Obamacare 2021 Rates for Collier County

Obamacare > Rates > Florida > Collier County

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

The health insurance rates listed below are for calendar year 2021.

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

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

Obamacare Providers, 69 Plans and 2021 Rates for Collier County, Florida

Below, you’ll find a summary of the 69 plans for Collier County, Florida and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Florida Blue (BlueCross BlueShield FL)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771
Toc - Plan #1 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1423 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$664,35
$754,04
$849,04
$1 186,53
$1 803,05 		$1 172,58
$1 262,27
$1 357,27
$1 694,76 		$1 680,81
$1 770,50
$1 865,50
$2 202,99 		$2 189,04
$2 278,73
$2 373,73
$2 711,22 		$508,23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 328,70
$1 508,08
$1 698,08
$2 373,06
$3 606,10 		$1 836,93
$2 016,31
$2 206,31
$2 881,29 		$2 345,16
$2 524,54
$2 714,54
$3 389,52 		$2 853,39
$3 032,77
$3 222,77
$3 897,75 		$508,23
Toc - Plan #2 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueOptions Bronze 1419 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$410,74
$466,19
$524,93
$733,58
$1 114,75 		$724,96
$780,41
$839,15
$1 047,80 		$1 039,18
$1 094,63
$1 153,37
$1 362,02 		$1 353,40
$1 408,85
$1 467,59
$1 676,24 		$314,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821,48
$932,38
$1 049,86
$1 467,16
$2 229,50 		$1 135,70
$1 246,60
$1 364,08
$1 781,38 		$1 449,92
$1 560,82
$1 678,30
$2 095,60 		$1 764,14
$1 875,04
$1 992,52
$2 409,82 		$314,22
Toc - Plan #3 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1431 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$684,15
$776,51
$874,34
$1 221,89
$1 856,78 		$1 207,52
$1 299,88
$1 397,71
$1 745,26 		$1 730,89
$1 823,25
$1 921,08
$2 268,63 		$2 254,26
$2 346,62
$2 444,45
$2 792,00 		$523,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 368,30
$1 553,02
$1 748,68
$2 443,78
$3 713,56 		$1 891,67
$2 076,39
$2 272,05
$2 967,15 		$2 415,04
$2 599,76
$2 795,42
$3 490,52 		$2 938,41
$3 123,13
$3 318,79
$4 013,89 		$523,37
Toc - Plan #4 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueOptions Platinum 1418 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$4,250 $8,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$800,79
$908,90
$1 023,41
$1 430,21
$2 173,34 		$1 413,39
$1 521,50
$1 636,01
$2 042,81 		$2 025,99
$2 134,10
$2 248,61
$2 655,41 		$2 638,59
$2 746,70
$2 861,21
$3 268,01 		$612,60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 601,58
$1 817,80
$2 046,82
$2 860,42
$4 346,68 		$2 214,18
$2 430,40
$2 659,42
$3 473,02 		$2 826,78
$3 043,00
$3 272,02
$4 085,62 		$3 439,38
$3 655,60
$3 884,62
$4 698,22 		$612,60
Toc - Plan #5 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 1416 ($0 Virtual Visits / 3 PCP Visits for $20)

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$442,68
$502,44
$565,75
$790,63
$1 201,43 		$781,33
$841,09
$904,40
$1 129,28 		$1 119,98
$1 179,74
$1 243,05
$1 467,93 		$1 458,63
$1 518,39
$1 581,70
$1 806,58 		$338,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$885,36
$1 004,88
$1 131,50
$1 581,26
$2 402,86 		$1 224,01
$1 343,53
$1 470,15
$1 919,91 		$1 562,66
$1 682,18
$1 808,80
$2 258,56 		$1 901,31
$2 020,83
$2 147,45
$2 597,21 		$338,65
Toc - Plan #6 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueOptions Platinum 1424 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$848,55
$963,10
$1 084,45
$1 515,51
$2 302,96 		$1 497,69
$1 612,24
$1 733,59
$2 164,65 		$2 146,83
$2 261,38
$2 382,73
$2 813,79 		$2 795,97
$2 910,52
$3 031,87
$3 462,93 		$649,14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 697,10
$1 926,20
$2 168,90
$3 031,02
$4 605,92 		$2 346,24
$2 575,34
$2 818,04
$3 680,16 		$2 995,38
$3 224,48
$3 467,18
$4 329,30 		$3 644,52
$3 873,62
$4 116,32
$4 978,44 		$649,14
Toc - Plan #7 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1410 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$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 		$605,61
$687,37
$773,97
$1 081,62
$1 643,63 		$1 068,90
$1 150,66
$1 237,26
$1 544,91 		$1 532,19
$1 613,95
$1 700,55
$2 008,20 		$1 995,48
$2 077,24
$2 163,84
$2 471,49 		$463,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 211,22
$1 374,74
$1 547,94
$2 163,24
$3 287,26 		$1 674,51
$1 838,03
$2 011,23
$2 626,53 		$2 137,80
$2 301,32
$2 474,52
$3 089,82 		$2 601,09
$2 764,61
$2 937,81
$3 553,11 		$463,29
Toc - Plan #8 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1505 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $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 		$674,13
$765,14
$861,54
$1 204,00
$1 829,59 		$1 189,84
$1 280,85
$1 377,25
$1 719,71 		$1 705,55
$1 796,56
$1 892,96
$2 235,42 		$2 221,26
$2 312,27
$2 408,67
$2 751,13 		$515,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 348,26
$1 530,28
$1 723,08
$2 408,00
$3 659,18 		$1 863,97
$2 045,99
$2 238,79
$2 923,71 		$2 379,68
$2 561,70
$2 754,50
$3 439,42 		$2 895,39
$3 077,41
$3 270,21
$3 955,13 		$515,71
Toc - Plan #9 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze (HSA) 1705 ($100+ in Rewards / $4 Condition Care Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$428,97
$486,88
$548,22
$766,14
$1 164,22 		$757,13
$815,04
$876,38
$1 094,30 		$1 085,29
$1 143,20
$1 204,54
$1 422,46 		$1 413,45
$1 471,36
$1 532,70
$1 750,62 		$328,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857,94
$973,76
$1 096,44
$1 532,28
$2 328,44 		$1 186,10
$1 301,92
$1 424,60
$1 860,44 		$1 514,26
$1 630,08
$1 752,76
$2 188,60 		$1 842,42
$1 958,24
$2 080,92
$2 516,76 		$328,16
Toc - Plan #10 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueOptions Silver 1706S ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 Annual Deductible
$8,150 $16,300 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 		$677,12
$768,53
$865,36
$1 209,34
$1 837,70 		$1 195,12
$1 286,53
$1 383,36
$1 727,34 		$1 713,12
$1 804,53
$1 901,36
$2 245,34 		$2 231,12
$2 322,53
$2 419,36
$2 763,34 		$518,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 354,24
$1 537,06
$1 730,72
$2 418,68
$3 675,40 		$1 872,24
$2 055,06
$2 248,72
$2 936,68 		$2 390,24
$2 573,06
$2 766,72
$3 454,68 		$2 908,24
$3 091,06
$3 284,72
$3 972,68 		$518,00
Toc - Plan #11 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 1707S ($0 Virtual Visits / $40 PCP Visits)

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

Annual Out of Pocket Expenses:

Individual Family
$8,150 $16,300 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 		$441,51
$501,11
$564,25
$788,54
$1 198,26 		$779,27
$838,87
$902,01
$1 126,30 		$1 117,03
$1 176,63
$1 239,77
$1 464,06 		$1 454,79
$1 514,39
$1 577,53
$1 801,82 		$337,76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883,02
$1 002,22
$1 128,50
$1 577,08
$2 396,52 		$1 220,78
$1 339,98
$1 466,26
$1 914,84 		$1 558,54
$1 677,74
$1 804,02
$2 252,60 		$1 896,30
$2 015,50
$2 141,78
$2 590,36 		$337,76
Toc - Plan #12 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueOptions Gold 1805 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$652,80
$740,93
$834,28
$1 165,90
$1 771,70 		$1 152,19
$1 240,32
$1 333,67
$1 665,29 		$1 651,58
$1 739,71
$1 833,06
$2 164,68 		$2 150,97
$2 239,10
$2 332,45
$2 664,07 		$499,39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 305,60
$1 481,86
$1 668,56
$2 331,80
$3 543,40 		$1 804,99
$1 981,25
$2 167,95
$2 831,19 		$2 304,38
$2 480,64
$2 667,34
$3 330,58 		$2 803,77
$2 980,03
$3 166,73
$3 829,97 		$499,39
Toc - Plan #13 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueOptions Bronze 2119 ($0 Deductible / $50 PCP Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$472,33
$536,09
$603,64
$843,58
$1 281,90 		$833,66
$897,42
$964,97
$1 204,91 		$1 194,99
$1 258,75
$1 326,30
$1 566,24 		$1 556,32
$1 620,08
$1 687,63
$1 927,57 		$361,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$944,66
$1 072,18
$1 207,28
$1 687,16
$2 563,80 		$1 305,99
$1 433,51
$1 568,61
$2 048,49 		$1 667,32
$1 794,84
$1 929,94
$2 409,82 		$2 028,65
$2 156,17
$2 291,27
$2 771,15 		$361,33

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #14 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 5 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$428,40
$486,22
$547,48
$765,10
$1 162,65 		$756,12
$813,94
$875,20
$1 092,82 		$1 083,84
$1 141,66
$1 202,92
$1 420,54 		$1 411,56
$1 469,38
$1 530,64
$1 748,26 		$327,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856,80
$972,44
$1 094,96
$1 530,20
$2 325,30 		$1 184,52
$1 300,16
$1 422,68
$1 857,92 		$1 512,24
$1 627,88
$1 750,40
$2 185,64 		$1 839,96
$1 955,60
$2 078,12
$2 513,36 		$327,72
Toc - Plan #15 Ambetter from Sunshine Health
Bronze

(EPO) Ambetter Essential Care 1 (2021)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$299,61
$340,05
$382,89
$535,09
$813,12 		$528,81
$569,25
$612,09
$764,29 		$758,01
$798,45
$841,29
$993,49 		$987,21
$1 027,65
$1 070,49
$1 222,69 		$229,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599,22
$680,10
$765,78
$1 070,18
$1 626,24 		$828,42
$909,30
$994,98
$1 299,38 		$1 057,62
$1 138,50
$1 224,18
$1 528,58 		$1 286,82
$1 367,70
$1 453,38
$1 757,78 		$229,20
Toc - Plan #16 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$306,47
$347,83
$391,65
$547,33
$831,72 		$540,91
$582,27
$626,09
$781,77 		$775,35
$816,71
$860,53
$1 016,21 		$1 009,79
$1 051,15
$1 094,97
$1 250,65 		$234,44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612,94
$695,66
$783,30
$1 094,66
$1 663,44 		$847,38
$930,10
$1 017,74
$1 329,10 		$1 081,82
$1 164,54
$1 252,18
$1 563,54 		$1 316,26
$1 398,98
$1 486,62
$1 797,98 		$234,44
Toc - Plan #17 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 10 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$307,02
$348,46
$392,36
$548,33
$833,24 		$541,89
$583,33
$627,23
$783,20 		$776,76
$818,20
$862,10
$1 018,07 		$1 011,63
$1 053,07
$1 096,97
$1 252,94 		$234,87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614,04
$696,92
$784,72
$1 096,66
$1 666,48 		$848,91
$931,79
$1 019,59
$1 331,53 		$1 083,78
$1 166,66
$1 254,46
$1 566,40 		$1 318,65
$1 401,53
$1 489,33
$1 801,27 		$234,87
Toc - Plan #18 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 4 (2021)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$428,44
$486,27
$547,54
$765,18
$1 162,76 		$756,19
$814,02
$875,29
$1 092,93 		$1 083,94
$1 141,77
$1 203,04
$1 420,68 		$1 411,69
$1 469,52
$1 530,79
$1 748,43 		$327,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856,88
$972,54
$1 095,08
$1 530,36
$2 325,52 		$1 184,63
$1 300,29
$1 422,83
$1 858,11 		$1 512,38
$1 628,04
$1 750,58
$2 185,86 		$1 840,13
$1 955,79
$2 078,33
$2 513,61 		$327,75
Toc - Plan #19 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 11 (2021)

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

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 		$417,82
$474,21
$533,96
$746,20
$1 133,93 		$737,44
$793,83
$853,58
$1 065,82 		$1 057,06
$1 113,45
$1 173,20
$1 385,44 		$1 376,68
$1 433,07
$1 492,82
$1 705,06 		$319,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835,64
$948,42
$1 067,92
$1 492,40
$2 267,86 		$1 155,26
$1 268,04
$1 387,54
$1 812,02 		$1 474,88
$1 587,66
$1 707,16
$2 131,64 		$1 794,50
$1 907,28
$2 026,78
$2 451,26 		$319,62
Toc - Plan #20 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 12 (2021)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408,65
$463,80
$522,24
$729,83
$1 109,04 		$721,26
$776,41
$834,85
$1 042,44 		$1 033,87
$1 089,02
$1 147,46
$1 355,05 		$1 346,48
$1 401,63
$1 460,07
$1 667,66 		$312,61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817,30
$927,60
$1 044,48
$1 459,66
$2 218,08 		$1 129,91
$1 240,21
$1 357,09
$1 772,27 		$1 442,52
$1 552,82
$1 669,70
$2 084,88 		$1 755,13
$1 865,43
$1 982,31
$2 397,49 		$312,61
Toc - Plan #21 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 24 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 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 		$423,64
$480,82
$541,40
$756,61
$1 149,74 		$747,72
$804,90
$865,48
$1 080,69 		$1 071,80
$1 128,98
$1 189,56
$1 404,77 		$1 395,88
$1 453,06
$1 513,64
$1 728,85 		$324,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$847,28
$961,64
$1 082,80
$1 513,22
$2 299,48 		$1 171,36
$1 285,72
$1 406,88
$1 837,30 		$1 495,44
$1 609,80
$1 730,96
$2 161,38 		$1 819,52
$1 933,88
$2 055,04
$2 485,46 		$324,08
Toc - Plan #22 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 29 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$404,96
$459,62
$517,53
$723,25
$1 099,04 		$714,75
$769,41
$827,32
$1 033,04 		$1 024,54
$1 079,20
$1 137,11
$1 342,83 		$1 334,33
$1 388,99
$1 446,90
$1 652,62 		$309,79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809,92
$919,24
$1 035,06
$1 446,50
$2 198,08 		$1 119,71
$1 229,03
$1 344,85
$1 756,29 		$1 429,50
$1 538,82
$1 654,64
$2 066,08 		$1 739,29
$1 848,61
$1 964,43
$2 375,87 		$309,79
Toc - Plan #23 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 25 HSA (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$422,53
$479,56
$539,98
$754,62
$1 146,72 		$745,76
$802,79
$863,21
$1 077,85 		$1 068,99
$1 126,02
$1 186,44
$1 401,08 		$1 392,22
$1 449,25
$1 509,67
$1 724,31 		$323,23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845,06
$959,12
$1 079,96
$1 509,24
$2 293,44 		$1 168,29
$1 282,35
$1 403,19
$1 832,47 		$1 491,52
$1 605,58
$1 726,42
$2 155,70 		$1 814,75
$1 928,81
$2 049,65
$2 478,93 		$323,23
Toc - Plan #24 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 26 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$430,80
$488,94
$550,55
$769,39
$1 169,16 		$760,35
$818,49
$880,10
$1 098,94 		$1 089,90
$1 148,04
$1 209,65
$1 428,49 		$1 419,45
$1 477,59
$1 539,20
$1 758,04 		$329,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861,60
$977,88
$1 101,10
$1 538,78
$2 338,32 		$1 191,15
$1 307,43
$1 430,65
$1 868,33 		$1 520,70
$1 636,98
$1 760,20
$2 197,88 		$1 850,25
$1 966,53
$2 089,75
$2 527,43 		$329,55
Toc - Plan #25 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 27 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$449,95
$510,68
$575,02
$803,59
$1 221,13 		$794,15
$854,88
$919,22
$1 147,79 		$1 138,35
$1 199,08
$1 263,42
$1 491,99 		$1 482,55
$1 543,28
$1 607,62
$1 836,19 		$344,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$899,90
$1 021,36
$1 150,04
$1 607,18
$2 442,26 		$1 244,10
$1 365,56
$1 494,24
$1 951,38 		$1 588,30
$1 709,76
$1 838,44
$2 295,58 		$1 932,50
$2 053,96
$2 182,64
$2 639,78 		$344,20
Toc - Plan #26 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 28 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$458,35
$520,21
$585,75
$818,59
$1 243,92 		$808,98
$870,84
$936,38
$1 169,22 		$1 159,61
$1 221,47
$1 287,01
$1 519,85 		$1 510,24
$1 572,10
$1 637,64
$1 870,48 		$350,63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$916,70
$1 040,42
$1 171,50
$1 637,18
$2 487,84 		$1 267,33
$1 391,05
$1 522,13
$1 987,81 		$1 617,96
$1 741,68
$1 872,76
$2 338,44 		$1 968,59
$2 092,31
$2 223,39
$2 689,07 		$350,63
Toc - Plan #27 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 12 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$424,73
$482,06
$542,79
$758,55
$1 152,70 		$749,64
$806,97
$867,70
$1 083,46 		$1 074,55
$1 131,88
$1 192,61
$1 408,37 		$1 399,46
$1 456,79
$1 517,52
$1 733,28 		$324,91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849,46
$964,12
$1 085,58
$1 517,10
$2 305,40 		$1 174,37
$1 289,03
$1 410,49
$1 842,01 		$1 499,28
$1 613,94
$1 735,40
$2 166,92 		$1 824,19
$1 938,85
$2 060,31
$2 491,83 		$324,91
Toc - Plan #28 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$318,53
$361,52
$407,07
$568,88
$864,46 		$562,20
$605,19
$650,74
$812,55 		$805,87
$848,86
$894,41
$1 056,22 		$1 049,54
$1 092,53
$1 138,08
$1 299,89 		$243,67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637,06
$723,04
$814,14
$1 137,76
$1 728,92 		$880,73
$966,71
$1 057,81
$1 381,43 		$1 124,40
$1 210,38
$1 301,48
$1 625,10 		$1 368,07
$1 454,05
$1 545,15
$1 868,77 		$243,67
Toc - Plan #29 Ambetter from Sunshine Health
Gold

(EPO) Ambetter Secure Care 5 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$445,26
$505,36
$569,03
$795,22
$1 208,41 		$785,88
$845,98
$909,65
$1 135,84 		$1 126,50
$1 186,60
$1 250,27
$1 476,46 		$1 467,12
$1 527,22
$1 590,89
$1 817,08 		$340,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890,52
$1 010,72
$1 138,06
$1 590,44
$2 416,82 		$1 231,14
$1 351,34
$1 478,68
$1 931,06 		$1 571,76
$1 691,96
$1 819,30
$2 271,68 		$1 912,38
$2 032,58
$2 159,92
$2 612,30 		$340,62
Toc - Plan #30 Ambetter from Sunshine Health
Bronze

(EPO) Ambetter Essential Care 1 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311,40
$353,43
$397,96
$556,15
$845,12 		$549,62
$591,65
$636,18
$794,37 		$787,84
$829,87
$874,40
$1 032,59 		$1 026,06
$1 068,09
$1 112,62
$1 270,81 		$238,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622,80
$706,86
$795,92
$1 112,30
$1 690,24 		$861,02
$945,08
$1 034,14
$1 350,52 		$1 099,24
$1 183,30
$1 272,36
$1 588,74 		$1 337,46
$1 421,52
$1 510,58
$1 826,96 		$238,22
Toc - Plan #31 Ambetter from Sunshine Health
Expanded Bronze

(EPO) Ambetter Essential Care 10 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319,11
$362,18
$407,81
$569,91
$866,03 		$563,22
$606,29
$651,92
$814,02 		$807,33
$850,40
$896,03
$1 058,13 		$1 051,44
$1 094,51
$1 140,14
$1 302,24 		$244,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638,22
$724,36
$815,62
$1 139,82
$1 732,06 		$882,33
$968,47
$1 059,73
$1 383,93 		$1 126,44
$1 212,58
$1 303,84
$1 628,04 		$1 370,55
$1 456,69
$1 547,95
$1 872,15 		$244,11
Toc - Plan #32 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 4 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$445,30
$505,41
$569,09
$795,30
$1 208,53 		$785,95
$846,06
$909,74
$1 135,95 		$1 126,60
$1 186,71
$1 250,39
$1 476,60 		$1 467,25
$1 527,36
$1 591,04
$1 817,25 		$340,65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890,60
$1 010,82
$1 138,18
$1 590,60
$2 417,06 		$1 231,25
$1 351,47
$1 478,83
$1 931,25 		$1 571,90
$1 692,12
$1 819,48
$2 271,90 		$1 912,55
$2 032,77
$2 160,13
$2 612,55 		$340,65
Toc - Plan #33 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 11 (2021) + Vision + Adult Dental

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

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 		$434,26
$492,88
$554,97
$775,57
$1 178,56 		$766,46
$825,08
$887,17
$1 107,77 		$1 098,66
$1 157,28
$1 219,37
$1 439,97 		$1 430,86
$1 489,48
$1 551,57
$1 772,17 		$332,20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868,52
$985,76
$1 109,94
$1 551,14
$2 357,12 		$1 200,72
$1 317,96
$1 442,14
$1 883,34 		$1 532,92
$1 650,16
$1 774,34
$2 215,54 		$1 865,12
$1 982,36
$2 106,54
$2 547,74 		$332,20
Toc - Plan #34 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 24 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 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 		$440,32
$499,75
$562,71
$786,39
$1 194,99 		$777,16
$836,59
$899,55
$1 123,23 		$1 114,00
$1 173,43
$1 236,39
$1 460,07 		$1 450,84
$1 510,27
$1 573,23
$1 796,91 		$336,84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880,64
$999,50
$1 125,42
$1 572,78
$2 389,98 		$1 217,48
$1 336,34
$1 462,26
$1 909,62 		$1 554,32
$1 673,18
$1 799,10
$2 246,46 		$1 891,16
$2 010,02
$2 135,94
$2 583,30 		$336,84
Toc - Plan #35 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 25 HSA (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$439,16
$498,43
$561,23
$784,32
$1 191,85 		$775,11
$834,38
$897,18
$1 120,27 		$1 111,06
$1 170,33
$1 233,13
$1 456,22 		$1 447,01
$1 506,28
$1 569,08
$1 792,17 		$335,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878,32
$996,86
$1 122,46
$1 568,64
$2 383,70 		$1 214,27
$1 332,81
$1 458,41
$1 904,59 		$1 550,22
$1 668,76
$1 794,36
$2 240,54 		$1 886,17
$2 004,71
$2 130,31
$2 576,49 		$335,95
Toc - Plan #36 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 26 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$447,75
$508,19
$572,22
$799,67
$1 215,18 		$790,27
$850,71
$914,74
$1 142,19 		$1 132,79
$1 193,23
$1 257,26
$1 484,71 		$1 475,31
$1 535,75
$1 599,78
$1 827,23 		$342,52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895,50
$1 016,38
$1 144,44
$1 599,34
$2 430,36 		$1 238,02
$1 358,90
$1 486,96
$1 941,86 		$1 580,54
$1 701,42
$1 829,48
$2 284,38 		$1 923,06
$2 043,94
$2 172,00
$2 626,90 		$342,52
Toc - Plan #37 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 27 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 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 		$467,66
$530,78
$597,65
$835,22
$1 269,20 		$825,41
$888,53
$955,40
$1 192,97 		$1 183,16
$1 246,28
$1 313,15
$1 550,72 		$1 540,91
$1 604,03
$1 670,90
$1 908,47 		$357,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$935,32
$1 061,56
$1 195,30
$1 670,44
$2 538,40 		$1 293,07
$1 419,31
$1 553,05
$2 028,19 		$1 650,82
$1 777,06
$1 910,80
$2 385,94 		$2 008,57
$2 134,81
$2 268,55
$2 743,69 		$357,75
Toc - Plan #38 Ambetter from Sunshine Health
Silver

(EPO) Ambetter Balanced Care 28 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$476,39
$540,69
$608,81
$850,81
$1 292,89 		$840,82
$905,12
$973,24
$1 215,24 		$1 205,25
$1 269,55
$1 337,67
$1 579,67 		$1 569,68
$1 633,98
$1 702,10
$1 944,10 		$364,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952,78
$1 081,38
$1 217,62
$1 701,62
$2 585,78 		$1 317,21
$1 445,81
$1 582,05
$2 066,05 		$1 681,64
$1 810,24
$1 946,48
$2 430,48 		$2 046,07
$2 174,67
$2 310,91
$2 794,91 		$364,43

ADVERTISEMENT

Florida Blue HMO (a BlueCross BlueShield FL company)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771
Toc - Plan #39 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 1490 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$509,81
$578,63
$651,54
$910,52
$1 383,62 		$899,81
$968,63
$1 041,54
$1 300,52 		$1 289,81
$1 358,63
$1 431,54
$1 690,52 		$1 679,81
$1 748,63
$1 821,54
$2 080,52 		$390,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 019,62
$1 157,26
$1 303,08
$1 821,04
$2 767,24 		$1 409,62
$1 547,26
$1 693,08
$2 211,04 		$1 799,62
$1 937,26
$2 083,08
$2 601,04 		$2 189,62
$2 327,26
$2 473,08
$2 991,04 		$390,00
Toc - Plan #40 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) BlueCare Bronze 1486 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$323,26
$366,90
$413,13
$577,34
$877,33 		$570,55
$614,19
$660,42
$824,63 		$817,84
$861,48
$907,71
$1 071,92 		$1 065,13
$1 108,77
$1 155,00
$1 319,21 		$247,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646,52
$733,80
$826,26
$1 154,68
$1 754,66 		$893,81
$981,09
$1 073,55
$1 401,97 		$1 141,10
$1 228,38
$1 320,84
$1 649,26 		$1 388,39
$1 475,67
$1 568,13
$1 896,55 		$247,29
Toc - Plan #41 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 1498 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$514,05
$583,45
$656,96
$918,09
$1 395,13 		$907,30
$976,70
$1 050,21
$1 311,34 		$1 300,55
$1 369,95
$1 443,46
$1 704,59 		$1 693,80
$1 763,20
$1 836,71
$2 097,84 		$393,25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 028,10
$1 166,90
$1 313,92
$1 836,18
$2 790,26 		$1 421,35
$1 560,15
$1 707,17
$2 229,43 		$1 814,60
$1 953,40
$2 100,42
$2 622,68 		$2 207,85
$2 346,65
$2 493,67
$3 015,93 		$393,25
Toc - Plan #42 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 1485 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$4,250 $8,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$555,27
$630,23
$709,64
$991,71
$1 507,00 		$980,05
$1 055,01
$1 134,42
$1 416,49 		$1 404,83
$1 479,79
$1 559,20
$1 841,27 		$1 829,61
$1 904,57
$1 983,98
$2 266,05 		$424,78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 110,54
$1 260,46
$1 419,28
$1 983,42
$3 014,00 		$1 535,32
$1 685,24
$1 844,06
$2 408,20 		$1 960,10
$2 110,02
$2 268,84
$2 832,98 		$2 384,88
$2 534,80
$2 693,62
$3 257,76 		$424,78
Toc - Plan #43 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 1483 ($0 Virtual Visits / 3 PCP Visits for $20)

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358,97
$407,43
$458,76
$641,12
$974,24 		$633,58
$682,04
$733,37
$915,73 		$908,19
$956,65
$1 007,98
$1 190,34 		$1 182,80
$1 231,26
$1 282,59
$1 464,95 		$274,61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717,94
$814,86
$917,52
$1 282,24
$1 948,48 		$992,55
$1 089,47
$1 192,13
$1 556,85 		$1 267,16
$1 364,08
$1 466,74
$1 831,46 		$1 541,77
$1 638,69
$1 741,35
$2 106,07 		$274,61
Toc - Plan #44 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) BlueCare Platinum 1491 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$599,34
$680,25
$765,96
$1 070,42
$1 626,61 		$1 057,84
$1 138,75
$1 224,46
$1 528,92 		$1 516,34
$1 597,25
$1 682,96
$1 987,42 		$1 974,84
$2 055,75
$2 141,46
$2 445,92 		$458,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 198,68
$1 360,50
$1 531,92
$2 140,84
$3 253,22 		$1 657,18
$1 819,00
$1 990,42
$2 599,34 		$2 115,68
$2 277,50
$2 448,92
$3 057,84 		$2 574,18
$2 736,00
$2 907,42
$3 516,34 		$458,50
Toc - Plan #45 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 1477 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$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 		$435,89
$494,74
$557,07
$778,50
$1 183,01 		$769,35
$828,20
$890,53
$1 111,96 		$1 102,81
$1 161,66
$1 223,99
$1 445,42 		$1 436,27
$1 495,12
$1 557,45
$1 778,88 		$333,46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871,78
$989,48
$1 114,14
$1 557,00
$2 366,02 		$1 205,24
$1 322,94
$1 447,60
$1 890,46 		$1 538,70
$1 656,40
$1 781,06
$2 223,92 		$1 872,16
$1 989,86
$2 114,52
$2 557,38 		$333,46
Toc - Plan #46 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 1565 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $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 		$512,62
$581,82
$655,13
$915,54
$1 391,25 		$904,77
$973,97
$1 047,28
$1 307,69 		$1 296,92
$1 366,12
$1 439,43
$1 699,84 		$1 689,07
$1 758,27
$1 831,58
$2 091,99 		$392,15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 025,24
$1 163,64
$1 310,26
$1 831,08
$2 782,50 		$1 417,39
$1 555,79
$1 702,41
$2 223,23 		$1 809,54
$1 947,94
$2 094,56
$2 615,38 		$2 201,69
$2 340,09
$2 486,71
$3 007,53 		$392,15
Toc - Plan #47 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze (HSA) 1765 ($100+ in Rewards / $4 Condition Care Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$341,54
$387,65
$436,49
$609,99
$926,94 		$602,82
$648,93
$697,77
$871,27 		$864,10
$910,21
$959,05
$1 132,55 		$1 125,38
$1 171,49
$1 220,33
$1 393,83 		$261,28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683,08
$775,30
$872,98
$1 219,98
$1 853,88 		$944,36
$1 036,58
$1 134,26
$1 481,26 		$1 205,64
$1 297,86
$1 395,54
$1 742,54 		$1 466,92
$1 559,14
$1 656,82
$2 003,82 		$261,28
Toc - Plan #48 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 1766S ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 Annual Deductible
$8,150 $16,300 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 		$505,82
$574,11
$646,44
$903,39
$1 372,80 		$892,77
$961,06
$1 033,39
$1 290,34 		$1 279,72
$1 348,01
$1 420,34
$1 677,29 		$1 666,67
$1 734,96
$1 807,29
$2 064,24 		$386,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 011,64
$1 148,22
$1 292,88
$1 806,78
$2 745,60 		$1 398,59
$1 535,17
$1 679,83
$2 193,73 		$1 785,54
$1 922,12
$2 066,78
$2 580,68 		$2 172,49
$2 309,07
$2 453,73
$2 967,63 		$386,95
Toc - Plan #49 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 1767S ($0 Virtual Visits / $40 PCP Visits)

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

Annual Out of Pocket Expenses:

Individual Family
$8,150 $16,300 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 		$357,10
$405,31
$456,37
$637,78
$969,17 		$630,28
$678,49
$729,55
$910,96 		$903,46
$951,67
$1 002,73
$1 184,14 		$1 176,64
$1 224,85
$1 275,91
$1 457,32 		$273,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714,20
$810,62
$912,74
$1 275,56
$1 938,34 		$987,38
$1 083,80
$1 185,92
$1 548,74 		$1 260,56
$1 356,98
$1 459,10
$1 821,92 		$1 533,74
$1 630,16
$1 732,28
$2 095,10 		$273,18
Toc - Plan #50 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 1865 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$491,54
$557,90
$628,19
$877,89
$1 334,04 		$867,57
$933,93
$1 004,22
$1 253,92 		$1 243,60
$1 309,96
$1 380,25
$1 629,95 		$1 619,63
$1 685,99
$1 756,28
$2 005,98 		$376,03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983,08
$1 115,80
$1 256,38
$1 755,78
$2 668,08 		$1 359,11
$1 491,83
$1 632,41
$2 131,81 		$1 735,14
$1 867,86
$2 008,44
$2 507,84 		$2 111,17
$2 243,89
$2 384,47
$2 883,87 		$376,03
Toc - Plan #51 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2179 ($0 Deductible / $50 PCP Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$391,62
$444,49
$500,49
$699,43
$1 062,86 		$691,21
$744,08
$800,08
$999,02 		$990,80
$1 043,67
$1 099,67
$1 298,61 		$1 290,39
$1 343,26
$1 399,26
$1 598,20 		$299,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783,24
$888,98
$1 000,98
$1 398,86
$2 125,72 		$1 082,83
$1 188,57
$1 300,57
$1 698,45 		$1 382,42
$1 488,16
$1 600,16
$1 998,04 		$1 682,01
$1 787,75
$1 899,75
$2 297,63 		$299,59
Toc - Plan #52 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2010 ($0 Labs / $0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 Annual Deductible
$8,150 $16,300 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 		$350,04
$397,30
$447,35
$625,17
$950,01 		$617,82
$665,08
$715,13
$892,95 		$885,60
$932,86
$982,91
$1 160,73 		$1 153,38
$1 200,64
$1 250,69
$1 428,51 		$267,78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700,08
$794,60
$894,70
$1 250,34
$1 900,02 		$967,86
$1 062,38
$1 162,48
$1 518,12 		$1 235,64
$1 330,16
$1 430,26
$1 785,90 		$1 503,42
$1 597,94
$1 698,04
$2 053,68 		$267,78
Toc - Plan #53 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 2011 ($0 Labs / $0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408,90
$464,10
$522,57
$730,30
$1 109,75 		$721,71
$776,91
$835,38
$1 043,11 		$1 034,52
$1 089,72
$1 148,19
$1 355,92 		$1 347,33
$1 402,53
$1 461,00
$1 668,73 		$312,81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817,80
$928,20
$1 045,14
$1 460,60
$2 219,50 		$1 130,61
$1 241,01
$1 357,95
$1 773,41 		$1 443,42
$1 553,82
$1 670,76
$2 086,22 		$1 756,23
$1 866,63
$1 983,57
$2 399,03 		$312,81
Toc - Plan #54 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2013 ($0 Virtual Visits / 2 PCP Visits for $50)

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301,92
$342,68
$385,85
$539,23
$819,41 		$532,89
$573,65
$616,82
$770,20 		$763,86
$804,62
$847,79
$1 001,17 		$994,83
$1 035,59
$1 078,76
$1 232,14 		$230,97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603,84
$685,36
$771,70
$1 078,46
$1 638,82 		$834,81
$916,33
$1 002,67
$1 309,43 		$1 065,78
$1 147,30
$1 233,64
$1 540,40 		$1 296,75
$1 378,27
$1 464,61
$1 771,37 		$230,97
Toc - Plan #55 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2014 ($0 Labs / $0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$277,27
$314,70
$354,35
$495,20
$752,51 		$489,38
$526,81
$566,46
$707,31 		$701,49
$738,92
$778,57
$919,42 		$913,60
$951,03
$990,68
$1 131,53 		$212,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554,54
$629,40
$708,70
$990,40
$1 505,02 		$766,65
$841,51
$920,81
$1 202,51 		$978,76
$1 053,62
$1 132,92
$1 414,62 		$1 190,87
$1 265,73
$1 345,03
$1 626,73 		$212,11
Toc - Plan #56 Florida Blue HMO (a BlueCross BlueShield FL company)
Platinum

(HMO) myBlue Platinum 2015 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$513,06
$582,32
$655,69
$916,33
$1 392,44 		$905,55
$974,81
$1 048,18
$1 308,82 		$1 298,04
$1 367,30
$1 440,67
$1 701,31 		$1 690,53
$1 759,79
$1 833,16
$2 093,80 		$392,49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 026,12
$1 164,64
$1 311,38
$1 832,66
$2 784,88 		$1 418,61
$1 557,13
$1 703,87
$2 225,15 		$1 811,10
$1 949,62
$2 096,36
$2 617,64 		$2 203,59
$2 342,11
$2 488,85
$3 010,13 		$392,49
Toc - Plan #57 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 2016 ($0 Virtual Visits / $100+ in Rewards)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,350 $10,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$444,47
$504,47
$568,03
$793,82
$1 206,29 		$784,49
$844,49
$908,05
$1 133,84 		$1 124,51
$1 184,51
$1 248,07
$1 473,86 		$1 464,53
$1 524,53
$1 588,09
$1 813,88 		$340,02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888,94
$1 008,94
$1 136,06
$1 587,64
$2 412,58 		$1 228,96
$1 348,96
$1 476,08
$1 927,66 		$1 568,98
$1 688,98
$1 816,10
$2 267,68 		$1 909,00
$2 029,00
$2 156,12
$2 607,70 		$340,02
Toc - Plan #58 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2146 (3 PCP Visits for $0 / $0 Virtual Visits)

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302,94
$343,84
$387,16
$541,05
$822,18 		$534,69
$575,59
$618,91
$772,80 		$766,44
$807,34
$850,66
$1 004,55 		$998,19
$1 039,09
$1 082,41
$1 236,30 		$231,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605,88
$687,68
$774,32
$1 082,10
$1 644,36 		$837,63
$919,43
$1 006,07
$1 313,85 		$1 069,38
$1 151,18
$1 237,82
$1 545,60 		$1 301,13
$1 382,93
$1 469,57
$1 777,35 		$231,75
Toc - Plan #59 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2149 ($0 Deductible / $50 PCP Visits / $75 Specialist Visits)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$332,14
$376,98
$424,47
$593,20
$901,43 		$586,23
$631,07
$678,56
$847,29 		$840,32
$885,16
$932,65
$1 101,38 		$1 094,41
$1 139,25
$1 186,74
$1 355,47 		$254,09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664,28
$753,96
$848,94
$1 186,40
$1 802,86 		$918,37
$1 008,05
$1 103,03
$1 440,49 		$1 172,46
$1 262,14
$1 357,12
$1 694,58 		$1 426,55
$1 516,23
$1 611,21
$1 948,67 		$254,09

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #60 Cigna Healthcare
Bronze

(EPO) Cigna Connect 8550

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

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$309,06
$350,79
$394,98
$551,99
$838,80 		$545,49
$587,22
$631,41
$788,42 		$781,92
$823,65
$867,84
$1 024,85 		$1 018,35
$1 060,08
$1 104,27
$1 261,28 		$236,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618,12
$701,58
$789,96
$1 103,98
$1 677,60 		$854,55
$938,01
$1 026,39
$1 340,41 		$1 090,98
$1 174,44
$1 262,82
$1 576,84 		$1 327,41
$1 410,87
$1 499,25
$1 813,27 		$236,43
Toc - Plan #61 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6500

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$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 		$324,27
$368,04
$414,41
$579,14
$880,06 		$572,33
$616,10
$662,47
$827,20 		$820,39
$864,16
$910,53
$1 075,26 		$1 068,45
$1 112,22
$1 158,59
$1 323,32 		$248,06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648,54
$736,08
$828,82
$1 158,28
$1 760,12 		$896,60
$984,14
$1 076,88
$1 406,34 		$1 144,66
$1 232,20
$1 324,94
$1 654,40 		$1 392,72
$1 480,26
$1 573,00
$1 902,46 		$248,06
Toc - Plan #62 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7000

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321,29
$364,66
$410,60
$573,82
$871,97 		$567,07
$610,44
$656,38
$819,60 		$812,85
$856,22
$902,16
$1 065,38 		$1 058,63
$1 102,00
$1 147,94
$1 311,16 		$245,78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642,58
$729,32
$821,20
$1 147,64
$1 743,94 		$888,36
$975,10
$1 066,98
$1 393,42 		$1 134,14
$1 220,88
$1 312,76
$1 639,20 		$1 379,92
$1 466,66
$1 558,54
$1 884,98 		$245,78
Toc - Plan #63 Cigna Healthcare
Silver

(EPO) Cigna Connect 6000

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393,55
$446,68
$502,96
$702,88
$1 068,10 		$694,62
$747,75
$804,03
$1 003,95 		$995,69
$1 048,82
$1 105,10
$1 305,02 		$1 296,76
$1 349,89
$1 406,17
$1 606,09 		$301,07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787,10
$893,36
$1 005,92
$1 405,76
$2 136,20 		$1 088,17
$1 194,43
$1 306,99
$1 706,83 		$1 389,24
$1 495,50
$1 608,06
$2 007,90 		$1 690,31
$1 796,57
$1 909,13
$2 308,97 		$301,07
Toc - Plan #64 Cigna Healthcare
Silver

(EPO) Cigna Connect 4500

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$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 		$396,88
$450,46
$507,21
$708,82
$1 077,13 		$700,49
$754,07
$810,82
$1 012,43 		$1 004,10
$1 057,68
$1 114,43
$1 316,04 		$1 307,71
$1 361,29
$1 418,04
$1 619,65 		$303,61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793,76
$900,92
$1 014,42
$1 417,64
$2 154,26 		$1 097,37
$1 204,53
$1 318,03
$1 721,25 		$1 400,98
$1 508,14
$1 621,64
$2 024,86 		$1 704,59
$1 811,75
$1 925,25
$2 328,47 		$303,61
Toc - Plan #65 Cigna Healthcare
Silver

(EPO) Cigna Connect 7200

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399,69
$453,64
$510,80
$713,84
$1 084,75 		$705,45
$759,40
$816,56
$1 019,60 		$1 011,21
$1 065,16
$1 122,32
$1 325,36 		$1 316,97
$1 370,92
$1 428,08
$1 631,12 		$305,76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799,38
$907,28
$1 021,60
$1 427,68
$2 169,50 		$1 105,14
$1 213,04
$1 327,36
$1 733,44 		$1 410,90
$1 518,80
$1 633,12
$2 039,20 		$1 716,66
$1 824,56
$1 938,88
$2 344,96 		$305,76
Toc - Plan #66 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$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 		$409,28
$464,53
$523,05
$730,97
$1 110,77 		$722,38
$777,63
$836,15
$1 044,07 		$1 035,48
$1 090,73
$1 149,25
$1 357,17 		$1 348,58
$1 403,83
$1 462,35
$1 670,27 		$313,10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818,56
$929,06
$1 046,10
$1 461,94
$2 221,54 		$1 131,66
$1 242,16
$1 359,20
$1 775,04 		$1 444,76
$1 555,26
$1 672,30
$2 088,14 		$1 757,86
$1 868,36
$1 985,40
$2 401,24 		$313,10
Toc - Plan #67 Cigna Healthcare
Gold

(EPO) Cigna Connect 2000

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$446,16
$506,40
$570,20
$796,85
$1 210,89 		$787,48
$847,72
$911,52
$1 138,17 		$1 128,80
$1 189,04
$1 252,84
$1 479,49 		$1 470,12
$1 530,36
$1 594,16
$1 820,81 		$341,32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892,32
$1 012,80
$1 140,40
$1 593,70
$2 421,78 		$1 233,64
$1 354,12
$1 481,72
$1 935,02 		$1 574,96
$1 695,44
$1 823,04
$2 276,34 		$1 916,28
$2 036,76
$2 164,36
$2 617,66 		$341,32
Toc - Plan #68 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 5500

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$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 		$326,30
$370,35
$417,01
$582,77
$885,57 		$575,92
$619,97
$666,63
$832,39 		$825,54
$869,59
$916,25
$1 082,01 		$1 075,16
$1 119,21
$1 165,87
$1 331,63 		$249,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652,60
$740,70
$834,02
$1 165,54
$1 771,14 		$902,22
$990,32
$1 083,64
$1 415,16 		$1 151,84
$1 239,94
$1 333,26
$1 664,78 		$1 401,46
$1 489,56
$1 582,88
$1 914,40 		$249,62
Toc - Plan #69 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500 Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$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 		$413,12
$468,89
$527,97
$737,83
$1 121,21 		$729,16
$784,93
$844,01
$1 053,87 		$1 045,20
$1 100,97
$1 160,05
$1 369,91 		$1 361,24
$1 417,01
$1 476,09
$1 685,95 		$316,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826,24
$937,78
$1 055,94
$1 475,66
$2 242,42 		$1 142,28
$1 253,82
$1 371,98
$1 791,70 		$1 458,32
$1 569,86
$1 688,02
$2 107,74 		$1 774,36
$1 885,90
$2 004,06
$2 423,78 		$316,04

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

Collier County is in “Rating Area 11” of Florida.

Currently, there are 69 plans offered in Rating Area 11.

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2021 Obamacare Plans for Collier County, FL

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