Santa Rosa County, Florida Obamacare 2024 Rates

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

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

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

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

Obamacare Providers, 120 Plans and 2024 Rates for Santa Rosa County, Florida

Below, you’ll find a summary of the 120 plans for Santa Rosa County, Florida and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |



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Florida Blue (BlueCross BlueShield FL)

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

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

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.08
$422.31
$475.52
$664.53
$1,009.83
$656.72
$706.95
$760.16
$949.17
$941.36
$991.59
$1,044.80
$1,233.81
$1,226.00
$1,276.23
$1,329.44
$1,518.45
$284.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.16
$844.62
$951.04
$1,329.06
$2,019.66
$1,028.80
$1,129.26
$1,235.68
$1,613.70
$1,313.44
$1,413.90
$1,520.32
$1,898.34
$1,598.08
$1,698.54
$1,804.96
$2,182.98
$284.64
Toc - Plan #2 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$504.84
$572.99
$645.19
$901.64
$1,370.14
$891.04
$959.19
$1,031.39
$1,287.84
$1,277.24
$1,345.39
$1,417.59
$1,674.04
$1,663.44
$1,731.59
$1,803.79
$2,060.24
$386.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,009.68
$1,145.98
$1,290.38
$1,803.28
$2,740.28
$1,395.88
$1,532.18
$1,676.58
$2,189.48
$1,782.08
$1,918.38
$2,062.78
$2,575.68
$2,168.28
$2,304.58
$2,448.98
$2,961.88
$386.20
Toc - Plan #3 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$662.67
$752.13
$846.89
$1,183.53
$1,798.49
$1,169.61
$1,259.07
$1,353.83
$1,690.47
$1,676.55
$1,766.01
$1,860.77
$2,197.41
$2,183.49
$2,272.95
$2,367.71
$2,704.35
$506.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,325.34
$1,504.26
$1,693.78
$2,367.06
$3,596.98
$1,832.28
$2,011.20
$2,200.72
$2,874.00
$2,339.22
$2,518.14
$2,707.66
$3,380.94
$2,846.16
$3,025.08
$3,214.60
$3,887.88
$506.94
Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$397.65
$451.33
$508.20
$710.20
$1,079.22
$701.85
$755.53
$812.40
$1,014.40
$1,006.05
$1,059.73
$1,116.60
$1,318.60
$1,310.25
$1,363.93
$1,420.80
$1,622.80
$304.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.30
$902.66
$1,016.40
$1,420.40
$2,158.44
$1,099.50
$1,206.86
$1,320.60
$1,724.60
$1,403.70
$1,511.06
$1,624.80
$2,028.80
$1,707.90
$1,815.26
$1,929.00
$2,333.00
$304.20
Toc - Plan #5 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$688.55
$781.50
$879.97
$1,229.75
$1,868.72
$1,215.29
$1,308.24
$1,406.71
$1,756.49
$1,742.03
$1,834.98
$1,933.45
$2,283.23
$2,268.77
$2,361.72
$2,460.19
$2,809.97
$526.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,377.10
$1,563.00
$1,759.94
$2,459.50
$3,737.44
$1,903.84
$2,089.74
$2,286.68
$2,986.24
$2,430.58
$2,616.48
$2,813.42
$3,512.98
$2,957.32
$3,143.22
$3,340.16
$4,039.72
$526.74
Toc - Plan #6 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$472.55
$536.34
$603.92
$843.97
$1,282.50
$834.05
$897.84
$965.42
$1,205.47
$1,195.55
$1,259.34
$1,326.92
$1,566.97
$1,557.05
$1,620.84
$1,688.42
$1,928.47
$361.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$945.10
$1,072.68
$1,207.84
$1,687.94
$2,565.00
$1,306.60
$1,434.18
$1,569.34
$2,049.44
$1,668.10
$1,795.68
$1,930.84
$2,410.94
$2,029.60
$2,157.18
$2,292.34
$2,772.44
$361.50
Toc - Plan #7 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,250 $12,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$569.43
$646.30
$727.73
$1,017.00
$1,545.43
$1,005.04
$1,081.91
$1,163.34
$1,452.61
$1,440.65
$1,517.52
$1,598.95
$1,888.22
$1,876.26
$1,953.13
$2,034.56
$2,323.83
$435.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,138.86
$1,292.60
$1,455.46
$2,034.00
$3,090.86
$1,574.47
$1,728.21
$1,891.07
$2,469.61
$2,010.08
$2,163.82
$2,326.68
$2,905.22
$2,445.69
$2,599.43
$2,762.29
$3,340.83
$435.61
Toc - Plan #8 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$387.22
$439.49
$494.87
$691.57
$1,050.92
$683.44
$735.71
$791.09
$987.79
$979.66
$1,031.93
$1,087.31
$1,284.01
$1,275.88
$1,328.15
$1,383.53
$1,580.23
$296.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774.44
$878.98
$989.74
$1,383.14
$2,101.84
$1,070.66
$1,175.20
$1,285.96
$1,679.36
$1,366.88
$1,471.42
$1,582.18
$1,975.58
$1,663.10
$1,767.64
$1,878.40
$2,271.80
$296.22
Toc - Plan #9 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,900 $11,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$552.96
$627.61
$706.68
$987.59
$1,500.73
$975.97
$1,050.62
$1,129.69
$1,410.60
$1,398.98
$1,473.63
$1,552.70
$1,833.61
$1,821.99
$1,896.64
$1,975.71
$2,256.62
$423.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,105.92
$1,255.22
$1,413.36
$1,975.18
$3,001.46
$1,528.93
$1,678.23
$1,836.37
$2,398.19
$1,951.94
$2,101.24
$2,259.38
$2,821.20
$2,374.95
$2,524.25
$2,682.39
$3,244.21
$423.01
Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.44
$472.66
$532.21
$743.76
$1,130.22
$735.02
$791.24
$850.79
$1,062.34
$1,053.60
$1,109.82
$1,169.37
$1,380.92
$1,372.18
$1,428.40
$1,487.95
$1,699.50
$318.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.88
$945.32
$1,064.42
$1,487.52
$2,260.44
$1,151.46
$1,263.90
$1,383.00
$1,806.10
$1,470.04
$1,582.48
$1,701.58
$2,124.68
$1,788.62
$1,901.06
$2,020.16
$2,443.26
$318.58
Toc - Plan #11 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.35
$443.05
$498.87
$697.17
$1,059.41
$688.97
$741.67
$797.49
$995.79
$987.59
$1,040.29
$1,096.11
$1,294.41
$1,286.21
$1,338.91
$1,394.73
$1,593.03
$298.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.70
$886.10
$997.74
$1,394.34
$2,118.82
$1,079.32
$1,184.72
$1,296.36
$1,692.96
$1,377.94
$1,483.34
$1,594.98
$1,991.58
$1,676.56
$1,781.96
$1,893.60
$2,290.20
$298.62
Toc - Plan #12 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$490.88
$557.15
$627.34
$876.71
$1,332.25
$866.40
$932.67
$1,002.86
$1,252.23
$1,241.92
$1,308.19
$1,378.38
$1,627.75
$1,617.44
$1,683.71
$1,753.90
$2,003.27
$375.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$981.76
$1,114.30
$1,254.68
$1,753.42
$2,664.50
$1,357.28
$1,489.82
$1,630.20
$2,128.94
$1,732.80
$1,865.34
$2,005.72
$2,504.46
$2,108.32
$2,240.86
$2,381.24
$2,879.98
$375.52
Toc - Plan #13 Florida Blue (BlueCross BlueShield FL)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$539.09
$611.87
$688.96
$962.81
$1,463.09
$951.49
$1,024.27
$1,101.36
$1,375.21
$1,363.89
$1,436.67
$1,513.76
$1,787.61
$1,776.29
$1,849.07
$1,926.16
$2,200.01
$412.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,078.18
$1,223.74
$1,377.92
$1,925.62
$2,926.18
$1,490.58
$1,636.14
$1,790.32
$2,338.02
$1,902.98
$2,048.54
$2,202.72
$2,750.42
$2,315.38
$2,460.94
$2,615.12
$3,162.82
$412.40
Toc - Plan #14 Florida Blue (BlueCross BlueShield FL)
Platinum

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$684.75
$777.19
$875.11
$1,222.96
$1,858.41
$1,208.58
$1,301.02
$1,398.94
$1,746.79
$1,732.41
$1,824.85
$1,922.77
$2,270.62
$2,256.24
$2,348.68
$2,446.60
$2,794.45
$523.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,369.50
$1,554.38
$1,750.22
$2,445.92
$3,716.82
$1,893.33
$2,078.21
$2,274.05
$2,969.75
$2,417.16
$2,602.04
$2,797.88
$3,493.58
$2,940.99
$3,125.87
$3,321.71
$4,017.41
$523.83
Toc - Plan #15 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-03 ($0 Virtual Visits / $0 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$741.52
$841.63
$947.66
$1,324.35
$2,012.49
$1,308.78
$1,408.89
$1,514.92
$1,891.61
$1,876.04
$1,976.15
$2,082.18
$2,458.87
$2,443.30
$2,543.41
$2,649.44
$3,026.13
$567.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,483.04
$1,683.26
$1,895.32
$2,648.70
$4,024.98
$2,050.30
$2,250.52
$2,462.58
$3,215.96
$2,617.56
$2,817.78
$3,029.84
$3,783.22
$3,184.82
$3,385.04
$3,597.10
$4,350.48
$567.26
Toc - Plan #16 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-04 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$530.00
$601.55
$677.34
$946.58
$1,438.42
$935.45
$1,007.00
$1,082.79
$1,352.03
$1,340.90
$1,412.45
$1,488.24
$1,757.48
$1,746.35
$1,817.90
$1,893.69
$2,162.93
$405.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,060.00
$1,203.10
$1,354.68
$1,893.16
$2,876.84
$1,465.45
$1,608.55
$1,760.13
$2,298.61
$1,870.90
$2,014.00
$2,165.58
$2,704.06
$2,276.35
$2,419.45
$2,571.03
$3,109.51
$405.45
Toc - Plan #17 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-05 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$1,000.55
$1,135.62
$1,278.70
$1,786.98
$2,715.49
$1,765.97
$1,901.04
$2,044.12
$2,552.40
$2,531.39
$2,666.46
$2,809.54
$3,317.82
$3,296.81
$3,431.88
$3,574.96
$4,083.24
$765.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,001.10
$2,271.24
$2,557.40
$3,573.96
$5,430.98
$2,766.52
$3,036.66
$3,322.82
$4,339.38
$3,531.94
$3,802.08
$4,088.24
$5,104.80
$4,297.36
$4,567.50
$4,853.66
$5,870.22
$765.42
Toc - Plan #18 Florida Blue (BlueCross BlueShield FL)
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$495.86
$562.80
$633.71
$885.61
$1,345.76
$875.19
$942.13
$1,013.04
$1,264.94
$1,254.52
$1,321.46
$1,392.37
$1,644.27
$1,633.85
$1,700.79
$1,771.70
$2,023.60
$379.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$991.72
$1,125.60
$1,267.42
$1,771.22
$2,691.52
$1,371.05
$1,504.93
$1,646.75
$2,150.55
$1,750.38
$1,884.26
$2,026.08
$2,529.88
$2,129.71
$2,263.59
$2,405.41
$2,909.21
$379.33
Toc - Plan #19 Florida Blue (BlueCross BlueShield FL)
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$793.22
$900.30
$1,013.74
$1,416.69
$2,152.80
$1,400.03
$1,507.11
$1,620.55
$2,023.50
$2,006.84
$2,113.92
$2,227.36
$2,630.31
$2,613.65
$2,720.73
$2,834.17
$3,237.12
$606.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,586.44
$1,800.60
$2,027.48
$2,833.38
$4,305.60
$2,193.25
$2,407.41
$2,634.29
$3,440.19
$2,800.06
$3,014.22
$3,241.10
$4,047.00
$3,406.87
$3,621.03
$3,847.91
$4,653.81
$606.81
Toc - Plan #20 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-08 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$1,040.68
$1,181.17
$1,329.99
$1,858.65
$2,824.41
$1,836.80
$1,977.29
$2,126.11
$2,654.77
$2,632.92
$2,773.41
$2,922.23
$3,450.89
$3,429.04
$3,569.53
$3,718.35
$4,247.01
$796.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,081.36
$2,362.34
$2,659.98
$3,717.30
$5,648.82
$2,877.48
$3,158.46
$3,456.10
$4,513.42
$3,673.60
$3,954.58
$4,252.22
$5,309.54
$4,469.72
$4,750.70
$5,048.34
$6,105.66
$796.12
Toc - Plan #21 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-09 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,250 $12,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$853.89
$969.17
$1,091.27
$1,525.05
$2,317.46
$1,507.12
$1,622.40
$1,744.50
$2,178.28
$2,160.35
$2,275.63
$2,397.73
$2,831.51
$2,813.58
$2,928.86
$3,050.96
$3,484.74
$653.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,707.78
$1,938.34
$2,182.54
$3,050.10
$4,634.92
$2,361.01
$2,591.57
$2,835.77
$3,703.33
$3,014.24
$3,244.80
$3,489.00
$4,356.56
$3,667.47
$3,898.03
$4,142.23
$5,009.79
$653.23
Toc - Plan #22 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze (HSA) 24J01-10 (Rewards $$$ / $4 Condition Care Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$515.53
$585.13
$658.85
$920.74
$1,399.15
$909.91
$979.51
$1,053.23
$1,315.12
$1,304.29
$1,373.89
$1,447.61
$1,709.50
$1,698.67
$1,768.27
$1,841.99
$2,103.88
$394.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,031.06
$1,170.26
$1,317.70
$1,841.48
$2,798.30
$1,425.44
$1,564.64
$1,712.08
$2,235.86
$1,819.82
$1,959.02
$2,106.46
$2,630.24
$2,214.20
$2,353.40
$2,500.84
$3,024.62
$394.38
Toc - Plan #23 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-12 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,900 $11,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$828.65
$940.52
$1,059.01
$1,479.97
$2,248.96
$1,462.57
$1,574.44
$1,692.93
$2,113.89
$2,096.49
$2,208.36
$2,326.85
$2,747.81
$2,730.41
$2,842.28
$2,960.77
$3,381.73
$633.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,657.30
$1,881.04
$2,118.02
$2,959.94
$4,497.92
$2,291.22
$2,514.96
$2,751.94
$3,593.86
$2,925.14
$3,148.88
$3,385.86
$4,227.78
$3,559.06
$3,782.80
$4,019.78
$4,861.70
$633.92
Toc - Plan #24 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-17 ($0 Virtual Visits / $50 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$554.94
$629.86
$709.21
$991.12
$1,506.11
$979.47
$1,054.39
$1,133.74
$1,415.65
$1,404.00
$1,478.92
$1,558.27
$1,840.18
$1,828.53
$1,903.45
$1,982.80
$2,264.71
$424.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,109.88
$1,259.72
$1,418.42
$1,982.24
$3,012.22
$1,534.41
$1,684.25
$1,842.95
$2,406.77
$1,958.94
$2,108.78
$2,267.48
$2,831.30
$2,383.47
$2,533.31
$2,692.01
$3,255.83
$424.53
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(PPO) BlueOptions Bronze 24J01-18S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$519.51
$589.64
$663.93
$927.84
$1,409.95
$916.94
$987.07
$1,061.36
$1,325.27
$1,314.37
$1,384.50
$1,458.79
$1,722.70
$1,711.80
$1,781.93
$1,856.22
$2,120.13
$397.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,039.02
$1,179.28
$1,327.86
$1,855.68
$2,819.90
$1,436.45
$1,576.71
$1,725.29
$2,253.11
$1,833.88
$1,974.14
$2,122.72
$2,650.54
$2,231.31
$2,371.57
$2,520.15
$3,047.97
$397.43
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Silver

(PPO) BlueOptions Silver 24J01-19S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$770.65
$874.69
$984.89
$1,376.38
$2,091.54
$1,360.20
$1,464.24
$1,574.44
$1,965.93
$1,949.75
$2,053.79
$2,163.99
$2,555.48
$2,539.30
$2,643.34
$2,753.54
$3,145.03
$589.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,541.30
$1,749.38
$1,969.78
$2,752.76
$4,183.08
$2,130.85
$2,338.93
$2,559.33
$3,342.31
$2,720.40
$2,928.48
$3,148.88
$3,931.86
$3,309.95
$3,518.03
$3,738.43
$4,521.41
$589.55
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Gold

(PPO) BlueOptions Gold 24J01-20S ($30 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$808.19
$917.30
$1,032.87
$1,443.43
$2,193.43
$1,426.46
$1,535.57
$1,651.14
$2,061.70
$2,044.73
$2,153.84
$2,269.41
$2,679.97
$2,663.00
$2,772.11
$2,887.68
$3,298.24
$618.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,616.38
$1,834.60
$2,065.74
$2,886.86
$4,386.86
$2,234.65
$2,452.87
$2,684.01
$3,505.13
$2,852.92
$3,071.14
$3,302.28
$4,123.40
$3,471.19
$3,689.41
$3,920.55
$4,741.67
$618.27
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Platinum

(PPO) BlueOptions Platinum 24J01-21S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$1,034.17
$1,173.78
$1,321.67
$1,847.03
$2,806.74
$1,825.31
$1,964.92
$2,112.81
$2,638.17
$2,616.45
$2,756.06
$2,903.95
$3,429.31
$3,407.59
$3,547.20
$3,695.09
$4,220.45
$791.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$2,068.34
$2,347.56
$2,643.34
$3,694.06
$5,613.48
$2,859.48
$3,138.70
$3,434.48
$4,485.20
$3,650.62
$3,929.84
$4,225.62
$5,276.34
$4,441.76
$4,720.98
$5,016.76
$6,067.48
$791.14

ADVERTISEMENT

Ambetter from Sunshine Health

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

Toc - Plan #29 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
$470.19
$533.66
$600.90
$839.75
$1,276.08
$829.88
$893.35
$960.59
$1,199.44
$1,189.57
$1,253.04
$1,320.28
$1,559.13
$1,549.26
$1,612.73
$1,679.97
$1,918.82
$359.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$940.38
$1,067.32
$1,201.80
$1,679.50
$2,552.16
$1,300.07
$1,427.01
$1,561.49
$2,039.19
$1,659.76
$1,786.70
$1,921.18
$2,398.88
$2,019.45
$2,146.39
$2,280.87
$2,758.57
$359.69
Toc - Plan #30 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.40
$440.83
$496.37
$693.67
$1,054.10
$685.52
$737.95
$793.49
$990.79
$982.64
$1,035.07
$1,090.61
$1,287.91
$1,279.76
$1,332.19
$1,387.73
$1,585.03
$297.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.80
$881.66
$992.74
$1,387.34
$2,108.20
$1,073.92
$1,178.78
$1,289.86
$1,684.46
$1,371.04
$1,475.90
$1,586.98
$1,981.58
$1,668.16
$1,773.02
$1,884.10
$2,278.70
$297.12
Toc - Plan #31 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
$490.23
$556.39
$626.50
$875.53
$1,330.45
$865.25
$931.41
$1,001.52
$1,250.55
$1,240.27
$1,306.43
$1,376.54
$1,625.57
$1,615.29
$1,681.45
$1,751.56
$2,000.59
$375.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$980.46
$1,112.78
$1,253.00
$1,751.06
$2,660.90
$1,355.48
$1,487.80
$1,628.02
$2,126.08
$1,730.50
$1,862.82
$2,003.04
$2,501.10
$2,105.52
$2,237.84
$2,378.06
$2,876.12
$375.02
Toc - Plan #32 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.12
$434.83
$489.62
$684.24
$1,039.77
$676.20
$727.91
$782.70
$977.32
$969.28
$1,020.99
$1,075.78
$1,270.40
$1,262.36
$1,314.07
$1,368.86
$1,563.48
$293.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.24
$869.66
$979.24
$1,368.48
$2,079.54
$1,059.32
$1,162.74
$1,272.32
$1,661.56
$1,352.40
$1,455.82
$1,565.40
$1,954.64
$1,645.48
$1,748.90
$1,858.48
$2,247.72
$293.08
Toc - Plan #33 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$439.89
$499.26
$562.16
$785.62
$1,193.82
$776.40
$835.77
$898.67
$1,122.13
$1,112.91
$1,172.28
$1,235.18
$1,458.64
$1,449.42
$1,508.79
$1,571.69
$1,795.15
$336.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.78
$998.52
$1,124.32
$1,571.24
$2,387.64
$1,216.29
$1,335.03
$1,460.83
$1,907.75
$1,552.80
$1,671.54
$1,797.34
$2,244.26
$1,889.31
$2,008.05
$2,133.85
$2,580.77
$336.51
Toc - Plan #34 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
$477.43
$541.87
$610.14
$852.67
$1,295.71
$842.65
$907.09
$975.36
$1,217.89
$1,207.87
$1,272.31
$1,340.58
$1,583.11
$1,573.09
$1,637.53
$1,705.80
$1,948.33
$365.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$954.86
$1,083.74
$1,220.28
$1,705.34
$2,591.42
$1,320.08
$1,448.96
$1,585.50
$2,070.56
$1,685.30
$1,814.18
$1,950.72
$2,435.78
$2,050.52
$2,179.40
$2,315.94
$2,801.00
$365.22
Toc - Plan #35 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$485.94
$551.53
$621.02
$867.88
$1,318.82
$857.68
$923.27
$992.76
$1,239.62
$1,229.42
$1,295.01
$1,364.50
$1,611.36
$1,601.16
$1,666.75
$1,736.24
$1,983.10
$371.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$971.88
$1,103.06
$1,242.04
$1,735.76
$2,637.64
$1,343.62
$1,474.80
$1,613.78
$2,107.50
$1,715.36
$1,846.54
$1,985.52
$2,479.24
$2,087.10
$2,218.28
$2,357.26
$2,850.98
$371.74
Toc - Plan #36 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
$449.45
$510.11
$574.38
$802.70
$1,219.78
$793.27
$853.93
$918.20
$1,146.52
$1,137.09
$1,197.75
$1,262.02
$1,490.34
$1,480.91
$1,541.57
$1,605.84
$1,834.16
$343.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$898.90
$1,020.22
$1,148.76
$1,605.40
$2,439.56
$1,242.72
$1,364.04
$1,492.58
$1,949.22
$1,586.54
$1,707.86
$1,836.40
$2,293.04
$1,930.36
$2,051.68
$2,180.22
$2,636.86
$343.82
Toc - Plan #37 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$517.01
$586.80
$660.73
$923.37
$1,403.15
$912.52
$982.31
$1,056.24
$1,318.88
$1,308.03
$1,377.82
$1,451.75
$1,714.39
$1,703.54
$1,773.33
$1,847.26
$2,109.90
$395.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,034.02
$1,173.60
$1,321.46
$1,846.74
$2,806.30
$1,429.53
$1,569.11
$1,716.97
$2,242.25
$1,825.04
$1,964.62
$2,112.48
$2,637.76
$2,220.55
$2,360.13
$2,507.99
$3,033.27
$395.51
Toc - Plan #38 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.70
$426.41
$480.13
$670.98
$1,019.63
$663.10
$713.81
$767.53
$958.38
$950.50
$1,001.21
$1,054.93
$1,245.78
$1,237.90
$1,288.61
$1,342.33
$1,533.18
$287.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$751.40
$852.82
$960.26
$1,341.96
$2,039.26
$1,038.80
$1,140.22
$1,247.66
$1,629.36
$1,326.20
$1,427.62
$1,535.06
$1,916.76
$1,613.60
$1,715.02
$1,822.46
$2,204.16
$287.40
Toc - Plan #39 Ambetter from Sunshine Health
Silver

(EPO) Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$475.81
$540.03
$608.07
$849.78
$1,291.32
$839.80
$904.02
$972.06
$1,213.77
$1,203.79
$1,268.01
$1,336.05
$1,577.76
$1,567.78
$1,632.00
$1,700.04
$1,941.75
$363.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$951.62
$1,080.06
$1,216.14
$1,699.56
$2,582.64
$1,315.61
$1,444.05
$1,580.13
$2,063.55
$1,679.60
$1,808.04
$1,944.12
$2,427.54
$2,043.59
$2,172.03
$2,308.11
$2,791.53
$363.99
Toc - Plan #40 Ambetter from Sunshine Health
Gold

(EPO) Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$446.74
$507.04
$570.92
$797.86
$1,212.42
$788.49
$848.79
$912.67
$1,139.61
$1,130.24
$1,190.54
$1,254.42
$1,481.36
$1,471.99
$1,532.29
$1,596.17
$1,823.11
$341.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$893.48
$1,014.08
$1,141.84
$1,595.72
$2,424.84
$1,235.23
$1,355.83
$1,483.59
$1,937.47
$1,576.98
$1,697.58
$1,825.34
$2,279.22
$1,918.73
$2,039.33
$2,167.09
$2,620.97
$341.75
Toc - Plan #41 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
$507.10
$575.54
$648.06
$905.66
$1,376.23
$895.02
$963.46
$1,035.98
$1,293.58
$1,282.94
$1,351.38
$1,423.90
$1,681.50
$1,670.86
$1,739.30
$1,811.82
$2,069.42
$387.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,014.20
$1,151.08
$1,296.12
$1,811.32
$2,752.46
$1,402.12
$1,539.00
$1,684.04
$2,199.24
$1,790.04
$1,926.92
$2,071.96
$2,587.16
$2,177.96
$2,314.84
$2,459.88
$2,975.08
$387.92
Toc - Plan #42 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$401.77
$456.00
$513.45
$717.55
$1,090.38
$709.12
$763.35
$820.80
$1,024.90
$1,016.47
$1,070.70
$1,128.15
$1,332.25
$1,323.82
$1,378.05
$1,435.50
$1,639.60
$307.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.54
$912.00
$1,026.90
$1,435.10
$2,180.76
$1,110.89
$1,219.35
$1,334.25
$1,742.45
$1,418.24
$1,526.70
$1,641.60
$2,049.80
$1,725.59
$1,834.05
$1,948.95
$2,357.15
$307.35
Toc - Plan #43 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
$486.38
$552.03
$621.58
$868.65
$1,320.00
$858.45
$924.10
$993.65
$1,240.72
$1,230.52
$1,296.17
$1,365.72
$1,612.79
$1,602.59
$1,668.24
$1,737.79
$1,984.86
$372.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$972.76
$1,104.06
$1,243.16
$1,737.30
$2,640.00
$1,344.83
$1,476.13
$1,615.23
$2,109.37
$1,716.90
$1,848.20
$1,987.30
$2,481.44
$2,088.97
$2,220.27
$2,359.37
$2,853.51
$372.07
Toc - Plan #44 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
$493.86
$560.52
$631.14
$882.01
$1,340.30
$871.65
$938.31
$1,008.93
$1,259.80
$1,249.44
$1,316.10
$1,386.72
$1,637.59
$1,627.23
$1,693.89
$1,764.51
$2,015.38
$377.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$987.72
$1,121.04
$1,262.28
$1,764.02
$2,680.60
$1,365.51
$1,498.83
$1,640.07
$2,141.81
$1,743.30
$1,876.62
$2,017.86
$2,519.60
$2,121.09
$2,254.41
$2,395.65
$2,897.39
$377.79
Toc - Plan #45 Ambetter from Sunshine Health
Gold

(EPO) Elite Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$534.81
$606.99
$683.47
$955.15
$1,451.44
$943.93
$1,016.11
$1,092.59
$1,364.27
$1,353.05
$1,425.23
$1,501.71
$1,773.39
$1,762.17
$1,834.35
$1,910.83
$2,182.51
$409.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,069.62
$1,213.98
$1,366.94
$1,910.30
$2,902.88
$1,478.74
$1,623.10
$1,776.06
$2,319.42
$1,887.86
$2,032.22
$2,185.18
$2,728.54
$2,296.98
$2,441.34
$2,594.30
$3,137.66
$409.12
Toc - Plan #46 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Standard Expanded Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.63
$441.08
$496.66
$694.08
$1,054.72
$685.92
$738.37
$793.95
$991.37
$983.21
$1,035.66
$1,091.24
$1,288.66
$1,280.50
$1,332.95
$1,388.53
$1,585.95
$297.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.26
$882.16
$993.32
$1,388.16
$2,109.44
$1,074.55
$1,179.45
$1,290.61
$1,685.45
$1,371.84
$1,476.74
$1,587.90
$1,982.74
$1,669.13
$1,774.03
$1,885.19
$2,280.03
$297.29
Toc - Plan #47 Ambetter from Sunshine Health
Silver

(EPO) Standard Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$492.18
$558.62
$629.00
$879.02
$1,335.76
$868.69
$935.13
$1,005.51
$1,255.53
$1,245.20
$1,311.64
$1,382.02
$1,632.04
$1,621.71
$1,688.15
$1,758.53
$2,008.55
$376.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$984.36
$1,117.24
$1,258.00
$1,758.04
$2,671.52
$1,360.87
$1,493.75
$1,634.51
$2,134.55
$1,737.38
$1,870.26
$2,011.02
$2,511.06
$2,113.89
$2,246.77
$2,387.53
$2,887.57
$376.51
Toc - Plan #48 Ambetter from Sunshine Health
Gold

(EPO) Standard Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$462.11
$524.49
$590.57
$825.32
$1,254.15
$815.62
$878.00
$944.08
$1,178.83
$1,169.13
$1,231.51
$1,297.59
$1,532.34
$1,522.64
$1,585.02
$1,651.10
$1,885.85
$353.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$924.22
$1,048.98
$1,181.14
$1,650.64
$2,508.30
$1,277.73
$1,402.49
$1,534.65
$2,004.15
$1,631.24
$1,756.00
$1,888.16
$2,357.66
$1,984.75
$2,109.51
$2,241.67
$2,711.17
$353.51
Toc - Plan #49 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.31
$449.80
$506.47
$707.79
$1,075.55
$699.48
$752.97
$809.64
$1,010.96
$1,002.65
$1,056.14
$1,112.81
$1,314.13
$1,305.82
$1,359.31
$1,415.98
$1,617.30
$303.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.62
$899.60
$1,012.94
$1,415.58
$2,151.10
$1,095.79
$1,202.77
$1,316.11
$1,718.75
$1,398.96
$1,505.94
$1,619.28
$2,021.92
$1,702.13
$1,809.11
$1,922.45
$2,325.09
$303.17
Toc - Plan #50 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$455.03
$516.44
$581.51
$812.66
$1,234.91
$803.12
$864.53
$929.60
$1,160.75
$1,151.21
$1,212.62
$1,277.69
$1,508.84
$1,499.30
$1,560.71
$1,625.78
$1,856.93
$348.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$910.06
$1,032.88
$1,163.02
$1,625.32
$2,469.82
$1,258.15
$1,380.97
$1,511.11
$1,973.41
$1,606.24
$1,729.06
$1,859.20
$2,321.50
$1,954.33
$2,077.15
$2,207.29
$2,669.59
$348.09
Toc - Plan #51 Ambetter from Sunshine Health
Silver

(EPO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$502.67
$570.52
$642.40
$897.75
$1,364.21
$887.20
$955.05
$1,026.93
$1,282.28
$1,271.73
$1,339.58
$1,411.46
$1,666.81
$1,656.26
$1,724.11
$1,795.99
$2,051.34
$384.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,005.34
$1,141.04
$1,284.80
$1,795.50
$2,728.42
$1,389.87
$1,525.57
$1,669.33
$2,180.03
$1,774.40
$1,910.10
$2,053.86
$2,564.56
$2,158.93
$2,294.63
$2,438.39
$2,949.09
$384.53
Toc - Plan #52 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
$464.92
$527.67
$594.15
$830.33
$1,261.76
$820.57
$883.32
$949.80
$1,185.98
$1,176.22
$1,238.97
$1,305.45
$1,541.63
$1,531.87
$1,594.62
$1,661.10
$1,897.28
$355.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$929.84
$1,055.34
$1,188.30
$1,660.66
$2,523.52
$1,285.49
$1,410.99
$1,543.95
$2,016.31
$1,641.14
$1,766.64
$1,899.60
$2,371.96
$1,996.79
$2,122.29
$2,255.25
$2,727.61
$355.65

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

(HMO) myBlue Bronze 1601 ($0 Virtual Visits / 3 PCP Visits for $0 then $45 / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.10
$432.55
$487.05
$680.64
$1,034.31
$672.64
$724.09
$778.59
$972.18
$964.18
$1,015.63
$1,070.13
$1,263.72
$1,255.72
$1,307.17
$1,361.67
$1,555.26
$291.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.20
$865.10
$974.10
$1,361.28
$2,068.62
$1,053.74
$1,156.64
$1,265.64
$1,652.82
$1,345.28
$1,448.18
$1,557.18
$1,944.36
$1,636.82
$1,739.72
$1,848.72
$2,235.90
$291.54
Toc - Plan #54 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
$516.49
$586.22
$660.07
$922.45
$1,401.75
$911.60
$981.33
$1,055.18
$1,317.56
$1,306.71
$1,376.44
$1,450.29
$1,712.67
$1,701.82
$1,771.55
$1,845.40
$2,107.78
$395.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,032.98
$1,172.44
$1,320.14
$1,844.90
$2,803.50
$1,428.09
$1,567.55
$1,715.25
$2,240.01
$1,823.20
$1,962.66
$2,110.36
$2,635.12
$2,218.31
$2,357.77
$2,505.47
$3,030.23
$395.11
Toc - Plan #55 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.75
$501.39
$564.56
$788.97
$1,198.91
$779.69
$839.33
$902.50
$1,126.91
$1,117.63
$1,177.27
$1,240.44
$1,464.85
$1,455.57
$1,515.21
$1,578.38
$1,802.79
$337.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$883.50
$1,002.78
$1,129.12
$1,577.94
$2,397.82
$1,221.44
$1,340.72
$1,467.06
$1,915.88
$1,559.38
$1,678.66
$1,805.00
$2,253.82
$1,897.32
$2,016.60
$2,142.94
$2,591.76
$337.94
Toc - Plan #56 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($0 Virtual Visits / $35 PCP Visit / $75 Specialist Visits / $30 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$401.11
$455.26
$512.62
$716.38
$1,088.61
$707.96
$762.11
$819.47
$1,023.23
$1,014.81
$1,068.96
$1,126.32
$1,330.08
$1,321.66
$1,375.81
$1,433.17
$1,636.93
$306.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802.22
$910.52
$1,025.24
$1,432.76
$2,177.22
$1,109.07
$1,217.37
$1,332.09
$1,739.61
$1,415.92
$1,524.22
$1,638.94
$2,046.46
$1,722.77
$1,831.07
$1,945.79
$2,353.31
$306.85
Toc - Plan #57 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237 ($0 Virtual Visits / $60 PCP Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419.02
$475.59
$535.51
$748.37
$1,137.22
$739.57
$796.14
$856.06
$1,068.92
$1,060.12
$1,116.69
$1,176.61
$1,389.47
$1,380.67
$1,437.24
$1,497.16
$1,710.02
$320.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$838.04
$951.18
$1,071.02
$1,496.74
$2,274.44
$1,158.59
$1,271.73
$1,391.57
$1,817.29
$1,479.14
$1,592.28
$1,712.12
$2,137.84
$1,799.69
$1,912.83
$2,032.67
$2,458.39
$320.55
Toc - Plan #58 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,650 $3,300 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.12
$423.49
$476.85
$666.39
$1,012.65
$658.56
$708.93
$762.29
$951.83
$944.00
$994.37
$1,047.73
$1,237.27
$1,229.44
$1,279.81
$1,333.17
$1,522.71
$285.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.24
$846.98
$953.70
$1,332.78
$2,025.30
$1,031.68
$1,132.42
$1,239.14
$1,618.22
$1,317.12
$1,417.86
$1,524.58
$1,903.66
$1,602.56
$1,703.30
$1,810.02
$2,189.10
$285.44
Toc - Plan #59 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.30
$410.08
$461.74
$645.28
$980.57
$637.69
$686.47
$738.13
$921.67
$914.08
$962.86
$1,014.52
$1,198.06
$1,190.47
$1,239.25
$1,290.91
$1,474.45
$276.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.60
$820.16
$923.48
$1,290.56
$1,961.14
$998.99
$1,096.55
$1,199.87
$1,566.95
$1,275.38
$1,372.94
$1,476.26
$1,843.34
$1,551.77
$1,649.33
$1,752.65
$2,119.73
$276.39
Toc - Plan #60 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.76
$444.65
$500.67
$699.68
$1,063.24
$691.46
$744.35
$800.37
$999.38
$991.16
$1,044.05
$1,100.07
$1,299.08
$1,290.86
$1,343.75
$1,399.77
$1,598.78
$299.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.52
$889.30
$1,001.34
$1,399.36
$2,126.48
$1,083.22
$1,189.00
$1,301.04
$1,699.06
$1,382.92
$1,488.70
$1,600.74
$1,998.76
$1,682.62
$1,788.40
$1,900.44
$2,298.46
$299.70
Toc - Plan #61 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 24M06-50 ($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
$446.65
$506.95
$570.82
$797.72
$1,212.21
$788.34
$848.64
$912.51
$1,139.41
$1,130.03
$1,190.33
$1,254.20
$1,481.10
$1,471.72
$1,532.02
$1,595.89
$1,822.79
$341.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$893.30
$1,013.90
$1,141.64
$1,595.44
$2,424.42
$1,234.99
$1,355.59
$1,483.33
$1,937.13
$1,576.68
$1,697.28
$1,825.02
$2,278.82
$1,918.37
$2,038.97
$2,166.71
$2,620.51
$341.69
Toc - Plan #62 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$442.18
$501.87
$565.11
$789.73
$1,200.08
$780.45
$840.14
$903.38
$1,128.00
$1,118.72
$1,178.41
$1,241.65
$1,466.27
$1,456.99
$1,516.68
$1,579.92
$1,804.54
$338.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$884.36
$1,003.74
$1,130.22
$1,579.46
$2,400.16
$1,222.63
$1,342.01
$1,468.49
$1,917.73
$1,560.90
$1,680.28
$1,806.76
$2,256.00
$1,899.17
$2,018.55
$2,145.03
$2,594.27
$338.27
Toc - Plan #63 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$509.24
$577.99
$650.81
$909.50
$1,382.08
$898.81
$967.56
$1,040.38
$1,299.07
$1,288.38
$1,357.13
$1,429.95
$1,688.64
$1,677.95
$1,746.70
$1,819.52
$2,078.21
$389.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,018.48
$1,155.98
$1,301.62
$1,819.00
$2,764.16
$1,408.05
$1,545.55
$1,691.19
$2,208.57
$1,797.62
$1,935.12
$2,080.76
$2,598.14
$2,187.19
$2,324.69
$2,470.33
$2,987.71
$389.57
Toc - Plan #64 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 24M05-74 ($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
$5,950 $11,900 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
$535.29
$607.55
$684.10
$956.03
$1,452.78
$944.79
$1,017.05
$1,093.60
$1,365.53
$1,354.29
$1,426.55
$1,503.10
$1,775.03
$1,763.79
$1,836.05
$1,912.60
$2,184.53
$409.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,070.58
$1,215.10
$1,368.20
$1,912.06
$2,905.56
$1,480.08
$1,624.60
$1,777.70
$2,321.56
$1,889.58
$2,034.10
$2,187.20
$2,731.06
$2,299.08
$2,443.60
$2,596.70
$3,140.56
$409.50
Toc - Plan #65 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) myBlue Platinum 24M05-75 ($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
$656.44
$745.06
$838.93
$1,172.40
$1,781.58
$1,158.62
$1,247.24
$1,341.11
$1,674.58
$1,660.80
$1,749.42
$1,843.29
$2,176.76
$2,162.98
$2,251.60
$2,345.47
$2,678.94
$502.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,312.88
$1,490.12
$1,677.86
$2,344.80
$3,563.16
$1,815.06
$1,992.30
$2,180.04
$2,846.98
$2,317.24
$2,494.48
$2,682.22
$3,349.16
$2,819.42
$2,996.66
$3,184.40
$3,851.34
$502.18
Toc - Plan #66 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 24M06-76 ($0 Virtual Visits / $10 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,200 $18,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.58
$466.01
$524.72
$733.30
$1,114.31
$724.67
$780.10
$838.81
$1,047.39
$1,038.76
$1,094.19
$1,152.90
$1,361.48
$1,352.85
$1,408.28
$1,466.99
$1,675.57
$314.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.16
$932.02
$1,049.44
$1,466.60
$2,228.62
$1,135.25
$1,246.11
$1,363.53
$1,780.69
$1,449.34
$1,560.20
$1,677.62
$2,094.78
$1,763.43
$1,874.29
$1,991.71
$2,408.87
$314.09
Toc - Plan #67 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) myBlue Platinum 24M05-00S ($0 Deductible / $10 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
$0 $0 Annual Deductible
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$653.71
$741.96
$835.44
$1,167.53
$1,774.17
$1,153.80
$1,242.05
$1,335.53
$1,667.62
$1,653.89
$1,742.14
$1,835.62
$2,167.71
$2,153.98
$2,242.23
$2,335.71
$2,667.80
$500.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,307.42
$1,483.92
$1,670.88
$2,335.06
$3,548.34
$1,807.51
$1,984.01
$2,170.97
$2,835.15
$2,307.60
$2,484.10
$2,671.06
$3,335.24
$2,807.69
$2,984.19
$3,171.15
$3,835.33
$500.09
Toc - Plan #68 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2237D ($0 Virtual Visits / $60 PCP Visits / Adult Dental / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$427.39
$485.09
$546.20
$763.32
$1,159.94
$754.34
$812.04
$873.15
$1,090.27
$1,081.29
$1,138.99
$1,200.10
$1,417.22
$1,408.24
$1,465.94
$1,527.05
$1,744.17
$326.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$854.78
$970.18
$1,092.40
$1,526.64
$2,319.88
$1,181.73
$1,297.13
$1,419.35
$1,853.59
$1,508.68
$1,624.08
$1,746.30
$2,180.54
$1,835.63
$1,951.03
$2,073.25
$2,507.49
$326.95
Toc - Plan #69 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 24M06-76D ($0 Virtual Visits / Adult Dental / $10 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,200 $18,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419.01
$475.58
$535.49
$748.35
$1,137.19
$739.55
$796.12
$856.03
$1,068.89
$1,060.09
$1,116.66
$1,176.57
$1,389.43
$1,380.63
$1,437.20
$1,497.11
$1,709.97
$320.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$838.02
$951.16
$1,070.98
$1,496.70
$2,274.38
$1,158.56
$1,271.70
$1,391.52
$1,817.24
$1,479.10
$1,592.24
$1,712.06
$2,137.78
$1,799.64
$1,912.78
$2,032.60
$2,458.32
$320.54
Toc - Plan #70 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K01-02 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$489.92
$556.06
$626.12
$875.00
$1,329.64
$864.71
$930.85
$1,000.91
$1,249.79
$1,239.50
$1,305.64
$1,375.70
$1,624.58
$1,614.29
$1,680.43
$1,750.49
$1,999.37
$374.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$979.84
$1,112.12
$1,252.24
$1,750.00
$2,659.28
$1,354.63
$1,486.91
$1,627.03
$2,124.79
$1,729.42
$1,861.70
$2,001.82
$2,499.58
$2,104.21
$2,236.49
$2,376.61
$2,874.37
$374.79
Toc - Plan #71 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K01-03 ($0 Virtual Visits / 3 PCP Visits for $0 then $40 / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413.38
$469.19
$528.30
$738.30
$1,121.91
$729.62
$785.43
$844.54
$1,054.54
$1,045.86
$1,101.67
$1,160.78
$1,370.78
$1,362.10
$1,417.91
$1,477.02
$1,687.02
$316.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.76
$938.38
$1,056.60
$1,476.60
$2,243.82
$1,143.00
$1,254.62
$1,372.84
$1,792.84
$1,459.24
$1,570.86
$1,689.08
$2,109.08
$1,775.48
$1,887.10
$2,005.32
$2,425.32
$316.24
Toc - Plan #72 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K01-04 ($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
$669.58
$759.97
$855.72
$1,195.87
$1,817.24
$1,181.81
$1,272.20
$1,367.95
$1,708.10
$1,694.04
$1,784.43
$1,880.18
$2,220.33
$2,206.27
$2,296.66
$2,392.41
$2,732.56
$512.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,339.16
$1,519.94
$1,711.44
$2,391.74
$3,634.48
$1,851.39
$2,032.17
$2,223.67
$2,903.97
$2,363.62
$2,544.40
$2,735.90
$3,416.20
$2,875.85
$3,056.63
$3,248.13
$3,928.43
$512.23
Toc - Plan #73 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(POS) BlueCare Bronze 24K01-05 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.65
$427.50
$481.36
$672.70
$1,022.23
$664.79
$715.64
$769.50
$960.84
$952.93
$1,003.78
$1,057.64
$1,248.98
$1,241.07
$1,291.92
$1,345.78
$1,537.12
$288.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.30
$855.00
$962.72
$1,345.40
$2,044.46
$1,041.44
$1,143.14
$1,250.86
$1,633.54
$1,329.58
$1,431.28
$1,539.00
$1,921.68
$1,617.72
$1,719.42
$1,827.14
$2,209.82
$288.14
Toc - Plan #74 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K01-06 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$7,150 $14,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$539.22
$612.01
$689.12
$963.05
$1,463.44
$951.72
$1,024.51
$1,101.62
$1,375.55
$1,364.22
$1,437.01
$1,514.12
$1,788.05
$1,776.72
$1,849.51
$1,926.62
$2,200.55
$412.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,078.44
$1,224.02
$1,378.24
$1,926.10
$2,926.88
$1,490.94
$1,636.52
$1,790.74
$2,338.60
$1,903.44
$2,049.02
$2,203.24
$2,751.10
$2,315.94
$2,461.52
$2,615.74
$3,163.60
$412.50
Toc - Plan #75 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K01-07 ($0 Virtual Visits / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$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
$704.13
$799.19
$899.88
$1,257.58
$1,911.01
$1,242.79
$1,337.85
$1,438.54
$1,796.24
$1,781.45
$1,876.51
$1,977.20
$2,334.90
$2,320.11
$2,415.17
$2,515.86
$2,873.56
$538.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,408.26
$1,598.38
$1,799.76
$2,515.16
$3,822.02
$1,946.92
$2,137.04
$2,338.42
$3,053.82
$2,485.58
$2,675.70
$2,877.08
$3,592.48
$3,024.24
$3,214.36
$3,415.74
$4,131.14
$538.66
Toc - Plan #76 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K01-08 ($0 Virtual Visits / $20 PCP Visit / $15 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,250 $12,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$609.13
$691.36
$778.47
$1,087.91
$1,653.18
$1,075.11
$1,157.34
$1,244.45
$1,553.89
$1,541.09
$1,623.32
$1,710.43
$2,019.87
$2,007.07
$2,089.30
$2,176.41
$2,485.85
$465.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,218.26
$1,382.72
$1,556.94
$2,175.82
$3,306.36
$1,684.24
$1,848.70
$2,022.92
$2,641.80
$2,150.22
$2,314.68
$2,488.90
$3,107.78
$2,616.20
$2,780.66
$2,954.88
$3,573.76
$465.98
Toc - Plan #77 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze (HSA) 24K01-09 (Rewards $$$ / $4 Condition Care Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.85
$449.29
$505.90
$706.99
$1,074.34
$698.68
$752.12
$808.73
$1,009.82
$1,001.51
$1,054.95
$1,111.56
$1,312.65
$1,304.34
$1,357.78
$1,414.39
$1,615.48
$302.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.70
$898.58
$1,011.80
$1,413.98
$2,148.68
$1,094.53
$1,201.41
$1,314.63
$1,716.81
$1,397.36
$1,504.24
$1,617.46
$2,019.64
$1,700.19
$1,807.07
$1,920.29
$2,322.47
$302.83
Toc - Plan #78 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K01-10 ($0 Virtual Visits / $20 Labs / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,900 $11,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$584.36
$663.25
$746.81
$1,043.67
$1,585.95
$1,031.40
$1,110.29
$1,193.85
$1,490.71
$1,478.44
$1,557.33
$1,640.89
$1,937.75
$1,925.48
$2,004.37
$2,087.93
$2,384.79
$447.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,168.72
$1,326.50
$1,493.62
$2,087.34
$3,171.90
$1,615.76
$1,773.54
$1,940.66
$2,534.38
$2,062.80
$2,220.58
$2,387.70
$2,981.42
$2,509.84
$2,667.62
$2,834.74
$3,428.46
$447.04
Toc - Plan #79 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K01-25 ($0 Virtual Visits / $50 PCP Visit / $30 Generic Meds / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.05
$500.59
$563.66
$787.72
$1,197.01
$778.45
$837.99
$901.06
$1,125.12
$1,115.85
$1,175.39
$1,238.46
$1,462.52
$1,453.25
$1,512.79
$1,575.86
$1,799.92
$337.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.10
$1,001.18
$1,127.32
$1,575.44
$2,394.02
$1,219.50
$1,338.58
$1,464.72
$1,912.84
$1,556.90
$1,675.98
$1,802.12
$2,250.24
$1,894.30
$2,013.38
$2,139.52
$2,587.64
$337.40
Toc - Plan #80 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(POS) BlueCare Bronze 24K01-31S (Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$402.73
$457.10
$514.69
$719.28
$1,093.01
$710.82
$765.19
$822.78
$1,027.37
$1,018.91
$1,073.28
$1,130.87
$1,335.46
$1,327.00
$1,381.37
$1,438.96
$1,643.55
$308.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.46
$914.20
$1,029.38
$1,438.56
$2,186.02
$1,113.55
$1,222.29
$1,337.47
$1,746.65
$1,421.64
$1,530.38
$1,645.56
$2,054.74
$1,729.73
$1,838.47
$1,953.65
$2,362.83
$308.09
Toc - Plan #81 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(POS) BlueCare Silver 24K01-32S ($40 PCP Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$518.84
$588.88
$663.08
$926.65
$1,408.13
$915.75
$985.79
$1,059.99
$1,323.56
$1,312.66
$1,382.70
$1,456.90
$1,720.47
$1,709.57
$1,779.61
$1,853.81
$2,117.38
$396.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,037.68
$1,177.76
$1,326.16
$1,853.30
$2,816.26
$1,434.59
$1,574.67
$1,723.07
$2,250.21
$1,831.50
$1,971.58
$2,119.98
$2,647.12
$2,228.41
$2,368.49
$2,516.89
$3,044.03
$396.91
Toc - Plan #82 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(POS) BlueCare Gold 24K01-33S ($30 PCP Visit / Multilingual Available/ Rewards $$$)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$566.35
$642.81
$723.80
$1,011.50
$1,537.07
$999.61
$1,076.07
$1,157.06
$1,444.76
$1,432.87
$1,509.33
$1,590.32
$1,878.02
$1,866.13
$1,942.59
$2,023.58
$2,311.28
$433.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,132.70
$1,285.62
$1,447.60
$2,023.00
$3,074.14
$1,565.96
$1,718.88
$1,880.86
$2,456.26
$1,999.22
$2,152.14
$2,314.12
$2,889.52
$2,432.48
$2,585.40
$2,747.38
$3,322.78
$433.26
Toc - Plan #83 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(POS) BlueCare Platinum 24K01-34S ($0 Deductible / $10 PCP Visits / $20 Specialist Visits / Multilingual Available / Rewards $$$)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$701.91
$796.67
$897.04
$1,253.61
$1,904.98
$1,238.87
$1,333.63
$1,434.00
$1,790.57
$1,775.83
$1,870.59
$1,970.96
$2,327.53
$2,312.79
$2,407.55
$2,507.92
$2,864.49
$536.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,403.82
$1,593.34
$1,794.08
$2,507.22
$3,809.96
$1,940.78
$2,130.30
$2,331.04
$3,044.18
$2,477.74
$2,667.26
$2,868.00
$3,581.14
$3,014.70
$3,204.22
$3,404.96
$4,118.10
$536.96

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #84 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite + PCP Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.28
$494.03
$556.27
$777.39
$1,181.32
$768.26
$827.01
$889.25
$1,110.37
$1,101.24
$1,159.99
$1,222.23
$1,443.35
$1,434.22
$1,492.97
$1,555.21
$1,776.33
$332.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$870.56
$988.06
$1,112.54
$1,554.78
$2,362.64
$1,203.54
$1,321.04
$1,445.52
$1,887.76
$1,536.52
$1,654.02
$1,778.50
$2,220.74
$1,869.50
$1,987.00
$2,111.48
$2,553.72
$332.98
Toc - Plan #85 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
$479.68
$544.42
$613.01
$856.68
$1,301.81
$846.62
$911.36
$979.95
$1,223.62
$1,213.56
$1,278.30
$1,346.89
$1,590.56
$1,580.50
$1,645.24
$1,713.83
$1,957.50
$366.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$959.36
$1,088.84
$1,226.02
$1,713.36
$2,603.62
$1,326.30
$1,455.78
$1,592.96
$2,080.30
$1,693.24
$1,822.72
$1,959.90
$2,447.24
$2,060.18
$2,189.66
$2,326.84
$2,814.18
$366.94
Toc - Plan #86 Oscar Insurance Company of Florida
Catastrophic

(EPO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.03
$329.18
$370.65
$517.98
$787.13
$511.90
$551.05
$592.52
$739.85
$733.77
$772.92
$814.39
$961.72
$955.64
$994.79
$1,036.26
$1,183.59
$221.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.06
$658.36
$741.30
$1,035.96
$1,574.26
$801.93
$880.23
$963.17
$1,257.83
$1,023.80
$1,102.10
$1,185.04
$1,479.70
$1,245.67
$1,323.97
$1,406.91
$1,701.57
$221.87
Toc - Plan #87 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite + Specialist Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$437.91
$497.02
$559.64
$782.10
$1,188.47
$772.91
$832.02
$894.64
$1,117.10
$1,107.91
$1,167.02
$1,229.64
$1,452.10
$1,442.91
$1,502.02
$1,564.64
$1,787.10
$335.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$875.82
$994.04
$1,119.28
$1,564.20
$2,376.94
$1,210.82
$1,329.04
$1,454.28
$1,899.20
$1,545.82
$1,664.04
$1,789.28
$2,234.20
$1,880.82
$1,999.04
$2,124.28
$2,569.20
$335.00
Toc - Plan #88 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
$509.12
$577.84
$650.65
$909.28
$1,381.73
$898.59
$967.31
$1,040.12
$1,298.75
$1,288.06
$1,356.78
$1,429.59
$1,688.22
$1,677.53
$1,746.25
$1,819.06
$2,077.69
$389.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,018.24
$1,155.68
$1,301.30
$1,818.56
$2,763.46
$1,407.71
$1,545.15
$1,690.77
$2,208.03
$1,797.18
$1,934.62
$2,080.24
$2,597.50
$2,186.65
$2,324.09
$2,469.71
$2,986.97
$389.47
Toc - Plan #89 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
$478.44
$543.02
$611.43
$854.48
$1,298.46
$844.44
$909.02
$977.43
$1,220.48
$1,210.44
$1,275.02
$1,343.43
$1,586.48
$1,576.44
$1,641.02
$1,709.43
$1,952.48
$366.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$956.88
$1,086.04
$1,222.86
$1,708.96
$2,596.92
$1,322.88
$1,452.04
$1,588.86
$2,074.96
$1,688.88
$1,818.04
$1,954.86
$2,440.96
$2,054.88
$2,184.04
$2,320.86
$2,806.96
$366.00
Toc - Plan #90 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
$8,000 $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
$488.27
$554.17
$623.99
$872.03
$1,325.13
$861.79
$927.69
$997.51
$1,245.55
$1,235.31
$1,301.21
$1,371.03
$1,619.07
$1,608.83
$1,674.73
$1,744.55
$1,992.59
$373.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$976.54
$1,108.34
$1,247.98
$1,744.06
$2,650.26
$1,350.06
$1,481.86
$1,621.50
$2,117.58
$1,723.58
$1,855.38
$1,995.02
$2,491.10
$2,097.10
$2,228.90
$2,368.54
$2,864.62
$373.52
Toc - Plan #91 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic 4700

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.02
$447.20
$503.55
$703.71
$1,069.35
$695.44
$748.62
$804.97
$1,005.13
$996.86
$1,050.04
$1,106.39
$1,306.55
$1,298.28
$1,351.46
$1,407.81
$1,607.97
$301.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.04
$894.40
$1,007.10
$1,407.42
$2,138.70
$1,089.46
$1,195.82
$1,308.52
$1,708.84
$1,390.88
$1,497.24
$1,609.94
$2,010.26
$1,692.30
$1,798.66
$1,911.36
$2,311.68
$301.42
Toc - Plan #92 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
$474.95
$539.06
$606.98
$848.25
$1,289.00
$838.28
$902.39
$970.31
$1,211.58
$1,201.61
$1,265.72
$1,333.64
$1,574.91
$1,564.94
$1,629.05
$1,696.97
$1,938.24
$363.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$949.90
$1,078.12
$1,213.96
$1,696.50
$2,578.00
$1,313.23
$1,441.45
$1,577.29
$2,059.83
$1,676.56
$1,804.78
$1,940.62
$2,423.16
$2,039.89
$2,168.11
$2,303.95
$2,786.49
$363.33
Toc - Plan #93 Oscar Insurance Company of Florida
Gold

(EPO) Gold Elite Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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
$555.89
$630.93
$710.42
$992.81
$1,508.67
$981.14
$1,056.18
$1,135.67
$1,418.06
$1,406.39
$1,481.43
$1,560.92
$1,843.31
$1,831.64
$1,906.68
$1,986.17
$2,268.56
$425.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,111.78
$1,261.86
$1,420.84
$1,985.62
$3,017.34
$1,537.03
$1,687.11
$1,846.09
$2,410.87
$1,962.28
$2,112.36
$2,271.34
$2,836.12
$2,387.53
$2,537.61
$2,696.59
$3,261.37
$425.25
Toc - Plan #94 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
$527.84
$599.09
$674.57
$942.71
$1,432.54
$931.63
$1,002.88
$1,078.36
$1,346.50
$1,335.42
$1,406.67
$1,482.15
$1,750.29
$1,739.21
$1,810.46
$1,885.94
$2,154.08
$403.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,055.68
$1,198.18
$1,349.14
$1,885.42
$2,865.08
$1,459.47
$1,601.97
$1,752.93
$2,289.21
$1,863.26
$2,005.76
$2,156.72
$2,693.00
$2,267.05
$2,409.55
$2,560.51
$3,096.79
$403.79
Toc - Plan #95 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Elite Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$427.49
$485.19
$546.32
$763.48
$1,160.18
$754.51
$812.21
$873.34
$1,090.50
$1,081.53
$1,139.23
$1,200.36
$1,417.52
$1,408.55
$1,466.25
$1,527.38
$1,744.54
$327.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$854.98
$970.38
$1,092.64
$1,526.96
$2,320.36
$1,182.00
$1,297.40
$1,419.66
$1,853.98
$1,509.02
$1,624.42
$1,746.68
$2,181.00
$1,836.04
$1,951.44
$2,073.70
$2,508.02
$327.02
Toc - Plan #96 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Bronze Classic Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.53
$443.24
$499.09
$697.47
$1,059.88
$689.28
$741.99
$797.84
$996.22
$988.03
$1,040.74
$1,096.59
$1,294.97
$1,286.78
$1,339.49
$1,395.34
$1,593.72
$298.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.06
$886.48
$998.18
$1,394.94
$2,119.76
$1,079.81
$1,185.23
$1,296.93
$1,693.69
$1,378.56
$1,483.98
$1,595.68
$1,992.44
$1,677.31
$1,782.73
$1,894.43
$2,291.19
$298.75
Toc - Plan #97 Oscar Insurance Company of Florida
Silver

(EPO) Silver Classic Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$475.93
$540.17
$608.23
$850.00
$1,291.66
$840.01
$904.25
$972.31
$1,214.08
$1,204.09
$1,268.33
$1,336.39
$1,578.16
$1,568.17
$1,632.41
$1,700.47
$1,942.24
$364.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$951.86
$1,080.34
$1,216.46
$1,700.00
$2,583.32
$1,315.94
$1,444.42
$1,580.54
$2,064.08
$1,680.02
$1,808.50
$1,944.62
$2,428.16
$2,044.10
$2,172.58
$2,308.70
$2,792.24
$364.08
Toc - Plan #98 Oscar Insurance Company of Florida
Gold

(EPO) Gold Classic Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$492.10
$558.52
$628.88
$878.86
$1,335.52
$868.55
$934.97
$1,005.33
$1,255.31
$1,245.00
$1,311.42
$1,381.78
$1,631.76
$1,621.45
$1,687.87
$1,758.23
$2,008.21
$376.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$984.20
$1,117.04
$1,257.76
$1,757.72
$2,671.04
$1,360.65
$1,493.49
$1,634.21
$2,134.17
$1,737.10
$1,869.94
$2,010.66
$2,510.62
$2,113.55
$2,246.39
$2,387.11
$2,887.07
$376.45

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0405 | Toll Free: 1-888-200-0405 | TTY: 1-888-200-0405

Toc - Plan #99 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,900 $7,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$400.28
$454.32
$511.56
$714.90
$1,086.36
$706.50
$760.54
$817.78
$1,021.12
$1,012.72
$1,066.76
$1,124.00
$1,327.34
$1,318.94
$1,372.98
$1,430.22
$1,633.56
$306.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$800.56
$908.64
$1,023.12
$1,429.80
$2,172.72
$1,106.78
$1,214.86
$1,329.34
$1,736.02
$1,413.00
$1,521.08
$1,635.56
$2,042.24
$1,719.22
$1,827.30
$1,941.78
$2,348.46
$306.22
Toc - Plan #100 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$320.80
$364.11
$409.98
$572.95
$870.65
$566.21
$609.52
$655.39
$818.36
$811.62
$854.93
$900.80
$1,063.77
$1,057.03
$1,100.34
$1,146.21
$1,309.18
$245.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.60
$728.22
$819.96
$1,145.90
$1,741.30
$887.01
$973.63
$1,065.37
$1,391.31
$1,132.42
$1,219.04
$1,310.78
$1,636.72
$1,377.83
$1,464.45
$1,556.19
$1,882.13
$245.41
Toc - Plan #101 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.29
$364.66
$410.61
$573.82
$871.98
$567.08
$610.45
$656.40
$819.61
$812.87
$856.24
$902.19
$1,065.40
$1,058.66
$1,102.03
$1,147.98
$1,311.19
$245.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$642.58
$729.32
$821.22
$1,147.64
$1,743.96
$888.37
$975.11
$1,067.01
$1,393.43
$1,134.16
$1,220.90
$1,312.80
$1,639.22
$1,379.95
$1,466.69
$1,558.59
$1,885.01
$245.79
Toc - Plan #102 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$460.07
$522.18
$587.97
$821.69
$1,248.64
$812.03
$874.14
$939.93
$1,173.65
$1,163.99
$1,226.10
$1,291.89
$1,525.61
$1,515.95
$1,578.06
$1,643.85
$1,877.57
$351.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$920.14
$1,044.36
$1,175.94
$1,643.38
$2,497.28
$1,272.10
$1,396.32
$1,527.90
$1,995.34
$1,624.06
$1,748.28
$1,879.86
$2,347.30
$1,976.02
$2,100.24
$2,231.82
$2,699.26
$351.96
Toc - Plan #103 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$452.25
$513.30
$577.97
$807.71
$1,227.40
$798.22
$859.27
$923.94
$1,153.68
$1,144.19
$1,205.24
$1,269.91
$1,499.65
$1,490.16
$1,551.21
$1,615.88
$1,845.62
$345.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$904.50
$1,026.60
$1,155.94
$1,615.42
$2,454.80
$1,250.47
$1,372.57
$1,501.91
$1,961.39
$1,596.44
$1,718.54
$1,847.88
$2,307.36
$1,942.41
$2,064.51
$2,193.85
$2,653.33
$345.97
Toc - Plan #104 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.38
$472.59
$532.14
$743.66
$1,130.06
$734.91
$791.12
$850.67
$1,062.19
$1,053.44
$1,109.65
$1,169.20
$1,380.72
$1,371.97
$1,428.18
$1,487.73
$1,699.25
$318.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.76
$945.18
$1,064.28
$1,487.32
$2,260.12
$1,151.29
$1,263.71
$1,382.81
$1,805.85
$1,469.82
$1,582.24
$1,701.34
$2,124.38
$1,788.35
$1,900.77
$2,019.87
$2,442.91
$318.53
Toc - Plan #105 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.84
$449.28
$505.88
$706.97
$1,074.31
$698.66
$752.10
$808.70
$1,009.79
$1,001.48
$1,054.92
$1,111.52
$1,312.61
$1,304.30
$1,357.74
$1,414.34
$1,615.43
$302.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.68
$898.56
$1,011.76
$1,413.94
$2,148.62
$1,094.50
$1,201.38
$1,314.58
$1,716.76
$1,397.32
$1,504.20
$1,617.40
$2,019.58
$1,700.14
$1,807.02
$1,920.22
$2,322.40
$302.82
Toc - Plan #106 UnitedHealthcare
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.09
$358.77
$403.97
$564.54
$857.88
$557.90
$600.58
$645.78
$806.35
$799.71
$842.39
$887.59
$1,048.16
$1,041.52
$1,084.20
$1,129.40
$1,289.97
$241.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.18
$717.54
$807.94
$1,129.08
$1,715.76
$873.99
$959.35
$1,049.75
$1,370.89
$1,115.80
$1,201.16
$1,291.56
$1,612.70
$1,357.61
$1,442.97
$1,533.37
$1,854.51
$241.81
Toc - Plan #107 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.76
$365.20
$411.21
$574.67
$873.26
$567.91
$611.35
$657.36
$820.82
$814.06
$857.50
$903.51
$1,066.97
$1,060.21
$1,103.65
$1,149.66
$1,313.12
$246.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.52
$730.40
$822.42
$1,149.34
$1,746.52
$889.67
$976.55
$1,068.57
$1,395.49
$1,135.82
$1,222.70
$1,314.72
$1,641.64
$1,381.97
$1,468.85
$1,560.87
$1,887.79
$246.15
Toc - Plan #108 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$337.41
$382.96
$431.21
$602.62
$915.74
$595.53
$641.08
$689.33
$860.74
$853.65
$899.20
$947.45
$1,118.86
$1,111.77
$1,157.32
$1,205.57
$1,376.98
$258.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$674.82
$765.92
$862.42
$1,205.24
$1,831.48
$932.94
$1,024.04
$1,120.54
$1,463.36
$1,191.06
$1,282.16
$1,378.66
$1,721.48
$1,449.18
$1,540.28
$1,636.78
$1,979.60
$258.12
Toc - Plan #109 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$399.40
$453.32
$510.43
$713.33
$1,083.97
$704.94
$758.86
$815.97
$1,018.87
$1,010.48
$1,064.40
$1,121.51
$1,324.41
$1,316.02
$1,369.94
$1,427.05
$1,629.95
$305.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798.80
$906.64
$1,020.86
$1,426.66
$2,167.94
$1,104.34
$1,212.18
$1,326.40
$1,732.20
$1,409.88
$1,517.72
$1,631.94
$2,037.74
$1,715.42
$1,823.26
$1,937.48
$2,343.28
$305.54
Toc - Plan #110 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.91
$458.44
$516.20
$721.38
$1,096.21
$712.90
$767.43
$825.19
$1,030.37
$1,021.89
$1,076.42
$1,134.18
$1,339.36
$1,330.88
$1,385.41
$1,443.17
$1,648.35
$308.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$807.82
$916.88
$1,032.40
$1,442.76
$2,192.42
$1,116.81
$1,225.87
$1,341.39
$1,751.75
$1,425.80
$1,534.86
$1,650.38
$2,060.74
$1,734.79
$1,843.85
$1,959.37
$2,369.73
$308.99
Toc - Plan #111 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$449.72
$510.43
$574.74
$803.20
$1,220.53
$793.75
$854.46
$918.77
$1,147.23
$1,137.78
$1,198.49
$1,262.80
$1,491.26
$1,481.81
$1,542.52
$1,606.83
$1,835.29
$344.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$899.44
$1,020.86
$1,149.48
$1,606.40
$2,441.06
$1,243.47
$1,364.89
$1,493.51
$1,950.43
$1,587.50
$1,708.92
$1,837.54
$2,294.46
$1,931.53
$2,052.95
$2,181.57
$2,638.49
$344.03
Toc - Plan #112 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$450.93
$511.81
$576.29
$805.36
$1,223.82
$795.89
$856.77
$921.25
$1,150.32
$1,140.85
$1,201.73
$1,266.21
$1,495.28
$1,485.81
$1,546.69
$1,611.17
$1,840.24
$344.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$901.86
$1,023.62
$1,152.58
$1,610.72
$2,447.64
$1,246.82
$1,368.58
$1,497.54
$1,955.68
$1,591.78
$1,713.54
$1,842.50
$2,300.64
$1,936.74
$2,058.50
$2,187.46
$2,645.60
$344.96
Toc - Plan #113 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$476.76
$541.13
$609.30
$851.50
$1,293.94
$841.48
$905.85
$974.02
$1,216.22
$1,206.20
$1,270.57
$1,338.74
$1,580.94
$1,570.92
$1,635.29
$1,703.46
$1,945.66
$364.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$953.52
$1,082.26
$1,218.60
$1,703.00
$2,587.88
$1,318.24
$1,446.98
$1,583.32
$2,067.72
$1,682.96
$1,811.70
$1,948.04
$2,432.44
$2,047.68
$2,176.42
$2,312.76
$2,797.16
$364.72
Toc - Plan #114 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$421.66
$478.58
$538.88
$753.08
$1,144.38
$744.23
$801.15
$861.45
$1,075.65
$1,066.80
$1,123.72
$1,184.02
$1,398.22
$1,389.37
$1,446.29
$1,506.59
$1,720.79
$322.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$843.32
$957.16
$1,077.76
$1,506.16
$2,288.76
$1,165.89
$1,279.73
$1,400.33
$1,828.73
$1,488.46
$1,602.30
$1,722.90
$2,151.30
$1,811.03
$1,924.87
$2,045.47
$2,473.87
$322.57

ADVERTISEMENT

Ambetter from Sunshine Health

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

Toc - Plan #115 Ambetter from Sunshine Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$398.25
$452.00
$508.95
$711.26
$1,080.83
$702.91
$756.66
$813.61
$1,015.92
$1,007.57
$1,061.32
$1,118.27
$1,320.58
$1,312.23
$1,365.98
$1,422.93
$1,625.24
$304.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.50
$904.00
$1,017.90
$1,422.52
$2,161.66
$1,101.16
$1,208.66
$1,322.56
$1,727.18
$1,405.82
$1,513.32
$1,627.22
$2,031.84
$1,710.48
$1,817.98
$1,931.88
$2,336.50
$304.66
Toc - Plan #116 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$498.17
$565.41
$636.65
$889.72
$1,352.01
$879.26
$946.50
$1,017.74
$1,270.81
$1,260.35
$1,327.59
$1,398.83
$1,651.90
$1,641.44
$1,708.68
$1,779.92
$2,032.99
$381.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$996.34
$1,130.82
$1,273.30
$1,779.44
$2,704.02
$1,377.43
$1,511.91
$1,654.39
$2,160.53
$1,758.52
$1,893.00
$2,035.48
$2,541.62
$2,139.61
$2,274.09
$2,416.57
$2,922.71
$381.09
Toc - Plan #117 Ambetter from Sunshine Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$475.81
$540.04
$608.08
$849.78
$1,291.33
$839.80
$904.03
$972.07
$1,213.77
$1,203.79
$1,268.02
$1,336.06
$1,577.76
$1,567.78
$1,632.01
$1,700.05
$1,941.75
$363.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$951.62
$1,080.08
$1,216.16
$1,699.56
$2,582.66
$1,315.61
$1,444.07
$1,580.15
$2,063.55
$1,679.60
$1,808.06
$1,944.14
$2,427.54
$2,043.59
$2,172.05
$2,308.13
$2,791.53
$363.99
Toc - Plan #118 Ambetter from Sunshine Health
Expanded Bronze

(HMO) Standard Ambetter Virtual Access Expanded Bronze (Virtual PCP selection required)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393.06
$446.11
$502.32
$701.98
$1,066.73
$693.74
$746.79
$803.00
$1,002.66
$994.42
$1,047.47
$1,103.68
$1,303.34
$1,295.10
$1,348.15
$1,404.36
$1,604.02
$300.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.12
$892.22
$1,004.64
$1,403.96
$2,133.46
$1,086.80
$1,192.90
$1,305.32
$1,704.64
$1,387.48
$1,493.58
$1,606.00
$2,005.32
$1,688.16
$1,794.26
$1,906.68
$2,306.00
$300.68
Toc - Plan #119 Ambetter from Sunshine Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$497.82
$565.02
$636.21
$889.10
$1,351.07
$878.65
$945.85
$1,017.04
$1,269.93
$1,259.48
$1,326.68
$1,397.87
$1,650.76
$1,640.31
$1,707.51
$1,778.70
$2,031.59
$380.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$995.64
$1,130.04
$1,272.42
$1,778.20
$2,702.14
$1,376.47
$1,510.87
$1,653.25
$2,159.03
$1,757.30
$1,891.70
$2,034.08
$2,539.86
$2,138.13
$2,272.53
$2,414.91
$2,920.69
$380.83
Toc - Plan #120 Ambetter from Sunshine Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$467.40
$530.49
$597.33
$834.77
$1,268.51
$824.96
$888.05
$954.89
$1,192.33
$1,182.52
$1,245.61
$1,312.45
$1,549.89
$1,540.08
$1,603.17
$1,670.01
$1,907.45
$357.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$934.80
$1,060.98
$1,194.66
$1,669.54
$2,537.02
$1,292.36
$1,418.54
$1,552.22
$2,027.10
$1,649.92
$1,776.10
$1,909.78
$2,384.66
$2,007.48
$2,133.66
$2,267.34
$2,742.22
$357.56

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

Santa Rosa County is in “Rating Area 16” of Florida.

Currently, there are 120 plans offered in Rating Area 16.

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2024 Obamacare Plans for Santa Rosa County, FL

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