1,519.26
$1,614.46
$1,952.58
$254.60
Toc - Plan #77 Ambetter from Sunshine Health
Silver

(EPO) Clear Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$445.73
$505.89
$569.63
$796.05
$1,209.68
$786.70
$846.86
$910.60
$1,137.02
$1,127.67
$1,187.83
$1,251.57
$1,477.99
$1,468.64
$1,528.80
$1,592.54
$1,818.96
$340.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$891.46
$1,011.78
$1,139.26
$1,592.10
$2,419.36
$1,232.43
$1,352.75
$1,480.23
$1,933.07
$1,573.40
$1,693.72
$1,821.20
$2,274.04
$1,914.37
$2,034.69
$2,162.17
$2,615.01
$340.97
Toc - Plan #78 Ambetter from Sunshine Health
Silver

(EPO) Enhanced Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$452.16
$513.19
$577.84
$807.53
$1,227.12
$798.05
$859.08
$923.73
$1,153.42
$1,143.94
$1,204.97
$1,269.62
$1,499.31
$1,489.83
$1,550.86
$1,615.51
$1,845.20
$345.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$904.32
$1,026.38
$1,155.68
$1,615.06
$2,454.24
$1,250.21
$1,372.27
$1,501.57
$1,960.95
$1,596.10
$1,718.16
$1,847.46
$2,306.84
$1,941.99
$2,064.05
$2,193.35
$2,652.73
$345.89
Toc - Plan #79 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$495.62
$562.52
$633.39
$885.16
$1,345.09
$874.76
$941.66
$1,012.53
$1,264.30
$1,253.90
$1,320.80
$1,391.67
$1,643.44
$1,633.04
$1,699.94
$1,770.81
$2,022.58
$379.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$991.24
$1,125.04
$1,266.78
$1,770.32
$2,690.18
$1,370.38
$1,504.18
$1,645.92
$2,149.46
$1,749.52
$1,883.32
$2,025.06
$2,528.60
$2,128.66
$2,262.46
$2,404.20
$2,907.74
$379.14
Toc - Plan #80 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.85
$406.15
$457.32
$639.11
$971.18
$631.60
$679.90
$731.07
$912.86
$905.35
$953.65
$1,004.82
$1,186.61
$1,179.10
$1,227.40
$1,278.57
$1,460.36
$273.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.70
$812.30
$914.64
$1,278.22
$1,942.36
$989.45
$1,086.05
$1,188.39
$1,551.97
$1,263.20
$1,359.80
$1,462.14
$1,825.72
$1,536.95
$1,633.55
$1,735.89
$2,099.47
$273.75
Toc - Plan #81 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.13
$465.48
$524.13
$732.47
$1,113.06
$723.87
$779.22
$837.87
$1,046.21
$1,037.61
$1,092.96
$1,151.61
$1,359.95
$1,351.35
$1,406.70
$1,465.35
$1,673.69
$313.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$820.26
$930.96
$1,048.26
$1,464.94
$2,226.12
$1,134.00
$1,244.70
$1,362.00
$1,778.68
$1,447.74
$1,558.44
$1,675.74
$2,092.42
$1,761.48
$1,872.18
$1,989.48
$2,406.16
$313.74
Toc - Plan #82 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$449.50
$510.18
$574.45
$802.80
$1,219.93
$793.36
$854.04
$918.31
$1,146.66
$1,137.22
$1,197.90
$1,262.17
$1,490.52
$1,481.08
$1,541.76
$1,606.03
$1,834.38
$343.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$899.00
$1,020.36
$1,148.90
$1,605.60
$2,439.86
$1,242.86
$1,364.22
$1,492.76
$1,949.46
$1,586.72
$1,708.08
$1,836.62
$2,293.32
$1,930.58
$2,051.94
$2,180.48
$2,637.18
$343.86
Toc - Plan #83 Ambetter from Sunshine Health
Gold

(EPO) Everyday Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$425.95
$483.44
$544.35
$760.73
$1,156.00
$751.79
$809.28
$870.19
$1,086.57
$1,077.63
$1,135.12
$1,196.03
$1,412.41
$1,403.47
$1,460.96
$1,521.87
$1,738.25
$325.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$851.90
$966.88
$1,088.70
$1,521.46
$2,312.00
$1,177.74
$1,292.72
$1,414.54
$1,847.30
$1,503.58
$1,618.56
$1,740.38
$2,173.14
$1,829.42
$1,944.40
$2,066.22
$2,498.98
$325.84

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 #84 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$807.18
$916.15
$1,031.58
$1,441.62
$2,190.69
$1,424.67
$1,533.64
$1,649.07
$2,059.11
$2,042.16
$2,151.13
$2,266.56
$2,676.60
$2,659.65
$2,768.62
$2,884.05
$3,294.09
$617.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,614.36
$1,832.30
$2,063.16
$2,883.24
$4,381.38
$2,231.85
$2,449.79
$2,680.65
$3,500.73
$2,849.34
$3,067.28
$3,298.14
$4,118.22
$3,466.83
$3,684.77
$3,915.63
$4,735.71
$617.49
Toc - Plan #85 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$474.53
$538.59
$606.45
$847.51
$1,287.87
$837.55
$901.61
$969.47
$1,210.53
$1,200.57
$1,264.63
$1,332.49
$1,573.55
$1,563.59
$1,627.65
$1,695.51
$1,936.57
$363.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$949.06
$1,077.18
$1,212.90
$1,695.02
$2,575.74
$1,312.08
$1,440.20
$1,575.92
$2,058.04
$1,675.10
$1,803.22
$1,938.94
$2,421.06
$2,038.12
$2,166.24
$2,301.96
$2,784.08
$363.02
Toc - Plan #86 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$447.70
$508.14
$572.16
$799.59
$1,215.06
$790.19
$850.63
$914.65
$1,142.08
$1,132.68
$1,193.12
$1,257.14
$1,484.57
$1,475.17
$1,535.61
$1,599.63
$1,827.06
$342.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$895.40
$1,016.28
$1,144.32
$1,599.18
$2,430.12
$1,237.89
$1,358.77
$1,486.81
$1,941.67
$1,580.38
$1,701.26
$1,829.30
$2,284.16
$1,922.87
$2,043.75
$2,171.79
$2,626.65
$342.49
Toc - Plan #87 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$712.20
$808.35
$910.19
$1,271.99
$1,932.91
$1,257.03
$1,353.18
$1,455.02
$1,816.82
$1,801.86
$1,898.01
$1,999.85
$2,361.65
$2,346.69
$2,442.84
$2,544.68
$2,906.48
$544.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,424.40
$1,616.70
$1,820.38
$2,543.98
$3,865.82
$1,969.23
$2,161.53
$2,365.21
$3,088.81
$2,514.06
$2,706.36
$2,910.04
$3,633.64
$3,058.89
$3,251.19
$3,454.87
$4,178.47
$544.83
Toc - Plan #88 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$7,700 $15,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$586.55
$665.73
$749.61
$1,047.58
$1,591.90
$1,035.26
$1,114.44
$1,198.32
$1,496.29
$1,483.97
$1,563.15
$1,647.03
$1,945.00
$1,932.68
$2,011.86
$2,095.74
$2,393.71
$448.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,173.10
$1,331.46
$1,499.22
$2,095.16
$3,183.80
$1,621.81
$1,780.17
$1,947.93
$2,543.87
$2,070.52
$2,228.88
$2,396.64
$2,992.58
$2,519.23
$2,677.59
$2,845.35
$3,441.29
$448.71
Toc - Plan #89 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$514.98
$584.50
$658.14
$919.75
$1,397.66
$908.94
$978.46
$1,052.10
$1,313.71
$1,302.90
$1,372.42
$1,446.06
$1,707.67
$1,696.86
$1,766.38
$1,840.02
$2,101.63
$393.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,029.96
$1,169.00
$1,316.28
$1,839.50
$2,795.32
$1,423.92
$1,562.96
$1,710.24
$2,233.46
$1,817.88
$1,956.92
$2,104.20
$2,627.42
$2,211.84
$2,350.88
$2,498.16
$3,021.38
$393.96
Toc - Plan #90 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$422.74
$479.81
$540.26
$755.01
$1,147.32
$746.14
$803.21
$863.66
$1,078.41
$1,069.54
$1,126.61
$1,187.06
$1,401.81
$1,392.94
$1,450.01
$1,510.46
$1,725.21
$323.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.48
$959.62
$1,080.52
$1,510.02
$2,294.64
$1,168.88
$1,283.02
$1,403.92
$1,833.42
$1,492.28
$1,606.42
$1,727.32
$2,156.82
$1,815.68
$1,929.82
$2,050.72
$2,480.22
$323.40
Toc - Plan #91 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$465.74
$528.61
$595.22
$831.81
$1,264.02
$822.03
$884.90
$951.51
$1,188.10
$1,178.32
$1,241.19
$1,307.80
$1,544.39
$1,534.61
$1,597.48
$1,664.09
$1,900.68
$356.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$931.48
$1,057.22
$1,190.44
$1,663.62
$2,528.04
$1,287.77
$1,413.51
$1,546.73
$2,019.91
$1,644.06
$1,769.80
$1,903.02
$2,376.20
$2,000.35
$2,126.09
$2,259.31
$2,732.49
$356.29
Toc - Plan #92 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$626.13
$710.66
$800.19
$1,118.27
$1,699.32
$1,105.12
$1,189.65
$1,279.18
$1,597.26
$1,584.11
$1,668.64
$1,758.17
$2,076.25
$2,063.10
$2,147.63
$2,237.16
$2,555.24
$478.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,252.26
$1,421.32
$1,600.38
$2,236.54
$3,398.64
$1,731.25
$1,900.31
$2,079.37
$2,715.53
$2,210.24
$2,379.30
$2,558.36
$3,194.52
$2,689.23
$2,858.29
$3,037.35
$3,673.51
$478.99
Toc - Plan #93 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 2354S ($30 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$645.51
$732.65
$824.96
$1,152.88
$1,751.91
$1,139.33
$1,226.47
$1,318.78
$1,646.70
$1,633.15
$1,720.29
$1,812.60
$2,140.52
$2,126.97
$2,214.11
$2,306.42
$2,634.34
$493.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,291.02
$1,465.30
$1,649.92
$2,305.76
$3,503.82
$1,784.84
$1,959.12
$2,143.74
$2,799.58
$2,278.66
$2,452.94
$2,637.56
$3,293.40
$2,772.48
$2,946.76
$3,131.38
$3,787.22
$493.82
Toc - Plan #94 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 2355S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$804.96
$913.63
$1,028.74
$1,437.66
$2,184.66
$1,420.75
$1,529.42
$1,644.53
$2,053.45
$2,036.54
$2,145.21
$2,260.32
$2,669.24
$2,652.33
$2,761.00
$2,876.11
$3,285.03
$615.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,609.92
$1,827.26
$2,057.48
$2,875.32
$4,369.32
$2,225.71
$2,443.05
$2,673.27
$3,491.11
$2,841.50
$3,058.84
$3,289.06
$4,106.90
$3,457.29
$3,674.63
$3,904.85
$4,722.69
$615.79
Toc - Plan #95 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2359 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 Not Applicable Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$498.00
$565.23
$636.44
$889.43
$1,351.57
$878.97
$946.20
$1,017.41
$1,270.40
$1,259.94
$1,327.17
$1,398.38
$1,651.37
$1,640.91
$1,708.14
$1,779.35
$2,032.34
$380.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$996.00
$1,130.46
$1,272.88
$1,778.86
$2,703.14
$1,376.97
$1,511.43
$1,653.85
$2,159.83
$1,757.94
$1,892.40
$2,034.82
$2,540.80
$2,138.91
$2,273.37
$2,415.79
$2,921.77
$380.97
Toc - Plan #96 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$330.50
$375.12
$422.38
$590.27
$896.98
$583.33
$627.95
$675.21
$843.10
$836.16
$880.78
$928.04
$1,095.93
$1,088.99
$1,133.61
$1,180.87
$1,348.76
$252.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$661.00
$750.24
$844.76
$1,180.54
$1,793.96
$913.83
$1,003.07
$1,097.59
$1,433.37
$1,166.66
$1,255.90
$1,350.42
$1,686.20
$1,419.49
$1,508.73
$1,603.25
$1,939.03
$252.83
Toc - Plan #97 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1602 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$311.13
$353.13
$397.62
$555.68
$844.41
$549.14
$591.14
$635.63
$793.69
$787.15
$829.15
$873.64
$1,031.70
$1,025.16
$1,067.16
$1,111.65
$1,269.71
$238.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$622.26
$706.26
$795.24
$1,111.36
$1,688.82
$860.27
$944.27
$1,033.25
$1,349.37
$1,098.28
$1,182.28
$1,271.26
$1,587.38
$1,336.29
$1,420.29
$1,509.27
$1,825.39
$238.01
Toc - Plan #98 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1603 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.03
$461.98
$520.18
$726.96
$1,104.68
$718.41
$773.36
$831.56
$1,038.34
$1,029.79
$1,084.74
$1,142.94
$1,349.72
$1,341.17
$1,396.12
$1,454.32
$1,661.10
$311.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.06
$923.96
$1,040.36
$1,453.92
$2,209.36
$1,125.44
$1,235.34
$1,351.74
$1,765.30
$1,436.82
$1,546.72
$1,663.12
$2,076.68
$1,748.20
$1,858.10
$1,974.50
$2,388.06
$311.38
Toc - Plan #99 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1604 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$387.99
$440.37
$495.85
$692.95
$1,053.00
$684.80
$737.18
$792.66
$989.76
$981.61
$1,033.99
$1,089.47
$1,286.57
$1,278.42
$1,330.80
$1,386.28
$1,583.38
$296.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.98
$880.74
$991.70
$1,385.90
$2,106.00
$1,072.79
$1,177.55
$1,288.51
$1,682.71
$1,369.60
$1,474.36
$1,585.32
$1,979.52
$1,666.41
$1,771.17
$1,882.13
$2,276.33
$296.81
Toc - Plan #100 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 1605 ($0 Virtual Visits / $0 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$940 $1,880 Annual Deductible
$4,700 $9,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$460.79
$523.00
$588.89
$822.97
$1,250.58
$813.29
$875.50
$941.39
$1,175.47
$1,165.79
$1,228.00
$1,293.89
$1,527.97
$1,518.29
$1,580.50
$1,646.39
$1,880.47
$352.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$921.58
$1,046.00
$1,177.78
$1,645.94
$2,501.16
$1,274.08
$1,398.50
$1,530.28
$1,998.44
$1,626.58
$1,751.00
$1,882.78
$2,350.94
$1,979.08
$2,103.50
$2,235.28
$2,703.44
$352.50
Toc - Plan #101 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1710 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413.53
$469.36
$528.49
$738.56
$1,122.32
$729.88
$785.71
$844.84
$1,054.91
$1,046.23
$1,102.06
$1,161.19
$1,371.26
$1,362.58
$1,418.41
$1,477.54
$1,687.61
$316.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$827.06
$938.72
$1,056.98
$1,477.12
$2,244.64
$1,143.41
$1,255.07
$1,373.33
$1,793.47
$1,459.76
$1,571.42
$1,689.68
$2,109.82
$1,776.11
$1,887.77
$2,006.03
$2,426.17
$316.35
Toc - Plan #102 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2017 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,400 $14,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384.87
$436.83
$491.86
$687.38
$1,044.54
$679.30
$731.26
$786.29
$981.81
$973.73
$1,025.69
$1,080.72
$1,276.24
$1,268.16
$1,320.12
$1,375.15
$1,570.67
$294.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$769.74
$873.66
$983.72
$1,374.76
$2,089.08
$1,064.17
$1,168.09
$1,278.15
$1,669.19
$1,358.60
$1,462.52
$1,572.58
$1,963.62
$1,653.03
$1,756.95
$1,867.01
$2,258.05
$294.43
Toc - Plan #103 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2127 ($0 Virtual Visits / $25 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$7,600 $15,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.41
$435.17
$490.00
$684.77
$1,040.57
$676.72
$728.48
$783.31
$978.08
$970.03
$1,021.79
$1,076.62
$1,271.39
$1,263.34
$1,315.10
$1,369.93
$1,564.70
$293.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.82
$870.34
$980.00
$1,369.54
$2,081.14
$1,060.13
$1,163.65
$1,273.31
$1,662.85
$1,353.44
$1,456.96
$1,566.62
$1,956.16
$1,646.75
$1,750.27
$1,859.93
$2,249.47
$293.31
Toc - Plan #104 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Deductible / $0 Virtual Visits / $35 PCP Visit / $80 Specialist Visits / $25 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.54
$405.81
$456.94
$638.57
$970.36
$631.06
$679.33
$730.46
$912.09
$904.58
$952.85
$1,003.98
$1,185.61
$1,178.10
$1,226.37
$1,277.50
$1,459.13
$273.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.08
$811.62
$913.88
$1,277.14
$1,940.72
$988.60
$1,085.14
$1,187.40
$1,550.66
$1,262.12
$1,358.66
$1,460.92
$1,824.18
$1,535.64
$1,632.18
$1,734.44
$2,097.70
$273.52
Toc - Plan #105 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2126 ($0 Virtual Visits / 3 PCP Visits for $0 / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$330.89
$375.56
$422.88
$590.97
$898.04
$584.02
$628.69
$676.01
$844.10
$837.15
$881.82
$929.14
$1,097.23
$1,090.28
$1,134.95
$1,182.27
$1,350.36
$253.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$661.78
$751.12
$845.76
$1,181.94
$1,796.08
$914.91
$1,004.25
$1,098.89
$1,435.07
$1,168.04
$1,257.38
$1,352.02
$1,688.20
$1,421.17
$1,510.51
$1,605.15
$1,941.33
$253.13
Toc - Plan #106 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237 ($0 Virtual Visits / $80 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.70
$427.55
$481.42
$672.79
$1,022.36
$664.88
$715.73
$769.60
$960.97
$953.06
$1,003.91
$1,057.78
$1,249.15
$1,241.24
$1,292.09
$1,345.96
$1,537.33
$288.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.40
$855.10
$962.84
$1,345.58
$2,044.72
$1,041.58
$1,143.28
$1,251.02
$1,633.76
$1,329.76
$1,431.46
$1,539.20
$1,921.94
$1,617.94
$1,719.64
$1,827.38
$2,210.12
$288.18
Toc - Plan #107 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2219 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.40
$367.06
$413.31
$577.59
$877.71
$570.80
$614.46
$660.71
$824.99
$818.20
$861.86
$908.11
$1,072.39
$1,065.60
$1,109.26
$1,155.51
$1,319.79
$247.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.80
$734.12
$826.62
$1,155.18
$1,755.42
$894.20
$981.52
$1,074.02
$1,402.58
$1,141.60
$1,228.92
$1,321.42
$1,649.98
$1,389.00
$1,476.32
$1,568.82
$1,897.38
$247.40
Toc - Plan #108 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2266 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.09
$367.84
$414.19
$578.82
$879.58
$572.02
$615.77
$662.12
$826.75
$819.95
$863.70
$910.05
$1,074.68
$1,067.88
$1,111.63
$1,157.98
$1,322.61
$247.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.18
$735.68
$828.38
$1,157.64
$1,759.16
$896.11
$983.61
$1,076.31
$1,405.57
$1,144.04
$1,231.54
$1,324.24
$1,653.50
$1,391.97
$1,479.47
$1,572.17
$1,901.43
$247.93
Toc - Plan #109 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) myBlue Bronze 2311S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$294.45
$334.20
$376.31
$525.89
$799.14
$519.70
$559.45
$601.56
$751.14
$744.95
$784.70
$826.81
$976.39
$970.20
$1,009.95
$1,052.06
$1,201.64
$225.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$588.90
$668.40
$752.62
$1,051.78
$1,598.28
$814.15
$893.65
$977.87
$1,277.03
$1,039.40
$1,118.90
$1,203.12
$1,502.28
$1,264.65
$1,344.15
$1,428.37
$1,727.53
$225.25
Toc - Plan #110 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2312S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.88
$358.52
$403.69
$564.16
$857.30
$557.53
$600.17
$645.34
$805.81
$799.18
$841.82
$886.99
$1,047.46
$1,040.83
$1,083.47
$1,128.64
$1,289.11
$241.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$631.76
$717.04
$807.38
$1,128.32
$1,714.60
$873.41
$958.69
$1,049.03
$1,369.97
$1,115.06
$1,200.34
$1,290.68
$1,611.62
$1,356.71
$1,441.99
$1,532.33
$1,853.27
$241.65
Toc - Plan #111 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2329 ($0 Deductible / $0 Virtual Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$346.20
$392.94
$442.44
$618.31
$939.59
$611.04
$657.78
$707.28
$883.15
$875.88
$922.62
$972.12
$1,147.99
$1,140.72
$1,187.46
$1,236.96
$1,412.83
$264.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$692.40
$785.88
$884.88
$1,236.62
$1,879.18
$957.24
$1,050.72
$1,149.72
$1,501.46
$1,222.08
$1,315.56
$1,414.56
$1,766.30
$1,486.92
$1,580.40
$1,679.40
$2,031.14
$264.84
Toc - Plan #112 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Connected Care Silver 2230 ($0 Primary Care Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Disponible en Espaņol / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,400 $14,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.34
$423.74
$477.13
$666.79
$1,013.24
$658.95
$709.35
$762.74
$952.40
$944.56
$994.96
$1,048.35
$1,238.01
$1,230.17
$1,280.57
$1,333.96
$1,523.62
$285.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.68
$847.48
$954.26
$1,333.58
$2,026.48
$1,032.29
$1,133.09
$1,239.87
$1,619.19
$1,317.90
$1,418.70
$1,525.48
$1,904.80
$1,603.51
$1,704.31
$1,811.09
$2,190.41
$285.61
Toc - Plan #113 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Connected Care Bronze 2231 ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Disponible en Espaņol / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$306.24
$347.58
$391.37
$546.94
$831.14
$540.51
$581.85
$625.64
$781.21
$774.78
$816.12
$859.91
$1,015.48
$1,009.05
$1,050.39
$1,094.18
$1,249.75
$234.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.48
$695.16
$782.74
$1,093.88
$1,662.28
$846.75
$929.43
$1,017.01
$1,328.15
$1,081.02
$1,163.70
$1,251.28
$1,562.42
$1,315.29
$1,397.97
$1,485.55
$1,796.69
$234.27
Toc - Plan #114 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Connected Care Silver 2332 ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / 24x7 Provider Access / Disponible en Espaņol / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.56
$410.37
$462.07
$645.75
$981.27
$638.15
$686.96
$738.66
$922.34
$914.74
$963.55
$1,015.25
$1,198.93
$1,191.33
$1,240.14
$1,291.84
$1,475.52
$276.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.12
$820.74
$924.14
$1,291.50
$1,962.54
$999.71
$1,097.33
$1,200.73
$1,568.09
$1,276.30
$1,373.92
$1,477.32
$1,844.68
$1,552.89
$1,650.51
$1,753.91
$2,121.27
$276.59
Toc - Plan #115 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2337 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364.64
$413.87
$466.01
$651.25
$989.63
$643.59
$692.82
$744.96
$930.20
$922.54
$971.77
$1,023.91
$1,209.15
$1,201.49
$1,250.72
$1,302.86
$1,488.10
$278.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.28
$827.74
$932.02
$1,302.50
$1,979.26
$1,008.23
$1,106.69
$1,210.97
$1,581.45
$1,287.18
$1,385.64
$1,489.92
$1,860.40
$1,566.13
$1,664.59
$1,768.87
$2,139.35
$278.95
Toc - Plan #116 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2313S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$379.18
$430.37
$484.59
$677.22
$1,029.09
$669.25
$720.44
$774.66
$967.29
$959.32
$1,010.51
$1,064.73
$1,257.36
$1,249.39
$1,300.58
$1,354.80
$1,547.43
$290.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.36
$860.74
$969.18
$1,354.44
$2,058.18
$1,048.43
$1,150.81
$1,259.25
$1,644.51
$1,338.50
$1,440.88
$1,549.32
$1,934.58
$1,628.57
$1,730.95
$1,839.39
$2,224.65
$290.07
Toc - Plan #117 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 2314S ($30 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$436.16
$495.04
$557.41
$778.98
$1,183.74
$769.82
$828.70
$891.07
$1,112.64
$1,103.48
$1,162.36
$1,224.73
$1,446.30
$1,437.14
$1,496.02
$1,558.39
$1,779.96
$333.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$872.32
$990.08
$1,114.82
$1,557.96
$2,367.48
$1,205.98
$1,323.74
$1,448.48
$1,891.62
$1,539.64
$1,657.40
$1,782.14
$2,225.28
$1,873.30
$1,991.06
$2,115.80
$2,558.94
$333.66
Toc - Plan #118 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237D ($0 Virtual Visits / $80 PCP Visits / Adult Dental / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384.36
$436.25
$491.21
$686.47
$1,043.15
$678.40
$730.29
$785.25
$980.51
$972.44
$1,024.33
$1,079.29
$1,274.55
$1,266.48
$1,318.37
$1,373.33
$1,568.59
$294.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.72
$872.50
$982.42
$1,372.94
$2,086.30
$1,062.76
$1,166.54
$1,276.46
$1,666.98
$1,356.80
$1,460.58
$1,570.50
$1,961.02
$1,650.84
$1,754.62
$1,864.54
$2,255.06
$294.04
Toc - Plan #119 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Connected Care Silver 2332D ($0 Virtual Visits / $0 Primary Care Visits with Select Providers / Adult Dental / 24x7 Provider Access / Disponible en Espaņol / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.20
$419.04
$471.84
$659.39
$1,002.01
$651.64
$701.48
$754.28
$941.83
$934.08
$983.92
$1,036.72
$1,224.27
$1,216.52
$1,266.36
$1,319.16
$1,506.71
$282.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.40
$838.08
$943.68
$1,318.78
$2,004.02
$1,020.84
$1,120.52
$1,226.12
$1,601.22
$1,303.28
$1,402.96
$1,508.56
$1,883.66
$1,585.72
$1,685.40
$1,791.00
$2,166.10
$282.44
Toc - Plan #120 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2337D ($0 Virtual Visits / Adult Dental / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.27
$422.53
$475.76
$664.87
$1,010.34
$657.06
$707.32
$760.55
$949.66
$941.85
$992.11
$1,045.34
$1,234.45
$1,226.64
$1,276.90
$1,330.13
$1,519.24
$284.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.54
$845.06
$951.52
$1,329.74
$2,020.68
$1,029.33
$1,129.85
$1,236.31
$1,614.53
$1,314.12
$1,414.64
$1,521.10
$1,899.32
$1,598.91
$1,699.43
$1,805.89
$2,184.11
$284.79

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #121 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$374.38
$424.91
$478.44
$668.62
$1,016.04
$660.77
$711.30
$764.83
$955.01
$947.16
$997.69
$1,051.22
$1,241.40
$1,233.55
$1,284.08
$1,337.61
$1,527.79
$286.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$748.76
$849.82
$956.88
$1,337.24
$2,032.08
$1,035.15
$1,136.21
$1,243.27
$1,623.63
$1,321.54
$1,422.60
$1,529.66
$1,910.02
$1,607.93
$1,708.99
$1,816.05
$2,196.41
$286.39
Toc - Plan #122 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$292.03
$331.44
$373.20
$521.54
$792.53
$515.42
$554.83
$596.59
$744.93
$738.81
$778.22
$819.98
$968.32
$962.20
$1,001.61
$1,043.37
$1,191.71
$223.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$584.06
$662.88
$746.40
$1,043.08
$1,585.06
$807.45
$886.27
$969.79
$1,266.47
$1,030.84
$1,109.66
$1,193.18
$1,489.86
$1,254.23
$1,333.05
$1,416.57
$1,713.25
$223.39
Toc - Plan #123 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$284.14
$322.49
$363.12
$507.45
$771.12
$501.50
$539.85
$580.48
$724.81
$718.86
$757.21
$797.84
$942.17
$936.22
$974.57
$1,015.20
$1,159.53
$217.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$568.28
$644.98
$726.24
$1,014.90
$1,542.24
$785.64
$862.34
$943.60
$1,232.26
$1,003.00
$1,079.70
$1,160.96
$1,449.62
$1,220.36
$1,297.06
$1,378.32
$1,666.98
$217.36
Toc - Plan #124 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- Deductible+PCP Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$344.84
$391.38
$440.69
$615.86
$935.86
$608.63
$655.17
$704.48
$879.65
$872.42
$918.96
$968.27
$1,143.44
$1,136.21
$1,182.75
$1,232.06
$1,407.23
$263.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$689.68
$782.76
$881.38
$1,231.72
$1,871.72
$953.47
$1,046.55
$1,145.17
$1,495.51
$1,217.26
$1,310.34
$1,408.96
$1,759.30
$1,481.05
$1,574.13
$1,672.75
$2,023.09
$263.79
Toc - Plan #125 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.86
$434.53
$489.28
$683.77
$1,039.05
$675.74
$727.41
$782.16
$976.65
$968.62
$1,020.29
$1,075.04
$1,269.53
$1,261.50
$1,313.17
$1,367.92
$1,562.41
$292.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.72
$869.06
$978.56
$1,367.54
$2,078.10
$1,058.60
$1,161.94
$1,271.44
$1,660.42
$1,351.48
$1,454.82
$1,564.32
$1,953.30
$1,644.36
$1,747.70
$1,857.20
$2,246.18
$292.88
Toc - Plan #126 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.64
$432.01
$486.44
$679.80
$1,033.02
$671.82
$723.19
$777.62
$970.98
$963.00
$1,014.37
$1,068.80
$1,262.16
$1,254.18
$1,305.55
$1,359.98
$1,553.34
$291.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$761.28
$864.02
$972.88
$1,359.60
$2,066.04
$1,052.46
$1,155.20
$1,264.06
$1,650.78
$1,343.64
$1,446.38
$1,555.24
$1,941.96
$1,634.82
$1,737.56
$1,846.42
$2,233.14
$291.18
Toc - Plan #127 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.42
$435.17
$489.99
$684.76
$1,040.56
$676.73
$728.48
$783.30
$978.07
$970.04
$1,021.79
$1,076.61
$1,271.38
$1,263.35
$1,315.10
$1,369.92
$1,564.69
$293.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.84
$870.34
$979.98
$1,369.52
$2,081.12
$1,060.15
$1,163.65
$1,273.29
$1,662.83
$1,353.46
$1,456.96
$1,566.60
$1,956.14
$1,646.77
$1,750.27
$1,859.91
$2,249.45
$293.31
Toc - Plan #128 Oscar Insurance Company of Florida
Catastrophic

(EPO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$218.35
$247.81
$279.04
$389.95
$592.57
$385.38
$414.84
$446.07
$556.98
$552.41
$581.87
$613.10
$724.01
$719.44
$748.90
$780.13
$891.04
$167.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$436.70
$495.62
$558.08
$779.90
$1,185.14
$603.73
$662.65
$725.11
$946.93
$770.76
$829.68
$892.14
$1,113.96
$937.79
$996.71
$1,059.17
$1,280.99
$167.03
Toc - Plan #129 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- Deductible+Specialist Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$344.39
$390.87
$440.11
$615.06
$934.64
$607.84
$654.32
$703.56
$878.51
$871.29
$917.77
$967.01
$1,141.96
$1,134.74
$1,181.22
$1,230.46
$1,405.41
$263.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.78
$781.74
$880.22
$1,230.12
$1,869.28
$952.23
$1,045.19
$1,143.67
$1,493.57
$1,215.68
$1,308.64
$1,407.12
$1,757.02
$1,479.13
$1,572.09
$1,670.57
$2,020.47
$263.45
Toc - Plan #130 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.86
$460.64
$518.68
$724.85
$1,101.48
$716.34
$771.12
$829.16
$1,035.33
$1,026.82
$1,081.60
$1,139.64
$1,345.81
$1,337.30
$1,392.08
$1,450.12
$1,656.29
$310.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.72
$921.28
$1,037.36
$1,449.70
$2,202.96
$1,122.20
$1,231.76
$1,347.84
$1,760.18
$1,432.68
$1,542.24
$1,658.32
$2,070.66
$1,743.16
$1,852.72
$1,968.80
$2,381.14
$310.48
Toc - Plan #131 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$302.45
$343.27
$386.52
$540.16
$820.83
$533.82
$574.64
$617.89
$771.53
$765.19
$806.01
$849.26
$1,002.90
$996.56
$1,037.38
$1,080.63
$1,234.27
$231.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.90
$686.54
$773.04
$1,080.32
$1,641.66
$836.27
$917.91
$1,004.41
$1,311.69
$1,067.64
$1,149.28
$1,235.78
$1,543.06
$1,299.01
$1,380.65
$1,467.15
$1,774.43
$231.37
Toc - Plan #132 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$387.87
$440.22
$495.68
$692.72
$1,052.65
$684.58
$736.93
$792.39
$989.43
$981.29
$1,033.64
$1,089.10
$1,286.14
$1,278.00
$1,330.35
$1,385.81
$1,582.85
$296.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.74
$880.44
$991.36
$1,385.44
$2,105.30
$1,072.45
$1,177.15
$1,288.07
$1,682.15
$1,369.16
$1,473.86
$1,584.78
$1,978.86
$1,665.87
$1,770.57
$1,881.49
$2,275.57
$296.71
Toc - Plan #133 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- Deductible Saver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.66
$443.38
$499.25
$697.69
$1,060.21
$689.50
$742.22
$798.09
$996.53
$988.34
$1,041.06
$1,096.93
$1,295.37
$1,287.18
$1,339.90
$1,395.77
$1,594.21
$298.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.32
$886.76
$998.50
$1,395.38
$2,120.42
$1,080.16
$1,185.60
$1,297.34
$1,694.22
$1,379.00
$1,484.44
$1,596.18
$1,993.06
$1,677.84
$1,783.28
$1,895.02
$2,291.90
$298.84
Toc - Plan #134 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- PCP Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$300.82
$341.42
$384.43
$537.25
$816.40
$530.94
$571.54
$614.55
$767.37
$761.06
$801.66
$844.67
$997.49
$991.18
$1,031.78
$1,074.79
$1,227.61
$230.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$601.64
$682.84
$768.86
$1,074.50
$1,632.80
$831.76
$912.96
$998.98
$1,304.62
$1,061.88
$1,143.08
$1,229.10
$1,534.74
$1,292.00
$1,373.20
$1,459.22
$1,764.86
$230.12
Toc - Plan #135 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- Deductible Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.53
$352.44
$396.85
$554.59
$842.75
$548.08
$589.99
$634.40
$792.14
$785.63
$827.54
$871.95
$1,029.69
$1,023.18
$1,065.09
$1,109.50
$1,267.24
$237.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.06
$704.88
$793.70
$1,109.18
$1,685.50
$858.61
$942.43
$1,031.25
$1,346.73
$1,096.16
$1,179.98
$1,268.80
$1,584.28
$1,333.71
$1,417.53
$1,506.35
$1,821.83
$237.55
Toc - Plan #136 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.87
$417.52
$470.13
$657.00
$998.38
$649.28
$698.93
$751.54
$938.41
$930.69
$980.34
$1,032.95
$1,219.82
$1,212.10
$1,261.75
$1,314.36
$1,501.23
$281.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.74
$835.04
$940.26
$1,314.00
$1,996.76
$1,017.15
$1,116.45
$1,221.67
$1,595.41
$1,298.56
$1,397.86
$1,503.08
$1,876.82
$1,579.97
$1,679.27
$1,784.49
$2,158.23
$281.41
Toc - Plan #137 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- PCP Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$392.33
$445.28
$501.38
$700.68
$1,064.75
$692.45
$745.40
$801.50
$1,000.80
$992.57
$1,045.52
$1,101.62
$1,300.92
$1,292.69
$1,345.64
$1,401.74
$1,601.04
$300.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.66
$890.56
$1,002.76
$1,401.36
$2,129.50
$1,084.78
$1,190.68
$1,302.88
$1,701.48
$1,384.90
$1,490.80
$1,603.00
$2,001.60
$1,685.02
$1,790.92
$1,903.12
$2,301.72
$300.12
Toc - Plan #138 Oscar Insurance Company of Florida
Silver

(EPO) Silver Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.42
$435.17
$489.99
$684.76
$1,040.56
$676.73
$728.48
$783.30
$978.07
$970.04
$1,021.79
$1,076.61
$1,271.38
$1,263.35
$1,315.10
$1,369.92
$1,564.69
$293.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.84
$870.34
$979.98
$1,369.52
$2,081.12
$1,060.15
$1,163.65
$1,273.29
$1,662.83
$1,353.46
$1,456.96
$1,566.60
$1,956.14
$1,646.77
$1,750.27
$1,859.91
$2,249.45
$293.31
Toc - Plan #139 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$444.38
$504.36
$567.91
$793.65
$1,206.03
$784.33
$844.31
$907.86
$1,133.60
$1,124.28
$1,184.26
$1,247.81
$1,473.55
$1,464.23
$1,524.21
$1,587.76
$1,813.50
$339.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.76
$1,008.72
$1,135.82
$1,587.30
$2,412.06
$1,228.71
$1,348.67
$1,475.77
$1,927.25
$1,568.66
$1,688.62
$1,815.72
$2,267.20
$1,908.61
$2,028.57
$2,155.67
$2,607.15
$339.95
Toc - Plan #140 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.08
$472.24
$531.74
$743.10
$1,129.22
$734.38
$790.54
$850.04
$1,061.40
$1,052.68
$1,108.84
$1,168.34
$1,379.70
$1,370.98
$1,427.14
$1,486.64
$1,698.00
$318.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.16
$944.48
$1,063.48
$1,486.20
$2,258.44
$1,150.46
$1,262.78
$1,381.78
$1,804.50
$1,468.76
$1,581.08
$1,700.08
$2,122.80
$1,787.06
$1,899.38
$2,018.38
$2,441.10
$318.30
Toc - Plan #141 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$335.88
$381.21
$429.24
$599.86
$911.55
$592.82
$638.15
$686.18
$856.80
$849.76
$895.09
$943.12
$1,113.74
$1,106.70
$1,152.03
$1,200.06
$1,370.68
$256.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$671.76
$762.42
$858.48
$1,199.72
$1,823.10
$928.70
$1,019.36
$1,115.42
$1,456.66
$1,185.64
$1,276.30
$1,372.36
$1,713.60
$1,442.58
$1,533.24
$1,629.30
$1,970.54
$256.94
Toc - Plan #142 Oscar Insurance Company of Florida
Silver

(EPO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.75
$433.27
$487.86
$681.78
$1,036.04
$673.78
$725.30
$779.89
$973.81
$965.81
$1,017.33
$1,071.92
$1,265.84
$1,257.84
$1,309.36
$1,363.95
$1,557.87
$292.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.50
$866.54
$975.72
$1,363.56
$2,072.08
$1,055.53
$1,158.57
$1,267.75
$1,655.59
$1,347.56
$1,450.60
$1,559.78
$1,947.62
$1,639.59
$1,742.63
$1,851.81
$2,239.65
$292.03
Toc - Plan #143 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$307.00
$348.43
$392.33
$548.28
$833.16
$541.84
$583.27
$627.17
$783.12
$776.68
$818.11
$862.01
$1,017.96
$1,011.52
$1,052.95
$1,096.85
$1,252.80
$234.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$614.00
$696.86
$784.66
$1,096.56
$1,666.32
$848.84
$931.70
$1,019.50
$1,331.40
$1,083.68
$1,166.54
$1,254.34
$1,566.24
$1,318.52
$1,401.38
$1,489.18
$1,801.08
$234.84
Toc - Plan #144 Oscar Insurance Company of Florida
Bronze

(EPO) Bronze Simple- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$271.05
$307.63
$346.39
$484.08
$735.61
$478.40
$514.98
$553.74
$691.43
$685.75
$722.33
$761.09
$898.78
$893.10
$929.68
$968.44
$1,106.13
$207.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$542.10
$615.26
$692.78
$968.16
$1,471.22
$749.45
$822.61
$900.13
$1,175.51
$956.80
$1,029.96
$1,107.48
$1,382.86
$1,164.15
$1,237.31
$1,314.83
$1,590.21
$207.35
Toc - Plan #145 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic- Standard

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$377.86
$428.86
$482.89
$674.84
$1,025.48
$666.91
$717.91
$771.94
$963.89
$955.96
$1,006.96
$1,060.99
$1,252.94
$1,245.01
$1,296.01
$1,350.04
$1,541.99
$289.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$755.72
$857.72
$965.78
$1,349.68
$2,050.96
$1,044.77
$1,146.77
$1,254.83
$1,638.73
$1,333.82
$1,435.82
$1,543.88
$1,927.78
$1,622.87
$1,724.87
$1,832.93
$2,216.83
$289.05
Toc - Plan #146 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$387.05
$439.29
$494.63
$691.25
$1,050.42
$683.13
$735.37
$790.71
$987.33
$979.21
$1,031.45
$1,086.79
$1,283.41
$1,275.29
$1,327.53
$1,382.87
$1,579.49
$296.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774.10
$878.58
$989.26
$1,382.50
$2,100.84
$1,070.18
$1,174.66
$1,285.34
$1,678.58
$1,366.26
$1,470.74
$1,581.42
$1,974.66
$1,662.34
$1,766.82
$1,877.50
$2,270.74
$296.08

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Cigna Healthcare

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

Toc - Plan #147 Cigna Healthcare
Bronze

(EPO) Cigna Connect 8700

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.77
$362.93
$408.66
$571.10
$867.84
$564.39
$607.55
$653.28
$815.72
$809.01
$852.17
$897.90
$1,060.34
$1,053.63
$1,096.79
$1,142.52
$1,304.96
$244.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$639.54
$725.86
$817.32
$1,142.20
$1,735.68
$884.16
$970.48
$1,061.94
$1,386.82
$1,128.78
$1,215.10
$1,306.56
$1,631.44
$1,373.40
$1,459.72
$1,551.18
$1,876.06
$244.62
Toc - Plan #148 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7300

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

Annual Out of Pocket Expenses:

Individual Family
$7,300 $14,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.12
$376.95
$424.45
$593.16
$901.37
$586.19
$631.02
$678.52
$847.23
$840.26
$885.09
$932.59
$1,101.30
$1,094.33
$1,139.16
$1,186.66
$1,355.37
$254.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.24
$753.90
$848.90
$1,186.32
$1,802.74
$918.31
$1,007.97
$1,102.97
$1,440.39
$1,172.38
$1,262.04
$1,357.04
$1,694.46
$1,426.45
$1,516.11
$1,611.11
$1,948.53
$254.07
Toc - Plan #149 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 8200

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

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$332.25
$377.10
$424.61
$593.40
$901.72
$586.42
$631.27
$678.78
$847.57
$840.59
$885.44
$932.95
$1,101.74
$1,094.76
$1,139.61
$1,187.12
$1,355.91
$254.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.50
$754.20
$849.22
$1,186.80
$1,803.44
$918.67
$1,008.37
$1,103.39
$1,440.97
$1,172.84
$1,262.54
$1,357.56
$1,695.14
$1,427.01
$1,516.71
$1,611.73
$1,949.31
$254.17
Toc - Plan #150 Cigna Healthcare
Silver

(EPO) Cigna Connect 4400

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

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 Annual Deductible
$9,050 $18,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.74
$433.28
$487.86
$681.79
$1,036.05
$673.77
$725.31
$779.89
$973.82
$965.80
$1,017.34
$1,071.92
$1,265.85
$1,257.83
$1,309.37
$1,363.95
$1,557.88
$292.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.48
$866.56
$975.72
$1,363.58
$2,072.10
$1,055.51
$1,158.59
$1,267.75
$1,655.61
$1,347.54
$1,450.62
$1,559.78
$1,947.64
$1,639.57
$1,742.65
$1,851.81
$2,239.67
$292.03
Toc - Plan #151 Cigna Healthcare
Silver

(EPO) Cigna Connect 4500

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.70
$437.77
$492.92
$688.85
$1,046.78
$680.76
$732.83
$787.98
$983.91
$975.82
$1,027.89
$1,083.04
$1,278.97
$1,270.88
$1,322.95
$1,378.10
$1,574.03
$295.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.40
$875.54
$985.84
$1,377.70
$2,093.56
$1,066.46
$1,170.60
$1,280.90
$1,672.76
$1,361.52
$1,465.66
$1,575.96
$1,967.82
$1,656.58
$1,760.72
$1,871.02
$2,262.88
$295.06
Toc - Plan #152 Cigna Healthcare
Silver

(EPO) Cigna Connect 8900

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.73
$441.21
$496.80
$694.27
$1,055.01
$686.11
$738.59
$794.18
$991.65
$983.49
$1,035.97
$1,091.56
$1,289.03
$1,280.87
$1,333.35
$1,388.94
$1,586.41
$297.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.46
$882.42
$993.60
$1,388.54
$2,110.02
$1,074.84
$1,179.80
$1,290.98
$1,685.92
$1,372.22
$1,477.18
$1,588.36
$1,983.30
$1,669.60
$1,774.56
$1,885.74
$2,280.68
$297.38
Toc - Plan #153 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389.35
$441.91
$497.58
$695.37
$1,056.68
$687.20
$739.76
$795.43
$993.22
$985.05
$1,037.61
$1,093.28
$1,291.07
$1,282.90
$1,335.46
$1,391.13
$1,588.92
$297.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.70
$883.82
$995.16
$1,390.74
$2,113.36
$1,076.55
$1,181.67
$1,293.01
$1,688.59
$1,374.40
$1,479.52
$1,590.86
$1,986.44
$1,672.25
$1,777.37
$1,888.71
$2,284.29
$297.85
Toc - Plan #154 Cigna Healthcare
Gold

(EPO) Cigna Connect 1950

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

Annual Out of Pocket Expenses:

Individual Family
$1,950 $3,900 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$463.41
$525.97
$592.23
$827.65
$1,257.69
$817.92
$880.48
$946.74
$1,182.16
$1,172.43
$1,234.99
$1,301.25
$1,536.67
$1,526.94
$1,589.50
$1,655.76
$1,891.18
$354.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$926.82
$1,051.94
$1,184.46
$1,655.30
$2,515.38
$1,281.33
$1,406.45
$1,538.97
$2,009.81
$1,635.84
$1,760.96
$1,893.48
$2,364.32
$1,990.35
$2,115.47
$2,247.99
$2,718.83
$354.51