Obamacare 2021 Rates for Orange County

Obamacare > Rates > Florida > Orange 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 Orange 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, 127 Plans and 2021 Rates for Orange County, Florida

Below, you’ll find a summary of the 127 plans for Orange 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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Bright Health

Local: 1-855-521-9335 | Toll Free: 1-855-521-9335

Toc - Plan #1 Bright Health
Gold

(EPO) Gold 1000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$445,47
$505,61
$569,31
$795,61
$1 209,00 		$786,25
$846,39
$910,09
$1 136,39 		$1 127,03
$1 187,17
$1 250,87
$1 477,17 		$1 467,81
$1 527,95
$1 591,65
$1 817,95 		$340,78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890,94
$1 011,22
$1 138,62
$1 591,22
$2 418,00 		$1 231,72
$1 352,00
$1 479,40
$1 932,00 		$1 572,50
$1 692,78
$1 820,18
$2 272,78 		$1 913,28
$2 033,56
$2 160,96
$2 613,56 		$340,78
Toc - Plan #2 Bright Health
Silver

(EPO) Silver 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$377,99
$429,02
$483,07
$675,09
$1 025,87 		$667,15
$718,18
$772,23
$964,25 		$956,31
$1 007,34
$1 061,39
$1 253,41 		$1 245,47
$1 296,50
$1 350,55
$1 542,57 		$289,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755,98
$858,04
$966,14
$1 350,18
$2 051,74 		$1 045,14
$1 147,20
$1 255,30
$1 639,34 		$1 334,30
$1 436,36
$1 544,46
$1 928,50 		$1 623,46
$1 725,52
$1 833,62
$2 217,66 		$289,16
Toc - Plan #3 Bright Health
Silver

(EPO) Silver 3000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$392,01
$444,93
$500,99
$700,13
$1 063,92 		$691,90
$744,82
$800,88
$1 000,02 		$991,79
$1 044,71
$1 100,77
$1 299,91 		$1 291,68
$1 344,60
$1 400,66
$1 599,80 		$299,89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784,02
$889,86
$1 001,98
$1 400,26
$2 127,84 		$1 083,91
$1 189,75
$1 301,87
$1 700,15 		$1 383,80
$1 489,64
$1 601,76
$2 000,04 		$1 683,69
$1 789,53
$1 901,65
$2 299,93 		$299,89
Toc - Plan #4 Bright Health
Silver

(EPO) Silver $0 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

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 		$410,18
$465,56
$524,21
$732,59
$1 113,24 		$723,97
$779,35
$838,00
$1 046,38 		$1 037,76
$1 093,14
$1 151,79
$1 360,17 		$1 351,55
$1 406,93
$1 465,58
$1 673,96 		$313,79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820,36
$931,12
$1 048,42
$1 465,18
$2 226,48 		$1 134,15
$1 244,91
$1 362,21
$1 778,97 		$1 447,94
$1 558,70
$1 676,00
$2 092,76 		$1 761,73
$1 872,49
$1 989,79
$2 406,55 		$313,79
Toc - Plan #5 Bright Health
Expanded Bronze

(EPO) Bronze 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

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 		$284,05
$322,39
$363,01
$507,31
$770,91 		$501,35
$539,69
$580,31
$724,61 		$718,65
$756,99
$797,61
$941,91 		$935,95
$974,29
$1 014,91
$1 159,21 		$217,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$568,10
$644,78
$726,02
$1 014,62
$1 541,82 		$785,40
$862,08
$943,32
$1 231,92 		$1 002,70
$1 079,38
$1 160,62
$1 449,22 		$1 220,00
$1 296,68
$1 377,92
$1 666,52 		$217,30
Toc - Plan #6 Bright Health
Expanded Bronze

(EPO) Bronze 5900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$295,73
$335,65
$377,94
$528,17
$802,61 		$521,96
$561,88
$604,17
$754,40 		$748,19
$788,11
$830,40
$980,63 		$974,42
$1 014,34
$1 056,63
$1 206,86 		$226,23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591,46
$671,30
$755,88
$1 056,34
$1 605,22 		$817,69
$897,53
$982,11
$1 282,57 		$1 043,92
$1 123,76
$1 208,34
$1 508,80 		$1 270,15
$1 349,99
$1 434,57
$1 735,03 		$226,23
Toc - Plan #7 Bright Health
Expanded Bronze

(EPO) Bronze 7000 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

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 		$336,96
$382,45
$430,63
$601,81
$914,50 		$594,73
$640,22
$688,40
$859,58 		$852,50
$897,99
$946,17
$1 117,35 		$1 110,27
$1 155,76
$1 203,94
$1 375,12 		$257,77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$673,92
$764,90
$861,26
$1 203,62
$1 829,00 		$931,69
$1 022,67
$1 119,03
$1 461,39 		$1 189,46
$1 280,44
$1 376,80
$1 719,16 		$1 447,23
$1 538,21
$1 634,57
$1 976,93 		$257,77
Toc - Plan #8 Bright Health
Catastrophic

(EPO) Catastrophic 3 $0 PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

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 		$232,72
$264,13
$297,41
$415,63
$631,59 		$410,75
$442,16
$475,44
$593,66 		$588,78
$620,19
$653,47
$771,69 		$766,81
$798,22
$831,50
$949,72 		$178,03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$465,44
$528,26
$594,82
$831,26
$1 263,18 		$643,47
$706,29
$772,85
$1 009,29 		$821,50
$884,32
$950,88
$1 187,32 		$999,53
$1 062,35
$1 128,91
$1 365,35 		$178,03
Toc - Plan #9 Bright Health
Silver

(EPO) Silver $0 Primary Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 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 		$391,96
$444,87
$500,92
$700,03
$1 063,77 		$691,81
$744,72
$800,77
$999,88 		$991,66
$1 044,57
$1 100,62
$1 299,73 		$1 291,51
$1 344,42
$1 400,47
$1 599,58 		$299,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783,92
$889,74
$1 001,84
$1 400,06
$2 127,54 		$1 083,77
$1 189,59
$1 301,69
$1 699,91 		$1 383,62
$1 489,44
$1 601,54
$1 999,76 		$1 683,47
$1 789,29
$1 901,39
$2 299,61 		$299,85
Toc - Plan #10 Bright Health
Expanded Bronze

(EPO) Bronze $0 Primary Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$295,59
$335,49
$377,76
$527,92
$802,22 		$521,71
$561,61
$603,88
$754,04 		$747,83
$787,73
$830,00
$980,16 		$973,95
$1 013,85
$1 056,12
$1 206,28 		$226,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591,18
$670,98
$755,52
$1 055,84
$1 604,44 		$817,30
$897,10
$981,64
$1 281,96 		$1 043,42
$1 123,22
$1 207,76
$1 508,08 		$1 269,54
$1 349,34
$1 433,88
$1 734,20 		$226,12
Toc - Plan #11 Bright Health
Expanded Bronze

(EPO) Bronze $0 Medical Deductible Direct

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9335

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 		$324,02
$367,77
$414,10
$578,71
$879,40 		$571,90
$615,65
$661,98
$826,59 		$819,78
$863,53
$909,86
$1 074,47 		$1 067,66
$1 111,41
$1 157,74
$1 322,35 		$247,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648,04
$735,54
$828,20
$1 157,42
$1 758,80 		$895,92
$983,42
$1 076,08
$1 405,30 		$1 143,80
$1 231,30
$1 323,96
$1 653,18 		$1 391,68
$1 479,18
$1 571,84
$1 901,06 		$247,88

ADVERTISEMENT

Florida Blue (BlueCross BlueShield FL)

Local: 1-800-352-2583 | Toll Free: 1-800-352-2583 | TTY: 1-800-955-8771
Toc - Plan #12 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 		$770,30
$874,29
$984,44
$1 375,76
$2 090,59 		$1 359,58
$1 463,57
$1 573,72
$1 965,04 		$1 948,86
$2 052,85
$2 163,00
$2 554,32 		$2 538,14
$2 642,13
$2 752,28
$3 143,60 		$589,28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 540,60
$1 748,58
$1 968,88
$2 751,52
$4 181,18 		$2 129,88
$2 337,86
$2 558,16
$3 340,80 		$2 719,16
$2 927,14
$3 147,44
$3 930,08 		$3 308,44
$3 516,42
$3 736,72
$4 519,36 		$589,28
Toc - Plan #13 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 		$476,25
$540,54
$608,65
$850,58
$1 292,54 		$840,58
$904,87
$972,98
$1 214,91 		$1 204,91
$1 269,20
$1 337,31
$1 579,24 		$1 569,24
$1 633,53
$1 701,64
$1 943,57 		$364,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952,50
$1 081,08
$1 217,30
$1 701,16
$2 585,08 		$1 316,83
$1 445,41
$1 581,63
$2 065,49 		$1 681,16
$1 809,74
$1 945,96
$2 429,82 		$2 045,49
$2 174,07
$2 310,29
$2 794,15 		$364,33
Toc - Plan #14 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 		$793,26
$900,35
$1 013,79
$1 416,76
$2 152,91 		$1 400,10
$1 507,19
$1 620,63
$2 023,60 		$2 006,94
$2 114,03
$2 227,47
$2 630,44 		$2 613,78
$2 720,87
$2 834,31
$3 237,28 		$606,84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 586,52
$1 800,70
$2 027,58
$2 833,52
$4 305,82 		$2 193,36
$2 407,54
$2 634,42
$3 440,36 		$2 800,20
$3 014,38
$3 241,26
$4 047,20 		$3 407,04
$3 621,22
$3 848,10
$4 654,04 		$606,84
Toc - Plan #15 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 		$928,50
$1 053,85
$1 186,62
$1 658,30
$2 519,95 		$1 638,80
$1 764,15
$1 896,92
$2 368,60 		$2 349,10
$2 474,45
$2 607,22
$3 078,90 		$3 059,40
$3 184,75
$3 317,52
$3 789,20 		$710,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 857,00
$2 107,70
$2 373,24
$3 316,60
$5 039,90 		$2 567,30
$2 818,00
$3 083,54
$4 026,90 		$3 277,60
$3 528,30
$3 793,84
$4 737,20 		$3 987,90
$4 238,60
$4 504,14
$5 447,50 		$710,30
Toc - Plan #16 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 		$513,28
$582,57
$655,97
$916,72
$1 393,04 		$905,94
$975,23
$1 048,63
$1 309,38 		$1 298,60
$1 367,89
$1 441,29
$1 702,04 		$1 691,26
$1 760,55
$1 833,95
$2 094,70 		$392,66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 026,56
$1 165,14
$1 311,94
$1 833,44
$2 786,08 		$1 419,22
$1 557,80
$1 704,60
$2 226,10 		$1 811,88
$1 950,46
$2 097,26
$2 618,76 		$2 204,54
$2 343,12
$2 489,92
$3 011,42 		$392,66
Toc - Plan #17 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 		$983,88
$1 116,70
$1 257,40
$1 757,21
$2 670,25 		$1 736,55
$1 869,37
$2 010,07
$2 509,88 		$2 489,22
$2 622,04
$2 762,74
$3 262,55 		$3 241,89
$3 374,71
$3 515,41
$4 015,22 		$752,67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 967,76
$2 233,40
$2 514,80
$3 514,42
$5 340,50 		$2 720,43
$2 986,07
$3 267,47
$4 267,09 		$3 473,10
$3 738,74
$4 020,14
$5 019,76 		$4 225,77
$4 491,41
$4 772,81
$5 772,43 		$752,67
Toc - Plan #18 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 		$702,20
$797,00
$897,41
$1 254,13
$1 905,77 		$1 239,38
$1 334,18
$1 434,59
$1 791,31 		$1 776,56
$1 871,36
$1 971,77
$2 328,49 		$2 313,74
$2 408,54
$2 508,95
$2 865,67 		$537,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 404,40
$1 594,00
$1 794,82
$2 508,26
$3 811,54 		$1 941,58
$2 131,18
$2 332,00
$3 045,44 		$2 478,76
$2 668,36
$2 869,18
$3 582,62 		$3 015,94
$3 205,54
$3 406,36
$4 119,80 		$537,18
Toc - Plan #19 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 		$781,64
$887,16
$998,94
$1 396,01
$2 121,37 		$1 379,59
$1 485,11
$1 596,89
$1 993,96 		$1 977,54
$2 083,06
$2 194,84
$2 591,91 		$2 575,49
$2 681,01
$2 792,79
$3 189,86 		$597,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 563,28
$1 774,32
$1 997,88
$2 792,02
$4 242,74 		$2 161,23
$2 372,27
$2 595,83
$3 389,97 		$2 759,18
$2 970,22
$3 193,78
$3 987,92 		$3 357,13
$3 568,17
$3 791,73
$4 585,87 		$597,95
Toc - Plan #20 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 		$497,38
$564,53
$635,65
$888,32
$1 349,89 		$877,88
$945,03
$1 016,15
$1 268,82 		$1 258,38
$1 325,53
$1 396,65
$1 649,32 		$1 638,88
$1 706,03
$1 777,15
$2 029,82 		$380,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$994,76
$1 129,06
$1 271,30
$1 776,64
$2 699,78 		$1 375,26
$1 509,56
$1 651,80
$2 157,14 		$1 755,76
$1 890,06
$2 032,30
$2 537,64 		$2 136,26
$2 270,56
$2 412,80
$2 918,14 		$380,50
Toc - Plan #21 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 		$785,11
$891,10
$1 003,37
$1 402,21
$2 130,79 		$1 385,72
$1 491,71
$1 603,98
$2 002,82 		$1 986,33
$2 092,32
$2 204,59
$2 603,43 		$2 586,94
$2 692,93
$2 805,20
$3 204,04 		$600,61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 570,22
$1 782,20
$2 006,74
$2 804,42
$4 261,58 		$2 170,83
$2 382,81
$2 607,35
$3 405,03 		$2 771,44
$2 983,42
$3 207,96
$4 005,64 		$3 372,05
$3 584,03
$3 808,57
$4 606,25 		$600,61
Toc - Plan #22 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 		$511,92
$581,03
$654,23
$914,29
$1 389,35 		$903,54
$972,65
$1 045,85
$1 305,91 		$1 295,16
$1 364,27
$1 437,47
$1 697,53 		$1 686,78
$1 755,89
$1 829,09
$2 089,15 		$391,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 023,84
$1 162,06
$1 308,46
$1 828,58
$2 778,70 		$1 415,46
$1 553,68
$1 700,08
$2 220,20 		$1 807,08
$1 945,30
$2 091,70
$2 611,82 		$2 198,70
$2 336,92
$2 483,32
$3 003,44 		$391,62
Toc - Plan #23 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 		$756,91
$859,09
$967,33
$1 351,84
$2 054,25 		$1 335,95
$1 438,13
$1 546,37
$1 930,88 		$1 914,99
$2 017,17
$2 125,41
$2 509,92 		$2 494,03
$2 596,21
$2 704,45
$3 088,96 		$579,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 513,82
$1 718,18
$1 934,66
$2 703,68
$4 108,50 		$2 092,86
$2 297,22
$2 513,70
$3 282,72 		$2 671,90
$2 876,26
$3 092,74
$3 861,76 		$3 250,94
$3 455,30
$3 671,78
$4 440,80 		$579,04
Toc - Plan #24 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 		$547,66
$621,59
$699,91
$978,12
$1 486,35 		$966,62
$1 040,55
$1 118,87
$1 397,08 		$1 385,58
$1 459,51
$1 537,83
$1 816,04 		$1 804,54
$1 878,47
$1 956,79
$2 235,00 		$418,96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 095,32
$1 243,18
$1 399,82
$1 956,24
$2 972,70 		$1 514,28
$1 662,14
$1 818,78
$2 375,20 		$1 933,24
$2 081,10
$2 237,74
$2 794,16 		$2 352,20
$2 500,06
$2 656,70
$3 213,12 		$418,96
Toc - Plan #25 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1456 ($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 		$501,42
$569,11
$640,81
$895,54
$1 360,85 		$885,01
$952,70
$1 024,40
$1 279,13 		$1 268,60
$1 336,29
$1 407,99
$1 662,72 		$1 652,19
$1 719,88
$1 791,58
$2 046,31 		$383,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 002,84
$1 138,22
$1 281,62
$1 791,08
$2 721,70 		$1 386,43
$1 521,81
$1 665,21
$2 174,67 		$1 770,02
$1 905,40
$2 048,80
$2 558,26 		$2 153,61
$2 288,99
$2 432,39
$2 941,85 		$383,59
Toc - Plan #26 Florida Blue (BlueCross BlueShield FL)
Bronze

(EPO) BlueSelect Bronze 1452 ($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 		$357,45
$405,71
$456,82
$638,41
$970,12 		$630,90
$679,16
$730,27
$911,86 		$904,35
$952,61
$1 003,72
$1 185,31 		$1 177,80
$1 226,06
$1 277,17
$1 458,76 		$273,45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714,90
$811,42
$913,64
$1 276,82
$1 940,24 		$988,35
$1 084,87
$1 187,09
$1 550,27 		$1 261,80
$1 358,32
$1 460,54
$1 823,72 		$1 535,25
$1 631,77
$1 733,99
$2 097,17 		$273,45
Toc - Plan #27 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1464 ($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 		$519,70
$589,86
$664,18
$928,18
$1 410,47 		$917,27
$987,43
$1 061,75
$1 325,75 		$1 314,84
$1 385,00
$1 459,32
$1 723,32 		$1 712,41
$1 782,57
$1 856,89
$2 120,89 		$397,57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 039,40
$1 179,72
$1 328,36
$1 856,36
$2 820,94 		$1 436,97
$1 577,29
$1 725,93
$2 253,93 		$1 834,54
$1 974,86
$2 123,50
$2 651,50 		$2 232,11
$2 372,43
$2 521,07
$3 049,07 		$397,57
Toc - Plan #28 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1451 ($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 		$614,06
$696,96
$784,77
$1 096,71
$1 666,56 		$1 083,82
$1 166,72
$1 254,53
$1 566,47 		$1 553,58
$1 636,48
$1 724,29
$2 036,23 		$2 023,34
$2 106,24
$2 194,05
$2 505,99 		$469,76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 228,12
$1 393,92
$1 569,54
$2 193,42
$3 333,12 		$1 697,88
$1 863,68
$2 039,30
$2 663,18 		$2 167,64
$2 333,44
$2 509,06
$3 132,94 		$2 637,40
$2 803,20
$2 978,82
$3 602,70 		$469,76
Toc - Plan #29 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1449 ($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 		$382,40
$434,02
$488,71
$682,97
$1 037,83 		$674,94
$726,56
$781,25
$975,51 		$967,48
$1 019,10
$1 073,79
$1 268,05 		$1 260,02
$1 311,64
$1 366,33
$1 560,59 		$292,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764,80
$868,04
$977,42
$1 365,94
$2 075,66 		$1 057,34
$1 160,58
$1 269,96
$1 658,48 		$1 349,88
$1 453,12
$1 562,50
$1 951,02 		$1 642,42
$1 745,66
$1 855,04
$2 243,56 		$292,54
Toc - Plan #30 Florida Blue (BlueCross BlueShield FL)
Platinum

(EPO) BlueSelect Platinum 1457 ($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 		$659,20
$748,19
$842,46
$1 177,33
$1 789,07 		$1 163,49
$1 252,48
$1 346,75
$1 681,62 		$1 667,78
$1 756,77
$1 851,04
$2 185,91 		$2 172,07
$2 261,06
$2 355,33
$2 690,20 		$504,29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 318,40
$1 496,38
$1 684,92
$2 354,66
$3 578,14 		$1 822,69
$2 000,67
$2 189,21
$2 858,95 		$2 326,98
$2 504,96
$2 693,50
$3 363,24 		$2 831,27
$3 009,25
$3 197,79
$3 867,53 		$504,29
Toc - Plan #31 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1443 ($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
$8,000 $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 		$455,74
$517,26
$582,44
$813,95
$1 236,88 		$804,38
$865,90
$931,08
$1 162,59 		$1 153,02
$1 214,54
$1 279,72
$1 511,23 		$1 501,66
$1 563,18
$1 628,36
$1 859,87 		$348,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911,48
$1 034,52
$1 164,88
$1 627,90
$2 473,76 		$1 260,12
$1 383,16
$1 513,52
$1 976,54 		$1 608,76
$1 731,80
$1 862,16
$2 325,18 		$1 957,40
$2 080,44
$2 210,80
$2 673,82 		$348,64
Toc - Plan #32 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1535 ($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 		$534,88
$607,09
$683,58
$955,30
$1 451,66 		$944,06
$1 016,27
$1 092,76
$1 364,48 		$1 353,24
$1 425,45
$1 501,94
$1 773,66 		$1 762,42
$1 834,63
$1 911,12
$2 182,84 		$409,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 069,76
$1 214,18
$1 367,16
$1 910,60
$2 903,32 		$1 478,94
$1 623,36
$1 776,34
$2 319,78 		$1 888,12
$2 032,54
$2 185,52
$2 728,96 		$2 297,30
$2 441,72
$2 594,70
$3 138,14 		$409,18
Toc - Plan #33 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze (HSA) 1735 ($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 		$372,72
$423,04
$476,34
$665,68
$1 011,56 		$657,85
$708,17
$761,47
$950,81 		$942,98
$993,30
$1 046,60
$1 235,94 		$1 228,11
$1 278,43
$1 331,73
$1 521,07 		$285,13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745,44
$846,08
$952,68
$1 331,36
$2 023,12 		$1 030,57
$1 131,21
$1 237,81
$1 616,49 		$1 315,70
$1 416,34
$1 522,94
$1 901,62 		$1 600,83
$1 701,47
$1 808,07
$2 186,75 		$285,13
Toc - Plan #34 Florida Blue (BlueCross BlueShield FL)
Silver

(EPO) BlueSelect Silver 1736S ($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 		$508,13
$576,73
$649,39
$907,52
$1 379,06 		$896,85
$965,45
$1 038,11
$1 296,24 		$1 285,57
$1 354,17
$1 426,83
$1 684,96 		$1 674,29
$1 742,89
$1 815,55
$2 073,68 		$388,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 016,26
$1 153,46
$1 298,78
$1 815,04
$2 758,12 		$1 404,98
$1 542,18
$1 687,50
$2 203,76 		$1 793,70
$1 930,90
$2 076,22
$2 592,48 		$2 182,42
$2 319,62
$2 464,94
$2 981,20 		$388,72
Toc - Plan #35 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 1737S ($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 		$381,81
$433,35
$487,95
$681,91
$1 036,23 		$673,89
$725,43
$780,03
$973,99 		$965,97
$1 017,51
$1 072,11
$1 266,07 		$1 258,05
$1 309,59
$1 364,19
$1 558,15 		$292,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763,62
$866,70
$975,90
$1 363,82
$2 072,46 		$1 055,70
$1 158,78
$1 267,98
$1 655,90 		$1 347,78
$1 450,86
$1 560,06
$1 947,98 		$1 639,86
$1 742,94
$1 852,14
$2 240,06 		$292,08
Toc - Plan #36 Florida Blue (BlueCross BlueShield FL)
Gold

(EPO) BlueSelect Gold 1835 ($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 		$510,99
$579,97
$653,05
$912,63
$1 386,83 		$901,90
$970,88
$1 043,96
$1 303,54 		$1 292,81
$1 361,79
$1 434,87
$1 694,45 		$1 683,72
$1 752,70
$1 825,78
$2 085,36 		$390,91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 021,98
$1 159,94
$1 306,10
$1 825,26
$2 773,66 		$1 412,89
$1 550,85
$1 697,01
$2 216,17 		$1 803,80
$1 941,76
$2 087,92
$2 607,08 		$2 194,71
$2 332,67
$2 478,83
$2 997,99 		$390,91
Toc - Plan #37 Florida Blue (BlueCross BlueShield FL)
Expanded Bronze

(EPO) BlueSelect Bronze 2139 ($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 		$408,03
$463,11
$521,46
$728,74
$1 107,39 		$720,17
$775,25
$833,60
$1 040,88 		$1 032,31
$1 087,39
$1 145,74
$1 353,02 		$1 344,45
$1 399,53
$1 457,88
$1 665,16 		$312,14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816,06
$926,22
$1 042,92
$1 457,48
$2 214,78 		$1 128,20
$1 238,36
$1 355,06
$1 769,62 		$1 440,34
$1 550,50
$1 667,20
$2 081,76 		$1 752,48
$1 862,64
$1 979,34
$2 393,90 		$312,14

ADVERTISEMENT

AvMed

Local: 1-800-477-8768 | Toll Free: 

Toc - Plan #38 AvMed
Gold

(HMO) AvMed Entrust Gold 125

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395,95
$449,41
$506,03
$707,17
$1 074,61 		$698,85
$752,31
$808,93
$1 010,07 		$1 001,75
$1 055,21
$1 111,83
$1 312,97 		$1 304,65
$1 358,11
$1 414,73
$1 615,87 		$302,90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791,90
$898,82
$1 012,06
$1 414,34
$2 149,22 		$1 094,80
$1 201,72
$1 314,96
$1 717,24 		$1 397,70
$1 504,62
$1 617,86
$2 020,14 		$1 700,60
$1 807,52
$1 920,76
$2 323,04 		$302,90
Toc - Plan #39 AvMed
Silver

(HMO) AvMed Entrust Silver 300

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$384,90
$436,86
$491,91
$687,44
$1 044,63 		$679,35
$731,31
$786,36
$981,89 		$973,80
$1 025,76
$1 080,81
$1 276,34 		$1 268,25
$1 320,21
$1 375,26
$1 570,79 		$294,45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769,80
$873,72
$983,82
$1 374,88
$2 089,26 		$1 064,25
$1 168,17
$1 278,27
$1 669,33 		$1 358,70
$1 462,62
$1 572,72
$1 963,78 		$1 653,15
$1 757,07
$1 867,17
$2 258,23 		$294,45
Toc - Plan #40 AvMed
Silver

(HMO) AvMed Entrust Silver 350

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$368,38
$418,11
$470,78
$657,92
$999,77 		$650,19
$699,92
$752,59
$939,73 		$932,00
$981,73
$1 034,40
$1 221,54 		$1 213,81
$1 263,54
$1 316,21
$1 503,35 		$281,81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736,76
$836,22
$941,56
$1 315,84
$1 999,54 		$1 018,57
$1 118,03
$1 223,37
$1 597,65 		$1 300,38
$1 399,84
$1 505,18
$1 879,46 		$1 582,19
$1 681,65
$1 786,99
$2 161,27 		$281,81
Toc - Plan #41 AvMed
Silver

(HMO) AvMed Entrust Silver 500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367,45
$417,06
$469,60
$656,27
$997,26 		$648,55
$698,16
$750,70
$937,37 		$929,65
$979,26
$1 031,80
$1 218,47 		$1 210,75
$1 260,36
$1 312,90
$1 499,57 		$281,10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734,90
$834,12
$939,20
$1 312,54
$1 994,52 		$1 016,00
$1 115,22
$1 220,30
$1 593,64 		$1 297,10
$1 396,32
$1 501,40
$1 874,74 		$1 578,20
$1 677,42
$1 782,50
$2 155,84 		$281,10
Toc - Plan #42 AvMed
Silver

(HMO) AvMed Entrust Silver 550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364,77
$414,01
$466,17
$651,47
$989,97 		$643,82
$693,06
$745,22
$930,52 		$922,87
$972,11
$1 024,27
$1 209,57 		$1 201,92
$1 251,16
$1 303,32
$1 488,62 		$279,05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729,54
$828,02
$932,34
$1 302,94
$1 979,94 		$1 008,59
$1 107,07
$1 211,39
$1 581,99 		$1 287,64
$1 386,12
$1 490,44
$1 861,04 		$1 566,69
$1 665,17
$1 769,49
$2 140,09 		$279,05
Toc - Plan #43 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 600

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303,43
$344,39
$387,78
$541,92
$823,51 		$535,55
$576,51
$619,90
$774,04 		$767,67
$808,63
$852,02
$1 006,16 		$999,79
$1 040,75
$1 084,14
$1 238,28 		$232,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606,86
$688,78
$775,56
$1 083,84
$1 647,02 		$838,98
$920,90
$1 007,68
$1 315,96 		$1 071,10
$1 153,02
$1 239,80
$1 548,08 		$1 303,22
$1 385,14
$1 471,92
$1 780,20 		$232,12
Toc - Plan #44 AvMed
Expanded Bronze

(HMO) AvMed Entrust Bronze 650

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279,05
$316,72
$356,62
$498,38
$757,33 		$492,52
$530,19
$570,09
$711,85 		$705,99
$743,66
$783,56
$925,32 		$919,46
$957,13
$997,03
$1 138,79 		$213,47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558,10
$633,44
$713,24
$996,76
$1 514,66 		$771,57
$846,91
$926,71
$1 210,23 		$985,04
$1 060,38
$1 140,18
$1 423,70 		$1 198,51
$1 273,85
$1 353,65
$1 637,17 		$213,47
Toc - Plan #45 AvMed
Catastrophic

(HMO) AvMed Catastrophic 100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$245,29
$278,40
$313,48
$438,08
$665,71 		$432,93
$466,04
$501,12
$625,72 		$620,57
$653,68
$688,76
$813,36 		$808,21
$841,32
$876,40
$1 001,00 		$187,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$490,58
$556,80
$626,96
$876,16
$1 331,42 		$678,22
$744,44
$814,60
$1 063,80 		$865,86
$932,08
$1 002,24
$1 251,44 		$1 053,50
$1 119,72
$1 189,88
$1 439,08 		$187,64
Toc - Plan #46 AvMed
Gold

(HMO) AvMed Entrust Gold 125 Adult Dental + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399,46
$453,39
$510,51
$713,44
$1 084,13 		$705,05
$758,98
$816,10
$1 019,03 		$1 010,64
$1 064,57
$1 121,69
$1 324,62 		$1 316,23
$1 370,16
$1 427,28
$1 630,21 		$305,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798,92
$906,78
$1 021,02
$1 426,88
$2 168,26 		$1 104,51
$1 212,37
$1 326,61
$1 732,47 		$1 410,10
$1 517,96
$1 632,20
$2 038,06 		$1 715,69
$1 823,55
$1 937,79
$2 343,65 		$305,59
Toc - Plan #47 AvMed
Silver

(HMO) AvMed Entrust Silver 300 Adult Dental + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$388,31
$440,73
$496,26
$693,52
$1 053,87 		$685,37
$737,79
$793,32
$990,58 		$982,43
$1 034,85
$1 090,38
$1 287,64 		$1 279,49
$1 331,91
$1 387,44
$1 584,70 		$297,06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776,62
$881,46
$992,52
$1 387,04
$2 107,74 		$1 073,68
$1 178,52
$1 289,58
$1 684,10 		$1 370,74
$1 475,58
$1 586,64
$1 981,16 		$1 667,80
$1 772,64
$1 883,70
$2 278,22 		$297,06
Toc - Plan #48 AvMed
Silver

(HMO) AvMed Entrust Silver 350 Adult Dental + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371,65
$421,82
$474,96
$663,76
$1 008,65 		$655,96
$706,13
$759,27
$948,07 		$940,27
$990,44
$1 043,58
$1 232,38 		$1 224,58
$1 274,75
$1 327,89
$1 516,69 		$284,31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743,30
$843,64
$949,92
$1 327,52
$2 017,30 		$1 027,61
$1 127,95
$1 234,23
$1 611,83 		$1 311,92
$1 412,26
$1 518,54
$1 896,14 		$1 596,23
$1 696,57
$1 802,85
$2 180,45 		$284,31
Toc - Plan #49 AvMed
Silver

(HMO) AvMed Entrust Silver 500 Adult Dental + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370,70
$420,75
$473,76
$662,07
$1 006,09 		$654,29
$704,34
$757,35
$945,66 		$937,88
$987,93
$1 040,94
$1 229,25 		$1 221,47
$1 271,52
$1 324,53
$1 512,84 		$283,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741,40
$841,50
$947,52
$1 324,14
$2 012,18 		$1 024,99
$1 125,09
$1 231,11
$1 607,73 		$1 308,58
$1 408,68
$1 514,70
$1 891,32 		$1 592,17
$1 692,27
$1 798,29
$2 174,91 		$283,59

ADVERTISEMENT

Ambetter from Sunshine Health

Local: 1-877-687-1169 | Toll Free: 1-877-687-1169 | TTY: 1-800-955-8770
Toc - Plan #50 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 		$394,94
$448,25
$504,72
$705,35
$1 071,85 		$697,06
$750,37
$806,84
$1 007,47 		$999,18
$1 052,49
$1 108,96
$1 309,59 		$1 301,30
$1 354,61
$1 411,08
$1 611,71 		$302,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789,88
$896,50
$1 009,44
$1 410,70
$2 143,70 		$1 092,00
$1 198,62
$1 311,56
$1 712,82 		$1 394,12
$1 500,74
$1 613,68
$2 014,94 		$1 696,24
$1 802,86
$1 915,80
$2 317,06 		$302,12
Toc - Plan #51 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 		$276,21
$313,49
$352,99
$493,30
$749,62 		$487,51
$524,79
$564,29
$704,60 		$698,81
$736,09
$775,59
$915,90 		$910,11
$947,39
$986,89
$1 127,20 		$211,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552,42
$626,98
$705,98
$986,60
$1 499,24 		$763,72
$838,28
$917,28
$1 197,90 		$975,02
$1 049,58
$1 128,58
$1 409,20 		$1 186,32
$1 260,88
$1 339,88
$1 620,50 		$211,30
Toc - Plan #52 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 		$282,53
$320,66
$361,07
$504,59
$766,77 		$498,66
$536,79
$577,20
$720,72 		$714,79
$752,92
$793,33
$936,85 		$930,92
$969,05
$1 009,46
$1 152,98 		$216,13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565,06
$641,32
$722,14
$1 009,18
$1 533,54 		$781,19
$857,45
$938,27
$1 225,31 		$997,32
$1 073,58
$1 154,40
$1 441,44 		$1 213,45
$1 289,71
$1 370,53
$1 657,57 		$216,13
Toc - Plan #53 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 		$283,05
$321,25
$361,72
$505,50
$768,16 		$499,57
$537,77
$578,24
$722,02 		$716,09
$754,29
$794,76
$938,54 		$932,61
$970,81
$1 011,28
$1 155,06 		$216,52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$566,10
$642,50
$723,44
$1 011,00
$1 536,32 		$782,62
$859,02
$939,96
$1 227,52 		$999,14
$1 075,54
$1 156,48
$1 444,04 		$1 215,66
$1 292,06
$1 373,00
$1 660,56 		$216,52
Toc - Plan #54 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 		$394,98
$448,29
$504,78
$705,42
$1 071,96 		$697,13
$750,44
$806,93
$1 007,57 		$999,28
$1 052,59
$1 109,08
$1 309,72 		$1 301,43
$1 354,74
$1 411,23
$1 611,87 		$302,15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789,96
$896,58
$1 009,56
$1 410,84
$2 143,92 		$1 092,11
$1 198,73
$1 311,71
$1 712,99 		$1 394,26
$1 500,88
$1 613,86
$2 015,14 		$1 696,41
$1 803,03
$1 916,01
$2 317,29 		$302,15
Toc - Plan #55 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 		$385,19
$437,18
$492,26
$687,93
$1 045,37 		$679,85
$731,84
$786,92
$982,59 		$974,51
$1 026,50
$1 081,58
$1 277,25 		$1 269,17
$1 321,16
$1 376,24
$1 571,91 		$294,66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770,38
$874,36
$984,52
$1 375,86
$2 090,74 		$1 065,04
$1 169,02
$1 279,18
$1 670,52 		$1 359,70
$1 463,68
$1 573,84
$1 965,18 		$1 654,36
$1 758,34
$1 868,50
$2 259,84 		$294,66
Toc - Plan #56 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 		$376,74
$427,58
$481,45
$672,83
$1 022,43 		$664,93
$715,77
$769,64
$961,02 		$953,12
$1 003,96
$1 057,83
$1 249,21 		$1 241,31
$1 292,15
$1 346,02
$1 537,40 		$288,19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753,48
$855,16
$962,90
$1 345,66
$2 044,86 		$1 041,67
$1 143,35
$1 251,09
$1 633,85 		$1 329,86
$1 431,54
$1 539,28
$1 922,04 		$1 618,05
$1 719,73
$1 827,47
$2 210,23 		$288,19
Toc - Plan #57 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 		$390,56
$443,27
$499,12
$697,52
$1 059,95 		$689,33
$742,04
$797,89
$996,29 		$988,10
$1 040,81
$1 096,66
$1 295,06 		$1 286,87
$1 339,58
$1 395,43
$1 593,83 		$298,77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781,12
$886,54
$998,24
$1 395,04
$2 119,90 		$1 079,89
$1 185,31
$1 297,01
$1 693,81 		$1 378,66
$1 484,08
$1 595,78
$1 992,58 		$1 677,43
$1 782,85
$1 894,55
$2 291,35 		$298,77
Toc - Plan #58 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 		$373,34
$423,73
$477,11
$666,76
$1 013,21 		$658,94
$709,33
$762,71
$952,36 		$944,54
$994,93
$1 048,31
$1 237,96 		$1 230,14
$1 280,53
$1 333,91
$1 523,56 		$285,60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746,68
$847,46
$954,22
$1 333,52
$2 026,42 		$1 032,28
$1 133,06
$1 239,82
$1 619,12 		$1 317,88
$1 418,66
$1 525,42
$1 904,72 		$1 603,48
$1 704,26
$1 811,02
$2 190,32 		$285,60
Toc - Plan #59 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 		$389,53
$442,11
$497,81
$695,69
$1 057,16 		$687,51
$740,09
$795,79
$993,67 		$985,49
$1 038,07
$1 093,77
$1 291,65 		$1 283,47
$1 336,05
$1 391,75
$1 589,63 		$297,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779,06
$884,22
$995,62
$1 391,38
$2 114,32 		$1 077,04
$1 182,20
$1 293,60
$1 689,36 		$1 375,02
$1 480,18
$1 591,58
$1 987,34 		$1 673,00
$1 778,16
$1 889,56
$2 285,32 		$297,98
Toc - Plan #60 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 		$397,16
$450,76
$507,55
$709,30
$1 077,85 		$700,98
$754,58
$811,37
$1 013,12 		$1 004,80
$1 058,40
$1 115,19
$1 316,94 		$1 308,62
$1 362,22
$1 419,01
$1 620,76 		$303,82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794,32
$901,52
$1 015,10
$1 418,60
$2 155,70 		$1 098,14
$1 205,34
$1 318,92
$1 722,42 		$1 401,96
$1 509,16
$1 622,74
$2 026,24 		$1 705,78
$1 812,98
$1 926,56
$2 330,06 		$303,82
Toc - Plan #61 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 		$414,81
$470,80
$530,11
$740,83
$1 125,77 		$732,13
$788,12
$847,43
$1 058,15 		$1 049,45
$1 105,44
$1 164,75
$1 375,47 		$1 366,77
$1 422,76
$1 482,07
$1 692,79 		$317,32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829,62
$941,60
$1 060,22
$1 481,66
$2 251,54 		$1 146,94
$1 258,92
$1 377,54
$1 798,98 		$1 464,26
$1 576,24
$1 694,86
$2 116,30 		$1 781,58
$1 893,56
$2 012,18
$2 433,62 		$317,32
Toc - Plan #62 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 		$422,55
$479,58
$540,01
$754,66
$1 146,78 		$745,79
$802,82
$863,25
$1 077,90 		$1 069,03
$1 126,06
$1 186,49
$1 401,14 		$1 392,27
$1 449,30
$1 509,73
$1 724,38 		$323,24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845,10
$959,16
$1 080,02
$1 509,32
$2 293,56 		$1 168,34
$1 282,40
$1 403,26
$1 832,56 		$1 491,58
$1 605,64
$1 726,50
$2 155,80 		$1 814,82
$1 928,88
$2 049,74
$2 479,04 		$323,24
Toc - Plan #63 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 		$391,56
$444,41
$500,40
$699,31
$1 062,68 		$691,10
$743,95
$799,94
$998,85 		$990,64
$1 043,49
$1 099,48
$1 298,39 		$1 290,18
$1 343,03
$1 399,02
$1 597,93 		$299,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783,12
$888,82
$1 000,80
$1 398,62
$2 125,36 		$1 082,66
$1 188,36
$1 300,34
$1 698,16 		$1 382,20
$1 487,90
$1 599,88
$1 997,70 		$1 681,74
$1 787,44
$1 899,42
$2 297,24 		$299,54
Toc - Plan #64 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 		$293,65
$333,29
$375,28
$524,45
$796,95 		$518,29
$557,93
$599,92
$749,09 		$742,93
$782,57
$824,56
$973,73 		$967,57
$1 007,21
$1 049,20
$1 198,37 		$224,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587,30
$666,58
$750,56
$1 048,90
$1 593,90 		$811,94
$891,22
$975,20
$1 273,54 		$1 036,58
$1 115,86
$1 199,84
$1 498,18 		$1 261,22
$1 340,50
$1 424,48
$1 722,82 		$224,64
Toc - Plan #65 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 		$410,49
$465,89
$524,59
$733,11
$1 114,04 		$724,51
$779,91
$838,61
$1 047,13 		$1 038,53
$1 093,93
$1 152,63
$1 361,15 		$1 352,55
$1 407,95
$1 466,65
$1 675,17 		$314,02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820,98
$931,78
$1 049,18
$1 466,22
$2 228,08 		$1 135,00
$1 245,80
$1 363,20
$1 780,24 		$1 449,02
$1 559,82
$1 677,22
$2 094,26 		$1 763,04
$1 873,84
$1 991,24
$2 408,28 		$314,02
Toc - Plan #66 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 		$287,09
$325,83
$366,88
$512,72
$779,12 		$506,70
$545,44
$586,49
$732,33 		$726,31
$765,05
$806,10
$951,94 		$945,92
$984,66
$1 025,71
$1 171,55 		$219,61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574,18
$651,66
$733,76
$1 025,44
$1 558,24 		$793,79
$871,27
$953,37
$1 245,05 		$1 013,40
$1 090,88
$1 172,98
$1 464,66 		$1 233,01
$1 310,49
$1 392,59
$1 684,27 		$219,61
Toc - Plan #67 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 		$294,19
$333,89
$375,96
$525,40
$798,40 		$519,24
$558,94
$601,01
$750,45 		$744,29
$783,99
$826,06
$975,50 		$969,34
$1 009,04
$1 051,11
$1 200,55 		$225,05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$588,38
$667,78
$751,92
$1 050,80
$1 596,80 		$813,43
$892,83
$976,97
$1 275,85 		$1 038,48
$1 117,88
$1 202,02
$1 500,90 		$1 263,53
$1 342,93
$1 427,07
$1 725,95 		$225,05
Toc - Plan #68 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 		$410,53
$465,94
$524,64
$733,19
$1 114,15 		$724,58
$779,99
$838,69
$1 047,24 		$1 038,63
$1 094,04
$1 152,74
$1 361,29 		$1 352,68
$1 408,09
$1 466,79
$1 675,34 		$314,05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821,06
$931,88
$1 049,28
$1 466,38
$2 228,30 		$1 135,11
$1 245,93
$1 363,33
$1 780,43 		$1 449,16
$1 559,98
$1 677,38
$2 094,48 		$1 763,21
$1 874,03
$1 991,43
$2 408,53 		$314,05
Toc - Plan #69 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 		$400,35
$454,38
$511,63
$715,00
$1 086,52 		$706,61
$760,64
$817,89
$1 021,26 		$1 012,87
$1 066,90
$1 124,15
$1 327,52 		$1 319,13
$1 373,16
$1 430,41
$1 633,78 		$306,26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800,70
$908,76
$1 023,26
$1 430,00
$2 173,04 		$1 106,96
$1 215,02
$1 329,52
$1 736,26 		$1 413,22
$1 521,28
$1 635,78
$2 042,52 		$1 719,48
$1 827,54
$1 942,04
$2 348,78 		$306,26
Toc - Plan #70 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 		$405,93
$460,72
$518,77
$724,98
$1 101,67 		$716,46
$771,25
$829,30
$1 035,51 		$1 026,99
$1 081,78
$1 139,83
$1 346,04 		$1 337,52
$1 392,31
$1 450,36
$1 656,57 		$310,53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811,86
$921,44
$1 037,54
$1 449,96
$2 203,34 		$1 122,39
$1 231,97
$1 348,07
$1 760,49 		$1 432,92
$1 542,50
$1 658,60
$2 071,02 		$1 743,45
$1 853,03
$1 969,13
$2 381,55 		$310,53
Toc - Plan #71 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 		$404,86
$459,51
$517,40
$723,07
$1 098,77 		$714,57
$769,22
$827,11
$1 032,78 		$1 024,28
$1 078,93
$1 136,82
$1 342,49 		$1 333,99
$1 388,64
$1 446,53
$1 652,20 		$309,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809,72
$919,02
$1 034,80
$1 446,14
$2 197,54 		$1 119,43
$1 228,73
$1 344,51
$1 755,85 		$1 429,14
$1 538,44
$1 654,22
$2 065,56 		$1 738,85
$1 848,15
$1 963,93
$2 375,27 		$309,71
Toc - Plan #72 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 		$412,79
$468,50
$527,53
$737,22
$1 120,28 		$728,56
$784,27
$843,30
$1 052,99 		$1 044,33
$1 100,04
$1 159,07
$1 368,76 		$1 360,10
$1 415,81
$1 474,84
$1 684,53 		$315,77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825,58
$937,00
$1 055,06
$1 474,44
$2 240,56 		$1 141,35
$1 252,77
$1 370,83
$1 790,21 		$1 457,12
$1 568,54
$1 686,60
$2 105,98 		$1 772,89
$1 884,31
$2 002,37
$2 421,75 		$315,77
Toc - Plan #73 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 		$431,14
$489,33
$550,98
$769,99
$1 170,08 		$760,95
$819,14
$880,79
$1 099,80 		$1 090,76
$1 148,95
$1 210,60
$1 429,61 		$1 420,57
$1 478,76
$1 540,41
$1 759,42 		$329,81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862,28
$978,66
$1 101,96
$1 539,98
$2 340,16 		$1 192,09
$1 308,47
$1 431,77
$1 869,79 		$1 521,90
$1 638,28
$1 761,58
$2 199,60 		$1 851,71
$1 968,09
$2 091,39
$2 529,41 		$329,81
Toc - Plan #74 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 		$439,18
$498,46
$561,26
$784,36
$1 191,92 		$775,15
$834,43
$897,23
$1 120,33 		$1 111,12
$1 170,40
$1 233,20
$1 456,30 		$1 447,09
$1 506,37
$1 569,17
$1 792,27 		$335,97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878,36
$996,92
$1 122,52
$1 568,72
$2 383,84 		$1 214,33
$1 332,89
$1 458,49
$1 904,69 		$1 550,30
$1 668,86
$1 794,46
$2 240,66 		$1 886,27
$2 004,83
$2 130,43
$2 576,63 		$335,97

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

(HMO) BlueCare Platinum 2151 ($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 		$790,25
$896,93
$1 009,94
$1 411,39
$2 144,74 		$1 394,79
$1 501,47
$1 614,48
$2 015,93 		$1 999,33
$2 106,01
$2 219,02
$2 620,47 		$2 603,87
$2 710,55
$2 823,56
$3 225,01 		$604,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 580,50
$1 793,86
$2 019,88
$2 822,78
$4 289,48 		$2 185,04
$2 398,40
$2 624,42
$3 427,32 		$2 789,58
$3 002,94
$3 228,96
$4 031,86 		$3 394,12
$3 607,48
$3 833,50
$4 636,40 		$604,54
Toc - Plan #76 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2153 ($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 		$473,30
$537,20
$604,88
$845,31
$1 284,54 		$835,37
$899,27
$966,95
$1 207,38 		$1 197,44
$1 261,34
$1 329,02
$1 569,45 		$1 559,51
$1 623,41
$1 691,09
$1 931,52 		$362,07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$946,60
$1 074,40
$1 209,76
$1 690,62
$2 569,08 		$1 308,67
$1 436,47
$1 571,83
$2 052,69 		$1 670,74
$1 798,54
$1 933,90
$2 414,76 		$2 032,81
$2 160,61
$2 295,97
$2 776,83 		$362,07
Toc - Plan #77 Florida Blue HMO (a BlueCross BlueShield FL company)
Bronze

(HMO) BlueCare Bronze 2154 ($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 		$426,23
$483,77
$544,72
$761,25
$1 156,79 		$752,30
$809,84
$870,79
$1 087,32 		$1 078,37
$1 135,91
$1 196,86
$1 413,39 		$1 404,44
$1 461,98
$1 522,93
$1 739,46 		$326,07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852,46
$967,54
$1 089,44
$1 522,50
$2 313,58 		$1 178,53
$1 293,61
$1 415,51
$1 848,57 		$1 504,60
$1 619,68
$1 741,58
$2 174,64 		$1 830,67
$1 945,75
$2 067,65
$2 500,71 		$326,07
Toc - Plan #78 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) BlueCare Gold 2156 ($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 		$675,90
$767,15
$863,80
$1 207,16
$1 834,39 		$1 192,96
$1 284,21
$1 380,86
$1 724,22 		$1 710,02
$1 801,27
$1 897,92
$2 241,28 		$2 227,08
$2 318,33
$2 414,98
$2 758,34 		$517,06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 351,80
$1 534,30
$1 727,60
$2 414,32
$3 668,78 		$1 868,86
$2 051,36
$2 244,66
$2 931,38 		$2 385,92
$2 568,42
$2 761,72
$3 448,44 		$2 902,98
$3 085,48
$3 278,78
$3 965,50 		$517,06
Toc - Plan #79 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) BlueCare Silver 2157 ($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 		$569,02
$645,84
$727,21
$1 016,27
$1 544,32 		$1 004,32
$1 081,14
$1 162,51
$1 451,57 		$1 439,62
$1 516,44
$1 597,81
$1 886,87 		$1 874,92
$1 951,74
$2 033,11
$2 322,17 		$435,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 138,04
$1 291,68
$1 454,42
$2 032,54
$3 088,64 		$1 573,34
$1 726,98
$1 889,72
$2 467,84 		$2 008,64
$2 162,28
$2 325,02
$2 903,14 		$2 443,94
$2 597,58
$2 760,32
$3 338,44 		$435,30
Toc - Plan #80 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) BlueCare Bronze 2159 ($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 		$516,36
$586,07
$659,91
$922,22
$1 401,40 		$911,38
$981,09
$1 054,93
$1 317,24 		$1 306,40
$1 376,11
$1 449,95
$1 712,26 		$1 701,42
$1 771,13
$1 844,97
$2 107,28 		$395,02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 032,72
$1 172,14
$1 319,82
$1 844,44
$2 802,80 		$1 427,74
$1 567,16
$1 714,84
$2 239,46 		$1 822,76
$1 962,18
$2 109,86
$2 634,48 		$2 217,78
$2 357,20
$2 504,88
$3 029,50 		$395,02
Toc - Plan #81 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1601 ($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 		$322,04
$365,52
$411,57
$575,16
$874,02 		$568,40
$611,88
$657,93
$821,52 		$814,76
$858,24
$904,29
$1 067,88 		$1 061,12
$1 104,60
$1 150,65
$1 314,24 		$246,36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644,08
$731,04
$823,14
$1 150,32
$1 748,04 		$890,44
$977,40
$1 069,50
$1 396,68 		$1 136,80
$1 223,76
$1 315,86
$1 643,04 		$1 383,16
$1 470,12
$1 562,22
$1 889,40 		$246,36
Toc - Plan #82 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1602 ($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 		$288,13
$327,03
$368,23
$514,60
$781,98 		$508,55
$547,45
$588,65
$735,02 		$728,97
$767,87
$809,07
$955,44 		$949,39
$988,29
$1 029,49
$1 175,86 		$220,42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576,26
$654,06
$736,46
$1 029,20
$1 563,96 		$796,68
$874,48
$956,88
$1 249,62 		$1 017,10
$1 094,90
$1 177,30
$1 470,04 		$1 237,52
$1 315,32
$1 397,72
$1 690,46 		$220,42
Toc - Plan #83 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1603 ($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
$5,900 $11,800 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418,03
$474,46
$534,24
$746,60
$1 134,53 		$737,82
$794,25
$854,03
$1 066,39 		$1 057,61
$1 114,04
$1 173,82
$1 386,18 		$1 377,40
$1 433,83
$1 493,61
$1 705,97 		$319,79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836,06
$948,92
$1 068,48
$1 493,20
$2 269,06 		$1 155,85
$1 268,71
$1 388,27
$1 812,99 		$1 475,64
$1 588,50
$1 708,06
$2 132,78 		$1 795,43
$1 908,29
$2 027,85
$2 452,57 		$319,79
Toc - Plan #84 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1604 ($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
$5,800 $11,600 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382,77
$434,44
$489,18
$683,63
$1 038,84 		$675,59
$727,26
$782,00
$976,45 		$968,41
$1 020,08
$1 074,82
$1 269,27 		$1 261,23
$1 312,90
$1 367,64
$1 562,09 		$292,82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765,54
$868,88
$978,36
$1 367,26
$2 077,68 		$1 058,36
$1 161,70
$1 271,18
$1 660,08 		$1 351,18
$1 454,52
$1 564,00
$1 952,90 		$1 644,00
$1 747,34
$1 856,82
$2 245,72 		$292,82
Toc - Plan #85 Florida Blue HMO (a BlueCross BlueShield FL company)
Gold

(HMO) myBlue Gold 1605 ($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 		$433,60
$492,14
$554,14
$774,41
$1 176,79 		$765,30
$823,84
$885,84
$1 106,11 		$1 097,00
$1 155,54
$1 217,54
$1 437,81 		$1 428,70
$1 487,24
$1 549,24
$1 769,51 		$331,70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867,20
$984,28
$1 108,28
$1 548,82
$2 353,58 		$1 198,90
$1 315,98
$1 439,98
$1 880,52 		$1 530,60
$1 647,68
$1 771,68
$2 212,22 		$1 862,30
$1 979,38
$2 103,38
$2 543,92 		$331,70
Toc - Plan #86 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1710 ($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
$6,200 $12,400 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 		$435,33
$494,10
$556,35
$777,50
$1 181,49 		$768,36
$827,13
$889,38
$1 110,53 		$1 101,39
$1 160,16
$1 222,41
$1 443,56 		$1 434,42
$1 493,19
$1 555,44
$1 776,59 		$333,03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870,66
$988,20
$1 112,70
$1 555,00
$2 362,98 		$1 203,69
$1 321,23
$1 445,73
$1 888,03 		$1 536,72
$1 654,26
$1 778,76
$2 221,06 		$1 869,75
$1 987,29
$2 111,79
$2 554,09 		$333,03
Toc - Plan #87 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 1711S ($0 Virtual Visits / $55 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
$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 		$320,10
$363,31
$409,09
$571,70
$868,75 		$564,98
$608,19
$653,97
$816,58 		$809,86
$853,07
$898,85
$1 061,46 		$1 054,74
$1 097,95
$1 143,73
$1 306,34 		$244,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640,20
$726,62
$818,18
$1 143,40
$1 737,50 		$885,08
$971,50
$1 063,06
$1 388,28 		$1 129,96
$1 216,38
$1 307,94
$1 633,16 		$1 374,84
$1 461,26
$1 552,82
$1 878,04 		$244,88
Toc - Plan #88 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 1712S ($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
$3,950 $7,900 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 		$427,01
$484,66
$545,72
$762,64
$1 158,91 		$753,67
$811,32
$872,38
$1 089,30 		$1 080,33
$1 137,98
$1 199,04
$1 415,96 		$1 406,99
$1 464,64
$1 525,70
$1 742,62 		$326,66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854,02
$969,32
$1 091,44
$1 525,28
$2 317,82 		$1 180,68
$1 295,98
$1 418,10
$1 851,94 		$1 507,34
$1 622,64
$1 744,76
$2 178,60 		$1 834,00
$1 949,30
$2 071,42
$2 505,26 		$326,66
Toc - Plan #89 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2017 ($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 		$374,90
$425,51
$479,12
$669,57
$1 017,48 		$661,70
$712,31
$765,92
$956,37 		$948,50
$999,11
$1 052,72
$1 243,17 		$1 235,30
$1 285,91
$1 339,52
$1 529,97 		$286,80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749,80
$851,02
$958,24
$1 339,14
$2 034,96 		$1 036,60
$1 137,82
$1 245,04
$1 625,94 		$1 323,40
$1 424,62
$1 531,84
$1 912,74 		$1 610,20
$1 711,42
$1 818,64
$2 199,54 		$286,80
Toc - Plan #90 Florida Blue HMO (a BlueCross BlueShield FL company)
Silver

(HMO) myBlue Silver 2127 ($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
$8,450 $16,900 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 		$363,03
$412,04
$463,95
$648,37
$985,26 		$640,75
$689,76
$741,67
$926,09 		$918,47
$967,48
$1 019,39
$1 203,81 		$1 196,19
$1 245,20
$1 297,11
$1 481,53 		$277,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726,06
$824,08
$927,90
$1 296,74
$1 970,52 		$1 003,78
$1 101,80
$1 205,62
$1 574,46 		$1 281,50
$1 379,52
$1 483,34
$1 852,18 		$1 559,22
$1 657,24
$1 761,06
$2 129,90 		$277,72
Toc - Plan #91 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2129 ($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 		$354,25
$402,07
$452,73
$632,69
$961,43 		$625,25
$673,07
$723,73
$903,69 		$896,25
$944,07
$994,73
$1 174,69 		$1 167,25
$1 215,07
$1 265,73
$1 445,69 		$271,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708,50
$804,14
$905,46
$1 265,38
$1 922,86 		$979,50
$1 075,14
$1 176,46
$1 536,38 		$1 250,50
$1 346,14
$1 447,46
$1 807,38 		$1 521,50
$1 617,14
$1 718,46
$2 078,38 		$271,00
Toc - Plan #92 Florida Blue HMO (a BlueCross BlueShield FL company)
Expanded Bronze

(HMO) myBlue Bronze 2126 (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 		$319,90
$363,09
$408,83
$571,34
$868,21 		$564,62
$607,81
$653,55
$816,06 		$809,34
$852,53
$898,27
$1 060,78 		$1 054,06
$1 097,25
$1 142,99
$1 305,50 		$244,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639,80
$726,18
$817,66
$1 142,68
$1 736,42 		$884,52
$970,90
$1 062,38
$1 387,40 		$1 129,24
$1 215,62
$1 307,10
$1 632,12 		$1 373,96
$1 460,34
$1 551,82
$1 876,84 		$244,72

ADVERTISEMENT

Oscar Insurance Company of Florida

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

Toc - Plan #93 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Simple

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

Annual Out of Pocket Expenses:

Individual Family
$7,300 $14,600 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 		$280,85
$318,75
$358,91
$501,58
$762,20 		$495,69
$533,59
$573,75
$716,42 		$710,53
$748,43
$788,59
$931,26 		$925,37
$963,27
$1 003,43
$1 146,10 		$214,84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561,70
$637,50
$717,82
$1 003,16
$1 524,40 		$776,54
$852,34
$932,66
$1 218,00 		$991,38
$1 067,18
$1 147,50
$1 432,84 		$1 206,22
$1 282,02
$1 362,34
$1 647,68 		$214,84
Toc - Plan #94 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Classic PCP Copay

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
$8,550 $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 		$293,27
$332,85
$374,78
$523,76
$795,90 		$517,61
$557,19
$599,12
$748,10 		$741,95
$781,53
$823,46
$972,44 		$966,29
$1 005,87
$1 047,80
$1 196,78 		$224,34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586,54
$665,70
$749,56
$1 047,52
$1 591,80 		$810,88
$890,04
$973,90
$1 271,86 		$1 035,22
$1 114,38
$1 198,24
$1 496,20 		$1 259,56
$1 338,72
$1 422,58
$1 720,54 		$224,34
Toc - Plan #95 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Classic

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
$8,550 $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 		$283,68
$321,97
$362,53
$506,64
$769,88 		$500,69
$538,98
$579,54
$723,65 		$717,70
$755,99
$796,55
$940,66 		$934,71
$973,00
$1 013,56
$1 157,67 		$217,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567,36
$643,94
$725,06
$1 013,28
$1 539,76 		$784,37
$860,95
$942,07
$1 230,29 		$1 001,38
$1 077,96
$1 159,08
$1 447,30 		$1 218,39
$1 294,97
$1 376,09
$1 664,31 		$217,01
Toc - Plan #96 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Classic Next

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $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 		$334,15
$379,25
$427,04
$596,78
$906,87 		$589,77
$634,87
$682,66
$852,40 		$845,39
$890,49
$938,28
$1 108,02 		$1 101,01
$1 146,11
$1 193,90
$1 363,64 		$255,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668,30
$758,50
$854,08
$1 193,56
$1 813,74 		$923,92
$1 014,12
$1 109,70
$1 449,18 		$1 179,54
$1 269,74
$1 365,32
$1 704,80 		$1 435,16
$1 525,36
$1 620,94
$1 960,42 		$255,62
Toc - Plan #97 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,550 $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 		$370,66
$420,69
$473,70
$661,99
$1 005,95 		$654,21
$704,24
$757,25
$945,54 		$937,76
$987,79
$1 040,80
$1 229,09 		$1 221,31
$1 271,34
$1 324,35
$1 512,64 		$283,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741,32
$841,38
$947,40
$1 323,98
$2 011,90 		$1 024,87
$1 124,93
$1 230,95
$1 607,53 		$1 308,42
$1 408,48
$1 514,50
$1 891,08 		$1 591,97
$1 692,03
$1 798,05
$2 174,63 		$283,55
Toc - Plan #98 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Saver 2

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

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 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 		$366,68
$416,17
$468,60
$654,87
$995,14 		$647,18
$696,67
$749,10
$935,37 		$927,68
$977,17
$1 029,60
$1 215,87 		$1 208,18
$1 257,67
$1 310,10
$1 496,37 		$280,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733,36
$832,34
$937,20
$1 309,74
$1 990,28 		$1 013,86
$1 112,84
$1 217,70
$1 590,24 		$1 294,36
$1 393,34
$1 498,20
$1 870,74 		$1 574,86
$1 673,84
$1 778,70
$2 151,24 		$280,50
Toc - Plan #99 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Classic Next

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
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$369,46
$419,32
$472,15
$659,83
$1 002,68 		$652,09
$701,95
$754,78
$942,46 		$934,72
$984,58
$1 037,41
$1 225,09 		$1 217,35
$1 267,21
$1 320,04
$1 507,72 		$282,63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738,92
$838,64
$944,30
$1 319,66
$2 005,36 		$1 021,55
$1 121,27
$1 226,93
$1 602,29 		$1 304,18
$1 403,90
$1 509,56
$1 884,92 		$1 586,81
$1 686,53
$1 792,19
$2 167,55 		$282,63
Toc - Plan #100 Oscar Insurance Company of Florida
Catastrophic

(EPO) Oscar Secure

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

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 		$230,68
$261,81
$294,80
$411,98
$626,04 		$407,14
$438,27
$471,26
$588,44 		$583,60
$614,73
$647,72
$764,90 		$760,06
$791,19
$824,18
$941,36 		$176,46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$461,36
$523,62
$589,60
$823,96
$1 252,08 		$637,82
$700,08
$766,06
$1 000,42 		$814,28
$876,54
$942,52
$1 176,88 		$990,74
$1 053,00
$1 118,98
$1 353,34 		$176,46
Toc - Plan #101 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze Classic Next 2

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $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 		$334,79
$379,98
$427,85
$597,92
$908,60 		$590,90
$636,09
$683,96
$854,03 		$847,01
$892,20
$940,07
$1 110,14 		$1 103,12
$1 148,31
$1 196,18
$1 366,25 		$256,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669,58
$759,96
$855,70
$1 195,84
$1 817,20 		$925,69
$1 016,07
$1 111,81
$1 451,95 		$1 181,80
$1 272,18
$1 367,92
$1 708,06 		$1 437,91
$1 528,29
$1 624,03
$1 964,17 		$256,11
Toc - Plan #102 Oscar Insurance Company of Florida
Gold

(EPO) Oscar Gold Classic

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$6,000 $12,000 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 		$390,28
$442,95
$498,76
$697,02
$1 059,18 		$688,83
$741,50
$797,31
$995,57 		$987,38
$1 040,05
$1 095,86
$1 294,12 		$1 285,93
$1 338,60
$1 394,41
$1 592,67 		$298,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780,56
$885,90
$997,52
$1 394,04
$2 118,36 		$1 079,11
$1 184,45
$1 296,07
$1 692,59 		$1 377,66
$1 483,00
$1 594,62
$1 991,14 		$1 676,21
$1 781,55
$1 893,17
$2 289,69 		$298,55
Toc - Plan #103 Oscar Insurance Company of Florida
Expanded Bronze

(EPO) Oscar Bronze HDHP

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
$7,000 $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 		$298,66
$338,97
$381,68
$533,39
$810,54 		$527,13
$567,44
$610,15
$761,86 		$755,60
$795,91
$838,62
$990,33 		$984,07
$1 024,38
$1 067,09
$1 218,80 		$228,47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597,32
$677,94
$763,36
$1 066,78
$1 621,08 		$825,79
$906,41
$991,83
$1 295,25 		$1 054,26
$1 134,88
$1 220,30
$1 523,72 		$1 282,73
$1 363,35
$1 448,77
$1 752,19 		$228,47
Toc - Plan #104 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Saver

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

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 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 		$365,88
$415,26
$467,58
$653,44
$992,97 		$645,77
$695,15
$747,47
$933,33 		$925,66
$975,04
$1 027,36
$1 213,22 		$1 205,55
$1 254,93
$1 307,25
$1 493,11 		$279,89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731,76
$830,52
$935,16
$1 306,88
$1 985,94 		$1 011,65
$1 110,41
$1 215,05
$1 586,77 		$1 291,54
$1 390,30
$1 494,94
$1 866,66 		$1 571,43
$1 670,19
$1 774,83
$2 146,55 		$279,89
Toc - Plan #105 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Classic Copay

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$376,30
$427,08
$480,89
$672,05
$1 021,24 		$664,16
$714,94
$768,75
$959,91 		$952,02
$1 002,80
$1 056,61
$1 247,77 		$1 239,88
$1 290,66
$1 344,47
$1 535,63 		$287,86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752,60
$854,16
$961,78
$1 344,10
$2 042,48 		$1 040,46
$1 142,02
$1 249,64
$1 631,96 		$1 328,32
$1 429,88
$1 537,50
$1 919,82 		$1 616,18
$1 717,74
$1 825,36
$2 207,68 		$287,86
Toc - Plan #106 Oscar Insurance Company of Florida
Silver

(EPO) Oscar Silver Classic $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
$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 		$379,01
$430,16
$484,36
$676,89
$1 028,60 		$668,94
$720,09
$774,29
$966,82 		$958,87
$1 010,02
$1 064,22
$1 256,75 		$1 248,80
$1 299,95
$1 354,15
$1 546,68 		$289,93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758,02
$860,32
$968,72
$1 353,78
$2 057,20 		$1 047,95
$1 150,25
$1 258,65
$1 643,71 		$1 337,88
$1 440,18
$1 548,58
$1 933,64 		$1 627,81
$1 730,11
$1 838,51
$2 223,57 		$289,93

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #107 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 		$309,47
$351,24
$395,50
$552,71
$839,89 		$546,21
$587,98
$632,24
$789,45 		$782,95
$824,72
$868,98
$1 026,19 		$1 019,69
$1 061,46
$1 105,72
$1 262,93 		$236,74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618,94
$702,48
$791,00
$1 105,42
$1 679,78 		$855,68
$939,22
$1 027,74
$1 342,16 		$1 092,42
$1 175,96
$1 264,48
$1 578,90 		$1 329,16
$1 412,70
$1 501,22
$1 815,64 		$236,74
Toc - Plan #108 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 		$324,69
$368,52
$414,95
$579,90
$881,21 		$573,08
$616,91
$663,34
$828,29 		$821,47
$865,30
$911,73
$1 076,68 		$1 069,86
$1 113,69
$1 160,12
$1 325,07 		$248,39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649,38
$737,04
$829,90
$1 159,80
$1 762,42 		$897,77
$985,43
$1 078,29
$1 408,19 		$1 146,16
$1 233,82
$1 326,68
$1 656,58 		$1 394,55
$1 482,21
$1 575,07
$1 904,97 		$248,39
Toc - Plan #109 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 		$321,71
$365,14
$411,14
$574,57
$873,11 		$567,82
$611,25
$657,25
$820,68 		$813,93
$857,36
$903,36
$1 066,79 		$1 060,04
$1 103,47
$1 149,47
$1 312,90 		$246,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643,42
$730,28
$822,28
$1 149,14
$1 746,22 		$889,53
$976,39
$1 068,39
$1 395,25 		$1 135,64
$1 222,50
$1 314,50
$1 641,36 		$1 381,75
$1 468,61
$1 560,61
$1 887,47 		$246,11
Toc - Plan #110 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 		$394,07
$447,27
$503,62
$703,80
$1 069,50 		$695,53
$748,73
$805,08
$1 005,26 		$996,99
$1 050,19
$1 106,54
$1 306,72 		$1 298,45
$1 351,65
$1 408,00
$1 608,18 		$301,46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788,14
$894,54
$1 007,24
$1 407,60
$2 139,00 		$1 089,60
$1 196,00
$1 308,70
$1 709,06 		$1 391,06
$1 497,46
$1 610,16
$2 010,52 		$1 692,52
$1 798,92
$1 911,62
$2 311,98 		$301,46
Toc - Plan #111 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 		$397,40
$451,05
$507,87
$709,75
$1 078,54 		$701,41
$755,06
$811,88
$1 013,76 		$1 005,42
$1 059,07
$1 115,89
$1 317,77 		$1 309,43
$1 363,08
$1 419,90
$1 621,78 		$304,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794,80
$902,10
$1 015,74
$1 419,50
$2 157,08 		$1 098,81
$1 206,11
$1 319,75
$1 723,51 		$1 402,82
$1 510,12
$1 623,76
$2 027,52 		$1 706,83
$1 814,13
$1 927,77
$2 331,53 		$304,01
Toc - Plan #112 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 		$400,21
$454,24
$511,47
$714,77
$1 086,17 		$706,37
$760,40
$817,63
$1 020,93 		$1 012,53
$1 066,56
$1 123,79
$1 327,09 		$1 318,69
$1 372,72
$1 429,95
$1 633,25 		$306,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800,42
$908,48
$1 022,94
$1 429,54
$2 172,34 		$1 106,58
$1 214,64
$1 329,10
$1 735,70 		$1 412,74
$1 520,80
$1 635,26
$2 041,86 		$1 718,90
$1 826,96
$1 941,42
$2 348,02 		$306,16
Toc - Plan #113 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 		$409,81
$465,13
$523,74
$731,92
$1 112,23 		$723,31
$778,63
$837,24
$1 045,42 		$1 036,81
$1 092,13
$1 150,74
$1 358,92 		$1 350,31
$1 405,63
$1 464,24
$1 672,42 		$313,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819,62
$930,26
$1 047,48
$1 463,84
$2 224,46 		$1 133,12
$1 243,76
$1 360,98
$1 777,34 		$1 446,62
$1 557,26
$1 674,48
$2 090,84 		$1 760,12
$1 870,76
$1 987,98
$2 404,34 		$313,50
Toc - Plan #114 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 		$446,75
$507,06
$570,94
$797,89
$1 212,47 		$788,51
$848,82
$912,70
$1 139,65 		$1 130,27
$1 190,58
$1 254,46
$1 481,41 		$1 472,03
$1 532,34
$1 596,22
$1 823,17 		$341,76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$893,50
$1 014,12
$1 141,88
$1 595,78
$2 424,94 		$1 235,26
$1 355,88
$1 483,64
$1 937,54 		$1 577,02
$1 697,64
$1 825,40
$2 279,30 		$1 918,78
$2 039,40
$2 167,16
$2 621,06 		$341,76
Toc - Plan #115 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 		$326,72
$370,83
$417,55
$583,53
$886,73 		$576,66
$620,77
$667,49
$833,47 		$826,60
$870,71
$917,43
$1 083,41 		$1 076,54
$1 120,65
$1 167,37
$1 333,35 		$249,94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653,44
$741,66
$835,10
$1 167,06
$1 773,46 		$903,38
$991,60
$1 085,04
$1 417,00 		$1 153,32
$1 241,54
$1 334,98
$1 666,94 		$1 403,26
$1 491,48
$1 584,92
$1 916,88 		$249,94
Toc - Plan #116 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 		$413,66
$469,50
$528,66
$738,80
$1 122,67 		$730,11
$785,95
$845,11
$1 055,25 		$1 046,56
$1 102,40
$1 161,56
$1 371,70 		$1 363,01
$1 418,85
$1 478,01
$1 688,15 		$316,45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827,32
$939,00
$1 057,32
$1 477,60
$2 245,34 		$1 143,77
$1 255,45
$1 373,77
$1 794,05 		$1 460,22
$1 571,90
$1 690,22
$2 110,50 		$1 776,67
$1 888,35
$2 006,67
$2 426,95 		$316,45

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-5716 | Toll Free: 1-888-560-5716 | TTY: 1-800-955-8771
Toc - Plan #117 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

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

Annual Out of Pocket Expenses:

Individual Family
$2,925 $5,850 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 		$435,66
$494,47
$556,77
$778,09
$1 182,38 		$768,94
$827,75
$890,05
$1 111,37 		$1 102,22
$1 161,03
$1 223,33
$1 444,65 		$1 435,50
$1 494,31
$1 556,61
$1 777,93 		$333,28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871,32
$988,94
$1 113,54
$1 556,18
$2 364,76 		$1 204,60
$1 322,22
$1 446,82
$1 889,46 		$1 537,88
$1 655,50
$1 780,10
$2 222,74 		$1 871,16
$1 988,78
$2 113,38
$2 556,02 		$333,28
Toc - Plan #118 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$415,07
$471,11
$530,46
$741,32
$1 126,51 		$732,60
$788,64
$847,99
$1 058,85 		$1 050,13
$1 106,17
$1 165,52
$1 376,38 		$1 367,66
$1 423,70
$1 483,05
$1 693,91 		$317,53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830,14
$942,22
$1 060,92
$1 482,64
$2 253,02 		$1 147,67
$1 259,75
$1 378,45
$1 800,17 		$1 465,20
$1 577,28
$1 695,98
$2 117,70 		$1 782,73
$1 894,81
$2 013,51
$2 435,23 		$317,53
Toc - Plan #119 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$289,30
$328,36
$369,73
$516,70
$785,17 		$510,62
$549,68
$591,05
$738,02 		$731,94
$771,00
$812,37
$959,34 		$953,26
$992,32
$1 033,69
$1 180,66 		$221,32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578,60
$656,72
$739,46
$1 033,40
$1 570,34 		$799,92
$878,04
$960,78
$1 254,72 		$1 021,24
$1 099,36
$1 182,10
$1 476,04 		$1 242,56
$1 320,68
$1 403,42
$1 697,36 		$221,32
Toc - Plan #120 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

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

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 		$410,51
$465,92
$524,63
$733,16
$1 114,11 		$724,55
$779,96
$838,67
$1 047,20 		$1 038,59
$1 094,00
$1 152,71
$1 361,24 		$1 352,63
$1 408,04
$1 466,75
$1 675,28 		$314,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821,02
$931,84
$1 049,26
$1 466,32
$2 228,22 		$1 135,06
$1 245,88
$1 363,30
$1 780,36 		$1 449,10
$1 559,92
$1 677,34
$2 094,40 		$1 763,14
$1 873,96
$1 991,38
$2 408,44 		$314,04
Toc - Plan #121 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$302,70
$343,56
$386,85
$540,62
$821,52 		$534,26
$575,12
$618,41
$772,18 		$765,82
$806,68
$849,97
$1 003,74 		$997,38
$1 038,24
$1 081,53
$1 235,30 		$231,56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605,40
$687,12
$773,70
$1 081,24
$1 643,04 		$836,96
$918,68
$1 005,26
$1 312,80 		$1 068,52
$1 150,24
$1 236,82
$1 544,36 		$1 300,08
$1 381,80
$1 468,38
$1 775,92 		$231,56
Toc - Plan #122 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 5

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

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 		$294,51
$334,27
$376,38
$525,99
$799,30 		$519,81
$559,57
$601,68
$751,29 		$745,11
$784,87
$826,98
$976,59 		$970,41
$1 010,17
$1 052,28
$1 201,89 		$225,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589,02
$668,54
$752,76
$1 051,98
$1 598,60 		$814,32
$893,84
$978,06
$1 277,28 		$1 039,62
$1 119,14
$1 203,36
$1 502,58 		$1 264,92
$1 344,44
$1 428,66
$1 727,88 		$225,30
Toc - Plan #123 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$2,925 $5,850 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 		$439,17
$498,46
$561,26
$784,35
$1 191,90 		$775,13
$834,42
$897,22
$1 120,31 		$1 111,09
$1 170,38
$1 233,18
$1 456,27 		$1 447,05
$1 506,34
$1 569,14
$1 792,23 		$335,96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878,34
$996,92
$1 122,52
$1 568,70
$2 383,80 		$1 214,30
$1 332,88
$1 458,48
$1 904,66 		$1 550,26
$1 668,84
$1 794,44
$2 240,62 		$1 886,22
$2 004,80
$2 130,40
$2 576,58 		$335,96
Toc - Plan #124 Molina Healthcare
Silver

(HMO) Confident Care Silver 1 + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$418,58
$475,09
$534,95
$747,59
$1 136,04 		$738,80
$795,31
$855,17
$1 067,81 		$1 059,02
$1 115,53
$1 175,39
$1 388,03 		$1 379,24
$1 435,75
$1 495,61
$1 708,25 		$320,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837,16
$950,18
$1 069,90
$1 495,18
$2 272,08 		$1 157,38
$1 270,40
$1 390,12
$1 815,40 		$1 477,60
$1 590,62
$1 710,34
$2 135,62 		$1 797,82
$1 910,84
$2 030,56
$2 455,84 		$320,22
Toc - Plan #125 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1 + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$292,81
$332,34
$374,21
$522,96
$794,69 		$516,81
$556,34
$598,21
$746,96 		$740,81
$780,34
$822,21
$970,96 		$964,81
$1 004,34
$1 046,21
$1 194,96 		$224,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585,62
$664,68
$748,42
$1 045,92
$1 589,38 		$809,62
$888,68
$972,42
$1 269,92 		$1 033,62
$1 112,68
$1 196,42
$1 493,92 		$1 257,62
$1 336,68
$1 420,42
$1 717,92 		$224,00
Toc - Plan #126 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

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

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 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 		$414,46
$470,41
$529,68
$740,22
$1 124,84 		$731,52
$787,47
$846,74
$1 057,28 		$1 048,58
$1 104,53
$1 163,80
$1 374,34 		$1 365,64
$1 421,59
$1 480,86
$1 691,40 		$317,06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828,92
$940,82
$1 059,36
$1 480,44
$2 249,68 		$1 145,98
$1 257,88
$1 376,42
$1 797,50 		$1 463,04
$1 574,94
$1 693,48
$2 114,56 		$1 780,10
$1 892,00
$2 010,54
$2 431,62 		$317,06
Toc - Plan #127 Molina Healthcare
Bronze

(HMO) Core Care Bronze 2

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

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 		$286,81
$325,53
$366,54
$512,24
$778,41 		$506,22
$544,94
$585,95
$731,65 		$725,63
$764,35
$805,36
$951,06 		$945,04
$983,76
$1 024,77
$1 170,47 		$219,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573,62
$651,06
$733,08
$1 024,48
$1 556,82 		$793,03
$870,47
$952,49
$1 243,89 		$1 012,44
$1 089,88
$1 171,90
$1 463,30 		$1 231,85
$1 309,29
$1 391,31
$1 682,71 		$219,41

‡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 Orange County here.

Orange County is in “Rating Area 48” of Florida.

Currently, there are 127 plans offered in Rating Area 48.

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