Obamacare 2021 Rates for Tarrant County

Obamacare > Rates > Texas > Tarrant 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 Tarrant County, TX.

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, 75 Plans and 2021 Rates for Tarrant County, Texas

Below, you’ll find a summary of the 75 plans for Tarrant County, Texas 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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Oscar Insurance Company

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

Toc - Plan #1 Oscar Insurance Company
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 		$264,18
$299,83
$337,61
$471,80
$716,95 		$466,27
$501,92
$539,70
$673,89 		$668,36
$704,01
$741,79
$875,98 		$870,45
$906,10
$943,88
$1 078,07 		$202,09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$528,36
$599,66
$675,22
$943,60
$1 433,90 		$730,45
$801,75
$877,31
$1 145,69 		$932,54
$1 003,84
$1 079,40
$1 347,78 		$1 134,63
$1 205,93
$1 281,49
$1 549,87 		$202,09
Toc - Plan #2 Oscar Insurance Company
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 		$272,81
$309,63
$348,64
$487,22
$740,38 		$481,50
$518,32
$557,33
$695,91 		$690,19
$727,01
$766,02
$904,60 		$898,88
$935,70
$974,71
$1 113,29 		$208,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$545,62
$619,26
$697,28
$974,44
$1 480,76 		$754,31
$827,95
$905,97
$1 183,13 		$963,00
$1 036,64
$1 114,66
$1 391,82 		$1 171,69
$1 245,33
$1 323,35
$1 600,51 		$208,69
Toc - Plan #3 Oscar Insurance Company
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 		$265,79
$301,66
$339,66
$474,68
$721,31 		$469,11
$504,98
$542,98
$678,00 		$672,43
$708,30
$746,30
$881,32 		$875,75
$911,62
$949,62
$1 084,64 		$203,32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$531,58
$603,32
$679,32
$949,36
$1 442,62 		$734,90
$806,64
$882,64
$1 152,68 		$938,22
$1 009,96
$1 085,96
$1 356,00 		$1 141,54
$1 213,28
$1 289,28
$1 559,32 		$203,32
Toc - Plan #4 Oscar Insurance Company
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 		$323,10
$366,71
$412,92
$577,05
$876,88 		$570,27
$613,88
$660,09
$824,22 		$817,44
$861,05
$907,26
$1 071,39 		$1 064,61
$1 108,22
$1 154,43
$1 318,56 		$247,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646,20
$733,42
$825,84
$1 154,10
$1 753,76 		$893,37
$980,59
$1 073,01
$1 401,27 		$1 140,54
$1 227,76
$1 320,18
$1 648,44 		$1 387,71
$1 474,93
$1 567,35
$1 895,61 		$247,17
Toc - Plan #5 Oscar Insurance Company
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 		$364,44
$413,63
$465,74
$650,87
$989,06 		$643,23
$692,42
$744,53
$929,66 		$922,02
$971,21
$1 023,32
$1 208,45 		$1 200,81
$1 250,00
$1 302,11
$1 487,24 		$278,79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728,88
$827,26
$931,48
$1 301,74
$1 978,12 		$1 007,67
$1 106,05
$1 210,27
$1 580,53 		$1 286,46
$1 384,84
$1 489,06
$1 859,32 		$1 565,25
$1 663,63
$1 767,85
$2 138,11 		$278,79
Toc - Plan #6 Oscar Insurance Company
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 		$357,77
$406,06
$457,22
$638,96
$970,96 		$631,46
$679,75
$730,91
$912,65 		$905,15
$953,44
$1 004,60
$1 186,34 		$1 178,84
$1 227,13
$1 278,29
$1 460,03 		$273,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715,54
$812,12
$914,44
$1 277,92
$1 941,92 		$989,23
$1 085,81
$1 188,13
$1 551,61 		$1 262,92
$1 359,50
$1 461,82
$1 825,30 		$1 536,61
$1 633,19
$1 735,51
$2 098,99 		$273,69
Toc - Plan #7 Oscar Insurance Company
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 		$366,35
$415,80
$468,18
$654,28
$994,25 		$646,60
$696,05
$748,43
$934,53 		$926,85
$976,30
$1 028,68
$1 214,78 		$1 207,10
$1 256,55
$1 308,93
$1 495,03 		$280,25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732,70
$831,60
$936,36
$1 308,56
$1 988,50 		$1 012,95
$1 111,85
$1 216,61
$1 588,81 		$1 293,20
$1 392,10
$1 496,86
$1 869,06 		$1 573,45
$1 672,35
$1 777,11
$2 149,31 		$280,25
Toc - Plan #8 Oscar Insurance Company
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 		$218,47
$247,95
$279,19
$390,16
$592,89 		$385,59
$415,07
$446,31
$557,28 		$552,71
$582,19
$613,43
$724,40 		$719,83
$749,31
$780,55
$891,52 		$167,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$436,94
$495,90
$558,38
$780,32
$1 185,78 		$604,06
$663,02
$725,50
$947,44 		$771,18
$830,14
$892,62
$1 114,56 		$938,30
$997,26
$1 059,74
$1 281,68 		$167,12
Toc - Plan #9 Oscar Insurance Company
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 		$322,81
$366,37
$412,53
$576,51
$876,07 		$569,75
$613,31
$659,47
$823,45 		$816,69
$860,25
$906,41
$1 070,39 		$1 063,63
$1 107,19
$1 153,35
$1 317,33 		$246,94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645,62
$732,74
$825,06
$1 153,02
$1 752,14 		$892,56
$979,68
$1 072,00
$1 399,96 		$1 139,50
$1 226,62
$1 318,94
$1 646,90 		$1 386,44
$1 473,56
$1 565,88
$1 893,84 		$246,94
Toc - Plan #10 Oscar Insurance Company
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 		$386,95
$439,17
$494,51
$691,07
$1 050,15 		$682,96
$735,18
$790,52
$987,08 		$978,97
$1 031,19
$1 086,53
$1 283,09 		$1 274,98
$1 327,20
$1 382,54
$1 579,10 		$296,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773,90
$878,34
$989,02
$1 382,14
$2 100,30 		$1 069,91
$1 174,35
$1 285,03
$1 678,15 		$1 365,92
$1 470,36
$1 581,04
$1 974,16 		$1 661,93
$1 766,37
$1 877,05
$2 270,17 		$296,01
Toc - Plan #11 Oscar Insurance Company
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 		$283,95
$322,27
$362,88
$507,12
$770,62 		$501,16
$539,48
$580,09
$724,33 		$718,37
$756,69
$797,30
$941,54 		$935,58
$973,90
$1 014,51
$1 158,75 		$217,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567,90
$644,54
$725,76
$1 014,24
$1 541,24 		$785,11
$861,75
$942,97
$1 231,45 		$1 002,32
$1 078,96
$1 160,18
$1 448,66 		$1 219,53
$1 296,17
$1 377,39
$1 665,87 		$217,21
Toc - Plan #12 Oscar Insurance Company
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 		$372,83
$423,16
$476,47
$665,87
$1 011,85 		$658,04
$708,37
$761,68
$951,08 		$943,25
$993,58
$1 046,89
$1 236,29 		$1 228,46
$1 278,79
$1 332,10
$1 521,50 		$285,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745,66
$846,32
$952,94
$1 331,74
$2 023,70 		$1 030,87
$1 131,53
$1 238,15
$1 616,95 		$1 316,08
$1 416,74
$1 523,36
$1 902,16 		$1 601,29
$1 701,95
$1 808,57
$2 187,37 		$285,21
Toc - Plan #13 Oscar Insurance Company
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 		$386,09
$438,20
$493,41
$689,53
$1 047,81 		$681,44
$733,55
$788,76
$984,88 		$976,79
$1 028,90
$1 084,11
$1 280,23 		$1 272,14
$1 324,25
$1 379,46
$1 575,58 		$295,35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772,18
$876,40
$986,82
$1 379,06
$2 095,62 		$1 067,53
$1 171,75
$1 282,17
$1 674,41 		$1 362,88
$1 467,10
$1 577,52
$1 969,76 		$1 658,23
$1 762,45
$1 872,87
$2 265,11 		$295,35

ADVERTISEMENT

Ambetter from Superior HealthPlan

Local: 1-877-687-1196 | Toll Free: 1-877-687-1196 | TTY: 1-800-735-2989
Toc - Plan #14 Ambetter from Superior HealthPlan
Bronze

(EPO) Ambetter Essential Care 1 (2021)

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

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 		$303,56
$344,53
$387,94
$542,14
$823,84 		$535,78
$576,75
$620,16
$774,36 		$768,00
$808,97
$852,38
$1 006,58 		$1 000,22
$1 041,19
$1 084,60
$1 238,80 		$232,22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607,12
$689,06
$775,88
$1 084,28
$1 647,68 		$839,34
$921,28
$1 008,10
$1 316,50 		$1 071,56
$1 153,50
$1 240,32
$1 548,72 		$1 303,78
$1 385,72
$1 472,54
$1 780,94 		$232,22
Toc - Plan #15 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 11 (2021)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360,57
$409,23
$460,79
$643,95
$978,55 		$636,40
$685,06
$736,62
$919,78 		$912,23
$960,89
$1 012,45
$1 195,61 		$1 188,06
$1 236,72
$1 288,28
$1 471,44 		$275,83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721,14
$818,46
$921,58
$1 287,90
$1 957,10 		$996,97
$1 094,29
$1 197,41
$1 563,73 		$1 272,80
$1 370,12
$1 473,24
$1 839,56 		$1 548,63
$1 645,95
$1 749,07
$2 115,39 		$275,83
Toc - Plan #16 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 5 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 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 		$359,59
$408,13
$459,55
$642,21
$975,91 		$634,67
$683,21
$734,63
$917,29 		$909,75
$958,29
$1 009,71
$1 192,37 		$1 184,83
$1 233,37
$1 284,79
$1 467,45 		$275,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719,18
$816,26
$919,10
$1 284,42
$1 951,82 		$994,26
$1 091,34
$1 194,18
$1 559,50 		$1 269,34
$1 366,42
$1 469,26
$1 834,58 		$1 544,42
$1 641,50
$1 744,34
$2 109,66 		$275,08
Toc - Plan #17 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 10 (2021)

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

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 		$314,63
$357,10
$402,09
$561,91
$853,88 		$555,32
$597,79
$642,78
$802,60 		$796,01
$838,48
$883,47
$1 043,29 		$1 036,70
$1 079,17
$1 124,16
$1 283,98 		$240,69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629,26
$714,20
$804,18
$1 123,82
$1 707,76 		$869,95
$954,89
$1 044,87
$1 364,51 		$1 110,64
$1 195,58
$1 285,56
$1 605,20 		$1 351,33
$1 436,27
$1 526,25
$1 845,89 		$240,69
Toc - Plan #18 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 5 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$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 		$480,09
$544,89
$613,54
$857,42
$1 302,94 		$847,35
$912,15
$980,80
$1 224,68 		$1 214,61
$1 279,41
$1 348,06
$1 591,94 		$1 581,87
$1 646,67
$1 715,32
$1 959,20 		$367,26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$960,18
$1 089,78
$1 227,08
$1 714,84
$2 605,88 		$1 327,44
$1 457,04
$1 594,34
$2 082,10 		$1 694,70
$1 824,30
$1 961,60
$2 449,36 		$2 061,96
$2 191,56
$2 328,86
$2 816,62 		$367,26
Toc - Plan #19 Ambetter from Superior HealthPlan
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021)

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

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 		$328,12
$372,40
$419,32
$586,00
$890,48 		$579,12
$623,40
$670,32
$837,00 		$830,12
$874,40
$921,32
$1 088,00 		$1 081,12
$1 125,40
$1 172,32
$1 339,00 		$251,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$656,24
$744,80
$838,64
$1 172,00
$1 780,96 		$907,24
$995,80
$1 089,64
$1 423,00 		$1 158,24
$1 246,80
$1 340,64
$1 674,00 		$1 409,24
$1 497,80
$1 591,64
$1 925,00 		$251,00
Toc - Plan #20 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 12 (2021)

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

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 		$353,14
$400,80
$451,30
$630,69
$958,39 		$623,28
$670,94
$721,44
$900,83 		$893,42
$941,08
$991,58
$1 170,97 		$1 163,56
$1 211,22
$1 261,72
$1 441,11 		$270,14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706,28
$801,60
$902,60
$1 261,38
$1 916,78 		$976,42
$1 071,74
$1 172,74
$1 531,52 		$1 246,56
$1 341,88
$1 442,88
$1 801,66 		$1 516,70
$1 612,02
$1 713,02
$2 071,80 		$270,14
Toc - Plan #21 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 29 (2021)

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

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 		$350,04
$397,28
$447,34
$625,15
$949,98 		$617,81
$665,05
$715,11
$892,92 		$885,58
$932,82
$982,88
$1 160,69 		$1 153,35
$1 200,59
$1 250,65
$1 428,46 		$267,77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700,08
$794,56
$894,68
$1 250,30
$1 899,96 		$967,85
$1 062,33
$1 162,45
$1 518,07 		$1 235,62
$1 330,10
$1 430,22
$1 785,84 		$1 503,39
$1 597,87
$1 697,99
$2 053,61 		$267,77
Toc - Plan #22 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 25 HSA (2021)

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

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 		$364,64
$413,86
$466,00
$651,23
$989,61 		$643,58
$692,80
$744,94
$930,17 		$922,52
$971,74
$1 023,88
$1 209,11 		$1 201,46
$1 250,68
$1 302,82
$1 488,05 		$278,94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729,28
$827,72
$932,00
$1 302,46
$1 979,22 		$1 008,22
$1 106,66
$1 210,94
$1 581,40 		$1 287,16
$1 385,60
$1 489,88
$1 860,34 		$1 566,10
$1 664,54
$1 768,82
$2 139,28 		$278,94
Toc - Plan #23 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 27 (2021)

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

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 		$385,41
$437,43
$492,54
$688,32
$1 045,97 		$680,24
$732,26
$787,37
$983,15 		$975,07
$1 027,09
$1 082,20
$1 277,98 		$1 269,90
$1 321,92
$1 377,03
$1 572,81 		$294,83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770,82
$874,86
$985,08
$1 376,64
$2 091,94 		$1 065,65
$1 169,69
$1 279,91
$1 671,47 		$1 360,48
$1 464,52
$1 574,74
$1 966,30 		$1 655,31
$1 759,35
$1 869,57
$2 261,13 		$294,83
Toc - Plan #24 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 28 (2021)

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

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 		$388,55
$440,99
$496,55
$693,92
$1 054,48 		$685,78
$738,22
$793,78
$991,15 		$983,01
$1 035,45
$1 091,01
$1 288,38 		$1 280,24
$1 332,68
$1 388,24
$1 585,61 		$297,23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777,10
$881,98
$993,10
$1 387,84
$2 108,96 		$1 074,33
$1 179,21
$1 290,33
$1 685,07 		$1 371,56
$1 476,44
$1 587,56
$1 982,30 		$1 668,79
$1 773,67
$1 884,79
$2 279,53 		$297,23
Toc - Plan #25 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 15 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$1,150 $2,300 Annual Deductible
$4,450 $8,900 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 		$490,37
$556,55
$626,68
$875,78
$1 330,83 		$865,49
$931,67
$1 001,80
$1 250,90 		$1 240,61
$1 306,79
$1 376,92
$1 626,02 		$1 615,73
$1 681,91
$1 752,04
$2 001,14 		$375,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$980,74
$1 113,10
$1 253,36
$1 751,56
$2 661,66 		$1 355,86
$1 488,22
$1 628,48
$2 126,68 		$1 730,98
$1 863,34
$2 003,60
$2 501,80 		$2 106,10
$2 238,46
$2 378,72
$2 876,92 		$375,12
Toc - Plan #26 Ambetter from Superior HealthPlan
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$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 		$485,60
$551,15
$620,59
$867,27
$1 317,90 		$857,08
$922,63
$992,07
$1 238,75 		$1 228,56
$1 294,11
$1 363,55
$1 610,23 		$1 600,04
$1 665,59
$1 735,03
$1 981,71 		$371,48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$971,20
$1 102,30
$1 241,18
$1 734,54
$2 635,80 		$1 342,68
$1 473,78
$1 612,66
$2 106,02 		$1 714,16
$1 845,26
$1 984,14
$2 477,50 		$2 085,64
$2 216,74
$2 355,62
$2 848,98 		$371,48
Toc - Plan #27 Ambetter from Superior HealthPlan
Bronze

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

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

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 		$307,05
$348,49
$392,39
$548,37
$833,30 		$541,93
$583,37
$627,27
$783,25 		$776,81
$818,25
$862,15
$1 018,13 		$1 011,69
$1 053,13
$1 097,03
$1 253,01 		$234,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614,10
$696,98
$784,78
$1 096,74
$1 666,60 		$848,98
$931,86
$1 019,66
$1 331,62 		$1 083,86
$1 166,74
$1 254,54
$1 566,50 		$1 318,74
$1 401,62
$1 489,42
$1 801,38 		$234,88
Toc - Plan #28 Ambetter from Superior HealthPlan
Expanded Bronze

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

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

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 		$318,24
$361,19
$406,70
$568,36
$863,69 		$561,69
$604,64
$650,15
$811,81 		$805,14
$848,09
$893,60
$1 055,26 		$1 048,59
$1 091,54
$1 137,05
$1 298,71 		$243,45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636,48
$722,38
$813,40
$1 136,72
$1 727,38 		$879,93
$965,83
$1 056,85
$1 380,17 		$1 123,38
$1 209,28
$1 300,30
$1 623,62 		$1 366,83
$1 452,73
$1 543,75
$1 867,07 		$243,45
Toc - Plan #29 Ambetter from Superior HealthPlan
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364,71
$413,93
$466,08
$651,35
$989,78 		$643,70
$692,92
$745,07
$930,34 		$922,69
$971,91
$1 024,06
$1 209,33 		$1 201,68
$1 250,90
$1 303,05
$1 488,32 		$278,99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729,42
$827,86
$932,16
$1 302,70
$1 979,56 		$1 008,41
$1 106,85
$1 211,15
$1 581,69 		$1 287,40
$1 385,84
$1 490,14
$1 860,68 		$1 566,39
$1 664,83
$1 769,13
$2 139,67 		$278,99
Toc - Plan #30 Ambetter from Superior HealthPlan
Silver

(EPO) Ambetter Balanced Care 5 (2021) + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 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 		$363,72
$412,81
$464,82
$649,59
$987,11 		$641,96
$691,05
$743,06
$927,83 		$920,20
$969,29
$1 021,30
$1 206,07 		$1 198,44
$1 247,53
$1 299,54
$1 484,31 		$278,24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727,44
$825,62
$929,64
$1 299,18
$1 974,22 		$1 005,68
$1 103,86
$1 207,88
$1 577,42 		$1 283,92
$1 382,10
$1 486,12
$1 855,66 		$1 562,16
$1 660,34
$1 764,36
$2 133,90 		$278,24
Toc - Plan #31 Ambetter from Superior HealthPlan
Expanded Bronze

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

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

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 		$331,88
$376,68
$424,13
$592,73
$900,70 		$585,76
$630,56
$678,01
$846,61 		$839,64
$884,44
$931,89
$1 100,49 		$1 093,52
$1 138,32
$1 185,77
$1 354,37 		$253,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663,76
$753,36
$848,26
$1 185,46
$1 801,40 		$917,64
$1 007,24
$1 102,14
$1 439,34 		$1 171,52
$1 261,12
$1 356,02
$1 693,22 		$1 425,40
$1 515,00
$1 609,90
$1 947,10 		$253,88
Toc - Plan #32 Ambetter from Superior HealthPlan
Silver

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

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

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 		$357,19
$405,40
$456,48
$637,93
$969,39 		$630,43
$678,64
$729,72
$911,17 		$903,67
$951,88
$1 002,96
$1 184,41 		$1 176,91
$1 225,12
$1 276,20
$1 457,65 		$273,24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714,38
$810,80
$912,96
$1 275,86
$1 938,78 		$987,62
$1 084,04
$1 186,20
$1 549,10 		$1 260,86
$1 357,28
$1 459,44
$1 822,34 		$1 534,10
$1 630,52
$1 732,68
$2 095,58 		$273,24
Toc - Plan #33 Ambetter from Superior HealthPlan
Silver

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

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

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 		$368,83
$418,61
$471,35
$658,71
$1 000,97 		$650,97
$700,75
$753,49
$940,85 		$933,11
$982,89
$1 035,63
$1 222,99 		$1 215,25
$1 265,03
$1 317,77
$1 505,13 		$282,14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737,66
$837,22
$942,70
$1 317,42
$2 001,94 		$1 019,80
$1 119,36
$1 224,84
$1 599,56 		$1 301,94
$1 401,50
$1 506,98
$1 881,70 		$1 584,08
$1 683,64
$1 789,12
$2 163,84 		$282,14
Toc - Plan #34 Ambetter from Superior HealthPlan
Silver

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

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

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 		$389,83
$442,45
$498,19
$696,22
$1 057,98 		$688,04
$740,66
$796,40
$994,43 		$986,25
$1 038,87
$1 094,61
$1 292,64 		$1 284,46
$1 337,08
$1 392,82
$1 590,85 		$298,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779,66
$884,90
$996,38
$1 392,44
$2 115,96 		$1 077,87
$1 183,11
$1 294,59
$1 690,65 		$1 376,08
$1 481,32
$1 592,80
$1 988,86 		$1 674,29
$1 779,53
$1 891,01
$2 287,07 		$298,21
Toc - Plan #35 Ambetter from Superior HealthPlan
Silver

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

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

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 		$393,01
$446,05
$502,25
$701,89
$1 066,59 		$693,65
$746,69
$802,89
$1 002,53 		$994,29
$1 047,33
$1 103,53
$1 303,17 		$1 294,93
$1 347,97
$1 404,17
$1 603,81 		$300,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786,02
$892,10
$1 004,50
$1 403,78
$2 133,18 		$1 086,66
$1 192,74
$1 305,14
$1 704,42 		$1 387,30
$1 493,38
$1 605,78
$2 005,06 		$1 687,94
$1 794,02
$1 906,42
$2 305,70 		$300,64
Toc - Plan #36 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 15 (2021) + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$1,150 $2,300 Annual Deductible
$4,450 $8,900 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 		$496,00
$562,94
$633,87
$885,83
$1 346,11 		$875,43
$942,37
$1 013,30
$1 265,26 		$1 254,86
$1 321,80
$1 392,73
$1 644,69 		$1 634,29
$1 701,23
$1 772,16
$2 024,12 		$379,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$992,00
$1 125,88
$1 267,74
$1 771,66
$2 692,22 		$1 371,43
$1 505,31
$1 647,17
$2 151,09 		$1 750,86
$1 884,74
$2 026,60
$2 530,52 		$2 130,29
$2 264,17
$2 406,03
$2 909,95 		$379,43
Toc - Plan #37 Ambetter from Superior HealthPlan
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$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 		$503,01
$570,90
$642,83
$898,35
$1 365,14 		$887,80
$955,69
$1 027,62
$1 283,14 		$1 272,59
$1 340,48
$1 412,41
$1 667,93 		$1 657,38
$1 725,27
$1 797,20
$2 052,72 		$384,79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 006,02
$1 141,80
$1 285,66
$1 796,70
$2 730,28 		$1 390,81
$1 526,59
$1 670,45
$2 181,49 		$1 775,60
$1 911,38
$2 055,24
$2 566,28 		$2 160,39
$2 296,17
$2 440,03
$2 951,07 		$384,79
Toc - Plan #38 Ambetter from Superior HealthPlan
Bronze

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

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

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 		$318,05
$360,98
$406,46
$568,02
$863,17 		$561,35
$604,28
$649,76
$811,32 		$804,65
$847,58
$893,06
$1 054,62 		$1 047,95
$1 090,88
$1 136,36
$1 297,92 		$243,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636,10
$721,96
$812,92
$1 136,04
$1 726,34 		$879,40
$965,26
$1 056,22
$1 379,34 		$1 122,70
$1 208,56
$1 299,52
$1 622,64 		$1 366,00
$1 451,86
$1 542,82
$1 865,94 		$243,30
Toc - Plan #39 Ambetter from Superior HealthPlan
Expanded Bronze

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

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

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 		$329,65
$374,14
$421,28
$588,74
$894,64 		$581,82
$626,31
$673,45
$840,91 		$833,99
$878,48
$925,62
$1 093,08 		$1 086,16
$1 130,65
$1 177,79
$1 345,25 		$252,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659,30
$748,28
$842,56
$1 177,48
$1 789,28 		$911,47
$1 000,45
$1 094,73
$1 429,65 		$1 163,64
$1 252,62
$1 346,90
$1 681,82 		$1 415,81
$1 504,79
$1 599,07
$1 933,99 		$252,17
Toc - Plan #40 Ambetter from Superior HealthPlan
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$377,78
$428,77
$482,79
$674,69
$1 025,26 		$666,77
$717,76
$771,78
$963,68 		$955,76
$1 006,75
$1 060,77
$1 252,67 		$1 244,75
$1 295,74
$1 349,76
$1 541,66 		$288,99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755,56
$857,54
$965,58
$1 349,38
$2 050,52 		$1 044,55
$1 146,53
$1 254,57
$1 638,37 		$1 333,54
$1 435,52
$1 543,56
$1 927,36 		$1 622,53
$1 724,51
$1 832,55
$2 216,35 		$288,99
Toc - Plan #41 Ambetter from Superior HealthPlan
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,350 $14,700 Annual Deductible
$7,350 $14,700 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 		$376,76
$427,61
$481,48
$672,87
$1 022,49 		$664,97
$715,82
$769,69
$961,08 		$953,18
$1 004,03
$1 057,90
$1 249,29 		$1 241,39
$1 292,24
$1 346,11
$1 537,50 		$288,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753,52
$855,22
$962,96
$1 345,74
$2 044,98 		$1 041,73
$1 143,43
$1 251,17
$1 633,95 		$1 329,94
$1 431,64
$1 539,38
$1 922,16 		$1 618,15
$1 719,85
$1 827,59
$2 210,37 		$288,21
Toc - Plan #42 Ambetter from Superior HealthPlan
Expanded Bronze

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

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

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 		$343,78
$390,18
$439,34
$613,97
$932,99 		$606,76
$653,16
$702,32
$876,95 		$869,74
$916,14
$965,30
$1 139,93 		$1 132,72
$1 179,12
$1 228,28
$1 402,91 		$262,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687,56
$780,36
$878,68
$1 227,94
$1 865,98 		$950,54
$1 043,34
$1 141,66
$1 490,92 		$1 213,52
$1 306,32
$1 404,64
$1 753,90 		$1 476,50
$1 569,30
$1 667,62
$2 016,88 		$262,98
Toc - Plan #43 Ambetter from Superior HealthPlan
Silver

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

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

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 		$370,00
$419,93
$472,84
$660,80
$1 004,14 		$653,04
$702,97
$755,88
$943,84 		$936,08
$986,01
$1 038,92
$1 226,88 		$1 219,12
$1 269,05
$1 321,96
$1 509,92 		$283,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740,00
$839,86
$945,68
$1 321,60
$2 008,28 		$1 023,04
$1 122,90
$1 228,72
$1 604,64 		$1 306,08
$1 405,94
$1 511,76
$1 887,68 		$1 589,12
$1 688,98
$1 794,80
$2 170,72 		$283,04
Toc - Plan #44 Ambetter from Superior HealthPlan
Silver

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

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

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 		$382,05
$433,61
$488,24
$682,32
$1 036,85 		$674,31
$725,87
$780,50
$974,58 		$966,57
$1 018,13
$1 072,76
$1 266,84 		$1 258,83
$1 310,39
$1 365,02
$1 559,10 		$292,26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764,10
$867,22
$976,48
$1 364,64
$2 073,70 		$1 056,36
$1 159,48
$1 268,74
$1 656,90 		$1 348,62
$1 451,74
$1 561,00
$1 949,16 		$1 640,88
$1 744,00
$1 853,26
$2 241,42 		$292,26
Toc - Plan #45 Ambetter from Superior HealthPlan
Silver

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

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

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 		$403,81
$458,31
$516,05
$721,18
$1 095,90 		$712,71
$767,21
$824,95
$1 030,08 		$1 021,61
$1 076,11
$1 133,85
$1 338,98 		$1 330,51
$1 385,01
$1 442,75
$1 647,88 		$308,90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807,62
$916,62
$1 032,10
$1 442,36
$2 191,80 		$1 116,52
$1 225,52
$1 341,00
$1 751,26 		$1 425,42
$1 534,42
$1 649,90
$2 060,16 		$1 734,32
$1 843,32
$1 958,80
$2 369,06 		$308,90
Toc - Plan #46 Ambetter from Superior HealthPlan
Silver

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

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

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 		$407,09
$462,04
$520,25
$727,05
$1 104,82 		$718,51
$773,46
$831,67
$1 038,47 		$1 029,93
$1 084,88
$1 143,09
$1 349,89 		$1 341,35
$1 396,30
$1 454,51
$1 661,31 		$311,42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814,18
$924,08
$1 040,50
$1 454,10
$2 209,64 		$1 125,60
$1 235,50
$1 351,92
$1 765,52 		$1 437,02
$1 546,92
$1 663,34
$2 076,94 		$1 748,44
$1 858,34
$1 974,76
$2 388,36 		$311,42
Toc - Plan #47 Ambetter from Superior HealthPlan
Gold

(EPO) Ambetter Secure Care 15 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$1,150 $2,300 Annual Deductible
$4,450 $8,900 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 		$513,77
$583,12
$656,59
$917,58
$1 394,36 		$906,80
$976,15
$1 049,62
$1 310,61 		$1 299,83
$1 369,18
$1 442,65
$1 703,64 		$1 692,86
$1 762,21
$1 835,68
$2 096,67 		$393,03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 027,54
$1 166,24
$1 313,18
$1 835,16
$2 788,72 		$1 420,57
$1 559,27
$1 706,21
$2 228,19 		$1 813,60
$1 952,30
$2 099,24
$2 621,22 		$2 206,63
$2 345,33
$2 492,27
$3 014,25 		$393,03

ADVERTISEMENT

Blue Cross and Blue Shield of Texas

Local: 1-888-697-0683 | Toll Free: 1-888-697-0683 | TTY: 1-800-735-2989
Toc - Plan #48 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Gold HMO_ 206

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

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 Annual Deductible
$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 		$415,20
$471,25
$530,62
$741,54
$1 126,85 		$732,83
$788,88
$848,25
$1 059,17 		$1 050,46
$1 106,51
$1 165,88
$1 376,80 		$1 368,09
$1 424,14
$1 483,51
$1 694,43 		$317,63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830,40
$942,50
$1 061,24
$1 483,08
$2 253,70 		$1 148,03
$1 260,13
$1 378,87
$1 800,71 		$1 465,66
$1 577,76
$1 696,50
$2 118,34 		$1 783,29
$1 895,39
$2 014,13
$2 435,97 		$317,63
Toc - Plan #49 Blue Cross and Blue Shield of Texas
Catastrophic

(HMO) Blue Advantage Security HMO_ 200

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$283,98
$322,32
$362,93
$507,19
$770,72 		$501,22
$539,56
$580,17
$724,43 		$718,46
$756,80
$797,41
$941,67 		$935,70
$974,04
$1 014,65
$1 158,91 		$217,24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567,96
$644,64
$725,86
$1 014,38
$1 541,44 		$785,20
$861,88
$943,10
$1 231,62 		$1 002,44
$1 079,12
$1 160,34
$1 448,86 		$1 219,68
$1 296,36
$1 377,58
$1 666,10 		$217,24
Toc - Plan #50 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Silver HMO_ 205

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

Annual Out of Pocket Expenses:

Individual Family
$1,900 $5,700 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 		$414,91
$470,92
$530,25
$741,02
$1 126,06 		$732,31
$788,32
$847,65
$1 058,42 		$1 049,71
$1 105,72
$1 165,05
$1 375,82 		$1 367,11
$1 423,12
$1 482,45
$1 693,22 		$317,40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829,82
$941,84
$1 060,50
$1 482,04
$2 252,12 		$1 147,22
$1 259,24
$1 377,90
$1 799,44 		$1 464,62
$1 576,64
$1 695,30
$2 116,84 		$1 782,02
$1 894,04
$2 012,70
$2 434,24 		$317,40
Toc - Plan #51 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Bronze HMO_ 204

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $17,100 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 		$312,53
$354,72
$399,41
$558,18
$848,20 		$551,61
$593,80
$638,49
$797,26 		$790,69
$832,88
$877,57
$1 036,34 		$1 029,77
$1 071,96
$1 116,65
$1 275,42 		$239,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625,06
$709,44
$798,82
$1 116,36
$1 696,40 		$864,14
$948,52
$1 037,90
$1 355,44 		$1 103,22
$1 187,60
$1 276,98
$1 594,52 		$1 342,30
$1 426,68
$1 516,06
$1 833,60 		$239,08
Toc - Plan #52 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Bronze HMO_ 301

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

Annual Out of Pocket Expenses:

Individual Family
$8,550 $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 		$309,83
$351,66
$395,97
$553,36
$840,89 		$546,85
$588,68
$632,99
$790,38 		$783,87
$825,70
$870,01
$1 027,40 		$1 020,89
$1 062,72
$1 107,03
$1 264,42 		$237,02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619,66
$703,32
$791,94
$1 106,72
$1 681,78 		$856,68
$940,34
$1 028,96
$1 343,74 		$1 093,70
$1 177,36
$1 265,98
$1 580,76 		$1 330,72
$1 414,38
$1 503,00
$1 817,78 		$237,02
Toc - Plan #53 Blue Cross and Blue Shield of Texas
Gold

(HMO) Blue Advantage Plus Gold_ 203

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

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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 		$459,02
$520,99
$586,63
$819,81
$1 245,78 		$810,17
$872,14
$937,78
$1 170,96 		$1 161,32
$1 223,29
$1 288,93
$1 522,11 		$1 512,47
$1 574,44
$1 640,08
$1 873,26 		$351,15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918,04
$1 041,98
$1 173,26
$1 639,62
$2 491,56 		$1 269,19
$1 393,13
$1 524,41
$1 990,77 		$1 620,34
$1 744,28
$1 875,56
$2 341,92 		$1 971,49
$2 095,43
$2 226,71
$2 693,07 		$351,15
Toc - Plan #54 Blue Cross and Blue Shield of Texas
Silver

(HMO) Blue Advantage Plus Silver_ 202

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $3,750 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 		$456,07
$517,64
$582,86
$814,54
$1 237,77 		$804,96
$866,53
$931,75
$1 163,43 		$1 153,85
$1 215,42
$1 280,64
$1 512,32 		$1 502,74
$1 564,31
$1 629,53
$1 861,21 		$348,89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$912,14
$1 035,28
$1 165,72
$1 629,08
$2 475,54 		$1 261,03
$1 384,17
$1 514,61
$1 977,97 		$1 609,92
$1 733,06
$1 863,50
$2 326,86 		$1 958,81
$2 081,95
$2 212,39
$2 675,75 		$348,89
Toc - Plan #55 Blue Cross and Blue Shield of Texas
Expanded Bronze

(HMO) Blue Advantage Plus Bronze_ 303

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

Annual Out of Pocket Expenses:

Individual Family
$4,900 $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 		$345,70
$392,37
$441,81
$617,42
$938,23 		$610,16
$656,83
$706,27
$881,88 		$874,62
$921,29
$970,73
$1 146,34 		$1 139,08
$1 185,75
$1 235,19
$1 410,80 		$264,46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691,40
$784,74
$883,62
$1 234,84
$1 876,46 		$955,86
$1 049,20
$1 148,08
$1 499,30 		$1 220,32
$1 313,66
$1 412,54
$1 763,76 		$1 484,78
$1 578,12
$1 677,00
$2 028,22 		$264,46
Toc - Plan #56 Blue Cross and Blue Shield of Texas
Bronze

(HMO) Blue Advantage Plus Bronze_ 305

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $15,000 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 		$322,98
$366,59
$412,77
$576,85
$876,58 		$570,06
$613,67
$659,85
$823,93 		$817,14
$860,75
$906,93
$1 071,01 		$1 064,22
$1 107,83
$1 154,01
$1 318,09 		$247,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645,96
$733,18
$825,54
$1 153,70
$1 753,16 		$893,04
$980,26
$1 072,62
$1 400,78 		$1 140,12
$1 227,34
$1 319,70
$1 647,86 		$1 387,20
$1 474,42
$1 566,78
$1 894,94 		$247,08

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #57 Molina Healthcare
Gold

(HMO) Molina Gold 3

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$354,37
$402,21
$452,89
$632,91
$961,77 		$625,47
$673,31
$723,99
$904,01 		$896,57
$944,41
$995,09
$1 175,11 		$1 167,67
$1 215,51
$1 266,19
$1 446,21 		$271,10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708,74
$804,42
$905,78
$1 265,82
$1 923,54 		$979,84
$1 075,52
$1 176,88
$1 536,92 		$1 250,94
$1 346,62
$1 447,98
$1 808,02 		$1 522,04
$1 617,72
$1 719,08
$2 079,12 		$271,10
Toc - Plan #58 Molina Healthcare
Silver

(HMO) Molina Silver 3 250

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$333,41
$378,42
$426,09
$595,47
$904,87 		$588,47
$633,48
$681,15
$850,53 		$843,53
$888,54
$936,21
$1 105,59 		$1 098,59
$1 143,60
$1 191,27
$1 360,65 		$255,06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666,82
$756,84
$852,18
$1 190,94
$1 809,74 		$921,88
$1 011,90
$1 107,24
$1 446,00 		$1 176,94
$1 266,96
$1 362,30
$1 701,06 		$1 432,00
$1 522,02
$1 617,36
$1 956,12 		$255,06
Toc - Plan #59 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$356,69
$404,84
$455,85
$637,04
$968,05 		$629,56
$677,71
$728,72
$909,91 		$902,43
$950,58
$1 001,59
$1 182,78 		$1 175,30
$1 223,45
$1 274,46
$1 455,65 		$272,87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713,38
$809,68
$911,70
$1 274,08
$1 936,10 		$986,25
$1 082,55
$1 184,57
$1 546,95 		$1 259,12
$1 355,42
$1 457,44
$1 819,82 		$1 531,99
$1 628,29
$1 730,31
$2 092,69 		$272,87
Toc - Plan #60 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$332,53
$377,43
$424,98
$593,91
$902,50 		$586,92
$631,82
$679,37
$848,30 		$841,31
$886,21
$933,76
$1 102,69 		$1 095,70
$1 140,60
$1 188,15
$1 357,08 		$254,39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665,06
$754,86
$849,96
$1 187,82
$1 805,00 		$919,45
$1 009,25
$1 104,35
$1 442,21 		$1 173,84
$1 263,64
$1 358,74
$1 696,60 		$1 428,23
$1 518,03
$1 613,13
$1 950,99 		$254,39
Toc - Plan #61 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

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

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 		$235,40
$267,18
$300,84
$420,43
$638,88 		$415,48
$447,26
$480,92
$600,51 		$595,56
$627,34
$661,00
$780,59 		$775,64
$807,42
$841,08
$960,67 		$180,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$470,80
$534,36
$601,68
$840,86
$1 277,76 		$650,88
$714,44
$781,76
$1 020,94 		$830,96
$894,52
$961,84
$1 201,02 		$1 011,04
$1 074,60
$1 141,92
$1 381,10 		$180,08
Toc - Plan #62 Molina Healthcare
Silver

(HMO) Constant Care Silver 2 250

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

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 		$332,23
$377,08
$424,59
$593,36
$901,67 		$586,39
$631,24
$678,75
$847,52 		$840,55
$885,40
$932,91
$1 101,68 		$1 094,71
$1 139,56
$1 187,07
$1 355,84 		$254,16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664,46
$754,16
$849,18
$1 186,72
$1 803,34 		$918,62
$1 008,32
$1 103,34
$1 440,88 		$1 172,78
$1 262,48
$1 357,50
$1 695,04 		$1 426,94
$1 516,64
$1 611,66
$1 949,20 		$254,16
Toc - Plan #63 Molina Healthcare
Bronze

(HMO) Core Care Bronze 2

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

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 		$233,37
$264,88
$298,25
$416,80
$633,37 		$411,90
$443,41
$476,78
$595,33 		$590,43
$621,94
$655,31
$773,86 		$768,96
$800,47
$833,84
$952,39 		$178,53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$466,74
$529,76
$596,50
$833,60
$1 266,74 		$645,27
$708,29
$775,03
$1 012,13 		$823,80
$886,82
$953,56
$1 190,66 		$1 002,33
$1 065,35
$1 132,09
$1 369,19 		$178,53
Toc - Plan #64 Molina Healthcare
Silver

(HMO) Constant Care Silver 4 250

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

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 		$328,80
$373,19
$420,20
$587,23
$892,36 		$580,33
$624,72
$671,73
$838,76 		$831,86
$876,25
$923,26
$1 090,29 		$1 083,39
$1 127,78
$1 174,79
$1 341,82 		$251,53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657,60
$746,38
$840,40
$1 174,46
$1 784,72 		$909,13
$997,91
$1 091,93
$1 425,99 		$1 160,66
$1 249,44
$1 343,46
$1 677,52 		$1 412,19
$1 500,97
$1 594,99
$1 929,05 		$251,53
Toc - Plan #65 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

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

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 		$246,33
$279,58
$314,80
$439,94
$668,53 		$434,77
$468,02
$503,24
$628,38 		$623,21
$656,46
$691,68
$816,82 		$811,65
$844,90
$880,12
$1 005,26 		$188,44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492,66
$559,16
$629,60
$879,88
$1 337,06 		$681,10
$747,60
$818,04
$1 068,32 		$869,54
$936,04
$1 006,48
$1 256,76 		$1 057,98
$1 124,48
$1 194,92
$1 445,20 		$188,44
Toc - Plan #66 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 5

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

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 		$239,65
$272,00
$306,27
$428,01
$650,41 		$422,98
$455,33
$489,60
$611,34 		$606,31
$638,66
$672,93
$794,67 		$789,64
$821,99
$856,26
$978,00 		$183,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$479,30
$544,00
$612,54
$856,02
$1 300,82 		$662,63
$727,33
$795,87
$1 039,35 		$845,96
$910,66
$979,20
$1 222,68 		$1 029,29
$1 093,99
$1 162,53
$1 406,01 		$183,33
Toc - Plan #67 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$360,15
$408,77
$460,28
$643,23
$977,46 		$635,67
$684,29
$735,80
$918,75 		$911,19
$959,81
$1 011,32
$1 194,27 		$1 186,71
$1 235,33
$1 286,84
$1 469,79 		$275,52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720,30
$817,54
$920,56
$1 286,46
$1 954,92 		$995,82
$1 093,06
$1 196,08
$1 561,98 		$1 271,34
$1 368,58
$1 471,60
$1 837,50 		$1 546,86
$1 644,10
$1 747,12
$2 113,02 		$275,52
Toc - Plan #68 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250 + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$336,00
$381,36
$429,41
$600,10
$911,91 		$593,04
$638,40
$686,45
$857,14 		$850,08
$895,44
$943,49
$1 114,18 		$1 107,12
$1 152,48
$1 200,53
$1 371,22 		$257,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672,00
$762,72
$858,82
$1 200,20
$1 823,82 		$929,04
$1 019,76
$1 115,86
$1 457,24 		$1 186,08
$1 276,80
$1 372,90
$1 714,28 		$1 443,12
$1 533,84
$1 629,94
$1 971,32 		$257,04
Toc - Plan #69 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1 + Vision

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

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 		$238,87
$271,12
$305,27
$426,62
$648,29 		$421,60
$453,85
$488,00
$609,35 		$604,33
$636,58
$670,73
$792,08 		$787,06
$819,31
$853,46
$974,81 		$182,73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$477,74
$542,24
$610,54
$853,24
$1 296,58 		$660,47
$724,97
$793,27
$1 035,97 		$843,20
$907,70
$976,00
$1 218,70 		$1 025,93
$1 090,43
$1 158,73
$1 401,43 		$182,73

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Friday Health Plans

Local: 1-844-451-4444 | Toll Free: 1-844-451-4444 | TTY: 1-800-659-2656
Toc - Plan #70 Friday Health Plans
Catastrophic

(EPO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

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 		$197,36
$224,00
$252,23
$352,49
$535,64 		$348,34
$374,98
$403,21
$503,47 		$499,32
$525,96
$554,19
$654,45 		$650,30
$676,94
$705,17
$805,43 		$150,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$394,72
$448,00
$504,46
$704,98
$1 071,28 		$545,70
$598,98
$655,44
$855,96 		$696,68
$749,96
$806,42
$1 006,94 		$847,66
$900,94
$957,40
$1 157,92 		$150,98
Toc - Plan #71 Friday Health Plans
Bronze

(EPO) Friday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

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 		$213,70
$242,55
$273,11
$381,67
$579,98 		$377,18
$406,03
$436,59
$545,15 		$540,66
$569,51
$600,07
$708,63 		$704,14
$732,99
$763,55
$872,11 		$163,48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$427,40
$485,10
$546,22
$763,34
$1 159,96 		$590,88
$648,58
$709,70
$926,82 		$754,36
$812,06
$873,18
$1 090,30 		$917,84
$975,54
$1 036,66
$1 253,78 		$163,48
Toc - Plan #72 Friday Health Plans
Expanded Bronze

(EPO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

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 		$226,19
$256,73
$289,08
$403,98
$613,89 		$399,23
$429,77
$462,12
$577,02 		$572,27
$602,81
$635,16
$750,06 		$745,31
$775,85
$808,20
$923,10 		$173,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452,38
$513,46
$578,16
$807,96
$1 227,78 		$625,42
$686,50
$751,20
$981,00 		$798,46
$859,54
$924,24
$1 154,04 		$971,50
$1 032,58
$1 097,28
$1 327,08 		$173,04
Toc - Plan #73 Friday Health Plans
Expanded Bronze

(EPO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

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 		$254,86
$289,26
$325,71
$455,17
$691,68 		$449,83
$484,23
$520,68
$650,14 		$644,80
$679,20
$715,65
$845,11 		$839,77
$874,17
$910,62
$1 040,08 		$194,97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$509,72
$578,52
$651,42
$910,34
$1 383,36 		$704,69
$773,49
$846,39
$1 105,31 		$899,66
$968,46
$1 041,36
$1 300,28 		$1 094,63
$1 163,43
$1 236,33
$1 495,25 		$194,97
Toc - Plan #74 Friday Health Plans
Silver

(EPO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

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 		$326,31
$370,37
$417,03
$582,80
$885,62 		$575,94
$620,00
$666,66
$832,43 		$825,57
$869,63
$916,29
$1 082,06 		$1 075,20
$1 119,26
$1 165,92
$1 331,69 		$249,63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652,62
$740,74
$834,06
$1 165,60
$1 771,24 		$902,25
$990,37
$1 083,69
$1 415,23 		$1 151,88
$1 240,00
$1 333,32
$1 664,86 		$1 401,51
$1 489,63
$1 582,95
$1 914,49 		$249,63
Toc - Plan #75 Friday Health Plans
Gold

(EPO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-451-4444

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 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 		$307,51
$349,02
$392,99
$549,21
$834,57 		$542,75
$584,26
$628,23
$784,45 		$777,99
$819,50
$863,47
$1 019,69 		$1 013,23
$1 054,74
$1 098,71
$1 254,93 		$235,24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615,02
$698,04
$785,98
$1 098,42
$1 669,14 		$850,26
$933,28
$1 021,22
$1 333,66 		$1 085,50
$1 168,52
$1 256,46
$1 568,90 		$1 320,74
$1 403,76
$1 491,70
$1 804,14 		$235,24

‡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 Tarrant County here.

Tarrant County is in “Rating Area 8” of Texas.

Currently, there are 75 plans offered in Rating Area 8.

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