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Texas Obamacare 2023 Rates

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Dallam County Sherman County Hansford County Ochiltree County Lipscomb County Hartley County Moore County Hutchinson County Roberts County Hemphill County Oldham County Potter County Carson County Gray County Wheeler County Deaf Smith County Randall County Armstrong County Donley County Collingsworth County Parmer County Castro County Swisher County Briscoe County Hall County Childress County Hardeman County Wilbarger County Bailey County Lamb County Hale County Floyd County Motley County Cottle County Foard County Wichita County Clay County Red River County Montague County Lamar County Grayson County Cooke County Fannin County Cochran County Hockley County Archer County Lubbock County Baylor County Crosby County Dickens County King County Knox County Bowie County Delta County Titus County Jack County Franklin County Hunt County Morris County Hopkins County Wise County Denton County Collin County Cass County Yoakum County Terry County Young County Lynn County Garza County Throckmorton County Kent County Haskell County Stonewall County Camp County Wood County Rains County Rockwall County Dallas County Tarrant County Parker County Marion County Palo Pinto County Upshur County Gaines County Dawson County Scurry County Borden County Fisher County Stephens County Shackelford County Jones County Harrison County Van Zandt County Kaufman County Gregg County Smith County Ellis County Johnson County Hood County Andrews County Martin County Howard County Mitchell County Panola County Erath County Nolan County Rusk County Eastland County Taylor County Callahan County Henderson County Navarro County Somervell County Hill County Comanche County Cherokee County Bosque County Anderson County El Paso County Hudspeth County Winkler County Shelby County Ector County Midland County Glasscock County Sterling County Culberson County Coke County Brown County Coleman County Runnels County Freestone County Reeves County Loving County Hamilton County Nacogdoches County McLennan County Limestone County San Augustine County Sabine County Mills County Coryell County Leon County Tom Green County Ward County Houston County Crane County Upton County Reagan County Angelina County Concho County Falls County Irion County San Saba County McCulloch County Trinity County Lampasas County Robertson County Pecos County Newton County Bell County Jasper County Polk County Tyler County Jeff Davis County Madison County Milam County Walker County Crockett County Schleicher County Menard County Burnet County Brazos County San Jacinto County Mason County Grimes County Llano County Williamson County Burleson County Presidio County Kimble County Sutton County Brewster County Montgomery County Terrell County Hardin County Travis County Liberty County Lee County Blanco County Gillespie County Washington County Bastrop County Orange County Hays County Jefferson County Waller County Val Verde County Kerr County Edwards County Harris County Fayette County Austin County Kendall County Caldwell County Real County Comal County Chambers County Colorado County Bandera County Guadalupe County Fort Bend County Gonzales County Bexar County Galveston County Medina County Wharton County Brazoria County Lavaca County Galveston County Uvalde County Kinney County Wilson County DeWitt County Jackson County Matagorda County Atascosa County Karnes County Victoria County Frio County Zavala County Maverick County Goliad County Live Oak County Calhoun County Calhoun County Bee County McMullen County La Salle County Dimmit County Refugio County Calhoun County Calhoun County Aransas County Calhoun County Webb County San Patricio County Aransas County Jim Wells County Duval County Nueces County Nueces County Kleberg County Kleberg County Jim Hogg County Zapata County Kenedy County Kenedy County Brooks County Hidalgo County Starr County Willacy County Willacy County Cameron County Cameron County Cameron County

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Oscar Insurance Company

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

Toc - Plan #1 Oscar Insurance Company
Bronze

(EPO) Bronze Simple

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$277.73
$315.21
$354.92
$496.00
$753.72
$490.18
$527.66
$567.37
$708.45
$702.63
$740.11
$779.82
$920.90
$915.08
$952.56
$992.27
$1,133.35
$212.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$555.46
$630.42
$709.84
$992.00
$1,507.44
$767.91
$842.87
$922.29
$1,204.45
$980.36
$1,055.32
$1,134.74
$1,416.90
$1,192.81
$1,267.77
$1,347.19
$1,629.35
$212.45
Toc - Plan #2 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$279.10
$316.77
$356.68
$498.46
$757.46
$492.61
$530.28
$570.19
$711.97
$706.12
$743.79
$783.70
$925.48
$919.63
$957.30
$997.21
$1,138.99
$213.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$558.20
$633.54
$713.36
$996.92
$1,514.92
$771.71
$847.05
$926.87
$1,210.43
$985.22
$1,060.56
$1,140.38
$1,423.94
$1,198.73
$1,274.07
$1,353.89
$1,637.45
$213.51
Toc - Plan #3 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $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
$316.34
$359.03
$404.27
$564.96
$858.52
$558.33
$601.02
$646.26
$806.95
$800.32
$843.01
$888.25
$1,048.94
$1,042.31
$1,085.00
$1,130.24
$1,290.93
$241.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.68
$718.06
$808.54
$1,129.92
$1,717.04
$874.67
$960.05
$1,050.53
$1,371.91
$1,116.66
$1,202.04
$1,292.52
$1,613.90
$1,358.65
$1,444.03
$1,534.51
$1,855.89
$241.99
Toc - Plan #4 Oscar Insurance Company
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,700 $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
$406.32
$461.17
$519.27
$725.68
$1,102.73
$717.15
$772.00
$830.10
$1,036.51
$1,027.98
$1,082.83
$1,140.93
$1,347.34
$1,338.81
$1,393.66
$1,451.76
$1,658.17
$310.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$812.64
$922.34
$1,038.54
$1,451.36
$2,205.46
$1,123.47
$1,233.17
$1,349.37
$1,762.19
$1,434.30
$1,544.00
$1,660.20
$2,073.02
$1,745.13
$1,854.83
$1,971.03
$2,383.85
$310.83
Toc - Plan #5 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,000 $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
$402.47
$456.79
$514.34
$718.79
$1,092.28
$710.35
$764.67
$822.22
$1,026.67
$1,018.23
$1,072.55
$1,130.10
$1,334.55
$1,326.11
$1,380.43
$1,437.98
$1,642.43
$307.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$804.94
$913.58
$1,028.68
$1,437.58
$2,184.56
$1,112.82
$1,221.46
$1,336.56
$1,745.46
$1,420.70
$1,529.34
$1,644.44
$2,053.34
$1,728.58
$1,837.22
$1,952.32
$2,361.22
$307.88
Toc - Plan #6 Oscar Insurance Company
Silver

(EPO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$406.78
$461.68
$519.85
$726.49
$1,103.97
$717.96
$772.86
$831.03
$1,037.67
$1,029.14
$1,084.04
$1,142.21
$1,348.85
$1,340.32
$1,395.22
$1,453.39
$1,660.03
$311.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$813.56
$923.36
$1,039.70
$1,452.98
$2,207.94
$1,124.74
$1,234.54
$1,350.88
$1,764.16
$1,435.92
$1,545.72
$1,662.06
$2,075.34
$1,747.10
$1,856.90
$1,973.24
$2,386.52
$311.18
Toc - Plan #7 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $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
$315.21
$357.75
$402.83
$562.95
$855.46
$556.34
$598.88
$643.96
$804.08
$797.47
$840.01
$885.09
$1,045.21
$1,038.60
$1,081.14
$1,126.22
$1,286.34
$241.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.42
$715.50
$805.66
$1,125.90
$1,710.92
$871.55
$956.63
$1,046.79
$1,367.03
$1,112.68
$1,197.76
$1,287.92
$1,608.16
$1,353.81
$1,438.89
$1,529.05
$1,849.29
$241.13
Toc - Plan #8 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$292.06
$331.48
$373.24
$521.61
$792.63
$515.48
$554.90
$596.66
$745.03
$738.90
$778.32
$820.08
$968.45
$962.32
$1,001.74
$1,043.50
$1,191.87
$223.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$584.12
$662.96
$746.48
$1,043.22
$1,585.26
$807.54
$886.38
$969.90
$1,266.64
$1,030.96
$1,109.80
$1,193.32
$1,490.06
$1,254.38
$1,333.22
$1,416.74
$1,713.48
$223.42
Toc - Plan #9 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

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
$296.70
$336.74
$379.16
$529.88
$805.21
$523.66
$563.70
$606.12
$756.84
$750.62
$790.66
$833.08
$983.80
$977.58
$1,017.62
$1,060.04
$1,210.76
$226.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$593.40
$673.48
$758.32
$1,059.76
$1,610.42
$820.36
$900.44
$985.28
$1,286.72
$1,047.32
$1,127.40
$1,212.24
$1,513.68
$1,274.28
$1,354.36
$1,439.20
$1,740.64
$226.96
Toc - Plan #10 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $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
$396.27
$449.75
$506.42
$707.72
$1,075.44
$699.41
$752.89
$809.56
$1,010.86
$1,002.55
$1,056.03
$1,112.70
$1,314.00
$1,305.69
$1,359.17
$1,415.84
$1,617.14
$303.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.54
$899.50
$1,012.84
$1,415.44
$2,150.88
$1,095.68
$1,202.64
$1,315.98
$1,718.58
$1,398.82
$1,505.78
$1,619.12
$2,021.72
$1,701.96
$1,808.92
$1,922.26
$2,324.86
$303.14
Toc - Plan #11 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414.31
$470.23
$529.47
$739.94
$1,124.40
$731.25
$787.17
$846.41
$1,056.88
$1,048.19
$1,104.11
$1,163.35
$1,373.82
$1,365.13
$1,421.05
$1,480.29
$1,690.76
$316.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$828.62
$940.46
$1,058.94
$1,479.88
$2,248.80
$1,145.56
$1,257.40
$1,375.88
$1,796.82
$1,462.50
$1,574.34
$1,692.82
$2,113.76
$1,779.44
$1,891.28
$2,009.76
$2,430.70
$316.94
Toc - Plan #12 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$404.39
$458.97
$516.79
$722.22
$1,097.48
$713.74
$768.32
$826.14
$1,031.57
$1,023.09
$1,077.67
$1,135.49
$1,340.92
$1,332.44
$1,387.02
$1,444.84
$1,650.27
$309.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.78
$917.94
$1,033.58
$1,444.44
$2,194.96
$1,118.13
$1,227.29
$1,342.93
$1,753.79
$1,427.48
$1,536.64
$1,652.28
$2,063.14
$1,736.83
$1,845.99
$1,961.63
$2,372.49
$309.35
Toc - Plan #13 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Standard

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $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
$283.57
$321.84
$362.39
$506.44
$769.59
$500.49
$538.76
$579.31
$723.36
$717.41
$755.68
$796.23
$940.28
$934.33
$972.60
$1,013.15
$1,157.20
$216.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$567.14
$643.68
$724.78
$1,012.88
$1,539.18
$784.06
$860.60
$941.70
$1,229.80
$1,000.98
$1,077.52
$1,158.62
$1,446.72
$1,217.90
$1,294.44
$1,375.54
$1,663.64
$216.92
Toc - Plan #14 Oscar Insurance Company
Bronze

(EPO) Bronze Simple- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$266.70
$302.69
$340.83
$476.31
$723.79
$470.72
$506.71
$544.85
$680.33
$674.74
$710.73
$748.87
$884.35
$878.76
$914.75
$952.89
$1,088.37
$204.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$533.40
$605.38
$681.66
$952.62
$1,447.58
$737.42
$809.40
$885.68
$1,156.64
$941.44
$1,013.42
$1,089.70
$1,360.66
$1,145.46
$1,217.44
$1,293.72
$1,564.68
$204.02
Toc - Plan #15 Oscar Insurance Company
Silver

(EPO) Silver Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.66
$450.19
$506.91
$708.41
$1,076.50
$700.09
$753.62
$810.34
$1,011.84
$1,003.52
$1,057.05
$1,113.77
$1,315.27
$1,306.95
$1,360.48
$1,417.20
$1,618.70
$303.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793.32
$900.38
$1,013.82
$1,416.82
$2,153.00
$1,096.75
$1,203.81
$1,317.25
$1,720.25
$1,400.18
$1,507.24
$1,620.68
$2,023.68
$1,703.61
$1,810.67
$1,924.11
$2,327.11
$303.43
Toc - Plan #16 Oscar Insurance Company
Gold

(EPO) Gold Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.99
$409.72
$461.34
$644.72
$979.71
$637.14
$685.87
$737.49
$920.87
$913.29
$962.02
$1,013.64
$1,197.02
$1,189.44
$1,238.17
$1,289.79
$1,473.17
$276.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.98
$819.44
$922.68
$1,289.44
$1,959.42
$998.13
$1,095.59
$1,198.83
$1,565.59
$1,274.28
$1,371.74
$1,474.98
$1,841.74
$1,550.43
$1,647.89
$1,751.13
$2,117.89
$276.15
Toc - Plan #17 Oscar Insurance Company
Bronze

(EPO) Bronze Simple (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$292.41
$331.88
$373.69
$522.23
$793.58
$516.10
$555.57
$597.38
$745.92
$739.79
$779.26
$821.07
$969.61
$963.48
$1,002.95
$1,044.76
$1,193.30
$223.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$584.82
$663.76
$747.38
$1,044.46
$1,587.16
$808.51
$887.45
$971.07
$1,268.15
$1,032.20
$1,111.14
$1,194.76
$1,491.84
$1,255.89
$1,334.83
$1,418.45
$1,715.53
$223.69
Toc - Plan #18 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$293.87
$333.53
$375.55
$524.83
$797.53
$518.67
$558.33
$600.35
$749.63
$743.47
$783.13
$825.15
$974.43
$968.27
$1,007.93
$1,049.95
$1,199.23
$224.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$587.74
$667.06
$751.10
$1,049.66
$1,595.06
$812.54
$891.86
$975.90
$1,274.46
$1,037.34
$1,116.66
$1,200.70
$1,499.26
$1,262.14
$1,341.46
$1,425.50
$1,724.06
$224.80
Toc - Plan #19 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.14
$378.10
$425.74
$594.97
$904.11
$587.98
$632.94
$680.58
$849.81
$842.82
$887.78
$935.42
$1,104.65
$1,097.66
$1,142.62
$1,190.26
$1,359.49
$254.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$666.28
$756.20
$851.48
$1,189.94
$1,808.22
$921.12
$1,011.04
$1,106.32
$1,444.78
$1,175.96
$1,265.88
$1,361.16
$1,699.62
$1,430.80
$1,520.72
$1,616.00
$1,954.46
$254.84
Toc - Plan #20 Oscar Insurance Company
Silver

(EPO) Silver Classic (Choice)

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
$8,700 $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
$428.04
$485.81
$547.02
$764.46
$1,161.66
$755.48
$813.25
$874.46
$1,091.90
$1,082.92
$1,140.69
$1,201.90
$1,419.34
$1,410.36
$1,468.13
$1,529.34
$1,746.78
$327.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.08
$971.62
$1,094.04
$1,528.92
$2,323.32
$1,183.52
$1,299.06
$1,421.48
$1,856.36
$1,510.96
$1,626.50
$1,748.92
$2,183.80
$1,838.40
$1,953.94
$2,076.36
$2,511.24
$327.44
Toc - Plan #21 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.97
$481.20
$541.82
$757.20
$1,150.64
$748.30
$805.53
$866.15
$1,081.53
$1,072.63
$1,129.86
$1,190.48
$1,405.86
$1,396.96
$1,454.19
$1,514.81
$1,730.19
$324.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$847.94
$962.40
$1,083.64
$1,514.40
$2,301.28
$1,172.27
$1,286.73
$1,407.97
$1,838.73
$1,496.60
$1,611.06
$1,732.30
$2,163.06
$1,820.93
$1,935.39
$2,056.63
$2,487.39
$324.33
Toc - Plan #22 Oscar Insurance Company
Silver

(EPO) Silver Classic- PCP Saver (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$428.52
$486.35
$547.63
$765.31
$1,162.97
$756.33
$814.16
$875.44
$1,093.12
$1,084.14
$1,141.97
$1,203.25
$1,420.93
$1,411.95
$1,469.78
$1,531.06
$1,748.74
$327.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$857.04
$972.70
$1,095.26
$1,530.62
$2,325.94
$1,184.85
$1,300.51
$1,423.07
$1,858.43
$1,512.66
$1,628.32
$1,750.88
$2,186.24
$1,840.47
$1,956.13
$2,078.69
$2,514.05
$327.81
Toc - Plan #23 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+Specialist Saver (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$331.95
$376.75
$424.22
$592.84
$900.88
$585.88
$630.68
$678.15
$846.77
$839.81
$884.61
$932.08
$1,100.70
$1,093.74
$1,138.54
$1,186.01
$1,354.63
$253.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$663.90
$753.50
$848.44
$1,185.68
$1,801.76
$917.83
$1,007.43
$1,102.37
$1,439.61
$1,171.76
$1,261.36
$1,356.30
$1,693.54
$1,425.69
$1,515.29
$1,610.23
$1,947.47
$253.93
Toc - Plan #24 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$307.53
$349.04
$393.02
$549.24
$834.62
$542.79
$584.30
$628.28
$784.50
$778.05
$819.56
$863.54
$1,019.76
$1,013.31
$1,054.82
$1,098.80
$1,255.02
$235.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$615.06
$698.08
$786.04
$1,098.48
$1,669.24
$850.32
$933.34
$1,021.30
$1,333.74
$1,085.58
$1,168.60
$1,256.56
$1,569.00
$1,320.84
$1,403.86
$1,491.82
$1,804.26
$235.26
Toc - Plan #25 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded (Choice)

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
$312.42
$354.59
$399.26
$557.96
$847.88
$551.41
$593.58
$638.25
$796.95
$790.40
$832.57
$877.24
$1,035.94
$1,029.39
$1,071.56
$1,116.23
$1,274.93
$238.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$624.84
$709.18
$798.52
$1,115.92
$1,695.76
$863.83
$948.17
$1,037.51
$1,354.91
$1,102.82
$1,187.16
$1,276.50
$1,593.90
$1,341.81
$1,426.15
$1,515.49
$1,832.89
$238.99
Toc - Plan #26 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver (Choice)

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
$417.43
$473.77
$533.47
$745.52
$1,132.88
$736.76
$793.10
$852.80
$1,064.85
$1,056.09
$1,112.43
$1,172.13
$1,384.18
$1,375.42
$1,431.76
$1,491.46
$1,703.51
$319.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.86
$947.54
$1,066.94
$1,491.04
$2,265.76
$1,154.19
$1,266.87
$1,386.27
$1,810.37
$1,473.52
$1,586.20
$1,705.60
$2,129.70
$1,792.85
$1,905.53
$2,024.93
$2,449.03
$319.33
Toc - Plan #27 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$436.46
$495.37
$557.78
$779.49
$1,184.52
$770.34
$829.25
$891.66
$1,113.37
$1,104.22
$1,163.13
$1,225.54
$1,447.25
$1,438.10
$1,497.01
$1,559.42
$1,781.13
$333.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$872.92
$990.74
$1,115.56
$1,558.98
$2,369.04
$1,206.80
$1,324.62
$1,449.44
$1,892.86
$1,540.68
$1,658.50
$1,783.32
$2,226.74
$1,874.56
$1,992.38
$2,117.20
$2,560.62
$333.88
Toc - Plan #28 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.00
$483.49
$544.41
$760.81
$1,156.13
$751.88
$809.37
$870.29
$1,086.69
$1,077.76
$1,135.25
$1,196.17
$1,412.57
$1,403.64
$1,461.13
$1,522.05
$1,738.45
$325.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.00
$966.98
$1,088.82
$1,521.62
$2,312.26
$1,177.88
$1,292.86
$1,414.70
$1,847.50
$1,503.76
$1,618.74
$1,740.58
$2,173.38
$1,829.64
$1,944.62
$2,066.46
$2,499.26
$325.88
Toc - Plan #29 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Standard (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$298.58
$338.88
$381.57
$533.24
$810.32
$526.99
$567.29
$609.98
$761.65
$755.40
$795.70
$838.39
$990.06
$983.81
$1,024.11
$1,066.80
$1,218.47
$228.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$597.16
$677.76
$763.14
$1,066.48
$1,620.64
$825.57
$906.17
$991.55
$1,294.89
$1,053.98
$1,134.58
$1,219.96
$1,523.30
$1,282.39
$1,362.99
$1,448.37
$1,751.71
$228.41
Toc - Plan #30 Oscar Insurance Company
Bronze

(EPO) Bronze Simple- Standard (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$280.78
$318.68
$358.83
$501.46
$762.02
$495.57
$533.47
$573.62
$716.25
$710.36
$748.26
$788.41
$931.04
$925.15
$963.05
$1,003.20
$1,145.83
$214.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$561.56
$637.36
$717.66
$1,002.92
$1,524.04
$776.35
$852.15
$932.45
$1,217.71
$991.14
$1,066.94
$1,147.24
$1,432.50
$1,205.93
$1,281.73
$1,362.03
$1,647.29
$214.79
Toc - Plan #31 Oscar Insurance Company
Silver

(EPO) Silver Classic- Standard (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.84
$474.24
$533.99
$746.25
$1,133.99
$737.48
$793.88
$853.63
$1,065.89
$1,057.12
$1,113.52
$1,173.27
$1,385.53
$1,376.76
$1,433.16
$1,492.91
$1,705.17
$319.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.68
$948.48
$1,067.98
$1,492.50
$2,267.98
$1,155.32
$1,268.12
$1,387.62
$1,812.14
$1,474.96
$1,587.76
$1,707.26
$2,131.78
$1,794.60
$1,907.40
$2,026.90
$2,451.42
$319.64
Toc - Plan #32 Oscar Insurance Company
Gold

(EPO) Gold Classic- Standard (Choice)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.22
$431.54
$485.91
$679.06
$1,031.89
$671.08
$722.40
$776.77
$969.92
$961.94
$1,013.26
$1,067.63
$1,260.78
$1,252.80
$1,304.12
$1,358.49
$1,551.64
$290.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.44
$863.08
$971.82
$1,358.12
$2,063.78
$1,051.30
$1,153.94
$1,262.68
$1,648.98
$1,342.16
$1,444.80
$1,553.54
$1,939.84
$1,633.02
$1,735.66
$1,844.40
$2,230.70
$290.86

ADVERTISEMENT

Community Health Choice

Local: 1-713-295-6704 | Toll Free: 1-855-315-5386 | TTY: 1-855-315-5386

Toc - Plan #33 Community Health Choice
Expanded Bronze

(HMO) Community Premier Bronze 003 (No deductible for PCP, Free Preventive Care, 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 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
$296.39
$336.40
$378.79
$529.35
$804.40
$523.13
$563.14
$605.53
$756.09
$749.87
$789.88
$832.27
$982.83
$976.61
$1,016.62
$1,059.01
$1,209.57
$226.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$592.78
$672.80
$757.58
$1,058.70
$1,608.80
$819.52
$899.54
$984.32
$1,285.44
$1,046.26
$1,126.28
$1,211.06
$1,512.18
$1,273.00
$1,353.02
$1,437.80
$1,738.92
$226.74
Toc - Plan #34 Community Health Choice
Silver

(HMO) Community Premier Silver 004 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$3,300 $6,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.97
$494.83
$557.17
$778.64
$1,183.22
$769.49
$828.35
$890.69
$1,112.16
$1,103.01
$1,161.87
$1,224.21
$1,445.68
$1,436.53
$1,495.39
$1,557.73
$1,779.20
$333.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871.94
$989.66
$1,114.34
$1,557.28
$2,366.44
$1,205.46
$1,323.18
$1,447.86
$1,890.80
$1,538.98
$1,656.70
$1,781.38
$2,224.32
$1,872.50
$1,990.22
$2,114.90
$2,557.84
$333.52
Toc - Plan #35 Community Health Choice
Gold

(HMO) Community Premier Gold 005 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.32
$423.72
$477.10
$666.75
$1,013.19
$658.91
$709.31
$762.69
$952.34
$944.50
$994.90
$1,048.28
$1,237.93
$1,230.09
$1,280.49
$1,333.87
$1,523.52
$285.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.64
$847.44
$954.20
$1,333.50
$2,026.38
$1,032.23
$1,133.03
$1,239.79
$1,619.09
$1,317.82
$1,418.62
$1,525.38
$1,904.68
$1,603.41
$1,704.21
$1,810.97
$2,190.27
$285.59
Toc - Plan #36 Community Health Choice
Expanded Bronze

(HMO) Community Premier Virtual Bronze 011 (Unlimited Free 24/7 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.07
$329.23
$370.71
$518.07
$787.26
$511.98
$551.14
$592.62
$739.98
$733.89
$773.05
$814.53
$961.89
$955.80
$994.96
$1,036.44
$1,183.80
$221.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.14
$658.46
$741.42
$1,036.14
$1,574.52
$802.05
$880.37
$963.33
$1,258.05
$1,023.96
$1,102.28
$1,185.24
$1,479.96
$1,245.87
$1,324.19
$1,407.15
$1,701.87
$221.91
Toc - Plan #37 Community Health Choice
Silver

(HMO) Community Premier Silver 012 (No deductible for PCP, Urgent Care & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$431.14
$489.34
$551.00
$770.01
$1,170.11
$760.96
$819.16
$880.82
$1,099.83
$1,090.78
$1,148.98
$1,210.64
$1,429.65
$1,420.60
$1,478.80
$1,540.46
$1,759.47
$329.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$862.28
$978.68
$1,102.00
$1,540.02
$2,340.22
$1,192.10
$1,308.50
$1,431.82
$1,869.84
$1,521.92
$1,638.32
$1,761.64
$2,199.66
$1,851.74
$1,968.14
$2,091.46
$2,529.48
$329.82
Toc - Plan #38 Community Health Choice
Silver

(HMO) Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$439.71
$499.07
$561.95
$785.32
$1,193.37
$776.09
$835.45
$898.33
$1,121.70
$1,112.47
$1,171.83
$1,234.71
$1,458.08
$1,448.85
$1,508.21
$1,571.09
$1,794.46
$336.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.42
$998.14
$1,123.90
$1,570.64
$2,386.74
$1,215.80
$1,334.52
$1,460.28
$1,907.02
$1,552.18
$1,670.90
$1,796.66
$2,243.40
$1,888.56
$2,007.28
$2,133.04
$2,579.78
$336.38
Toc - Plan #39 Community Health Choice
Expanded Bronze

(HMO) Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$252.59
$286.69
$322.81
$451.12
$685.52
$445.82
$479.92
$516.04
$644.35
$639.05
$673.15
$709.27
$837.58
$832.28
$866.38
$902.50
$1,030.81
$193.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$505.18
$573.38
$645.62
$902.24
$1,371.04
$698.41
$766.61
$838.85
$1,095.47
$891.64
$959.84
$1,032.08
$1,288.70
$1,084.87
$1,153.07
$1,225.31
$1,481.93
$193.23
Toc - Plan #40 Community Health Choice
Bronze

(HMO) Community Premier Bronze 017 (No copay for Preventive Care, 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.45
$330.79
$372.47
$520.52
$790.99
$514.41
$553.75
$595.43
$743.48
$737.37
$776.71
$818.39
$966.44
$960.33
$999.67
$1,041.35
$1,189.40
$222.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.90
$661.58
$744.94
$1,041.04
$1,581.98
$805.86
$884.54
$967.90
$1,264.00
$1,028.82
$1,107.50
$1,190.86
$1,486.96
$1,251.78
$1,330.46
$1,413.82
$1,709.92
$222.96
Toc - Plan #41 Community Health Choice
Expanded Bronze

(HMO) Community Premier Bronze 018 (No deductible for PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$297.41
$337.56
$380.09
$531.18
$807.18
$524.93
$565.08
$607.61
$758.70
$752.45
$792.60
$835.13
$986.22
$979.97
$1,020.12
$1,062.65
$1,213.74
$227.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$594.82
$675.12
$760.18
$1,062.36
$1,614.36
$822.34
$902.64
$987.70
$1,289.88
$1,049.86
$1,130.16
$1,215.22
$1,517.40
$1,277.38
$1,357.68
$1,442.74
$1,744.92
$227.52
Toc - Plan #42 Community Health Choice
Silver

(HMO) Community Select Silver 019 (Limited Network, No deductible for PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$4,900 $9,800 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
$348.14
$395.14
$444.92
$621.77
$944.85
$614.47
$661.47
$711.25
$888.10
$880.80
$927.80
$977.58
$1,154.43
$1,147.13
$1,194.13
$1,243.91
$1,420.76
$266.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696.28
$790.28
$889.84
$1,243.54
$1,889.70
$962.61
$1,056.61
$1,156.17
$1,509.87
$1,228.94
$1,322.94
$1,422.50
$1,776.20
$1,495.27
$1,589.27
$1,688.83
$2,042.53
$266.33
Toc - Plan #43 Community Health Choice
Silver

(HMO) Community Premier Silver 020 (No deductible for PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.56
$484.14
$545.14
$761.83
$1,157.68
$752.88
$810.46
$871.46
$1,088.15
$1,079.20
$1,136.78
$1,197.78
$1,414.47
$1,405.52
$1,463.10
$1,524.10
$1,740.79
$326.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.12
$968.28
$1,090.28
$1,523.66
$2,315.36
$1,179.44
$1,294.60
$1,416.60
$1,849.98
$1,505.76
$1,620.92
$1,742.92
$2,176.30
$1,832.08
$1,947.24
$2,069.24
$2,502.62
$326.32
Toc - Plan #44 Community Health Choice
Gold

(HMO) Community Premier Gold 021 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.84
$424.31
$477.76
$667.67
$1,014.60
$659.83
$710.30
$763.75
$953.66
$945.82
$996.29
$1,049.74
$1,239.65
$1,231.81
$1,282.28
$1,335.73
$1,525.64
$285.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.68
$848.62
$955.52
$1,335.34
$2,029.20
$1,033.67
$1,134.61
$1,241.51
$1,621.33
$1,319.66
$1,420.60
$1,527.50
$1,907.32
$1,605.65
$1,706.59
$1,813.49
$2,193.31
$285.99
Toc - Plan #45 Community Health Choice
Gold

(HMO) Community Select Gold 022 (Limited Network, No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-315-5386

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 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
$307.69
$349.23
$393.23
$549.54
$835.08
$543.07
$584.61
$628.61
$784.92
$778.45
$819.99
$863.99
$1,020.30
$1,013.83
$1,055.37
$1,099.37
$1,255.68
$235.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$615.38
$698.46
$786.46
$1,099.08
$1,670.16
$850.76
$933.84
$1,021.84
$1,334.46
$1,086.14
$1,169.22
$1,257.22
$1,569.84
$1,321.52
$1,404.60
$1,492.60
$1,805.22
$235.38

ADVERTISEMENT

Ambetter from Superior HealthPlan

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

Toc - Plan #46 Ambetter from Superior HealthPlan
Silver

(EPO) Complete Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415.43
$471.50
$530.90
$741.94
$1,127.44
$733.22
$789.29
$848.69
$1,059.73
$1,051.01
$1,107.08
$1,166.48
$1,377.52
$1,368.80
$1,424.87
$1,484.27
$1,695.31
$317.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$830.86
$943.00
$1,061.80
$1,483.88
$2,254.88
$1,148.65
$1,260.79
$1,379.59
$1,801.67
$1,466.44
$1,578.58
$1,697.38
$2,119.46
$1,784.23
$1,896.37
$2,015.17
$2,437.25
$317.79
Toc - Plan #47 Ambetter from Superior HealthPlan
Gold

(EPO) Complete Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.40
$434.02
$488.70
$682.95
$1,037.81
$674.93
$726.55
$781.23
$975.48
$967.46
$1,019.08
$1,073.76
$1,268.01
$1,259.99
$1,311.61
$1,366.29
$1,560.54
$292.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.80
$868.04
$977.40
$1,365.90
$2,075.62
$1,057.33
$1,160.57
$1,269.93
$1,658.43
$1,349.86
$1,453.10
$1,562.46
$1,950.96
$1,642.39
$1,745.63
$1,854.99
$2,243.49
$292.53
Toc - Plan #48 Ambetter from Superior HealthPlan
Silver

(EPO) Clear Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.27
$466.78
$525.59
$734.52
$1,116.17
$725.89
$781.40
$840.21
$1,049.14
$1,040.51
$1,096.02
$1,154.83
$1,363.76
$1,355.13
$1,410.64
$1,469.45
$1,678.38
$314.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.54
$933.56
$1,051.18
$1,469.04
$2,232.34
$1,137.16
$1,248.18
$1,365.80
$1,783.66
$1,451.78
$1,562.80
$1,680.42
$2,098.28
$1,766.40
$1,877.42
$1,995.04
$2,412.90
$314.62
Toc - Plan #49 Ambetter from Superior HealthPlan
Silver

(EPO) Focused Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.74
$465.04
$523.63
$731.77
$1,112.00
$723.18
$778.48
$837.07
$1,045.21
$1,036.62
$1,091.92
$1,150.51
$1,358.65
$1,350.06
$1,405.36
$1,463.95
$1,672.09
$313.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$819.48
$930.08
$1,047.26
$1,463.54
$2,224.00
$1,132.92
$1,243.52
$1,360.70
$1,776.98
$1,446.36
$1,556.96
$1,674.14
$2,090.42
$1,759.80
$1,870.40
$1,987.58
$2,403.86
$313.44
Toc - Plan #50 Ambetter from Superior HealthPlan
Gold

(EPO) Everyday Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.14
$422.37
$475.58
$664.63
$1,009.96
$656.82
$707.05
$760.26
$949.31
$941.50
$991.73
$1,044.94
$1,233.99
$1,226.18
$1,276.41
$1,329.62
$1,518.67
$284.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.28
$844.74
$951.16
$1,329.26
$2,019.92
$1,028.96
$1,129.42
$1,235.84
$1,613.94
$1,313.64
$1,414.10
$1,520.52
$1,898.62
$1,598.32
$1,698.78
$1,805.20
$2,183.30
$284.68
Toc - Plan #51 Ambetter from Superior HealthPlan
Gold

(EPO) Clear Gold

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

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.90
$419.82
$472.72
$660.62
$1,003.88
$652.86
$702.78
$755.68
$943.58
$935.82
$985.74
$1,038.64
$1,226.54
$1,218.78
$1,268.70
$1,321.60
$1,509.50
$282.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$739.80
$839.64
$945.44
$1,321.24
$2,007.76
$1,022.76
$1,122.60
$1,228.40
$1,604.20
$1,305.72
$1,405.56
$1,511.36
$1,887.16
$1,588.68
$1,688.52
$1,794.32
$2,170.12
$282.96
Toc - Plan #52 Ambetter from Superior HealthPlan
Silver

(EPO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.45
$464.71
$523.26
$731.25
$1,111.21
$722.67
$777.93
$836.48
$1,044.47
$1,035.89
$1,091.15
$1,149.70
$1,357.69
$1,349.11
$1,404.37
$1,462.92
$1,670.91
$313.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.90
$929.42
$1,046.52
$1,462.50
$2,222.42
$1,132.12
$1,242.64
$1,359.74
$1,775.72
$1,445.34
$1,555.86
$1,672.96
$2,088.94
$1,758.56
$1,869.08
$1,986.18
$2,402.16
$313.22
Toc - Plan #53 Ambetter from Superior HealthPlan
Gold

(EPO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.19
$419.02
$471.81
$659.36
$1,001.96
$651.61
$701.44
$754.23
$941.78
$934.03
$983.86
$1,036.65
$1,224.20
$1,216.45
$1,266.28
$1,319.07
$1,506.62
$282.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.38
$838.04
$943.62
$1,318.72
$2,003.92
$1,020.80
$1,120.46
$1,226.04
$1,601.14
$1,303.22
$1,402.88
$1,508.46
$1,883.56
$1,585.64
$1,685.30
$1,790.88
$2,165.98
$282.42
Toc - Plan #54 Ambetter from Superior HealthPlan
Gold

(EPO) Complete Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.31
$452.07
$509.02
$711.36
$1,080.98
$703.01
$756.77
$813.72
$1,016.06
$1,007.71
$1,061.47
$1,118.42
$1,320.76
$1,312.41
$1,366.17
$1,423.12
$1,625.46
$304.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.62
$904.14
$1,018.04
$1,422.72
$2,161.96
$1,101.32
$1,208.84
$1,322.74
$1,727.42
$1,406.02
$1,513.54
$1,627.44
$2,032.12
$1,710.72
$1,818.24
$1,932.14
$2,336.82
$304.70
Toc - Plan #55 Ambetter from Superior HealthPlan
Silver

(EPO) Complete Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$432.71
$491.11
$552.99
$772.80
$1,174.34
$763.72
$822.12
$884.00
$1,103.81
$1,094.73
$1,153.13
$1,215.01
$1,434.82
$1,425.74
$1,484.14
$1,546.02
$1,765.83
$331.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$865.42
$982.22
$1,105.98
$1,545.60
$2,348.68
$1,196.43
$1,313.23
$1,436.99
$1,876.61
$1,527.44
$1,644.24
$1,768.00
$2,207.62
$1,858.45
$1,975.25
$2,099.01
$2,538.63
$331.01
Toc - Plan #56 Ambetter from Superior HealthPlan
Silver

(EPO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.78
$484.38
$545.41
$762.21
$1,158.25
$753.26
$810.86
$871.89
$1,088.69
$1,079.74
$1,137.34
$1,198.37
$1,415.17
$1,406.22
$1,463.82
$1,524.85
$1,741.65
$326.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.56
$968.76
$1,090.82
$1,524.42
$2,316.50
$1,180.04
$1,295.24
$1,417.30
$1,850.90
$1,506.52
$1,621.72
$1,743.78
$2,177.38
$1,833.00
$1,948.20
$2,070.26
$2,503.86
$326.48
Toc - Plan #57 Ambetter from Superior HealthPlan
Gold

(EPO) Everyday Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$387.62
$439.94
$495.37
$692.27
$1,051.97
$684.14
$736.46
$791.89
$988.79
$980.66
$1,032.98
$1,088.41
$1,285.31
$1,277.18
$1,329.50
$1,384.93
$1,581.83
$296.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$775.24
$879.88
$990.74
$1,384.54
$2,103.94
$1,071.76
$1,176.40
$1,287.26
$1,681.06
$1,368.28
$1,472.92
$1,583.78
$1,977.58
$1,664.80
$1,769.44
$1,880.30
$2,274.10
$296.52
Toc - Plan #58 Ambetter from Superior HealthPlan
Silver

(EPO) Clear Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$428.38
$486.20
$547.46
$765.07
$1,162.60
$756.08
$813.90
$875.16
$1,092.77
$1,083.78
$1,141.60
$1,202.86
$1,420.47
$1,411.48
$1,469.30
$1,530.56
$1,748.17
$327.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.76
$972.40
$1,094.92
$1,530.14
$2,325.20
$1,184.46
$1,300.10
$1,422.62
$1,857.84
$1,512.16
$1,627.80
$1,750.32
$2,185.54
$1,839.86
$1,955.50
$2,078.02
$2,513.24
$327.70
Toc - Plan #59 Ambetter from Superior HealthPlan
Gold

(EPO) Clear Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.28
$437.28
$492.38
$688.10
$1,045.63
$680.01
$732.01
$787.11
$982.83
$974.74
$1,026.74
$1,081.84
$1,277.56
$1,269.47
$1,321.47
$1,376.57
$1,572.29
$294.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.56
$874.56
$984.76
$1,376.20
$2,091.26
$1,065.29
$1,169.29
$1,279.49
$1,670.93
$1,360.02
$1,464.02
$1,574.22
$1,965.66
$1,654.75
$1,758.75
$1,868.95
$2,260.39
$294.73

ADVERTISEMENT

Blue Cross and Blue Shield of Texas

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

Toc - Plan #60 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 206

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

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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
$378.22
$429.28
$483.37
$675.50
$1,026.49
$667.56
$718.62
$772.71
$964.84
$956.90
$1,007.96
$1,062.05
$1,254.18
$1,246.24
$1,297.30
$1,351.39
$1,543.52
$289.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.44
$858.56
$966.74
$1,351.00
$2,052.98
$1,045.78
$1,147.90
$1,256.08
$1,640.34
$1,335.12
$1,437.24
$1,545.42
$1,929.68
$1,624.46
$1,726.58
$1,834.76
$2,219.02
$289.34
Toc - Plan #61 Blue Cross and Blue Shield of Texas
Catastrophic

(HMO) Blue Advantage Security HMO? 200

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$277.00
$314.40
$354.01
$494.72
$751.78
$488.91
$526.31
$565.92
$706.63
$700.82
$738.22
$777.83
$918.54
$912.73
$950.13
$989.74
$1,130.45
$211.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$554.00
$628.80
$708.02
$989.44
$1,503.56
$765.91
$840.71
$919.93
$1,201.35
$977.82
$1,052.62
$1,131.84
$1,413.26
$1,189.73
$1,264.53
$1,343.75
$1,625.17
$211.91
Toc - Plan #62 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 205

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

Annual Out of Pocket Expenses:

Individual Family
$2,050 $6,150 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
$454.89
$516.30
$581.35
$812.43
$1,234.57
$802.88
$864.29
$929.34
$1,160.42
$1,150.87
$1,212.28
$1,277.33
$1,508.41
$1,498.86
$1,560.27
$1,625.32
$1,856.40
$347.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$909.78
$1,032.60
$1,162.70
$1,624.86
$2,469.14
$1,257.77
$1,380.59
$1,510.69
$1,972.85
$1,605.76
$1,728.58
$1,858.68
$2,320.84
$1,953.75
$2,076.57
$2,206.67
$2,668.83
$347.99
Toc - Plan #63 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 204

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $17,400 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
$309.52
$351.31
$395.57
$552.80
$840.04
$546.30
$588.09
$632.35
$789.58
$783.08
$824.87
$869.13
$1,026.36
$1,019.86
$1,061.65
$1,105.91
$1,263.14
$236.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619.04
$702.62
$791.14
$1,105.60
$1,680.08
$855.82
$939.40
$1,027.92
$1,342.38
$1,092.60
$1,176.18
$1,264.70
$1,579.16
$1,329.38
$1,412.96
$1,501.48
$1,815.94
$236.78
Toc - Plan #64 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 302

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.91
$365.36
$411.40
$574.93
$873.66
$568.17
$611.62
$657.66
$821.19
$814.43
$857.88
$903.92
$1,067.45
$1,060.69
$1,104.14
$1,150.18
$1,313.71
$246.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.82
$730.72
$822.80
$1,149.86
$1,747.32
$890.08
$976.98
$1,069.06
$1,396.12
$1,136.34
$1,223.24
$1,315.32
$1,642.38
$1,382.60
$1,469.50
$1,561.58
$1,888.64
$246.26
Toc - Plan #65 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO? 301

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

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 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
$307.92
$349.49
$393.52
$549.94
$835.69
$543.48
$585.05
$629.08
$785.50
$779.04
$820.61
$864.64
$1,021.06
$1,014.60
$1,056.17
$1,100.20
$1,256.62
$235.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$615.84
$698.98
$787.04
$1,099.88
$1,671.38
$851.40
$934.54
$1,022.60
$1,335.44
$1,086.96
$1,170.10
$1,258.16
$1,571.00
$1,322.52
$1,405.66
$1,493.72
$1,806.56
$235.56
Toc - Plan #66 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 603

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,500 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$389.33
$441.89
$497.56
$695.34
$1,056.64
$687.17
$739.73
$795.40
$993.18
$985.01
$1,037.57
$1,093.24
$1,291.02
$1,282.85
$1,335.41
$1,391.08
$1,588.86
$297.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.66
$883.78
$995.12
$1,390.68
$2,113.28
$1,076.50
$1,181.62
$1,292.96
$1,688.52
$1,374.34
$1,479.46
$1,590.80
$1,986.36
$1,672.18
$1,777.30
$1,888.64
$2,284.20
$297.84
Toc - Plan #67 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 702

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322.34
$365.86
$411.96
$575.71
$874.84
$568.93
$612.45
$658.55
$822.30
$815.52
$859.04
$905.14
$1,068.89
$1,062.11
$1,105.63
$1,151.73
$1,315.48
$246.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$644.68
$731.72
$823.92
$1,151.42
$1,749.68
$891.27
$978.31
$1,070.51
$1,398.01
$1,137.86
$1,224.90
$1,317.10
$1,644.60
$1,384.45
$1,471.49
$1,563.69
$1,891.19
$246.59
Toc - Plan #68 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO? 706

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.36
$435.11
$489.93
$684.68
$1,040.44
$676.63
$728.38
$783.20
$977.95
$969.90
$1,021.65
$1,076.47
$1,271.22
$1,263.17
$1,314.92
$1,369.74
$1,564.49
$293.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.72
$870.22
$979.86
$1,369.36
$2,080.88
$1,059.99
$1,163.49
$1,273.13
$1,662.63
$1,353.26
$1,456.76
$1,566.40
$1,955.90
$1,646.53
$1,750.03
$1,859.67
$2,249.17
$293.27
Toc - Plan #69 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO? 705

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$457.17
$518.89
$584.26
$816.50
$1,240.76
$806.90
$868.62
$933.99
$1,166.23
$1,156.63
$1,218.35
$1,283.72
$1,515.96
$1,506.36
$1,568.08
$1,633.45
$1,865.69
$349.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$914.34
$1,037.78
$1,168.52
$1,633.00
$2,481.52
$1,264.07
$1,387.51
$1,518.25
$1,982.73
$1,613.80
$1,737.24
$1,867.98
$2,332.46
$1,963.53
$2,086.97
$2,217.71
$2,682.19
$349.73
Toc - Plan #70 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO? 704

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$301.17
$341.83
$384.89
$537.89
$817.37
$531.56
$572.22
$615.28
$768.28
$761.95
$802.61
$845.67
$998.67
$992.34
$1,033.00
$1,076.06
$1,229.06
$230.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$602.34
$683.66
$769.78
$1,075.78
$1,634.74
$832.73
$914.05
$1,000.17
$1,306.17
$1,063.12
$1,144.44
$1,230.56
$1,536.56
$1,293.51
$1,374.83
$1,460.95
$1,766.95
$230.39
Toc - Plan #71 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO? 707

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $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
$321.28
$364.65
$410.60
$573.81
$871.96
$567.06
$610.43
$656.38
$819.59
$812.84
$856.21
$902.16
$1,065.37
$1,058.62
$1,101.99
$1,147.94
$1,311.15
$245.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$642.56
$729.30
$821.20
$1,147.62
$1,743.92
$888.34
$975.08
$1,066.98
$1,393.40
$1,134.12
$1,220.86
$1,312.76
$1,639.18
$1,379.90
$1,466.64
$1,558.54
$1,884.96
$245.78
Toc - Plan #72 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Plus Gold? 203

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

Annual Out of Pocket Expenses:

Individual Family
$850 $2,550 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
$467.11
$530.16
$596.96
$834.25
$1,267.72
$824.45
$887.50
$954.30
$1,191.59
$1,181.79
$1,244.84
$1,311.64
$1,548.93
$1,539.13
$1,602.18
$1,668.98
$1,906.27
$357.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$934.22
$1,060.32
$1,193.92
$1,668.50
$2,535.44
$1,291.56
$1,417.66
$1,551.26
$2,025.84
$1,648.90
$1,775.00
$1,908.60
$2,383.18
$2,006.24
$2,132.34
$2,265.94
$2,740.52
$357.34
Toc - Plan #73 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 202

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,250 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
$558.85
$634.30
$714.21
$998.11
$1,516.73
$986.37
$1,061.82
$1,141.73
$1,425.63
$1,413.89
$1,489.34
$1,569.25
$1,853.15
$1,841.41
$1,916.86
$1,996.77
$2,280.67
$427.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,117.70
$1,268.60
$1,428.42
$1,996.22
$3,033.46
$1,545.22
$1,696.12
$1,855.94
$2,423.74
$1,972.74
$2,123.64
$2,283.46
$2,851.26
$2,400.26
$2,551.16
$2,710.98
$3,278.78
$427.52
Toc - Plan #74 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Plus Bronze? 303

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $16,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.15
$434.88
$489.67
$684.31
$1,039.87
$676.26
$727.99
$782.78
$977.42
$969.37
$1,021.10
$1,075.89
$1,270.53
$1,262.48
$1,314.21
$1,369.00
$1,563.64
$293.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.30
$869.76
$979.34
$1,368.62
$2,079.74
$1,059.41
$1,162.87
$1,272.45
$1,661.73
$1,352.52
$1,455.98
$1,565.56
$1,954.84
$1,645.63
$1,749.09
$1,858.67
$2,247.95
$293.11
Toc - Plan #75 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Plus Bronze? 305

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $17,400 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
$365.34
$414.66
$466.90
$652.49
$991.52
$644.82
$694.14
$746.38
$931.97
$924.30
$973.62
$1,025.86
$1,211.45
$1,203.78
$1,253.10
$1,305.34
$1,490.93
$279.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.68
$829.32
$933.80
$1,304.98
$1,983.04
$1,010.16
$1,108.80
$1,213.28
$1,584.46
$1,289.64
$1,388.28
$1,492.76
$1,863.94
$1,569.12
$1,667.76
$1,772.24
$2,143.42
$279.48
Toc - Plan #76 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 605

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $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
$564.17
$640.33
$721.01
$1,007.61
$1,531.16
$995.76
$1,071.92
$1,152.60
$1,439.20
$1,427.35
$1,503.51
$1,584.19
$1,870.79
$1,858.94
$1,935.10
$2,015.78
$2,302.38
$431.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,128.34
$1,280.66
$1,442.02
$2,015.22
$3,062.32
$1,559.93
$1,712.25
$1,873.61
$2,446.81
$1,991.52
$2,143.84
$2,305.20
$2,878.40
$2,423.11
$2,575.43
$2,736.79
$3,309.99
$431.59
Toc - Plan #77 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Plus Gold? 706

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$465.30
$528.11
$594.65
$831.02
$1,262.82
$821.25
$884.06
$950.60
$1,186.97
$1,177.20
$1,240.01
$1,306.55
$1,542.92
$1,533.15
$1,595.96
$1,662.50
$1,898.87
$355.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$930.60
$1,056.22
$1,189.30
$1,662.04
$2,525.64
$1,286.55
$1,412.17
$1,545.25
$2,017.99
$1,642.50
$1,768.12
$1,901.20
$2,373.94
$1,998.45
$2,124.07
$2,257.15
$2,729.89
$355.95
Toc - Plan #78 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver? 705

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$555.49
$630.48
$709.91
$992.10
$1,507.60
$980.44
$1,055.43
$1,134.86
$1,417.05
$1,405.39
$1,480.38
$1,559.81
$1,842.00
$1,830.34
$1,905.33
$1,984.76
$2,266.95
$424.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,110.98
$1,260.96
$1,419.82
$1,984.20
$3,015.20
$1,535.93
$1,685.91
$1,844.77
$2,409.15
$1,960.88
$2,110.86
$2,269.72
$2,834.10
$2,385.83
$2,535.81
$2,694.67
$3,259.05
$424.95
Toc - Plan #79 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Plus Bronze? 704

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.84
$416.37
$468.82
$655.18
$995.61
$647.47
$697.00
$749.45
$935.81
$928.10
$977.63
$1,030.08
$1,216.44
$1,208.73
$1,258.26
$1,310.71
$1,497.07
$280.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.68
$832.74
$937.64
$1,310.36
$1,991.22
$1,014.31
$1,113.37
$1,218.27
$1,590.99
$1,294.94
$1,394.00
$1,498.90
$1,871.62
$1,575.57
$1,674.63
$1,779.53
$2,152.25
$280.63
Toc - Plan #80 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Plus Bronze? 707

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.46
$443.17
$499.01
$697.36
$1,059.71
$689.16
$741.87
$797.71
$996.06
$987.86
$1,040.57
$1,096.41
$1,294.76
$1,286.56
$1,339.27
$1,395.11
$1,593.46
$298.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.92
$886.34
$998.02
$1,394.72
$2,119.42
$1,079.62
$1,185.04
$1,296.72
$1,693.42
$1,378.32
$1,483.74
$1,595.42
$1,992.12
$1,677.02
$1,782.44
$1,894.12
$2,290.82
$298.70
Toc - Plan #81 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) MyBlue Health? Bronze 402

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

Annual Out of Pocket Expenses:

Individual Family
$7,400 $17,400 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
$244.10
$277.06
$311.96
$435.97
$662.50
$430.84
$463.80
$498.70
$622.71
$617.58
$650.54
$685.44
$809.45
$804.32
$837.28
$872.18
$996.19
$186.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$488.20
$554.12
$623.92
$871.94
$1,325.00
$674.94
$740.86
$810.66
$1,058.68
$861.68
$927.60
$997.40
$1,245.42
$1,048.42
$1,114.34
$1,184.14
$1,432.16
$186.74
Toc - Plan #82 Blue Cross and Blue Shield of Texas
Gold

(HMO) MyBlue Health? Gold 403

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

Annual Out of Pocket Expenses:

Individual Family
$1,100 $3,300 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
$295.95
$335.90
$378.23
$528.57
$803.21
$522.35
$562.30
$604.63
$754.97
$748.75
$788.70
$831.03
$981.37
$975.15
$1,015.10
$1,057.43
$1,207.77
$226.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$591.90
$671.80
$756.46
$1,057.14
$1,606.42
$818.30
$898.20
$982.86
$1,283.54
$1,044.70
$1,124.60
$1,209.26
$1,509.94
$1,271.10
$1,351.00
$1,435.66
$1,736.34
$226.40
Toc - Plan #83 Blue Cross and Blue Shield of Texas
Silver

(HMO) MyBlue Health Silver? 405

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

Annual Out of Pocket Expenses:

Individual Family
$2,700 $8,100 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
$359.90
$408.48
$459.95
$642.77
$976.76
$635.22
$683.80
$735.27
$918.09
$910.54
$959.12
$1,010.59
$1,193.41
$1,185.86
$1,234.44
$1,285.91
$1,468.73
$275.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$719.80
$816.96
$919.90
$1,285.54
$1,953.52
$995.12
$1,092.28
$1,195.22
$1,560.86
$1,270.44
$1,367.60
$1,470.54
$1,836.18
$1,545.76
$1,642.92
$1,745.86
$2,111.50
$275.32

ADVERTISEMENT

UnitedHealthcare

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

Toc - Plan #84 UnitedHealthcare
Gold

(HMO) UHC Gold Value $1,900 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 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
$367.91
$417.58
$470.19
$657.09
$998.51
$649.36
$699.03
$751.64
$938.54
$930.81
$980.48
$1,033.09
$1,219.99
$1,212.26
$1,261.93
$1,314.54
$1,501.44
$281.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.82
$835.16
$940.38
$1,314.18
$1,997.02
$1,017.27
$1,116.61
$1,221.83
$1,595.63
$1,298.72
$1,398.06
$1,503.28
$1,877.08
$1,580.17
$1,679.51
$1,784.73
$2,158.53
$281.45
Toc - Plan #85 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.83
$474.23
$533.98
$746.24
$1,133.98
$737.47
$793.87
$853.62
$1,065.88
$1,057.11
$1,113.51
$1,173.26
$1,385.52
$1,376.75
$1,433.15
$1,492.90
$1,705.16
$319.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.66
$948.46
$1,067.96
$1,492.48
$2,267.96
$1,155.30
$1,268.10
$1,387.60
$1,812.12
$1,474.94
$1,587.74
$1,707.24
$2,131.76
$1,794.58
$1,907.38
$2,026.88
$2,451.40
$319.64
Toc - Plan #86 UnitedHealthcare
Silver

(HMO) UHC Silver Value HSA

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

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
$423.31
$480.46
$540.99
$756.04
$1,148.87
$747.14
$804.29
$864.82
$1,079.87
$1,070.97
$1,128.12
$1,188.65
$1,403.70
$1,394.80
$1,451.95
$1,512.48
$1,727.53
$323.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$846.62
$960.92
$1,081.98
$1,512.08
$2,297.74
$1,170.45
$1,284.75
$1,405.81
$1,835.91
$1,494.28
$1,608.58
$1,729.64
$2,159.74
$1,818.11
$1,932.41
$2,053.47
$2,483.57
$323.83
Toc - Plan #87 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en espaņol)

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$406.23
$461.07
$519.16
$725.52
$1,102.50
$716.99
$771.83
$829.92
$1,036.28
$1,027.75
$1,082.59
$1,140.68
$1,347.04
$1,338.51
$1,393.35
$1,451.44
$1,657.80
$310.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$812.46
$922.14
$1,038.32
$1,451.04
$2,205.00
$1,123.22
$1,232.90
$1,349.08
$1,761.80
$1,433.98
$1,543.66
$1,659.84
$2,072.56
$1,744.74
$1,854.42
$1,970.60
$2,383.32
$310.76
Toc - Plan #88 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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
$298.46
$338.76
$381.44
$533.06
$810.03
$526.78
$567.08
$609.76
$761.38
$755.10
$795.40
$838.08
$989.70
$983.42
$1,023.72
$1,066.40
$1,218.02
$228.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.92
$677.52
$762.88
$1,066.12
$1,620.06
$825.24
$905.84
$991.20
$1,294.44
$1,053.56
$1,134.16
$1,219.52
$1,522.76
$1,281.88
$1,362.48
$1,447.84
$1,751.08
$228.32
Toc - Plan #89 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en espaņol)

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

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,100 $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
$291.48
$330.83
$372.52
$520.59
$791.09
$514.46
$553.81
$595.50
$743.57
$737.44
$776.79
$818.48
$966.55
$960.42
$999.77
$1,041.46
$1,189.53
$222.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.96
$661.66
$745.04
$1,041.18
$1,582.18
$805.94
$884.64
$968.02
$1,264.16
$1,028.92
$1,107.62
$1,191.00
$1,487.14
$1,251.90
$1,330.60
$1,413.98
$1,710.12
$222.98
Toc - Plan #90 UnitedHealthcare
Gold

(HMO) UHC Gold Standard $0 Deductible ($3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$371.40
$421.54
$474.65
$663.32
$1,007.98
$655.52
$705.66
$758.77
$947.44
$939.64
$989.78
$1,042.89
$1,231.56
$1,223.76
$1,273.90
$1,327.01
$1,515.68
$284.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.80
$843.08
$949.30
$1,326.64
$2,015.96
$1,026.92
$1,127.20
$1,233.42
$1,610.76
$1,311.04
$1,411.32
$1,517.54
$1,894.88
$1,595.16
$1,695.44
$1,801.66
$2,179.00
$284.12
Toc - Plan #91 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.94
$330.21
$371.82
$519.61
$789.60
$513.51
$552.78
$594.39
$742.18
$736.08
$775.35
$816.96
$964.75
$958.65
$997.92
$1,039.53
$1,187.32
$222.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$581.88
$660.42
$743.64
$1,039.22
$1,579.20
$804.45
$882.99
$966.21
$1,261.79
$1,027.02
$1,105.56
$1,188.78
$1,484.36
$1,249.59
$1,328.13
$1,411.35
$1,706.93
$222.57
Toc - Plan #92 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $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
$298.21
$338.47
$381.12
$532.61
$809.35
$526.34
$566.60
$609.25
$760.74
$754.47
$794.73
$837.38
$988.87
$982.60
$1,022.86
$1,065.51
$1,217.00
$228.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.42
$676.94
$762.24
$1,065.22
$1,618.70
$824.55
$905.07
$990.37
$1,293.35
$1,052.68
$1,133.20
$1,218.50
$1,521.48
$1,280.81
$1,361.33
$1,446.63
$1,749.61
$228.13
Toc - Plan #93 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$282.33
$320.44
$360.82
$504.24
$766.24
$498.31
$536.42
$576.80
$720.22
$714.29
$752.40
$792.78
$936.20
$930.27
$968.38
$1,008.76
$1,152.18
$215.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$564.66
$640.88
$721.64
$1,008.48
$1,532.48
$780.64
$856.86
$937.62
$1,224.46
$996.62
$1,072.84
$1,153.60
$1,440.44
$1,212.60
$1,288.82
$1,369.58
$1,656.42
$215.98
Toc - Plan #94 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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
$417.03
$473.33
$532.97
$744.82
$1,131.83
$736.06
$792.36
$852.00
$1,063.85
$1,055.09
$1,111.39
$1,171.03
$1,382.88
$1,374.12
$1,430.42
$1,490.06
$1,701.91
$319.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.06
$946.66
$1,065.94
$1,489.64
$2,263.66
$1,153.09
$1,265.69
$1,384.97
$1,808.67
$1,472.12
$1,584.72
$1,704.00
$2,127.70
$1,791.15
$1,903.75
$2,023.03
$2,446.73
$319.03
Toc - Plan #95 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, Dental + Vision)

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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
$435.36
$494.13
$556.39
$777.55
$1,181.56
$768.41
$827.18
$889.44
$1,110.60
$1,101.46
$1,160.23
$1,222.49
$1,443.65
$1,434.51
$1,493.28
$1,555.54
$1,776.70
$333.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$870.72
$988.26
$1,112.78
$1,555.10
$2,363.12
$1,203.77
$1,321.31
$1,445.83
$1,888.15
$1,536.82
$1,654.36
$1,778.88
$2,221.20
$1,869.87
$1,987.41
$2,111.93
$2,554.25
$333.05
Toc - Plan #96 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.49
$493.15
$555.28
$776.01
$1,179.22
$766.88
$825.54
$887.67
$1,108.40
$1,099.27
$1,157.93
$1,220.06
$1,440.79
$1,431.66
$1,490.32
$1,552.45
$1,773.18
$332.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.98
$986.30
$1,110.56
$1,552.02
$2,358.44
$1,201.37
$1,318.69
$1,442.95
$1,884.41
$1,533.76
$1,651.08
$1,775.34
$2,216.80
$1,866.15
$1,983.47
$2,107.73
$2,549.19
$332.39
Toc - Plan #97 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.21
$474.67
$534.48
$746.93
$1,135.03
$738.14
$794.60
$854.41
$1,066.86
$1,058.07
$1,114.53
$1,174.34
$1,386.79
$1,378.00
$1,434.46
$1,494.27
$1,706.72
$319.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.42
$949.34
$1,068.96
$1,493.86
$2,270.06
$1,156.35
$1,269.27
$1,388.89
$1,813.79
$1,476.28
$1,589.20
$1,708.82
$2,133.72
$1,796.21
$1,909.13
$2,028.75
$2,453.65
$319.93
Toc - Plan #98 UnitedHealthcare
Gold

(HMO) UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.39
$416.99
$469.53
$656.17
$997.11
$648.45
$698.05
$750.59
$937.23
$929.51
$979.11
$1,031.65
$1,218.29
$1,210.57
$1,260.17
$1,312.71
$1,499.35
$281.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.78
$833.98
$939.06
$1,312.34
$1,994.22
$1,015.84
$1,115.04
$1,220.12
$1,593.40
$1,296.90
$1,396.10
$1,501.18
$1,874.46
$1,577.96
$1,677.16
$1,782.24
$2,155.52
$281.06
Toc - Plan #99 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$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
$366.99
$416.53
$469.01
$655.45
$996.01
$647.74
$697.28
$749.76
$936.20
$928.49
$978.03
$1,030.51
$1,216.95
$1,209.24
$1,258.78
$1,311.26
$1,497.70
$280.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.98
$833.06
$938.02
$1,310.90
$1,992.02
$1,014.73
$1,113.81
$1,218.77
$1,591.65
$1,295.48
$1,394.56
$1,499.52
$1,872.40
$1,576.23
$1,675.31
$1,780.27
$2,153.15
$280.75
Toc - Plan #100 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, Dental + Vision)

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.31
$437.33
$492.43
$688.17
$1,045.74
$680.07
$732.09
$787.19
$982.93
$974.83
$1,026.85
$1,081.95
$1,277.69
$1,269.59
$1,321.61
$1,376.71
$1,572.45
$294.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.62
$874.66
$984.86
$1,376.34
$2,091.48
$1,065.38
$1,169.42
$1,279.62
$1,671.10
$1,360.14
$1,464.18
$1,574.38
$1,965.86
$1,654.90
$1,758.94
$1,869.14
$2,260.62
$294.76
Toc - Plan #101 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.93
$427.81
$481.71
$673.19
$1,022.98
$665.28
$716.16
$770.06
$961.54
$953.63
$1,004.51
$1,058.41
$1,249.89
$1,241.98
$1,292.86
$1,346.76
$1,538.24
$288.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.86
$855.62
$963.42
$1,346.38
$2,045.96
$1,042.21
$1,143.97
$1,251.77
$1,634.73
$1,330.56
$1,432.32
$1,540.12
$1,923.08
$1,618.91
$1,720.67
$1,828.47
$2,211.43
$288.35

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-2025 | Toll Free: 1-888-560-2025

Toc - Plan #102 Molina Healthcare
Silver

(HMO) Molina Silver 3 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.21
$491.69
$553.64
$773.71
$1,175.73
$764.61
$823.09
$885.04
$1,105.11
$1,096.01
$1,154.49
$1,216.44
$1,436.51
$1,427.41
$1,485.89
$1,547.84
$1,767.91
$331.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$866.42
$983.38
$1,107.28
$1,547.42
$2,351.46
$1,197.82
$1,314.78
$1,438.68
$1,878.82
$1,529.22
$1,646.18
$1,770.08
$2,210.22
$1,860.62
$1,977.58
$2,101.48
$2,541.62
$331.40
Toc - Plan #103 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 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
$372.43
$422.71
$475.97
$665.16
$1,010.78
$657.34
$707.62
$760.88
$950.07
$942.25
$992.53
$1,045.79
$1,234.98
$1,227.16
$1,277.44
$1,330.70
$1,519.89
$284.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.86
$845.42
$951.94
$1,330.32
$2,021.56
$1,029.77
$1,130.33
$1,236.85
$1,615.23
$1,314.68
$1,415.24
$1,521.76
$1,900.14
$1,599.59
$1,700.15
$1,806.67
$2,185.05
$284.91
Toc - Plan #104 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.94
$487.99
$549.47
$767.88
$1,166.87
$758.85
$816.90
$878.38
$1,096.79
$1,087.76
$1,145.81
$1,207.29
$1,425.70
$1,416.67
$1,474.72
$1,536.20
$1,754.61
$328.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.88
$975.98
$1,098.94
$1,535.76
$2,333.74
$1,188.79
$1,304.89
$1,427.85
$1,864.67
$1,517.70
$1,633.80
$1,756.76
$2,193.58
$1,846.61
$1,962.71
$2,085.67
$2,522.49
$328.91
Toc - Plan #105 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$372.39
$422.66
$475.92
$665.09
$1,010.67
$657.27
$707.54
$760.80
$949.97
$942.15
$992.42
$1,045.68
$1,234.85
$1,227.03
$1,277.30
$1,330.56
$1,519.73
$284.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.78
$845.32
$951.84
$1,330.18
$2,021.34
$1,029.66
$1,130.20
$1,236.72
$1,615.06
$1,314.54
$1,415.08
$1,521.60
$1,899.94
$1,599.42
$1,699.96
$1,806.48
$2,184.82
$284.88
Toc - Plan #106 Molina Healthcare
Silver

(HMO) Constant Care Silver 8 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.10
$480.21
$540.72
$755.65
$1,148.28
$746.77
$803.88
$864.39
$1,079.32
$1,070.44
$1,127.55
$1,188.06
$1,402.99
$1,394.11
$1,451.22
$1,511.73
$1,726.66
$323.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$846.20
$960.42
$1,081.44
$1,511.30
$2,296.56
$1,169.87
$1,284.09
$1,405.11
$1,834.97
$1,493.54
$1,607.76
$1,728.78
$2,158.64
$1,817.21
$1,931.43
$2,052.45
$2,482.31
$323.67
Toc - Plan #107 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 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
$376.47
$427.29
$481.13
$672.37
$1,021.74
$664.47
$715.29
$769.13
$960.37
$952.47
$1,003.29
$1,057.13
$1,248.37
$1,240.47
$1,291.29
$1,345.13
$1,536.37
$288.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.94
$854.58
$962.26
$1,344.74
$2,043.48
$1,040.94
$1,142.58
$1,250.26
$1,632.74
$1,328.94
$1,430.58
$1,538.26
$1,920.74
$1,616.94
$1,718.58
$1,826.26
$2,208.74
$288.00
Toc - Plan #108 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2025

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.31
$494.08
$556.33
$777.47
$1,181.44
$768.32
$827.09
$889.34
$1,110.48
$1,101.33
$1,160.10
$1,222.35
$1,443.49
$1,434.34
$1,493.11
$1,555.36
$1,776.50
$333.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$870.62
$988.16
$1,112.66
$1,554.94
$2,362.88
$1,203.63
$1,321.17
$1,445.67
$1,887.95
$1,536.64
$1,654.18
$1,778.68
$2,220.96
$1,869.65
$1,987.19
$2,111.69
$2,553.97
$333.01

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #109 Aetna CVS Health
Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$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
$374.74
$425.33
$478.92
$669.29
$1,017.05
$661.42
$712.01
$765.60
$955.97
$948.10
$998.69
$1,052.28
$1,242.65
$1,234.78
$1,285.37
$1,338.96
$1,529.33
$286.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.48
$850.66
$957.84
$1,338.58
$2,034.10
$1,036.16
$1,137.34
$1,244.52
$1,625.26
$1,322.84
$1,424.02
$1,531.20
$1,911.94
$1,609.52
$1,710.70
$1,817.88
$2,198.62
$286.68
Toc - Plan #110 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.63
$403.64
$454.50
$635.16
$965.19
$627.69
$675.70
$726.56
$907.22
$899.75
$947.76
$998.62
$1,179.28
$1,171.81
$1,219.82
$1,270.68
$1,451.34
$272.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.26
$807.28
$909.00
$1,270.32
$1,930.38
$983.32
$1,079.34
$1,181.06
$1,542.38
$1,255.38
$1,351.40
$1,453.12
$1,814.44
$1,527.44
$1,623.46
$1,725.18
$2,086.50
$272.06
Toc - Plan #111 Aetna CVS Health
Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.72
$404.87
$455.88
$637.09
$968.13
$629.61
$677.76
$728.77
$909.98
$902.50
$950.65
$1,001.66
$1,182.87
$1,175.39
$1,223.54
$1,274.55
$1,455.76
$272.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.44
$809.74
$911.76
$1,274.18
$1,936.26
$986.33
$1,082.63