Obamacare 2022 Rates for Oakland County

Obamacare > Rates > Michigan > Oakland 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 Oakland County, MI.

The health insurance rates listed below are for calendar year 2022.

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, 115 Plans and 2022 Rates for Oakland County, Michigan

Below, you’ll find a summary of the 115 plans for Oakland County, Michigan 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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Blue Cross Blue Shield of Michigan Mutual Insurance Company

Local: 1-888-288-2738 | Toll Free: 1-888-288-2738 | TTY: 1-800-481-8704
Toc - Plan #1 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Catastrophic

(PPO) Blue Cross® Premier PPO Value

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-288-2738

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$231.42
$262.66
$295.75
$413.32
$628.07 		$408.46
$439.70
$472.79
$590.36 		$585.50
$616.74
$649.83
$767.40 		$762.54
$793.78
$826.87
$944.44 		$177.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$462.84
$525.32
$591.50
$826.64
$1,256.14 		$639.88
$702.36
$768.54
$1,003.68 		$816.92
$879.40
$945.58
$1,180.72 		$993.96
$1,056.44
$1,122.62
$1,357.76 		$177.04
Toc - Plan #2 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Expanded Bronze

(PPO) Blue Cross® Premier PPO Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-288-2738

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 		$316.21
$358.90
$404.12
$564.75
$858.19 		$558.11
$600.80
$646.02
$806.65 		$800.01
$842.70
$887.92
$1,048.55 		$1,041.91
$1,084.60
$1,129.82
$1,290.45 		$241.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.42
$717.80
$808.24
$1,129.50
$1,716.38 		$874.32
$959.70
$1,050.14
$1,371.40 		$1,116.22
$1,201.60
$1,292.04
$1,613.30 		$1,358.12
$1,443.50
$1,533.94
$1,855.20 		$241.90
Toc - Plan #3 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Silver

(PPO) Blue Cross® Premier PPO Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-288-2738

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$423.64
$480.83
$541.41
$756.62
$1,149.76 		$747.72
$804.91
$865.49
$1,080.70 		$1,071.80
$1,128.99
$1,189.57
$1,404.78 		$1,395.88
$1,453.07
$1,513.65
$1,728.86 		$324.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$847.28
$961.66
$1,082.82
$1,513.24
$2,299.52 		$1,171.36
$1,285.74
$1,406.90
$1,837.32 		$1,495.44
$1,609.82
$1,730.98
$2,161.40 		$1,819.52
$1,933.90
$2,055.06
$2,485.48 		$324.08
Toc - Plan #4 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Gold

(PPO) Blue Cross® Premier PPO Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-288-2738

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$535.58
$607.88
$684.47
$956.55
$1,453.56 		$945.30
$1,017.60
$1,094.19
$1,366.27 		$1,355.02
$1,427.32
$1,503.91
$1,775.99 		$1,764.74
$1,837.04
$1,913.63
$2,185.71 		$409.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,071.16
$1,215.76
$1,368.94
$1,913.10
$2,907.12 		$1,480.88
$1,625.48
$1,778.66
$2,322.82 		$1,890.60
$2,035.20
$2,188.38
$2,732.54 		$2,300.32
$2,444.92
$2,598.10
$3,142.26 		$409.72
Toc - Plan #5 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Bronze

(PPO) Blue Cross® Premier PPO Bronze Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-288-2738

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$291.08
$330.38
$372.00
$519.87
$789.99 		$513.76
$553.06
$594.68
$742.55 		$736.44
$775.74
$817.36
$965.23 		$959.12
$998.42
$1,040.04
$1,187.91 		$222.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582.16
$660.76
$744.00
$1,039.74
$1,579.98 		$804.84
$883.44
$966.68
$1,262.42 		$1,027.52
$1,106.12
$1,189.36
$1,485.10 		$1,250.20
$1,328.80
$1,412.04
$1,707.78 		$222.68
Toc - Plan #6 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Silver

(PPO) Blue Cross® Premier PPO Silver Saver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-288-2738

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 		$413.27
$469.06
$528.16
$738.10
$1,121.61 		$729.42
$785.21
$844.31
$1,054.25 		$1,045.57
$1,101.36
$1,160.46
$1,370.40 		$1,361.72
$1,417.51
$1,476.61
$1,686.55 		$316.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.54
$938.12
$1,056.32
$1,476.20
$2,243.22 		$1,142.69
$1,254.27
$1,372.47
$1,792.35 		$1,458.84
$1,570.42
$1,688.62
$2,108.50 		$1,774.99
$1,886.57
$2,004.77
$2,424.65 		$316.15
Toc - Plan #7 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Expanded Bronze

(PPO) Blue Cross® Premier PPO Bronze Extra

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-288-2738

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$327.65
$371.88
$418.74
$585.18
$889.24 		$578.30
$622.53
$669.39
$835.83 		$828.95
$873.18
$920.04
$1,086.48 		$1,079.60
$1,123.83
$1,170.69
$1,337.13 		$250.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.30
$743.76
$837.48
$1,170.36
$1,778.48 		$905.95
$994.41
$1,088.13
$1,421.01 		$1,156.60
$1,245.06
$1,338.78
$1,671.66 		$1,407.25
$1,495.71
$1,589.43
$1,922.31 		$250.65
Toc - Plan #8 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Silver

(PPO) Blue Cross® Premier PPO Silver Extra

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-288-2738

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$461.65
$523.97
$589.99
$824.51
$1,252.92 		$814.81
$877.13
$943.15
$1,177.67 		$1,167.97
$1,230.29
$1,296.31
$1,530.83 		$1,521.13
$1,583.45
$1,649.47
$1,883.99 		$353.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$923.30
$1,047.94
$1,179.98
$1,649.02
$2,505.84 		$1,276.46
$1,401.10
$1,533.14
$2,002.18 		$1,629.62
$1,754.26
$1,886.30
$2,355.34 		$1,982.78
$2,107.42
$2,239.46
$2,708.50 		$353.16

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Priority Health

Local: 1-855-682-5217 | Toll Free: 1-855-682-5217 | TTY: 1-888-551-6761
Toc - Plan #9 Priority Health
Gold

(HMO) MyPriority Gold 1100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$1,100 $2,200 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 		$412.78
$468.51
$527.53
$737.23
$1,120.28 		$728.56
$784.29
$843.31
$1,053.01 		$1,044.34
$1,100.07
$1,159.09
$1,368.79 		$1,360.12
$1,415.85
$1,474.87
$1,684.57 		$315.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.56
$937.02
$1,055.06
$1,474.46
$2,240.56 		$1,141.34
$1,252.80
$1,370.84
$1,790.24 		$1,457.12
$1,568.58
$1,686.62
$2,106.02 		$1,772.90
$1,884.36
$2,002.40
$2,421.80 		$315.78
Toc - Plan #10 Priority Health
Expanded Bronze

(HMO) MyPriority HSA Bronze 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$228.39
$259.22
$291.88
$407.90
$619.85 		$403.11
$433.94
$466.60
$582.62 		$577.83
$608.66
$641.32
$757.34 		$752.55
$783.38
$816.04
$932.06 		$174.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$456.78
$518.44
$583.76
$815.80
$1,239.70 		$631.50
$693.16
$758.48
$990.52 		$806.22
$867.88
$933.20
$1,165.24 		$980.94
$1,042.60
$1,107.92
$1,339.96 		$174.72
Toc - Plan #11 Priority Health
Expanded Bronze

(HMO) MyPriority HSA Bronze 7050 - Beaumont Health Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$205.55
$233.30
$262.69
$367.11
$557.86 		$362.80
$390.55
$419.94
$524.36 		$520.05
$547.80
$577.19
$681.61 		$677.30
$705.05
$734.44
$838.86 		$157.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$411.10
$466.60
$525.38
$734.22
$1,115.72 		$568.35
$623.85
$682.63
$891.47 		$725.60
$781.10
$839.88
$1,048.72 		$882.85
$938.35
$997.13
$1,205.97 		$157.25
Toc - Plan #12 Priority Health
Expanded Bronze

(HMO) MyPriority HSA Bronze 7050 - Ascension St. John Providence Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$198.25
$225.01
$253.36
$354.07
$538.05 		$349.91
$376.67
$405.02
$505.73 		$501.57
$528.33
$556.68
$657.39 		$653.23
$679.99
$708.34
$809.05 		$151.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$396.50
$450.02
$506.72
$708.14
$1,076.10 		$548.16
$601.68
$658.38
$859.80 		$699.82
$753.34
$810.04
$1,011.46 		$851.48
$905.00
$961.70
$1,163.12 		$151.66
Toc - Plan #13 Priority Health
Expanded Bronze

(HMO) MyPriority HSA Bronze 7050 - St. Joseph Mercy Health System Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$206.01
$233.82
$263.28
$367.93
$559.11 		$363.61
$391.42
$420.88
$525.53 		$521.21
$549.02
$578.48
$683.13 		$678.81
$706.62
$736.08
$840.73 		$157.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$412.02
$467.64
$526.56
$735.86
$1,118.22 		$569.62
$625.24
$684.16
$893.46 		$727.22
$782.84
$841.76
$1,051.06 		$884.82
$940.44
$999.36
$1,208.66 		$157.60
Toc - Plan #14 Priority Health
Expanded Bronze

(HMO) MyPriority Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$214.28
$243.21
$273.85
$382.70
$581.56 		$378.20
$407.13
$437.77
$546.62 		$542.12
$571.05
$601.69
$710.54 		$706.04
$734.97
$765.61
$874.46 		$163.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$428.56
$486.42
$547.70
$765.40
$1,163.12 		$592.48
$650.34
$711.62
$929.32 		$756.40
$814.26
$875.54
$1,093.24 		$920.32
$978.18
$1,039.46
$1,257.16 		$163.92
Toc - Plan #15 Priority Health
Expanded Bronze

(HMO) MyPriority Bronze 8700 - Beaumont Health Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$192.85
$218.88
$246.46
$344.43
$523.39 		$340.38
$366.41
$393.99
$491.96 		$487.91
$513.94
$541.52
$639.49 		$635.44
$661.47
$689.05
$787.02 		$147.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$385.70
$437.76
$492.92
$688.86
$1,046.78 		$533.23
$585.29
$640.45
$836.39 		$680.76
$732.82
$787.98
$983.92 		$828.29
$880.35
$935.51
$1,131.45 		$147.53
Toc - Plan #16 Priority Health
Expanded Bronze

(HMO) MyPriority Bronze 8700 - Ascension St. John Providence Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$186.00
$211.11
$237.71
$332.20
$504.80 		$328.29
$353.40
$380.00
$474.49 		$470.58
$495.69
$522.29
$616.78 		$612.87
$637.98
$664.58
$759.07 		$142.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$372.00
$422.22
$475.42
$664.40
$1,009.60 		$514.29
$564.51
$617.71
$806.69 		$656.58
$706.80
$760.00
$948.98 		$798.87
$849.09
$902.29
$1,091.27 		$142.29
Toc - Plan #17 Priority Health
Expanded Bronze

(HMO) MyPriority Bronze 8700 - St. Joseph Mercy Health System Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$193.28
$219.37
$247.01
$345.20
$524.56 		$341.14
$367.23
$394.87
$493.06 		$489.00
$515.09
$542.73
$640.92 		$636.86
$662.95
$690.59
$788.78 		$147.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$386.56
$438.74
$494.02
$690.40
$1,049.12 		$534.42
$586.60
$641.88
$838.26 		$682.28
$734.46
$789.74
$986.12 		$830.14
$882.32
$937.60
$1,133.98 		$147.86
Toc - Plan #18 Priority Health
Expanded Bronze

(HMO) MyPriority Telehealth PCP Bronze 8700 - (Doctor On Demand PCP selection required)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$201.43
$228.62
$257.43
$359.75
$546.68 		$355.52
$382.71
$411.52
$513.84 		$509.61
$536.80
$565.61
$667.93 		$663.70
$690.89
$719.70
$822.02 		$154.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$402.86
$457.24
$514.86
$719.50
$1,093.36 		$556.95
$611.33
$668.95
$873.59 		$711.04
$765.42
$823.04
$1,027.68 		$865.13
$919.51
$977.13
$1,181.77 		$154.09
Toc - Plan #19 Priority Health
Expanded Bronze

(HMO) MyPriority Travel Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$246.42
$279.69
$314.92
$440.11
$668.78 		$434.93
$468.20
$503.43
$628.62 		$623.44
$656.71
$691.94
$817.13 		$811.95
$845.22
$880.45
$1,005.64 		$188.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492.84
$559.38
$629.84
$880.22
$1,337.56 		$681.35
$747.89
$818.35
$1,068.73 		$869.86
$936.40
$1,006.86
$1,257.24 		$1,058.37
$1,124.91
$1,195.37
$1,445.75 		$188.51
Toc - Plan #20 Priority Health
Silver

(HMO) MyPriority Silver 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.02
$340.52
$383.43
$535.84
$814.25 		$529.54
$570.04
$612.95
$765.36 		$759.06
$799.56
$842.47
$994.88 		$988.58
$1,029.08
$1,071.99
$1,224.40 		$229.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.04
$681.04
$766.86
$1,071.68
$1,628.50 		$829.56
$910.56
$996.38
$1,301.20 		$1,059.08
$1,140.08
$1,225.90
$1,530.72 		$1,288.60
$1,369.60
$1,455.42
$1,760.24 		$229.52
Toc - Plan #21 Priority Health
Silver

(HMO) MyPriority Silver 3500 - Beaumont Health Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$270.02
$306.47
$345.09
$482.26
$732.83 		$476.59
$513.04
$551.66
$688.83 		$683.16
$719.61
$758.23
$895.40 		$889.73
$926.18
$964.80
$1,101.97 		$206.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.04
$612.94
$690.18
$964.52
$1,465.66 		$746.61
$819.51
$896.75
$1,171.09 		$953.18
$1,026.08
$1,103.32
$1,377.66 		$1,159.75
$1,232.65
$1,309.89
$1,584.23 		$206.57
Toc - Plan #22 Priority Health
Silver

(HMO) MyPriority Silver 3500 - Ascension St. John Providence Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$260.42
$295.58
$332.82
$465.11
$706.78 		$459.64
$494.80
$532.04
$664.33 		$658.86
$694.02
$731.26
$863.55 		$858.08
$893.24
$930.48
$1,062.77 		$199.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$520.84
$591.16
$665.64
$930.22
$1,413.56 		$720.06
$790.38
$864.86
$1,129.44 		$919.28
$989.60
$1,064.08
$1,328.66 		$1,118.50
$1,188.82
$1,263.30
$1,527.88 		$199.22
Toc - Plan #23 Priority Health
Silver

(HMO) MyPriority Silver 3500 - St. Joseph Mercy Health System Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$270.62
$307.15
$345.85
$483.33
$734.46 		$477.64
$514.17
$552.87
$690.35 		$684.66
$721.19
$759.89
$897.37 		$891.68
$928.21
$966.91
$1,104.39 		$207.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541.24
$614.30
$691.70
$966.66
$1,468.92 		$748.26
$821.32
$898.72
$1,173.68 		$955.28
$1,028.34
$1,105.74
$1,380.70 		$1,162.30
$1,235.36
$1,312.76
$1,587.72 		$207.02
Toc - Plan #24 Priority Health
Silver

(HMO) MyPriority Silver 2500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$312.95
$355.20
$399.95
$558.93
$849.35 		$552.36
$594.61
$639.36
$798.34 		$791.77
$834.02
$878.77
$1,037.75 		$1,031.18
$1,073.43
$1,118.18
$1,277.16 		$239.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.90
$710.40
$799.90
$1,117.86
$1,698.70 		$865.31
$949.81
$1,039.31
$1,357.27 		$1,104.72
$1,189.22
$1,278.72
$1,596.68 		$1,344.13
$1,428.63
$1,518.13
$1,836.09 		$239.41
Toc - Plan #25 Priority Health
Silver

(HMO) MyPriority Silver 2500 - Beaumont Health Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.65
$319.67
$359.95
$503.03
$764.40 		$497.11
$535.13
$575.41
$718.49 		$712.57
$750.59
$790.87
$933.95 		$928.03
$966.05
$1,006.33
$1,149.41 		$215.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.30
$639.34
$719.90
$1,006.06
$1,528.80 		$778.76
$854.80
$935.36
$1,221.52 		$994.22
$1,070.26
$1,150.82
$1,436.98 		$1,209.68
$1,285.72
$1,366.28
$1,652.44 		$215.46
Toc - Plan #26 Priority Health
Silver

(HMO) MyPriority Silver 2500 - Ascension St. John Providence Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$271.64
$308.31
$347.16
$485.15
$737.23 		$479.44
$516.11
$554.96
$692.95 		$687.24
$723.91
$762.76
$900.75 		$895.04
$931.71
$970.56
$1,108.55 		$207.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543.28
$616.62
$694.32
$970.30
$1,474.46 		$751.08
$824.42
$902.12
$1,178.10 		$958.88
$1,032.22
$1,109.92
$1,385.90 		$1,166.68
$1,240.02
$1,317.72
$1,593.70 		$207.80
Toc - Plan #27 Priority Health
Silver

(HMO) MyPriority Silver 2500 - St. Joseph Mercy Health System Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282.28
$320.39
$360.75
$504.15
$766.11 		$498.22
$536.33
$576.69
$720.09 		$714.16
$752.27
$792.63
$936.03 		$930.10
$968.21
$1,008.57
$1,151.97 		$215.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.56
$640.78
$721.50
$1,008.30
$1,532.22 		$780.50
$856.72
$937.44
$1,224.24 		$996.44
$1,072.66
$1,153.38
$1,440.18 		$1,212.38
$1,288.60
$1,369.32
$1,656.12 		$215.94
Toc - Plan #28 Priority Health
Silver

(HMO) MyPriority Silver 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$283.70
$322.00
$362.57
$506.69
$769.96 		$500.73
$539.03
$579.60
$723.72 		$717.76
$756.06
$796.63
$940.75 		$934.79
$973.09
$1,013.66
$1,157.78 		$217.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.40
$644.00
$725.14
$1,013.38
$1,539.92 		$784.43
$861.03
$942.17
$1,230.41 		$1,001.46
$1,078.06
$1,159.20
$1,447.44 		$1,218.49
$1,295.09
$1,376.23
$1,664.47 		$217.03
Toc - Plan #29 Priority Health
Silver

(HMO) MyPriority Silver 5500 - Beaumont Health Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$255.33
$289.80
$326.31
$456.02
$692.97 		$450.66
$485.13
$521.64
$651.35 		$645.99
$680.46
$716.97
$846.68 		$841.32
$875.79
$912.30
$1,042.01 		$195.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$510.66
$579.60
$652.62
$912.04
$1,385.94 		$705.99
$774.93
$847.95
$1,107.37 		$901.32
$970.26
$1,043.28
$1,302.70 		$1,096.65
$1,165.59
$1,238.61
$1,498.03 		$195.33
Toc - Plan #30 Priority Health
Silver

(HMO) MyPriority Silver 5500 - Ascension St. John Providence Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$246.25
$279.49
$314.71
$439.80
$668.32 		$434.63
$467.87
$503.09
$628.18 		$623.01
$656.25
$691.47
$816.56 		$811.39
$844.63
$879.85
$1,004.94 		$188.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492.50
$558.98
$629.42
$879.60
$1,336.64 		$680.88
$747.36
$817.80
$1,067.98 		$869.26
$935.74
$1,006.18
$1,256.36 		$1,057.64
$1,124.12
$1,194.56
$1,444.74 		$188.38
Toc - Plan #31 Priority Health
Silver

(HMO) MyPriority Silver 5500 - St. Joseph Mercy Health System Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$255.90
$290.45
$327.04
$457.04
$694.51 		$451.66
$486.21
$522.80
$652.80 		$647.42
$681.97
$718.56
$848.56 		$843.18
$877.73
$914.32
$1,044.32 		$195.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$511.80
$580.90
$654.08
$914.08
$1,389.02 		$707.56
$776.66
$849.84
$1,109.84 		$903.32
$972.42
$1,045.60
$1,305.60 		$1,099.08
$1,168.18
$1,241.36
$1,501.36 		$195.76
Toc - Plan #32 Priority Health
Silver

(HMO) MyPriority Telehealth PCP Silver 5500 - (Doctor On Demand PCP selection required)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$266.68
$302.68
$340.82
$476.29
$723.77 		$470.69
$506.69
$544.83
$680.30 		$674.70
$710.70
$748.84
$884.31 		$878.71
$914.71
$952.85
$1,088.32 		$204.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$533.36
$605.36
$681.64
$952.58
$1,447.54 		$737.37
$809.37
$885.65
$1,156.59 		$941.38
$1,013.38
$1,089.66
$1,360.60 		$1,145.39
$1,217.39
$1,293.67
$1,564.61 		$204.01
Toc - Plan #33 Priority Health
Silver

(HMO) MyPriority Travel Silver 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.44
$386.40
$435.08
$608.03
$923.95 		$600.88
$646.84
$695.52
$868.47 		$861.32
$907.28
$955.96
$1,128.91 		$1,121.76
$1,167.72
$1,216.40
$1,389.35 		$260.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.88
$772.80
$870.16
$1,216.06
$1,847.90 		$941.32
$1,033.24
$1,130.60
$1,476.50 		$1,201.76
$1,293.68
$1,391.04
$1,736.94 		$1,462.20
$1,554.12
$1,651.48
$1,997.38 		$260.44
Toc - Plan #34 Priority Health
Gold

(HMO) MyPriority Gold Copay+ - Beaumont Health Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.93
$422.14
$475.33
$664.27
$1,009.42 		$656.46
$706.67
$759.86
$948.80 		$940.99
$991.20
$1,044.39
$1,233.33 		$1,225.52
$1,275.73
$1,328.92
$1,517.86 		$284.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.86
$844.28
$950.66
$1,328.54
$2,018.84 		$1,028.39
$1,128.81
$1,235.19
$1,613.07 		$1,312.92
$1,413.34
$1,519.72
$1,897.60 		$1,597.45
$1,697.87
$1,804.25
$2,182.13 		$284.53
Toc - Plan #35 Priority Health
Gold

(HMO) MyPriority Gold Copay+ - Ascension St. John Providence Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.71
$407.14
$458.43
$640.66
$973.54 		$633.12
$681.55
$732.84
$915.07 		$907.53
$955.96
$1,007.25
$1,189.48 		$1,181.94
$1,230.37
$1,281.66
$1,463.89 		$274.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.42
$814.28
$916.86
$1,281.32
$1,947.08 		$991.83
$1,088.69
$1,191.27
$1,555.73 		$1,266.24
$1,363.10
$1,465.68
$1,830.14 		$1,540.65
$1,637.51
$1,740.09
$2,104.55 		$274.41
Toc - Plan #36 Priority Health
Gold

(HMO) MyPriority Gold Copay+ - St. Joseph Mercy Health System Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-682-5217

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.76
$423.08
$476.39
$665.75
$1,011.67 		$657.92
$708.24
$761.55
$950.91 		$943.08
$993.40
$1,046.71
$1,236.07 		$1,228.24
$1,278.56
$1,331.87
$1,521.23 		$285.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.52
$846.16
$952.78
$1,331.50
$2,023.34 		$1,030.68
$1,131.32
$1,237.94
$1,616.66 		$1,315.84
$1,416.48
$1,523.10
$1,901.82 		$1,601.00
$1,701.64
$1,808.26
$2,186.98 		$285.16

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-4087 | Toll Free: 1-888-560-4087 | TTY: 1-888-665-4629
Toc - Plan #37 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-4087

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$261.53
$296.83
$334.23
$467.09
$709.79 		$461.60
$496.90
$534.30
$667.16 		$661.67
$696.97
$734.37
$867.23 		$861.74
$897.04
$934.44
$1,067.30 		$200.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523.06
$593.66
$668.46
$934.18
$1,419.58 		$723.13
$793.73
$868.53
$1,134.25 		$923.20
$993.80
$1,068.60
$1,334.32 		$1,123.27
$1,193.87
$1,268.67
$1,534.39 		$200.07
Toc - Plan #38 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-4087

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 		$256.24
$290.83
$327.47
$457.64
$695.42 		$452.26
$486.85
$523.49
$653.66 		$648.28
$682.87
$719.51
$849.68 		$844.30
$878.89
$915.53
$1,045.70 		$196.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$512.48
$581.66
$654.94
$915.28
$1,390.84 		$708.50
$777.68
$850.96
$1,111.30 		$904.52
$973.70
$1,046.98
$1,307.32 		$1,100.54
$1,169.72
$1,243.00
$1,503.34 		$196.02
Toc - Plan #39 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-4087

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 		$254.06
$288.36
$324.69
$453.75
$689.51 		$448.41
$482.71
$519.04
$648.10 		$642.76
$677.06
$713.39
$842.45 		$837.11
$871.41
$907.74
$1,036.80 		$194.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$508.12
$576.72
$649.38
$907.50
$1,379.02 		$702.47
$771.07
$843.73
$1,101.85 		$896.82
$965.42
$1,038.08
$1,296.20 		$1,091.17
$1,159.77
$1,232.43
$1,490.55 		$194.35
Toc - Plan #40 Molina Healthcare
Silver

(HMO) Constant Care Silver 7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-4087

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 		$251.04
$284.93
$320.82
$448.35
$681.31 		$443.08
$476.97
$512.86
$640.39 		$635.12
$669.01
$704.90
$832.43 		$827.16
$861.05
$896.94
$1,024.47 		$192.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$502.08
$569.86
$641.64
$896.70
$1,362.62 		$694.12
$761.90
$833.68
$1,088.74 		$886.16
$953.94
$1,025.72
$1,280.78 		$1,078.20
$1,145.98
$1,217.76
$1,472.82 		$192.04
Toc - Plan #41 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-4087

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$268.94
$305.25
$343.71
$480.33
$729.91 		$474.68
$510.99
$549.45
$686.07 		$680.42
$716.73
$755.19
$891.81 		$886.16
$922.47
$960.93
$1,097.55 		$205.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$537.88
$610.50
$687.42
$960.66
$1,459.82 		$743.62
$816.24
$893.16
$1,166.40 		$949.36
$1,021.98
$1,098.90
$1,372.14 		$1,155.10
$1,227.72
$1,304.64
$1,577.88 		$205.74
Toc - Plan #42 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-4087

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 		$262.47
$297.90
$335.44
$468.77
$712.34 		$463.26
$498.69
$536.23
$669.56 		$664.05
$699.48
$737.02
$870.35 		$864.84
$900.27
$937.81
$1,071.14 		$200.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524.94
$595.80
$670.88
$937.54
$1,424.68 		$725.73
$796.59
$871.67
$1,138.33 		$926.52
$997.38
$1,072.46
$1,339.12 		$1,127.31
$1,198.17
$1,273.25
$1,539.91 		$200.79
Toc - Plan #43 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-4087

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 		$253.60
$287.84
$324.10
$452.93
$688.27 		$447.60
$481.84
$518.10
$646.93 		$641.60
$675.84
$712.10
$840.93 		$835.60
$869.84
$906.10
$1,034.93 		$194.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$507.20
$575.68
$648.20
$905.86
$1,376.54 		$701.20
$769.68
$842.20
$1,099.86 		$895.20
$963.68
$1,036.20
$1,293.86 		$1,089.20
$1,157.68
$1,230.20
$1,487.86 		$194.00

ADVERTISEMENT

Ambetter from Meridian

Local: 1-833-993-2426 | Toll Free: 1-833-993-2426

Toc - Plan #44 Ambetter from Meridian
Bronze

(HMO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 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 		$171.10
$194.19
$218.66
$305.57
$464.34 		$301.99
$325.08
$349.55
$436.46 		$432.88
$455.97
$480.44
$567.35 		$563.77
$586.86
$611.33
$698.24 		$130.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$342.20
$388.38
$437.32
$611.14
$928.68 		$473.09
$519.27
$568.21
$742.03 		$603.98
$650.16
$699.10
$872.92 		$734.87
$781.05
$829.99
$1,003.81 		$130.89
Toc - Plan #45 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

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 		$185.91
$210.99
$237.58
$332.01
$504.52 		$328.12
$353.20
$379.79
$474.22 		$470.33
$495.41
$522.00
$616.43 		$612.54
$637.62
$664.21
$758.64 		$142.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$371.82
$421.98
$475.16
$664.02
$1,009.04 		$514.03
$564.19
$617.37
$806.23 		$656.24
$706.40
$759.58
$948.44 		$798.45
$848.61
$901.79
$1,090.65 		$142.21
Toc - Plan #46 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

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 		$244.71
$277.73
$312.72
$437.03
$664.11 		$431.90
$464.92
$499.91
$624.22 		$619.09
$652.11
$687.10
$811.41 		$806.28
$839.30
$874.29
$998.60 		$187.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$489.42
$555.46
$625.44
$874.06
$1,328.22 		$676.61
$742.65
$812.63
$1,061.25 		$863.80
$929.84
$999.82
$1,248.44 		$1,050.99
$1,117.03
$1,187.01
$1,435.63 		$187.19
Toc - Plan #47 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

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 		$241.35
$273.93
$308.44
$431.04
$655.01 		$425.98
$458.56
$493.07
$615.67 		$610.61
$643.19
$677.70
$800.30 		$795.24
$827.82
$862.33
$984.93 		$184.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$482.70
$547.86
$616.88
$862.08
$1,310.02 		$667.33
$732.49
$801.51
$1,046.71 		$851.96
$917.12
$986.14
$1,231.34 		$1,036.59
$1,101.75
$1,170.77
$1,415.97 		$184.63
Toc - Plan #48 Ambetter from Meridian
Gold

(HMO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

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 		$266.68
$302.67
$340.81
$476.27
$723.74 		$470.68
$506.67
$544.81
$680.27 		$674.68
$710.67
$748.81
$884.27 		$878.68
$914.67
$952.81
$1,088.27 		$204.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$533.36
$605.34
$681.62
$952.54
$1,447.48 		$737.36
$809.34
$885.62
$1,156.54 		$941.36
$1,013.34
$1,089.62
$1,360.54 		$1,145.36
$1,217.34
$1,293.62
$1,564.54 		$204.00
Toc - Plan #49 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$187.23
$212.49
$239.26
$334.37
$508.11 		$330.45
$355.71
$382.48
$477.59 		$473.67
$498.93
$525.70
$620.81 		$616.89
$642.15
$668.92
$764.03 		$143.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$374.46
$424.98
$478.52
$668.74
$1,016.22 		$517.68
$568.20
$621.74
$811.96 		$660.90
$711.42
$764.96
$955.18 		$804.12
$854.64
$908.18
$1,098.40 		$143.22
Toc - Plan #50 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care: $1,500 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$203.48
$230.93
$260.03
$363.39
$552.21 		$359.13
$386.58
$415.68
$519.04 		$514.78
$542.23
$571.33
$674.69 		$670.43
$697.88
$726.98
$830.34 		$155.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$406.96
$461.86
$520.06
$726.78
$1,104.42 		$562.61
$617.51
$675.71
$882.43 		$718.26
$773.16
$831.36
$1,038.08 		$873.91
$928.81
$987.01
$1,193.73 		$155.65
Toc - Plan #51 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$214.90
$243.90
$274.63
$383.80
$583.22 		$379.29
$408.29
$439.02
$548.19 		$543.68
$572.68
$603.41
$712.58 		$708.07
$737.07
$767.80
$876.97 		$164.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$429.80
$487.80
$549.26
$767.60
$1,166.44 		$594.19
$652.19
$713.65
$931.99 		$758.58
$816.58
$878.04
$1,096.38 		$922.97
$980.97
$1,042.43
$1,260.77 		$164.39
Toc - Plan #52 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$6,100 $12,200 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 		$226.26
$256.79
$289.14
$404.08
$614.03 		$399.34
$429.87
$462.22
$577.16 		$572.42
$602.95
$635.30
$750.24 		$745.50
$776.03
$808.38
$923.32 		$173.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452.52
$513.58
$578.28
$808.16
$1,228.06 		$625.60
$686.66
$751.36
$981.24 		$798.68
$859.74
$924.44
$1,154.32 		$971.76
$1,032.82
$1,097.52
$1,327.40 		$173.08
Toc - Plan #53 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 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 		$226.33
$256.87
$289.24
$404.21
$614.23 		$399.47
$430.01
$462.38
$577.35 		$572.61
$603.15
$635.52
$750.49 		$745.75
$776.29
$808.66
$923.63 		$173.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452.66
$513.74
$578.48
$808.42
$1,228.46 		$625.80
$686.88
$751.62
$981.56 		$798.94
$860.02
$924.76
$1,154.70 		$972.08
$1,033.16
$1,097.90
$1,327.84 		$173.14
Toc - Plan #54 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$233.60
$265.12
$298.53
$417.19
$633.96 		$412.29
$443.81
$477.22
$595.88 		$590.98
$622.50
$655.91
$774.57 		$769.67
$801.19
$834.60
$953.26 		$178.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$467.20
$530.24
$597.06
$834.38
$1,267.92 		$645.89
$708.93
$775.75
$1,013.07 		$824.58
$887.62
$954.44
$1,191.76 		$1,003.27
$1,066.31
$1,133.13
$1,370.45 		$178.69
Toc - Plan #55 Ambetter from Meridian
Gold

(HMO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$249.80
$283.51
$319.23
$446.12
$677.92 		$440.89
$474.60
$510.32
$637.21 		$631.98
$665.69
$701.41
$828.30 		$823.07
$856.78
$892.50
$1,019.39 		$191.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499.60
$567.02
$638.46
$892.24
$1,355.84 		$690.69
$758.11
$829.55
$1,083.33 		$881.78
$949.20
$1,020.64
$1,274.42 		$1,072.87
$1,140.29
$1,211.73
$1,465.51 		$191.09
Toc - Plan #56 Ambetter from Meridian
Bronze

(HMO) Ambetter Essential Care 1 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 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 		$186.12
$211.24
$237.85
$332.39
$505.11 		$328.50
$353.62
$380.23
$474.77 		$470.88
$496.00
$522.61
$617.15 		$613.26
$638.38
$664.99
$759.53 		$142.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$372.24
$422.48
$475.70
$664.78
$1,010.22 		$514.62
$564.86
$618.08
$807.16 		$657.00
$707.24
$760.46
$949.54 		$799.38
$849.62
$902.84
$1,091.92 		$142.38
Toc - Plan #57 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

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 		$202.23
$229.51
$258.43
$361.16
$548.81 		$356.92
$384.20
$413.12
$515.85 		$511.61
$538.89
$567.81
$670.54 		$666.30
$693.58
$722.50
$825.23 		$154.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$404.46
$459.02
$516.86
$722.32
$1,097.62 		$559.15
$613.71
$671.55
$877.01 		$713.84
$768.40
$826.24
$1,031.70 		$868.53
$923.09
$980.93
$1,186.39 		$154.69
Toc - Plan #58 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 11 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

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 		$266.19
$302.11
$340.17
$475.39
$722.41 		$469.82
$505.74
$543.80
$679.02 		$673.45
$709.37
$747.43
$882.65 		$877.08
$913.00
$951.06
$1,086.28 		$203.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$532.38
$604.22
$680.34
$950.78
$1,444.82 		$736.01
$807.85
$883.97
$1,154.41 		$939.64
$1,011.48
$1,087.60
$1,358.04 		$1,143.27
$1,215.11
$1,291.23
$1,561.67 		$203.63
Toc - Plan #59 Ambetter from Meridian
Gold

(HMO) Ambetter Secure Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

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 		$290.09
$329.24
$370.72
$518.08
$787.28 		$512.00
$551.15
$592.63
$739.99 		$733.91
$773.06
$814.54
$961.90 		$955.82
$994.97
$1,036.45
$1,183.81 		$221.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.18
$658.48
$741.44
$1,036.16
$1,574.56 		$802.09
$880.39
$963.35
$1,258.07 		$1,024.00
$1,102.30
$1,185.26
$1,479.98 		$1,245.91
$1,324.21
$1,407.17
$1,701.89 		$221.91
Toc - Plan #60 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$203.66
$231.15
$260.27
$363.72
$552.71 		$359.45
$386.94
$416.06
$519.51 		$515.24
$542.73
$571.85
$675.30 		$671.03
$698.52
$727.64
$831.09 		$155.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$407.32
$462.30
$520.54
$727.44
$1,105.42 		$563.11
$618.09
$676.33
$883.23 		$718.90
$773.88
$832.12
$1,039.02 		$874.69
$929.67
$987.91
$1,194.81 		$155.79
Toc - Plan #61 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care: $1,500 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$221.34
$251.21
$282.86
$395.29
$600.68 		$390.65
$420.52
$452.17
$564.60 		$559.96
$589.83
$621.48
$733.91 		$729.27
$759.14
$790.79
$903.22 		$169.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$442.68
$502.42
$565.72
$790.58
$1,201.36 		$611.99
$671.73
$735.03
$959.89 		$781.30
$841.04
$904.34
$1,129.20 		$950.61
$1,010.35
$1,073.65
$1,298.51 		$169.31
Toc - Plan #62 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$233.77
$265.31
$298.74
$417.49
$634.42 		$412.59
$444.13
$477.56
$596.31 		$591.41
$622.95
$656.38
$775.13 		$770.23
$801.77
$835.20
$953.95 		$178.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$467.54
$530.62
$597.48
$834.98
$1,268.84 		$646.36
$709.44
$776.30
$1,013.80 		$825.18
$888.26
$955.12
$1,192.62 		$1,004.00
$1,067.08
$1,133.94
$1,371.44 		$178.82
Toc - Plan #63 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 31 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 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 		$246.20
$279.42
$314.63
$439.69
$668.15 		$434.53
$467.75
$502.96
$628.02 		$622.86
$656.08
$691.29
$816.35 		$811.19
$844.41
$879.62
$1,004.68 		$188.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492.40
$558.84
$629.26
$879.38
$1,336.30 		$680.73
$747.17
$817.59
$1,067.71 		$869.06
$935.50
$1,005.92
$1,256.04 		$1,057.39
$1,123.83
$1,194.25
$1,444.37 		$188.33
Toc - Plan #64 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 32 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$254.10
$288.40
$324.73
$453.81
$689.61 		$448.48
$482.78
$519.11
$648.19 		$642.86
$677.16
$713.49
$842.57 		$837.24
$871.54
$907.87
$1,036.95 		$194.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$508.20
$576.80
$649.46
$907.62
$1,379.22 		$702.58
$771.18
$843.84
$1,102.00 		$896.96
$965.56
$1,038.22
$1,296.38 		$1,091.34
$1,159.94
$1,232.60
$1,490.76 		$194.38
Toc - Plan #65 Ambetter from Meridian
Gold

(HMO) Ambetter Secure Care 20 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$271.72
$308.40
$347.25
$485.28
$737.43 		$479.58
$516.26
$555.11
$693.14 		$687.44
$724.12
$762.97
$901.00 		$895.30
$931.98
$970.83
$1,108.86 		$207.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543.44
$616.80
$694.50
$970.56
$1,474.86 		$751.30
$824.66
$902.36
$1,178.42 		$959.16
$1,032.52
$1,110.22
$1,386.28 		$1,167.02
$1,240.38
$1,318.08
$1,594.14 		$207.86
Toc - Plan #66 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 12 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

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 		$262.54
$297.97
$335.51
$468.88
$712.51 		$463.38
$498.81
$536.35
$669.72 		$664.22
$699.65
$737.19
$870.56 		$865.06
$900.49
$938.03
$1,071.40 		$200.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$525.08
$595.94
$671.02
$937.76
$1,425.02 		$725.92
$796.78
$871.86
$1,138.60 		$926.76
$997.62
$1,072.70
$1,339.44 		$1,127.60
$1,198.46
$1,273.54
$1,540.28 		$200.84
Toc - Plan #67 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

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 		$178.69
$202.80
$228.35
$319.12
$484.93 		$315.38
$339.49
$365.04
$455.81 		$452.07
$476.18
$501.73
$592.50 		$588.76
$612.87
$638.42
$729.19 		$136.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$357.38
$405.60
$456.70
$638.24
$969.86 		$494.07
$542.29
$593.39
$774.93 		$630.76
$678.98
$730.08
$911.62 		$767.45
$815.67
$866.77
$1,048.31 		$136.69
Toc - Plan #68 Ambetter from Meridian
Silver

(HMO) Ambetter Virtual Access Silver ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$230.20
$261.26
$294.18
$411.11
$624.73 		$406.29
$437.35
$470.27
$587.20 		$582.38
$613.44
$646.36
$763.29 		$758.47
$789.53
$822.45
$939.38 		$176.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$460.40
$522.52
$588.36
$822.22
$1,249.46 		$636.49
$698.61
$764.45
$998.31 		$812.58
$874.70
$940.54
$1,174.40 		$988.67
$1,050.79
$1,116.63
$1,350.49 		$176.09
Toc - Plan #69 Ambetter from Meridian
Gold

(HMO) Ambetter Virtual Access Gold ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-993-2426

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$253.98
$288.26
$324.58
$453.59
$689.28 		$448.27
$482.55
$518.87
$647.88 		$642.56
$676.84
$713.16
$842.17 		$836.85
$871.13
$907.45
$1,036.46 		$194.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$507.96
$576.52
$649.16
$907.18
$1,378.56 		$702.25
$770.81
$843.45
$1,101.47 		$896.54
$965.10
$1,037.74
$1,295.76 		$1,090.83
$1,159.39
$1,232.03
$1,490.05 		$194.29

ADVERTISEMENT

US Health and Life

Local:  | Toll Free: 

Toc - Plan #70 US Health and Life
Expanded Bronze

(EPO) Balanced Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$187.52
$212.83
$239.65
$334.91
$508.93 		$330.97
$356.28
$383.10
$478.36 		$474.42
$499.73
$526.55
$621.81 		$617.87
$643.18
$670.00
$765.26 		$143.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$375.04
$425.66
$479.30
$669.82
$1,017.86 		$518.49
$569.11
$622.75
$813.27 		$661.94
$712.56
$766.20
$956.72 		$805.39
$856.01
$909.65
$1,100.17 		$143.45
Toc - Plan #71 US Health and Life
Expanded Bronze

(EPO) Balanced Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$182.97
$207.67
$233.83
$326.78
$496.57 		$322.94
$347.64
$373.80
$466.75 		$462.91
$487.61
$513.77
$606.72 		$602.88
$627.58
$653.74
$746.69 		$139.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$365.94
$415.34
$467.66
$653.56
$993.14 		$505.91
$555.31
$607.63
$793.53 		$645.88
$695.28
$747.60
$933.50 		$785.85
$835.25
$887.57
$1,073.47 		$139.97
Toc - Plan #72 US Health and Life
Expanded Bronze

(EPO) HSA Eligible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$207.71
$235.75
$265.46
$370.98
$563.73 		$366.61
$394.65
$424.36
$529.88 		$525.51
$553.55
$583.26
$688.78 		$684.41
$712.45
$742.16
$847.68 		$158.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$415.42
$471.50
$530.92
$741.96
$1,127.46 		$574.32
$630.40
$689.82
$900.86 		$733.22
$789.30
$848.72
$1,059.76 		$892.12
$948.20
$1,007.62
$1,218.66 		$158.90
Toc - Plan #73 US Health and Life
Expanded Bronze

(EPO) No Deductible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$210.24
$238.62
$268.69
$375.49
$570.59 		$371.07
$399.45
$429.52
$536.32 		$531.90
$560.28
$590.35
$697.15 		$692.73
$721.11
$751.18
$857.98 		$160.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$420.48
$477.24
$537.38
$750.98
$1,141.18 		$581.31
$638.07
$698.21
$911.81 		$742.14
$798.90
$859.04
$1,072.64 		$902.97
$959.73
$1,019.87
$1,233.47 		$160.83
Toc - Plan #74 US Health and Life
Silver

(EPO) Balanced Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$4,500 $9,000 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 		$260.37
$295.52
$332.75
$465.02
$706.65 		$459.55
$494.70
$531.93
$664.20 		$658.73
$693.88
$731.11
$863.38 		$857.91
$893.06
$930.29
$1,062.56 		$199.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$520.74
$591.04
$665.50
$930.04
$1,413.30 		$719.92
$790.22
$864.68
$1,129.22 		$919.10
$989.40
$1,063.86
$1,328.40 		$1,118.28
$1,188.58
$1,263.04
$1,527.58 		$199.18
Toc - Plan #75 US Health and Life
Silver

(EPO) No Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$261.29
$296.56
$333.92
$466.66
$709.13 		$461.17
$496.44
$533.80
$666.54 		$661.05
$696.32
$733.68
$866.42 		$860.93
$896.20
$933.56
$1,066.30 		$199.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$522.58
$593.12
$667.84
$933.32
$1,418.26 		$722.46
$793.00
$867.72
$1,133.20 		$922.34
$992.88
$1,067.60
$1,333.08 		$1,122.22
$1,192.76
$1,267.48
$1,532.96 		$199.88
Toc - Plan #76 US Health and Life
Silver

(EPO) Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$250.41
$284.22
$320.02
$447.23
$679.61 		$441.97
$475.78
$511.58
$638.79 		$633.53
$667.34
$703.14
$830.35 		$825.09
$858.90
$894.70
$1,021.91 		$191.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$500.82
$568.44
$640.04
$894.46
$1,359.22 		$692.38
$760.00
$831.60
$1,086.02 		$883.94
$951.56
$1,023.16
$1,277.58 		$1,075.50
$1,143.12
$1,214.72
$1,469.14 		$191.56
Toc - Plan #77 US Health and Life
Gold

(EPO) Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$289.77
$328.89
$370.32
$517.53
$786.43 		$511.44
$550.56
$591.99
$739.20 		$733.11
$772.23
$813.66
$960.87 		$954.78
$993.90
$1,035.33
$1,182.54 		$221.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.54
$657.78
$740.64
$1,035.06
$1,572.86 		$801.21
$879.45
$962.31
$1,256.73 		$1,022.88
$1,101.12
$1,183.98
$1,478.40 		$1,244.55
$1,322.79
$1,405.65
$1,700.07 		$221.67

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0324 | Toll Free: 1-888-200-0324 | TTY: 1-888-200-0324
Toc - Plan #78 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ ($3 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$209.10
$237.33
$267.23
$373.45
$567.49 		$369.06
$397.29
$427.19
$533.41 		$529.02
$557.25
$587.15
$693.37 		$688.98
$717.21
$747.11
$853.33 		$159.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$418.20
$474.66
$534.46
$746.90
$1,134.98 		$578.16
$634.62
$694.42
$906.86 		$738.12
$794.58
$854.38
$1,066.82 		$898.08
$954.54
$1,014.34
$1,226.78 		$159.96
Toc - Plan #79 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ (HSA)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$209.94
$238.28
$268.30
$374.95
$569.77 		$370.54
$398.88
$428.90
$535.55 		$531.14
$559.48
$589.50
$696.15 		$691.74
$720.08
$750.10
$856.75 		$160.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$419.88
$476.56
$536.60
$749.90
$1,139.54 		$580.48
$637.16
$697.20
$910.50 		$741.08
$797.76
$857.80
$1,071.10 		$901.68
$958.36
$1,018.40
$1,231.70 		$160.60
Toc - Plan #80 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential+ (Low Premium)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$198.46
$225.25
$253.63
$354.45
$538.62 		$350.28
$377.07
$405.45
$506.27 		$502.10
$528.89
$557.27
$658.09 		$653.92
$680.71
$709.09
$809.91 		$151.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$396.92
$450.50
$507.26
$708.90
$1,077.24 		$548.74
$602.32
$659.08
$860.72 		$700.56
$754.14
$810.90
$1,012.54 		$852.38
$905.96
$962.72
$1,164.36 		$151.82
Toc - Plan #81 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Essential+ Saver (Low Premium + HSA)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$210.81
$239.26
$269.41
$376.50
$572.13 		$372.08
$400.53
$430.68
$537.77 		$533.35
$561.80
$591.95
$699.04 		$694.62
$723.07
$753.22
$860.31 		$161.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$421.62
$478.52
$538.82
$753.00
$1,144.26 		$582.89
$639.79
$700.09
$914.27 		$744.16
$801.06
$861.36
$1,075.54 		$905.43
$962.33
$1,022.63
$1,236.81 		$161.27
Toc - Plan #82 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$251.78
$285.77
$321.77
$449.68
$683.33 		$444.39
$478.38
$514.38
$642.29 		$637.00
$670.99
$706.99
$834.90 		$829.61
$863.60
$899.60
$1,027.51 		$192.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$503.56
$571.54
$643.54
$899.36
$1,366.66 		$696.17
$764.15
$836.15
$1,091.97 		$888.78
$956.76
$1,028.76
$1,284.58 		$1,081.39
$1,149.37
$1,221.37
$1,477.19 		$192.61
Toc - Plan #83 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + Unlimited Free Primary Care & Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$252.07
$286.10
$322.14
$450.19
$684.11 		$444.90
$478.93
$514.97
$643.02 		$637.73
$671.76
$707.80
$835.85 		$830.56
$864.59
$900.63
$1,028.68 		$192.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.14
$572.20
$644.28
$900.38
$1,368.22 		$696.97
$765.03
$837.11
$1,093.21 		$889.80
$957.86
$1,029.94
$1,286.04 		$1,082.63
$1,150.69
$1,222.77
$1,478.87 		$192.83
Toc - Plan #84 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ (HSA)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$3,300 $6,600 Annual Deductible
$6,950 $13,900 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 		$251.75
$285.73
$321.73
$449.62
$683.24 		$444.34
$478.32
$514.32
$642.21 		$636.93
$670.91
$706.91
$834.80 		$829.52
$863.50
$899.50
$1,027.39 		$192.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$503.50
$571.46
$643.46
$899.24
$1,366.48 		$696.09
$764.05
$836.05
$1,091.83 		$888.68
$956.64
$1,028.64
$1,284.42 		$1,081.27
$1,149.23
$1,221.23
$1,477.01 		$192.59
Toc - Plan #85 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$252.52
$286.61
$322.72
$451.00
$685.34 		$445.70
$479.79
$515.90
$644.18 		$638.88
$672.97
$709.08
$837.36 		$832.06
$866.15
$902.26
$1,030.54 		$193.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$505.04
$573.22
$645.44
$902.00
$1,370.68 		$698.22
$766.40
$838.62
$1,095.18 		$891.40
$959.58
$1,031.80
$1,288.36 		$1,084.58
$1,152.76
$1,224.98
$1,481.54 		$193.18
Toc - Plan #86 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$256.19
$290.78
$327.41
$457.56
$695.30 		$452.18
$486.77
$523.40
$653.55 		$648.17
$682.76
$719.39
$849.54 		$844.16
$878.75
$915.38
$1,045.53 		$195.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$512.38
$581.56
$654.82
$915.12
$1,390.60 		$708.37
$777.55
$850.81
$1,111.11 		$904.36
$973.54
$1,046.80
$1,307.10 		$1,100.35
$1,169.53
$1,242.79
$1,503.09 		$195.99
Toc - Plan #87 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ Extra ($3 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$269.62
$306.02
$344.58
$481.55
$731.76 		$475.88
$512.28
$550.84
$687.81 		$682.14
$718.54
$757.10
$894.07 		$888.40
$924.80
$963.36
$1,100.33 		$206.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.24
$612.04
$689.16
$963.10
$1,463.52 		$745.50
$818.30
$895.42
$1,169.36 		$951.76
$1,024.56
$1,101.68
$1,375.62 		$1,158.02
$1,230.82
$1,307.94
$1,581.88 		$206.26
Toc - Plan #88 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ Extra ($3 Rx + Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301.20
$341.86
$384.94
$537.95
$817.46 		$531.62
$572.28
$615.36
$768.37 		$762.04
$802.70
$845.78
$998.79 		$992.46
$1,033.12
$1,076.20
$1,229.21 		$230.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.40
$683.72
$769.88
$1,075.90
$1,634.92 		$832.82
$914.14
$1,000.30
$1,306.32 		$1,063.24
$1,144.56
$1,230.72
$1,536.74 		$1,293.66
$1,374.98
$1,461.14
$1,767.16 		$230.42
Toc - Plan #89 UnitedHealthcare
Gold

(HMO) UHC Gold Value+ ($3 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$2,250 $4,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$278.89
$316.54
$356.42
$498.10
$756.91 		$492.24
$529.89
$569.77
$711.45 		$705.59
$743.24
$783.12
$924.80 		$918.94
$956.59
$996.47
$1,138.15 		$213.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.78
$633.08
$712.84
$996.20
$1,513.82 		$771.13
$846.43
$926.19
$1,209.55 		$984.48
$1,059.78
$1,139.54
$1,422.90 		$1,197.83
$1,273.13
$1,352.89
$1,636.25 		$213.35
Toc - Plan #90 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$286.71
$325.42
$366.42
$512.07
$778.14 		$506.05
$544.76
$585.76
$731.41 		$725.39
$764.10
$805.10
$950.75 		$944.73
$983.44
$1,024.44
$1,170.09 		$219.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.42
$650.84
$732.84
$1,024.14
$1,556.28 		$792.76
$870.18
$952.18
$1,243.48 		$1,012.10
$1,089.52
$1,171.52
$1,462.82 		$1,231.44
$1,308.86
$1,390.86
$1,682.16 		$219.34
Toc - Plan #91 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ Extra ($3 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0324

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$297.72
$337.91
$380.48
$531.72
$808.00 		$525.47
$565.66
$608.23
$759.47 		$753.22
$793.41
$835.98
$987.22 		$980.97
$1,021.16
$1,063.73
$1,214.97 		$227.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$595.44
$675.82
$760.96
$1,063.44
$1,616.00 		$823.19
$903.57
$988.71
$1,291.19 		$1,050.94
$1,131.32
$1,216.46
$1,518.94 		$1,278.69
$1,359.07
$1,444.21
$1,746.69 		$227.75

ADVERTISEMENT

McLaren Health Plan Community

Local: 1-888-327-0671 | Toll Free: 1-888-327-0671 | TTY: 1-800-356-3232
Toc - Plan #92 McLaren Health Plan Community
Catastrophic

(HMO) McLaren Young Adult/Catastrophic

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-327-0671

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$203.59
$231.08
$260.19
$363.61
$552.55 		$359.34
$386.83
$415.94
$519.36 		$515.09
$542.58
$571.69
$675.11 		$670.84
$698.33
$727.44
$830.86 		$155.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$407.18
$462.16
$520.38
$727.22
$1,105.10 		$562.93
$617.91
$676.13
$882.97 		$718.68
$773.66
$831.88
$1,038.72 		$874.43
$929.41
$987.63
$1,194.47 		$155.75
Toc - Plan #93 McLaren Health Plan Community
Silver

(HMO) McLaren Silver Exchange

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-327-0671

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 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 		$335.31
$380.58
$428.52
$598.86
$910.03 		$591.82
$637.09
$685.03
$855.37 		$848.33
$893.60
$941.54
$1,111.88 		$1,104.84
$1,150.11
$1,198.05
$1,368.39 		$256.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.62
$761.16
$857.04
$1,197.72
$1,820.06 		$927.13
$1,017.67
$1,113.55
$1,454.23 		$1,183.64
$1,274.18
$1,370.06
$1,710.74 		$1,440.15
$1,530.69
$1,626.57
$1,967.25 		$256.51
Toc - Plan #94 McLaren Health Plan Community
Gold

(HMO) McLaren Gold 1400

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-327-0671

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 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 		$332.12
$376.96
$424.45
$593.17
$901.37 		$586.19
$631.03
$678.52
$847.24 		$840.26
$885.10
$932.59
$1,101.31 		$1,094.33
$1,139.17
$1,186.66
$1,355.38 		$254.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.24
$753.92
$848.90
$1,186.34
$1,802.74 		$918.31
$1,007.99
$1,102.97
$1,440.41 		$1,172.38
$1,262.06
$1,357.04
$1,694.48 		$1,426.45
$1,516.13
$1,611.11
$1,948.55 		$254.07
Toc - Plan #95 McLaren Health Plan Community
Bronze

(HMO) McLaren Bronze 6500

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-327-0671

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$226.14
$256.67
$289.01
$403.89
$613.76 		$399.14
$429.67
$462.01
$576.89 		$572.14
$602.67
$635.01
$749.89 		$745.14
$775.67
$808.01
$922.89 		$173.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452.28
$513.34
$578.02
$807.78
$1,227.52 		$625.28
$686.34
$751.02
$980.78 		$798.28
$859.34
$924.02
$1,153.78 		$971.28
$1,032.34
$1,097.02
$1,326.78 		$173.00
Toc - Plan #96 McLaren Health Plan Community
Expanded Bronze

(HMO) McLaren Bronze Saver

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-327-0671

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 		$236.18
$268.06
$301.83
$421.81
$640.98 		$416.85
$448.73
$482.50
$602.48 		$597.52
$629.40
$663.17
$783.15 		$778.19
$810.07
$843.84
$963.82 		$180.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$472.36
$536.12
$603.66
$843.62
$1,281.96 		$653.03
$716.79
$784.33
$1,024.29 		$833.70
$897.46
$965.00
$1,204.96 		$1,014.37
$1,078.13
$1,145.67
$1,385.63 		$180.67
Toc - Plan #97 McLaren Health Plan Community
Silver

(HMO) McLaren Silver Exchange VCP

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-327-0671

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 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 		$318.63
$361.65
$407.21
$569.08
$864.77 		$562.38
$605.40
$650.96
$812.83 		$806.13
$849.15
$894.71
$1,056.58 		$1,049.88
$1,092.90
$1,138.46
$1,300.33 		$243.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637.26
$723.30
$814.42
$1,138.16
$1,729.54 		$881.01
$967.05
$1,058.17
$1,381.91 		$1,124.76
$1,210.80
$1,301.92
$1,625.66 		$1,368.51
$1,454.55
$1,545.67
$1,869.41 		$243.75
Toc - Plan #98 McLaren Health Plan Community
Bronze

(HMO) McLaren Bronze 6500 VCP

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-327-0671

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$214.95
$243.97
$274.71
$383.90
$583.38 		$379.39
$408.41
$439.15
$548.34 		$543.83
$572.85
$603.59
$712.78 		$708.27
$737.29
$768.03
$877.22 		$164.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$429.90
$487.94
$549.42
$767.80
$1,166.76 		$594.34
$652.38
$713.86
$932.24 		$758.78
$816.82
$878.30
$1,096.68 		$923.22
$981.26
$1,042.74
$1,261.12 		$164.44

ADVERTISEMENT

Blue Care Network of Michigan

Local: 1-888-227-2345 | Toll Free: 1-888-227-2345 | TTY: 1-800-257-9980
Toc - Plan #99 Blue Care Network of Michigan
Catastrophic

(HMO) Blue Cross® Select HMO Value

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$170.66
$193.70
$218.10
$304.80
$463.17 		$301.21
$324.25
$348.65
$435.35 		$431.76
$454.80
$479.20
$565.90 		$562.31
$585.35
$609.75
$696.45 		$130.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$341.32
$387.40
$436.20
$609.60
$926.34 		$471.87
$517.95
$566.75
$740.15 		$602.42
$648.50
$697.30
$870.70 		$732.97
$779.05
$827.85
$1,001.25 		$130.55
Toc - Plan #100 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Select HMO Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.14
$363.36
$409.14
$571.77
$868.86 		$565.05
$608.27
$654.05
$816.68 		$809.96
$853.18
$898.96
$1,061.59 		$1,054.87
$1,098.09
$1,143.87
$1,306.50 		$244.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.28
$726.72
$818.28
$1,143.54
$1,737.72 		$885.19
$971.63
$1,063.19
$1,388.45 		$1,130.10
$1,216.54
$1,308.10
$1,633.36 		$1,375.01
$1,461.45
$1,553.01
$1,878.27 		$244.91
Toc - Plan #101 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Preferred HMO Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.49
$397.81
$447.93
$625.98
$951.23 		$618.61
$665.93
$716.05
$894.10 		$886.73
$934.05
$984.17
$1,162.22 		$1,154.85
$1,202.17
$1,252.29
$1,430.34 		$268.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.98
$795.62
$895.86
$1,251.96
$1,902.46 		$969.10
$1,063.74
$1,163.98
$1,520.08 		$1,237.22
$1,331.86
$1,432.10
$1,788.20 		$1,505.34
$1,599.98
$1,700.22
$2,056.32 		$268.12
Toc - Plan #102 Blue Care Network of Michigan
Gold

(HMO) Blue Cross® Preferred HMO Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$850 $1,700 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.07
$434.78
$489.56
$684.16
$1,039.65 		$676.12
$727.83
$782.61
$977.21 		$969.17
$1,020.88
$1,075.66
$1,270.26 		$1,262.22
$1,313.93
$1,368.71
$1,563.31 		$293.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.14
$869.56
$979.12
$1,368.32
$2,079.30 		$1,059.19
$1,162.61
$1,272.17
$1,661.37 		$1,352.24
$1,455.66
$1,565.22
$1,954.42 		$1,645.29
$1,748.71
$1,858.27
$2,247.47 		$293.05
Toc - Plan #103 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Metro Detroit HMO Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$298.79
$339.13
$381.85
$533.64
$810.92 		$527.36
$567.70
$610.42
$762.21 		$755.93
$796.27
$838.99
$990.78 		$984.50
$1,024.84
$1,067.56
$1,219.35 		$228.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.58
$678.26
$763.70
$1,067.28
$1,621.84 		$826.15
$906.83
$992.27
$1,295.85 		$1,054.72
$1,135.40
$1,220.84
$1,524.42 		$1,283.29
$1,363.97
$1,449.41
$1,752.99 		$228.57
Toc - Plan #104 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Select HMO Silver Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$296.49
$336.52
$378.91
$529.53
$804.67 		$523.30
$563.33
$605.72
$756.34 		$750.11
$790.14
$832.53
$983.15 		$976.92
$1,016.95
$1,059.34
$1,209.96 		$226.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.98
$673.04
$757.82
$1,059.06
$1,609.34 		$819.79
$899.85
$984.63
$1,285.87 		$1,046.60
$1,126.66
$1,211.44
$1,512.68 		$1,273.41
$1,353.47
$1,438.25
$1,739.49 		$226.81
Toc - Plan #105 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Metro Detroit HMO Silver Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$276.73
$314.09
$353.66
$494.24
$751.05 		$488.43
$525.79
$565.36
$705.94 		$700.13
$737.49
$777.06
$917.64 		$911.83
$949.19
$988.76
$1,129.34 		$211.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.46
$628.18
$707.32
$988.48
$1,502.10 		$765.16
$839.88
$919.02
$1,200.18 		$976.86
$1,051.58
$1,130.72
$1,411.88 		$1,188.56
$1,263.28
$1,342.42
$1,623.58 		$211.70
Toc - Plan #106 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Preferred HMO Silver Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$324.60
$368.42
$414.84
$579.74
$880.96 		$572.92
$616.74
$663.16
$828.06 		$821.24
$865.06
$911.48
$1,076.38 		$1,069.56
$1,113.38
$1,159.80
$1,324.70 		$248.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.20
$736.84
$829.68
$1,159.48
$1,761.92 		$897.52
$985.16
$1,078.00
$1,407.80 		$1,145.84
$1,233.48
$1,326.32
$1,656.12 		$1,394.16
$1,481.80
$1,574.64
$1,904.44 		$248.32
Toc - Plan #107 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Select HMO Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$207.15
$235.12
$264.74
$369.97
$562.21 		$365.62
$393.59
$423.21
$528.44 		$524.09
$552.06
$581.68
$686.91 		$682.56
$710.53
$740.15
$845.38 		$158.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$414.30
$470.24
$529.48
$739.94
$1,124.42 		$572.77
$628.71
$687.95
$898.41 		$731.24
$787.18
$846.42
$1,056.88 		$889.71
$945.65
$1,004.89
$1,215.35 		$158.47
Toc - Plan #108 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Metro Detroit HMO Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$193.35
$219.45
$247.10
$345.32
$524.75 		$341.26
$367.36
$395.01
$493.23 		$489.17
$515.27
$542.92
$641.14 		$637.08
$663.18
$690.83
$789.05 		$147.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$386.70
$438.90
$494.20
$690.64
$1,049.50 		$534.61
$586.81
$642.11
$838.55 		$682.52
$734.72
$790.02
$986.46 		$830.43
$882.63
$937.93
$1,134.37 		$147.91
Toc - Plan #109 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Select HMO Bronze Saver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

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 		$217.15
$246.47
$277.52
$387.83
$589.35 		$383.27
$412.59
$443.64
$553.95 		$549.39
$578.71
$609.76
$720.07 		$715.51
$744.83
$775.88
$886.19 		$166.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$434.30
$492.94
$555.04
$775.66
$1,178.70 		$600.42
$659.06
$721.16
$941.78 		$766.54
$825.18
$887.28
$1,107.90 		$932.66
$991.30
$1,053.40
$1,274.02 		$166.12
Toc - Plan #110 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Metro Detroit HMO Bronze Saver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

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 		$202.68
$230.04
$259.03
$361.99
$550.07 		$357.73
$385.09
$414.08
$517.04 		$512.78
$540.14
$569.13
$672.09 		$667.83
$695.19
$724.18
$827.14 		$155.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$405.36
$460.08
$518.06
$723.98
$1,100.14 		$560.41
$615.13
$673.11
$879.03 		$715.46
$770.18
$828.16
$1,034.08 		$870.51
$925.23
$983.21
$1,189.13 		$155.05
Toc - Plan #111 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Preferred HMO Bronze Saver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

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 		$237.73
$269.82
$303.82
$424.59
$645.20 		$419.59
$451.68
$485.68
$606.45 		$601.45
$633.54
$667.54
$788.31 		$783.31
$815.40
$849.40
$970.17 		$181.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$475.46
$539.64
$607.64
$849.18
$1,290.40 		$657.32
$721.50
$789.50
$1,031.04 		$839.18
$903.36
$971.36
$1,212.90 		$1,021.04
$1,085.22
$1,153.22
$1,394.76 		$181.86
Toc - Plan #112 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Preferred HMO Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$226.78
$257.40
$289.82
$405.03
$615.48 		$400.27
$430.89
$463.31
$578.52 		$573.76
$604.38
$636.80
$752.01 		$747.25
$777.87
$810.29
$925.50 		$173.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$453.56
$514.80
$579.64
$810.06
$1,230.96 		$627.05
$688.29
$753.13
$983.55 		$800.54
$861.78
$926.62
$1,157.04 		$974.03
$1,035.27
$1,100.11
$1,330.53 		$173.49
Toc - Plan #113 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Select HMO Silver Extra

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$331.67
$376.45
$423.87
$592.36
$900.15 		$585.40
$630.18
$677.60
$846.09 		$839.13
$883.91
$931.33
$1,099.82 		$1,092.86
$1,137.64
$1,185.06
$1,353.55 		$253.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663.34
$752.90
$847.74
$1,184.72
$1,800.30 		$917.07
$1,006.63
$1,101.47
$1,438.45 		$1,170.80
$1,260.36
$1,355.20
$1,692.18 		$1,424.53
$1,514.09
$1,608.93
$1,945.91 		$253.73
Toc - Plan #114 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Preferred HMO Silver Extra

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.10
$412.12
$464.04
$648.50
$985.45 		$640.87
$689.89
$741.81
$926.27 		$918.64
$967.66
$1,019.58
$1,204.04 		$1,196.41
$1,245.43
$1,297.35
$1,481.81 		$277.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.20
$824.24
$928.08
$1,297.00
$1,970.90 		$1,003.97
$1,102.01
$1,205.85
$1,574.77 		$1,281.74
$1,379.78
$1,483.62
$1,852.54 		$1,559.51
$1,657.55
$1,761.39
$2,130.31 		$277.77
Toc - Plan #115 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Metro Detroit HMO Silver Extra

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-227-2345

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.55
$351.34
$395.60
$552.86
$840.12 		$546.36
$588.15
$632.41
$789.67 		$783.17
$824.96
$869.22
$1,026.48 		$1,019.98
$1,061.77
$1,106.03
$1,263.29 		$236.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.10
$702.68
$791.20
$1,105.72
$1,680.24 		$855.91
$939.49
$1,028.01
$1,342.53 		$1,092.72
$1,176.30
$1,264.82
$1,579.34 		$1,329.53
$1,413.11
$1,501.63
$1,816.15 		$236.81

‡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 Oakland County here.

Oakland County is in “” of Michigan.

Currently, there are 115 plans offered in .

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2022 Obamacare Plans for Oakland County, MI

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