Obamacare 2023 Rates for Genesee County

Obamacare > Rates > Michigan > Genesee County

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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 Genesee County, MI.

The health insurance rates listed below are for calendar year 2023.

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, 111 Plans and 2023 Rates for Genesee County, Michigan

Below, you’ll find a summary of the 111 plans for Genesee 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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Genesee County Resources

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$211.42
$239.96
$270.19
$377.60
$573.79 		$373.16
$401.70
$431.93
$539.34 		$534.90
$563.44
$593.67
$701.08 		$696.64
$725.18
$755.41
$862.82 		$161.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$422.84
$479.92
$540.38
$755.20
$1,147.58 		$584.58
$641.66
$702.12
$916.94 		$746.32
$803.40
$863.86
$1,078.68 		$908.06
$965.14
$1,025.60
$1,240.42 		$161.74
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
$7,500 $15,000 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 		$281.58
$319.59
$359.86
$502.90
$764.21 		$496.99
$535.00
$575.27
$718.31 		$712.40
$750.41
$790.68
$933.72 		$927.81
$965.82
$1,006.09
$1,149.13 		$215.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.16
$639.18
$719.72
$1,005.80
$1,528.42 		$778.57
$854.59
$935.13
$1,221.21 		$993.98
$1,070.00
$1,150.54
$1,436.62 		$1,209.39
$1,285.41
$1,365.95
$1,652.03 		$215.41
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
$2,875 $5,750 Annual Deductible
$8,800 $17,600 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 		$381.08
$432.53
$487.02
$680.61
$1,034.25 		$672.61
$724.06
$778.55
$972.14 		$964.14
$1,015.59
$1,070.08
$1,263.67 		$1,255.67
$1,307.12
$1,361.61
$1,555.20 		$291.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.16
$865.06
$974.04
$1,361.22
$2,068.50 		$1,053.69
$1,156.59
$1,265.57
$1,652.75 		$1,345.22
$1,448.12
$1,557.10
$1,944.28 		$1,636.75
$1,739.65
$1,848.63
$2,235.81 		$291.53
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
$1,050 $2,100 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 		$467.59
$530.71
$597.58
$835.12
$1,269.04 		$825.30
$888.42
$955.29
$1,192.83 		$1,183.01
$1,246.13
$1,313.00
$1,550.54 		$1,540.72
$1,603.84
$1,670.71
$1,908.25 		$357.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$935.18
$1,061.42
$1,195.16
$1,670.24
$2,538.08 		$1,292.89
$1,419.13
$1,552.87
$2,027.95 		$1,650.60
$1,776.84
$1,910.58
$2,385.66 		$2,008.31
$2,134.55
$2,268.29
$2,743.37 		$357.71
Toc - Plan #5 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Bronze

(PPO) Blue Cross® Premier PPO Bronze Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$259.64
$294.69
$331.82
$463.72
$704.66 		$458.26
$493.31
$530.44
$662.34 		$656.88
$691.93
$729.06
$860.96 		$855.50
$890.55
$927.68
$1,059.58 		$198.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519.28
$589.38
$663.64
$927.44
$1,409.32 		$717.90
$788.00
$862.26
$1,126.06 		$916.52
$986.62
$1,060.88
$1,324.68 		$1,115.14
$1,185.24
$1,259.50
$1,523.30 		$198.62
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
$3,400 $6,800 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 		$381.14
$432.59
$487.10
$680.72
$1,034.41 		$672.71
$724.16
$778.67
$972.29 		$964.28
$1,015.73
$1,070.24
$1,263.86 		$1,255.85
$1,307.30
$1,361.81
$1,555.43 		$291.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.28
$865.18
$974.20
$1,361.44
$2,068.82 		$1,053.85
$1,156.75
$1,265.77
$1,653.01 		$1,345.42
$1,448.32
$1,557.34
$1,944.58 		$1,636.99
$1,739.89
$1,848.91
$2,236.15 		$291.57
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
$7,500 $15,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$294.97
$334.79
$376.97
$526.82
$800.55 		$520.62
$560.44
$602.62
$752.47 		$746.27
$786.09
$828.27
$978.12 		$971.92
$1,011.74
$1,053.92
$1,203.77 		$225.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.94
$669.58
$753.94
$1,053.64
$1,601.10 		$815.59
$895.23
$979.59
$1,279.29 		$1,041.24
$1,120.88
$1,205.24
$1,504.94 		$1,266.89
$1,346.53
$1,430.89
$1,730.59 		$225.65
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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.14
$459.83
$517.77
$723.58
$1,099.55 		$715.07
$769.76
$827.70
$1,033.51 		$1,025.00
$1,079.69
$1,137.63
$1,343.44 		$1,334.93
$1,389.62
$1,447.56
$1,653.37 		$309.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.28
$919.66
$1,035.54
$1,447.16
$2,199.10 		$1,120.21
$1,229.59
$1,345.47
$1,757.09 		$1,430.14
$1,539.52
$1,655.40
$2,067.02 		$1,740.07
$1,849.45
$1,965.33
$2,376.95 		$309.93
Toc - Plan #9 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Gold

(PPO) Blue Cross® Premier PPO Gold Extra

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$509.06
$577.78
$650.58
$909.18
$1,381.59 		$898.49
$967.21
$1,040.01
$1,298.61 		$1,287.92
$1,356.64
$1,429.44
$1,688.04 		$1,677.35
$1,746.07
$1,818.87
$2,077.47 		$389.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,018.12
$1,155.56
$1,301.16
$1,818.36
$2,763.18 		$1,407.55
$1,544.99
$1,690.59
$2,207.79 		$1,796.98
$1,934.42
$2,080.02
$2,597.22 		$2,186.41
$2,323.85
$2,469.45
$2,986.65 		$389.43

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Priority Health

Local: 1-855-682-5217 | Toll Free: 1-855-682-5217 | TTY: 1-888-551-6761
Toc - Plan #10 Priority Health
Expanded Bronze

(HMO) MyPriority HSA Bronze 7100

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

Annual Out of Pocket Expenses:

Individual Family
$7,100 $14,200 Annual Deductible
$7,100 $14,200 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 		$269.08
$305.41
$343.88
$480.58
$730.28 		$474.93
$511.26
$549.73
$686.43 		$680.78
$717.11
$755.58
$892.28 		$886.63
$922.96
$961.43
$1,098.13 		$205.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538.16
$610.82
$687.76
$961.16
$1,460.56 		$744.01
$816.67
$893.61
$1,167.01 		$949.86
$1,022.52
$1,099.46
$1,372.86 		$1,155.71
$1,228.37
$1,305.31
$1,578.71 		$205.85
Toc - Plan #11 Priority Health
Expanded Bronze

(HMO) MyPriority Bronze 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$245.89
$279.09
$314.25
$439.16
$667.35 		$434.00
$467.20
$502.36
$627.27 		$622.11
$655.31
$690.47
$815.38 		$810.22
$843.42
$878.58
$1,003.49 		$188.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$491.78
$558.18
$628.50
$878.32
$1,334.70 		$679.89
$746.29
$816.61
$1,066.43 		$868.00
$934.40
$1,004.72
$1,254.54 		$1,056.11
$1,122.51
$1,192.83
$1,442.65 		$188.11
Toc - Plan #12 Priority Health
Expanded Bronze

(HMO) MyPriority Telehealth PCP Bronze 9100 - Virtual First

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$232.37
$263.74
$296.97
$415.01
$630.65 		$410.13
$441.50
$474.73
$592.77 		$587.89
$619.26
$652.49
$770.53 		$765.65
$797.02
$830.25
$948.29 		$177.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$464.74
$527.48
$593.94
$830.02
$1,261.30 		$642.50
$705.24
$771.70
$1,007.78 		$820.26
$883.00
$949.46
$1,185.54 		$998.02
$1,060.76
$1,127.22
$1,363.30 		$177.76
Toc - Plan #13 Priority Health
Expanded Bronze

(HMO) MyPriority Travel Bronze 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282.77
$320.94
$361.38
$505.03
$767.44 		$499.09
$537.26
$577.70
$721.35 		$715.41
$753.58
$794.02
$937.67 		$931.73
$969.90
$1,010.34
$1,153.99 		$216.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.54
$641.88
$722.76
$1,010.06
$1,534.88 		$781.86
$858.20
$939.08
$1,226.38 		$998.18
$1,074.52
$1,155.40
$1,442.70 		$1,214.50
$1,290.84
$1,371.72
$1,659.02 		$216.32
Toc - Plan #14 Priority Health
Silver

(HMO) MyPriority Silver 3600

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

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$335.69
$381.01
$429.01
$599.54
$911.06 		$592.49
$637.81
$685.81
$856.34 		$849.29
$894.61
$942.61
$1,113.14 		$1,106.09
$1,151.41
$1,199.41
$1,369.94 		$256.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.38
$762.02
$858.02
$1,199.08
$1,822.12 		$928.18
$1,018.82
$1,114.82
$1,455.88 		$1,184.98
$1,275.62
$1,371.62
$1,712.68 		$1,441.78
$1,532.42
$1,628.42
$1,969.48 		$256.80
Toc - Plan #15 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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.53
$368.34
$414.75
$579.61
$880.77 		$572.80
$616.61
$663.02
$827.88 		$821.07
$864.88
$911.29
$1,076.15 		$1,069.34
$1,113.15
$1,159.56
$1,324.42 		$248.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.06
$736.68
$829.50
$1,159.22
$1,761.54 		$897.33
$984.95
$1,077.77
$1,407.49 		$1,145.60
$1,233.22
$1,326.04
$1,655.76 		$1,393.87
$1,481.49
$1,574.31
$1,904.03 		$248.27
Toc - Plan #16 Priority Health
Silver

(HMO) MyPriority Telehealth PCP Silver 5500 - Virtual First

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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$306.68
$348.08
$391.94
$547.73
$832.33 		$541.29
$582.69
$626.55
$782.34 		$775.90
$817.30
$861.16
$1,016.95 		$1,010.51
$1,051.91
$1,095.77
$1,251.56 		$234.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.36
$696.16
$783.88
$1,095.46
$1,664.66 		$847.97
$930.77
$1,018.49
$1,330.07 		$1,082.58
$1,165.38
$1,253.10
$1,564.68 		$1,317.19
$1,399.99
$1,487.71
$1,799.29 		$234.61
Toc - Plan #17 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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.43
$442.00
$497.69
$695.52
$1,056.91 		$687.34
$739.91
$795.60
$993.43 		$985.25
$1,037.82
$1,093.51
$1,291.34 		$1,283.16
$1,335.73
$1,391.42
$1,589.25 		$297.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.86
$884.00
$995.38
$1,391.04
$2,113.82 		$1,076.77
$1,181.91
$1,293.29
$1,688.95 		$1,374.68
$1,479.82
$1,591.20
$1,986.86 		$1,672.59
$1,777.73
$1,889.11
$2,284.77 		$297.91
Toc - Plan #18 Priority Health
Expanded Bronze

(HMO) MyPriority Standard Bronze 7500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$248.05
$281.54
$317.01
$443.02
$673.21 		$437.81
$471.30
$506.77
$632.78 		$627.57
$661.06
$696.53
$822.54 		$817.33
$850.82
$886.29
$1,012.30 		$189.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$496.10
$563.08
$634.02
$886.04
$1,346.42 		$685.86
$752.84
$823.78
$1,075.80 		$875.62
$942.60
$1,013.54
$1,265.56 		$1,065.38
$1,132.36
$1,203.30
$1,455.32 		$189.76
Toc - Plan #19 Priority Health
Silver

(HMO) MyPriority Standard Silver 5800

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$346.21
$392.95
$442.46
$618.33
$939.61 		$611.06
$657.80
$707.31
$883.18 		$875.91
$922.65
$972.16
$1,148.03 		$1,140.76
$1,187.50
$1,237.01
$1,412.88 		$264.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.42
$785.90
$884.92
$1,236.66
$1,879.22 		$957.27
$1,050.75
$1,149.77
$1,501.51 		$1,222.12
$1,315.60
$1,414.62
$1,766.36 		$1,486.97
$1,580.45
$1,679.47
$2,031.21 		$264.85
Toc - Plan #20 Priority Health
Gold

(HMO) MyPriority Standard Gold 2000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$455.96
$517.51
$582.72
$814.34
$1,237.48 		$804.77
$866.32
$931.53
$1,163.15 		$1,153.58
$1,215.13
$1,280.34
$1,511.96 		$1,502.39
$1,563.94
$1,629.15
$1,860.77 		$348.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.92
$1,035.02
$1,165.44
$1,628.68
$2,474.96 		$1,260.73
$1,383.83
$1,514.25
$1,977.49 		$1,609.54
$1,732.64
$1,863.06
$2,326.30 		$1,958.35
$2,081.45
$2,211.87
$2,675.11 		$348.81

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-4087 | Toll Free: 1-888-560-4087 | TTY: 1-888-665-4629
Toc - Plan #21 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
$1,900 $3,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$286.21
$324.85
$365.78
$511.18
$776.78 		$505.16
$543.80
$584.73
$730.13 		$724.11
$762.75
$803.68
$949.08 		$943.06
$981.70
$1,022.63
$1,168.03 		$218.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.42
$649.70
$731.56
$1,022.36
$1,553.56 		$791.37
$868.65
$950.51
$1,241.31 		$1,010.32
$1,087.60
$1,169.46
$1,460.26 		$1,229.27
$1,306.55
$1,388.41
$1,679.21 		$218.95
Toc - Plan #22 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
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$283.05
$321.26
$361.74
$505.53
$768.20 		$499.59
$537.80
$578.28
$722.07 		$716.13
$754.34
$794.82
$938.61 		$932.67
$970.88
$1,011.36
$1,155.15 		$216.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$566.10
$642.52
$723.48
$1,011.06
$1,536.40 		$782.64
$859.06
$940.02
$1,227.60 		$999.18
$1,075.60
$1,156.56
$1,444.14 		$1,215.72
$1,292.14
$1,373.10
$1,660.68 		$216.54
Toc - Plan #23 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$286.18
$324.82
$365.74
$511.12
$776.70 		$505.11
$543.75
$584.67
$730.05 		$724.04
$762.68
$803.60
$948.98 		$942.97
$981.61
$1,022.53
$1,167.91 		$218.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.36
$649.64
$731.48
$1,022.24
$1,553.40 		$791.29
$868.57
$950.41
$1,241.17 		$1,010.22
$1,087.50
$1,169.34
$1,460.10 		$1,229.15
$1,306.43
$1,388.27
$1,679.03 		$218.93
Toc - Plan #24 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$280.90
$318.83
$359.00
$501.69
$762.37 		$495.79
$533.72
$573.89
$716.58 		$710.68
$748.61
$788.78
$931.47 		$925.57
$963.50
$1,003.67
$1,146.36 		$214.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.80
$637.66
$718.00
$1,003.38
$1,524.74 		$776.69
$852.55
$932.89
$1,218.27 		$991.58
$1,067.44
$1,147.78
$1,433.16 		$1,206.47
$1,282.33
$1,362.67
$1,648.05 		$214.89
Toc - Plan #25 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
$1,900 $3,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$290.98
$330.26
$371.87
$519.68
$789.71 		$513.58
$552.86
$594.47
$742.28 		$736.18
$775.46
$817.07
$964.88 		$958.78
$998.06
$1,039.67
$1,187.48 		$222.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.96
$660.52
$743.74
$1,039.36
$1,579.42 		$804.56
$883.12
$966.34
$1,261.96 		$1,027.16
$1,105.72
$1,188.94
$1,484.56 		$1,249.76
$1,328.32
$1,411.54
$1,707.16 		$222.60
Toc - Plan #26 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
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$289.19
$328.23
$369.59
$516.50
$784.87 		$510.42
$549.46
$590.82
$737.73 		$731.65
$770.69
$812.05
$958.96 		$952.88
$991.92
$1,033.28
$1,180.19 		$221.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.38
$656.46
$739.18
$1,033.00
$1,569.74 		$799.61
$877.69
$960.41
$1,254.23 		$1,020.84
$1,098.92
$1,181.64
$1,475.46 		$1,242.07
$1,320.15
$1,402.87
$1,696.69 		$221.23

ADVERTISEMENT

Ambetter from Meridian

Local: 1-833-993-2426 | Toll Free: 1-833-993-2426 | TTY: 1-833-993-2426
Toc - Plan #27 Ambetter from Meridian
Bronze

(HMO) Clear Bronze

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 		$214.25
$243.17
$273.80
$382.64
$581.46 		$378.15
$407.07
$437.70
$546.54 		$542.05
$570.97
$601.60
$710.44 		$705.95
$734.87
$765.50
$874.34 		$163.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$428.50
$486.34
$547.60
$765.28
$1,162.92 		$592.40
$650.24
$711.50
$929.18 		$756.30
$814.14
$875.40
$1,093.08 		$920.20
$978.04
$1,039.30
$1,256.98 		$163.90
Toc - Plan #28 Ambetter from Meridian
Expanded Bronze

(HMO) Choice Bronze 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 		$233.44
$264.94
$298.32
$416.90
$633.52 		$412.01
$443.51
$476.89
$595.47 		$590.58
$622.08
$655.46
$774.04 		$769.15
$800.65
$834.03
$952.61 		$178.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$466.88
$529.88
$596.64
$833.80
$1,267.04 		$645.45
$708.45
$775.21
$1,012.37 		$824.02
$887.02
$953.78
$1,190.94 		$1,002.59
$1,065.59
$1,132.35
$1,369.51 		$178.57
Toc - Plan #29 Ambetter from Meridian
Silver

(HMO) Complete Silver

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 		$282.54
$320.67
$361.08
$504.60
$766.79 		$498.68
$536.81
$577.22
$720.74 		$714.82
$752.95
$793.36
$936.88 		$930.96
$969.09
$1,009.50
$1,153.02 		$216.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.08
$641.34
$722.16
$1,009.20
$1,533.58 		$781.22
$857.48
$938.30
$1,225.34 		$997.36
$1,073.62
$1,154.44
$1,441.48 		$1,213.50
$1,289.76
$1,370.58
$1,657.62 		$216.14
Toc - Plan #30 Ambetter from Meridian
Gold

(HMO) Complete Gold

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
$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 		$316.30
$358.99
$404.22
$564.90
$858.42 		$558.27
$600.96
$646.19
$806.87 		$800.24
$842.93
$888.16
$1,048.84 		$1,042.21
$1,084.90
$1,130.13
$1,290.81 		$241.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.60
$717.98
$808.44
$1,129.80
$1,716.84 		$874.57
$959.95
$1,050.41
$1,371.77 		$1,116.54
$1,201.92
$1,292.38
$1,613.74 		$1,358.51
$1,443.89
$1,534.35
$1,855.71 		$241.97
Toc - Plan #31 Ambetter from Meridian
Expanded Bronze

(HMO) Everyday Bronze

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 		$233.64
$265.17
$298.57
$417.26
$634.06 		$412.36
$443.89
$477.29
$595.98 		$591.08
$622.61
$656.01
$774.70 		$769.80
$801.33
$834.73
$953.42 		$178.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$467.28
$530.34
$597.14
$834.52
$1,268.12 		$646.00
$709.06
$775.86
$1,013.24 		$824.72
$887.78
$954.58
$1,191.96 		$1,003.44
$1,066.50
$1,133.30
$1,370.68 		$178.72
Toc - Plan #32 Ambetter from Meridian
Expanded Bronze

(HMO) Elite Bronze

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 		$265.90
$301.79
$339.81
$474.88
$721.63 		$469.31
$505.20
$543.22
$678.29 		$672.72
$708.61
$746.63
$881.70 		$876.13
$912.02
$950.04
$1,085.11 		$203.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$531.80
$603.58
$679.62
$949.76
$1,443.26 		$735.21
$806.99
$883.03
$1,153.17 		$938.62
$1,010.40
$1,086.44
$1,356.58 		$1,142.03
$1,213.81
$1,289.85
$1,559.99 		$203.41
Toc - Plan #33 Ambetter from Meridian
Silver

(HMO) Clear Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$272.29
$309.03
$347.97
$486.29
$738.96 		$480.58
$517.32
$556.26
$694.58 		$688.87
$725.61
$764.55
$902.87 		$897.16
$933.90
$972.84
$1,111.16 		$208.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$544.58
$618.06
$695.94
$972.58
$1,477.92 		$752.87
$826.35
$904.23
$1,180.87 		$961.16
$1,034.64
$1,112.52
$1,389.16 		$1,169.45
$1,242.93
$1,320.81
$1,597.45 		$208.29
Toc - Plan #34 Ambetter from Meridian
Silver

(HMO) Focused Silver

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
$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 		$276.89
$314.26
$353.85
$494.51
$751.46 		$488.70
$526.07
$565.66
$706.32 		$700.51
$737.88
$777.47
$918.13 		$912.32
$949.69
$989.28
$1,129.94 		$211.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.78
$628.52
$707.70
$989.02
$1,502.92 		$765.59
$840.33
$919.51
$1,200.83 		$977.40
$1,052.14
$1,131.32
$1,412.64 		$1,189.21
$1,263.95
$1,343.13
$1,624.45 		$211.81
Toc - Plan #35 Ambetter from Meridian
Gold

(HMO) Everyday Gold

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 		$302.09
$342.86
$386.06
$539.52
$819.85 		$533.18
$573.95
$617.15
$770.61 		$764.27
$805.04
$848.24
$1,001.70 		$995.36
$1,036.13
$1,079.33
$1,232.79 		$231.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.18
$685.72
$772.12
$1,079.04
$1,639.70 		$835.27
$916.81
$1,003.21
$1,310.13 		$1,066.36
$1,147.90
$1,234.30
$1,541.22 		$1,297.45
$1,378.99
$1,465.39
$1,772.31 		$231.09
Toc - Plan #36 Ambetter from Meridian
Gold

(HMO) Elite Gold

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.41
$397.70
$447.81
$625.81
$950.98 		$618.46
$665.75
$715.86
$893.86 		$886.51
$933.80
$983.91
$1,161.91 		$1,154.56
$1,201.85
$1,251.96
$1,429.96 		$268.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.82
$795.40
$895.62
$1,251.62
$1,901.96 		$968.87
$1,063.45
$1,163.67
$1,519.67 		$1,236.92
$1,331.50
$1,431.72
$1,787.72 		$1,504.97
$1,599.55
$1,699.77
$2,055.77 		$268.05
Toc - Plan #37 Ambetter from Meridian
Bronze

(HMO) CMS Standard Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$202.95
$230.34
$259.36
$362.46
$550.79 		$358.20
$385.59
$414.61
$517.71 		$513.45
$540.84
$569.86
$672.96 		$668.70
$696.09
$725.11
$828.21 		$155.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$405.90
$460.68
$518.72
$724.92
$1,101.58 		$561.15
$615.93
$673.97
$880.17 		$716.40
$771.18
$829.22
$1,035.42 		$871.65
$926.43
$984.47
$1,190.67 		$155.25
Toc - Plan #38 Ambetter from Meridian
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$228.04
$258.82
$291.42
$407.26
$618.88 		$402.48
$433.26
$465.86
$581.70 		$576.92
$607.70
$640.30
$756.14 		$751.36
$782.14
$814.74
$930.58 		$174.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$456.08
$517.64
$582.84
$814.52
$1,237.76 		$630.52
$692.08
$757.28
$988.96 		$804.96
$866.52
$931.72
$1,163.40 		$979.40
$1,040.96
$1,106.16
$1,337.84 		$174.44
Toc - Plan #39 Ambetter from Meridian
Silver

(HMO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$274.91
$312.02
$351.33
$490.98
$746.09 		$485.21
$522.32
$561.63
$701.28 		$695.51
$732.62
$771.93
$911.58 		$905.81
$942.92
$982.23
$1,121.88 		$210.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.82
$624.04
$702.66
$981.96
$1,492.18 		$760.12
$834.34
$912.96
$1,192.26 		$970.42
$1,044.64
$1,123.26
$1,402.56 		$1,180.72
$1,254.94
$1,333.56
$1,612.86 		$210.30
Toc - Plan #40 Ambetter from Meridian
Gold

(HMO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$298.19
$338.44
$381.08
$532.56
$809.27 		$526.30
$566.55
$609.19
$760.67 		$754.41
$794.66
$837.30
$988.78 		$982.52
$1,022.77
$1,065.41
$1,216.89 		$228.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596.38
$676.88
$762.16
$1,065.12
$1,618.54 		$824.49
$904.99
$990.27
$1,293.23 		$1,052.60
$1,133.10
$1,218.38
$1,521.34 		$1,280.71
$1,361.21
$1,446.49
$1,749.45 		$228.11
Toc - Plan #41 Ambetter from Meridian
Bronze

(HMO) Clear Bronze + 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 		$226.91
$257.54
$289.98
$405.25
$615.82 		$400.49
$431.12
$463.56
$578.83 		$574.07
$604.70
$637.14
$752.41 		$747.65
$778.28
$810.72
$925.99 		$173.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$453.82
$515.08
$579.96
$810.50
$1,231.64 		$627.40
$688.66
$753.54
$984.08 		$800.98
$862.24
$927.12
$1,157.66 		$974.56
$1,035.82
$1,100.70
$1,331.24 		$173.58
Toc - Plan #42 Ambetter from Meridian
Expanded Bronze

(HMO) Choice Bronze 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 		$247.23
$280.60
$315.95
$441.54
$670.96 		$436.35
$469.72
$505.07
$630.66 		$625.47
$658.84
$694.19
$819.78 		$814.59
$847.96
$883.31
$1,008.90 		$189.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494.46
$561.20
$631.90
$883.08
$1,341.92 		$683.58
$750.32
$821.02
$1,072.20 		$872.70
$939.44
$1,010.14
$1,261.32 		$1,061.82
$1,128.56
$1,199.26
$1,450.44 		$189.12
Toc - Plan #43 Ambetter from Meridian
Silver

(HMO) Complete Silver + 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 		$299.24
$339.62
$382.41
$534.42
$812.10 		$528.15
$568.53
$611.32
$763.33 		$757.06
$797.44
$840.23
$992.24 		$985.97
$1,026.35
$1,069.14
$1,221.15 		$228.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.48
$679.24
$764.82
$1,068.84
$1,624.20 		$827.39
$908.15
$993.73
$1,297.75 		$1,056.30
$1,137.06
$1,222.64
$1,526.66 		$1,285.21
$1,365.97
$1,451.55
$1,755.57 		$228.91
Toc - Plan #44 Ambetter from Meridian
Gold

(HMO) Complete Gold + 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
$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 		$334.99
$380.21
$428.11
$598.28
$909.15 		$591.25
$636.47
$684.37
$854.54 		$847.51
$892.73
$940.63
$1,110.80 		$1,103.77
$1,148.99
$1,196.89
$1,367.06 		$256.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.98
$760.42
$856.22
$1,196.56
$1,818.30 		$926.24
$1,016.68
$1,112.48
$1,452.82 		$1,182.50
$1,272.94
$1,368.74
$1,709.08 		$1,438.76
$1,529.20
$1,625.00
$1,965.34 		$256.26
Toc - Plan #45 Ambetter from Meridian
Expanded Bronze

(HMO) Everyday Bronze + 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 		$247.44
$280.83
$316.22
$441.91
$671.53 		$436.72
$470.11
$505.50
$631.19 		$626.00
$659.39
$694.78
$820.47 		$815.28
$848.67
$884.06
$1,009.75 		$189.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494.88
$561.66
$632.44
$883.82
$1,343.06 		$684.16
$750.94
$821.72
$1,073.10 		$873.44
$940.22
$1,011.00
$1,262.38 		$1,062.72
$1,129.50
$1,200.28
$1,451.66 		$189.28
Toc - Plan #46 Ambetter from Meridian
Expanded Bronze

(HMO) Elite Bronze + 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 		$281.61
$319.62
$359.89
$502.94
$764.27 		$497.04
$535.05
$575.32
$718.37 		$712.47
$750.48
$790.75
$933.80 		$927.90
$965.91
$1,006.18
$1,149.23 		$215.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.22
$639.24
$719.78
$1,005.88
$1,528.54 		$778.65
$854.67
$935.21
$1,221.31 		$994.08
$1,070.10
$1,150.64
$1,436.74 		$1,209.51
$1,285.53
$1,366.07
$1,652.17 		$215.43
Toc - Plan #47 Ambetter from Meridian
Silver

(HMO) Focused Silver + Vision + Adult Dental

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
$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 		$293.25
$332.83
$374.76
$523.73
$795.86 		$517.58
$557.16
$599.09
$748.06 		$741.91
$781.49
$823.42
$972.39 		$966.24
$1,005.82
$1,047.75
$1,196.72 		$224.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586.50
$665.66
$749.52
$1,047.46
$1,591.72 		$810.83
$889.99
$973.85
$1,271.79 		$1,035.16
$1,114.32
$1,198.18
$1,496.12 		$1,259.49
$1,338.65
$1,422.51
$1,720.45 		$224.33
Toc - Plan #48 Ambetter from Meridian
Gold

(HMO) Everyday Gold + 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 		$319.94
$363.12
$408.88
$571.40
$868.30 		$564.69
$607.87
$653.63
$816.15 		$809.44
$852.62
$898.38
$1,060.90 		$1,054.19
$1,097.37
$1,143.13
$1,305.65 		$244.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.88
$726.24
$817.76
$1,142.80
$1,736.60 		$884.63
$970.99
$1,062.51
$1,387.55 		$1,129.38
$1,215.74
$1,307.26
$1,632.30 		$1,374.13
$1,460.49
$1,552.01
$1,877.05 		$244.75
Toc - Plan #49 Ambetter from Meridian
Silver

(HMO) Clear Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.38
$327.29
$368.53
$515.02
$782.62 		$508.98
$547.89
$589.13
$735.62 		$729.58
$768.49
$809.73
$956.22 		$950.18
$989.09
$1,030.33
$1,176.82 		$220.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.76
$654.58
$737.06
$1,030.04
$1,565.24 		$797.36
$875.18
$957.66
$1,250.64 		$1,017.96
$1,095.78
$1,178.26
$1,471.24 		$1,238.56
$1,316.38
$1,398.86
$1,691.84 		$220.60
Toc - Plan #50 Ambetter from Meridian
Gold

(HMO) Elite Gold + 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
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.11
$421.20
$474.27
$662.79
$1,007.17 		$655.00
$705.09
$758.16
$946.68 		$938.89
$988.98
$1,042.05
$1,230.57 		$1,222.78
$1,272.87
$1,325.94
$1,514.46 		$283.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.22
$842.40
$948.54
$1,325.58
$2,014.34 		$1,026.11
$1,126.29
$1,232.43
$1,609.47 		$1,310.00
$1,410.18
$1,516.32
$1,893.36 		$1,593.89
$1,694.07
$1,800.21
$2,177.25 		$283.89
Toc - Plan #51 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze - Virtual PCP selection required

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 		$225.95
$256.44
$288.75
$403.53
$613.20 		$398.79
$429.28
$461.59
$576.37 		$571.63
$602.12
$634.43
$749.21 		$744.47
$774.96
$807.27
$922.05 		$172.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$451.90
$512.88
$577.50
$807.06
$1,226.40 		$624.74
$685.72
$750.34
$979.90 		$797.58
$858.56
$923.18
$1,152.74 		$970.42
$1,031.40
$1,096.02
$1,325.58 		$172.84
Toc - Plan #52 Ambetter from Meridian
Silver

(HMO) Ambetter Virtual Access Silver - Virtual PCP selection required

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

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$7,400 $14,800 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 		$271.02
$307.59
$346.34
$484.01
$735.51 		$478.34
$514.91
$553.66
$691.33 		$685.66
$722.23
$760.98
$898.65 		$892.98
$929.55
$968.30
$1,105.97 		$207.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$542.04
$615.18
$692.68
$968.02
$1,471.02 		$749.36
$822.50
$900.00
$1,175.34 		$956.68
$1,029.82
$1,107.32
$1,382.66 		$1,164.00
$1,237.14
$1,314.64
$1,589.98 		$207.32
Toc - Plan #53 Ambetter from Meridian
Gold

(HMO) Ambetter Virtual Access Gold - Virtual PCP selection required

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 		$307.66
$349.18
$393.18
$549.46
$834.96 		$543.01
$584.53
$628.53
$784.81 		$778.36
$819.88
$863.88
$1,020.16 		$1,013.71
$1,055.23
$1,099.23
$1,255.51 		$235.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.32
$698.36
$786.36
$1,098.92
$1,669.92 		$850.67
$933.71
$1,021.71
$1,334.27 		$1,086.02
$1,169.06
$1,257.06
$1,569.62 		$1,321.37
$1,404.41
$1,492.41
$1,804.97 		$235.35

ADVERTISEMENT

US Health and Life

Local: 1-833-600-1311 | Toll Free: 

Toc - Plan #54 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care 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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$186.69
$211.89
$238.59
$333.43
$506.68 		$329.51
$354.71
$381.41
$476.25 		$472.33
$497.53
$524.23
$619.07 		$615.15
$640.35
$667.05
$761.89 		$142.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$373.38
$423.78
$477.18
$666.86
$1,013.36 		$516.20
$566.60
$620.00
$809.68 		$659.02
$709.42
$762.82
$952.50 		$801.84
$852.24
$905.64
$1,095.32 		$142.82
Toc - Plan #55 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Balanced Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$184.50
$209.41
$235.79
$329.52
$500.74 		$325.64
$350.55
$376.93
$470.66 		$466.78
$491.69
$518.07
$611.80 		$607.92
$632.83
$659.21
$752.94 		$141.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$369.00
$418.82
$471.58
$659.04
$1,001.48 		$510.14
$559.96
$612.72
$800.18 		$651.28
$701.10
$753.86
$941.32 		$792.42
$842.24
$895.00
$1,082.46 		$141.14
Toc - Plan #56 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care No Deductible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$212.76
$241.48
$271.90
$379.98
$577.42 		$375.52
$404.24
$434.66
$542.74 		$538.28
$567.00
$597.42
$705.50 		$701.04
$729.76
$760.18
$868.26 		$162.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$425.52
$482.96
$543.80
$759.96
$1,154.84 		$588.28
$645.72
$706.56
$922.72 		$751.04
$808.48
$869.32
$1,085.48 		$913.80
$971.24
$1,032.08
$1,248.24 		$162.76
Toc - Plan #57 US Health and Life
Silver

(EPO) Ascension Personalized Care Balanced Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$268.64
$304.91
$343.32
$479.79
$729.09 		$474.15
$510.42
$548.83
$685.30 		$679.66
$715.93
$754.34
$890.81 		$885.17
$921.44
$959.85
$1,096.32 		$205.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$537.28
$609.82
$686.64
$959.58
$1,458.18 		$742.79
$815.33
$892.15
$1,165.09 		$948.30
$1,020.84
$1,097.66
$1,370.60 		$1,153.81
$1,226.35
$1,303.17
$1,576.11 		$205.51
Toc - Plan #58 US Health and Life
Silver

(EPO) Ascension Personalized Care No Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$269.51
$305.89
$344.43
$481.34
$731.44 		$475.68
$512.06
$550.60
$687.51 		$681.85
$718.23
$756.77
$893.68 		$888.02
$924.40
$962.94
$1,099.85 		$206.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.02
$611.78
$688.86
$962.68
$1,462.88 		$745.19
$817.95
$895.03
$1,168.85 		$951.36
$1,024.12
$1,101.20
$1,375.02 		$1,157.53
$1,230.29
$1,307.37
$1,581.19 		$206.17
Toc - Plan #59 US Health and Life
Silver

(EPO) Ascension Personalized Care Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$247.91
$281.38
$316.83
$442.77
$672.82 		$437.56
$471.03
$506.48
$632.42 		$627.21
$660.68
$696.13
$822.07 		$816.86
$850.33
$885.78
$1,011.72 		$189.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$495.82
$562.76
$633.66
$885.54
$1,345.64 		$685.47
$752.41
$823.31
$1,075.19 		$875.12
$942.06
$1,012.96
$1,264.84 		$1,064.77
$1,131.71
$1,202.61
$1,454.49 		$189.65
Toc - Plan #60 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$188.81
$214.30
$241.30
$337.22
$512.43 		$333.25
$358.74
$385.74
$481.66 		$477.69
$503.18
$530.18
$626.10 		$622.13
$647.62
$674.62
$770.54 		$144.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$377.62
$428.60
$482.60
$674.44
$1,024.86 		$522.06
$573.04
$627.04
$818.88 		$666.50
$717.48
$771.48
$963.32 		$810.94
$861.92
$915.92
$1,107.76 		$144.44
Toc - Plan #61 US Health and Life
Silver

(EPO) Ascension Personalized Care Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$249.61
$283.31
$319.01
$445.81
$677.45 		$440.57
$474.27
$509.97
$636.77 		$631.53
$665.23
$700.93
$827.73 		$822.49
$856.19
$891.89
$1,018.69 		$190.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499.22
$566.62
$638.02
$891.62
$1,354.90 		$690.18
$757.58
$828.98
$1,082.58 		$881.14
$948.54
$1,019.94
$1,273.54 		$1,072.10
$1,139.50
$1,210.90
$1,464.50 		$190.96
Toc - Plan #62 US Health and Life
Gold

(EPO) Ascension Personalized Care Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.14
$346.34
$389.97
$544.99
$828.16 		$538.58
$579.78
$623.41
$778.43 		$772.02
$813.22
$856.85
$1,011.87 		$1,005.46
$1,046.66
$1,090.29
$1,245.31 		$233.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.28
$692.68
$779.94
$1,089.98
$1,656.32 		$843.72
$926.12
$1,013.38
$1,323.42 		$1,077.16
$1,159.56
$1,246.82
$1,556.86 		$1,310.60
$1,393.00
$1,480.26
$1,790.30 		$233.44

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0324 | Toll Free: 1-888-200-0324 | TTY: 1-888-200-0324
Toc - Plan #63 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $8,900 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$223.76
$253.97
$285.97
$399.64
$607.29 		$394.94
$425.15
$457.15
$570.82 		$566.12
$596.33
$628.33
$742.00 		$737.30
$767.51
$799.51
$913.18 		$171.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$447.52
$507.94
$571.94
$799.28
$1,214.58 		$618.70
$679.12
$743.12
$970.46 		$789.88
$850.30
$914.30
$1,141.64 		$961.06
$1,021.48
$1,085.48
$1,312.82 		$171.18
Toc - Plan #64 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
$7,250 $14,500 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 		$227.98
$258.76
$291.36
$407.17
$618.74 		$402.38
$433.16
$465.76
$581.57 		$576.78
$607.56
$640.16
$755.97 		$751.18
$781.96
$814.56
$930.37 		$174.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$455.96
$517.52
$582.72
$814.34
$1,237.48 		$630.36
$691.92
$757.12
$988.74 		$804.76
$866.32
$931.52
$1,163.14 		$979.16
$1,040.72
$1,105.92
$1,337.54 		$174.40
Toc - Plan #65 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Essential HSA

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$224.09
$254.34
$286.39
$400.22
$608.18 		$395.52
$425.77
$457.82
$571.65 		$566.95
$597.20
$629.25
$743.08 		$738.38
$768.63
$800.68
$914.51 		$171.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$448.18
$508.68
$572.78
$800.44
$1,216.36 		$619.61
$680.11
$744.21
$971.87 		$791.04
$851.54
$915.64
$1,143.30 		$962.47
$1,022.97
$1,087.07
$1,314.73 		$171.43
Toc - Plan #66 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.45
$363.71
$409.53
$572.32
$869.69 		$565.59
$608.85
$654.67
$817.46 		$810.73
$853.99
$899.81
$1,062.60 		$1,055.87
$1,099.13
$1,144.95
$1,307.74 		$245.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.90
$727.42
$819.06
$1,144.64
$1,739.38 		$886.04
$972.56
$1,064.20
$1,389.78 		$1,131.18
$1,217.70
$1,309.34
$1,634.92 		$1,376.32
$1,462.84
$1,554.48
$1,880.06 		$245.14
Toc - Plan #67 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$338.62
$384.33
$432.76
$604.77
$919.01 		$597.66
$643.37
$691.80
$863.81 		$856.70
$902.41
$950.84
$1,122.85 		$1,115.74
$1,161.45
$1,209.88
$1,381.89 		$259.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677.24
$768.66
$865.52
$1,209.54
$1,838.02 		$936.28
$1,027.70
$1,124.56
$1,468.58 		$1,195.32
$1,286.74
$1,383.60
$1,727.62 		$1,454.36
$1,545.78
$1,642.64
$1,986.66 		$259.04
Toc - Plan #68 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317.42
$360.27
$405.66
$566.91
$861.48 		$560.25
$603.10
$648.49
$809.74 		$803.08
$845.93
$891.32
$1,052.57 		$1,045.91
$1,088.76
$1,134.15
$1,295.40 		$242.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.84
$720.54
$811.32
$1,133.82
$1,722.96 		$877.67
$963.37
$1,054.15
$1,376.65 		$1,120.50
$1,206.20
$1,296.98
$1,619.48 		$1,363.33
$1,449.03
$1,539.81
$1,862.31 		$242.83
Toc - Plan #69 UnitedHealthcare
Silver

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

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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$268.25
$304.46
$342.82
$479.09
$728.03 		$473.46
$509.67
$548.03
$684.30 		$678.67
$714.88
$753.24
$889.51 		$883.88
$920.09
$958.45
$1,094.72 		$205.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.50
$608.92
$685.64
$958.18
$1,456.06 		$741.71
$814.13
$890.85
$1,163.39 		$946.92
$1,019.34
$1,096.06
$1,368.60 		$1,152.13
$1,224.55
$1,301.27
$1,573.81 		$205.21
Toc - Plan #70 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.55
$319.56
$359.83
$502.85
$764.14 		$496.94
$534.95
$575.22
$718.24 		$712.33
$750.34
$790.61
$933.63 		$927.72
$965.73
$1,006.00
$1,149.02 		$215.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.10
$639.12
$719.66
$1,005.70
$1,528.28 		$778.49
$854.51
$935.05
$1,221.09 		$993.88
$1,069.90
$1,150.44
$1,436.48 		$1,209.27
$1,285.29
$1,365.83
$1,651.87 		$215.39
Toc - Plan #71 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$212.44
$241.12
$271.50
$379.42
$576.56 		$374.96
$403.64
$434.02
$541.94 		$537.48
$566.16
$596.54
$704.46 		$700.00
$728.68
$759.06
$866.98 		$162.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$424.88
$482.24
$543.00
$758.84
$1,153.12 		$587.40
$644.76
$705.52
$921.36 		$749.92
$807.28
$868.04
$1,083.88 		$912.44
$969.80
$1,030.56
$1,246.40 		$162.52
Toc - Plan #72 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$222.96
$253.06
$284.94
$398.20
$605.11 		$393.52
$423.62
$455.50
$568.76 		$564.08
$594.18
$626.06
$739.32 		$734.64
$764.74
$796.62
$909.88 		$170.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$445.92
$506.12
$569.88
$796.40
$1,210.22 		$616.48
$676.68
$740.44
$966.96 		$787.04
$847.24
$911.00
$1,137.52 		$957.60
$1,017.80
$1,081.56
$1,308.08 		$170.56
Toc - Plan #73 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$212.14
$240.78
$271.11
$378.88
$575.74 		$374.43
$403.07
$433.40
$541.17 		$536.72
$565.36
$595.69
$703.46 		$699.01
$727.65
$757.98
$865.75 		$162.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$424.28
$481.56
$542.22
$757.76
$1,151.48 		$586.57
$643.85
$704.51
$920.05 		$748.86
$806.14
$866.80
$1,082.34 		$911.15
$968.43
$1,029.09
$1,244.63 		$162.29
Toc - Plan #74 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,150 $4,300 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.81
$351.63
$395.94
$553.32
$840.82 		$546.81
$588.63
$632.94
$790.32 		$783.81
$825.63
$869.94
$1,027.32 		$1,020.81
$1,062.63
$1,106.94
$1,264.32 		$237.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.62
$703.26
$791.88
$1,106.64
$1,681.64 		$856.62
$940.26
$1,028.88
$1,343.64 		$1,093.62
$1,177.26
$1,265.88
$1,580.64 		$1,330.62
$1,414.26
$1,502.88
$1,817.64 		$237.00
Toc - Plan #75 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,350 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

Individual Family
$3,350 $6,700 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.26
$319.23
$359.45
$502.33
$763.34 		$496.43
$534.40
$574.62
$717.50 		$711.60
$749.57
$789.79
$932.67 		$926.77
$964.74
$1,004.96
$1,147.84 		$215.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.52
$638.46
$718.90
$1,004.66
$1,526.68 		$777.69
$853.63
$934.07
$1,219.83 		$992.86
$1,068.80
$1,149.24
$1,435.00 		$1,208.03
$1,283.97
$1,364.41
$1,650.17 		$215.17
Toc - Plan #76 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$280.71
$318.61
$358.75
$501.36
$761.86 		$495.46
$533.36
$573.50
$716.11 		$710.21
$748.11
$788.25
$930.86 		$924.96
$962.86
$1,003.00
$1,145.61 		$214.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.42
$637.22
$717.50
$1,002.72
$1,523.72 		$776.17
$851.97
$932.25
$1,217.47 		$990.92
$1,066.72
$1,147.00
$1,432.22 		$1,205.67
$1,281.47
$1,361.75
$1,646.97 		$214.75
Toc - Plan #77 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$275.68
$312.90
$352.32
$492.36
$748.19 		$486.57
$523.79
$563.21
$703.25 		$697.46
$734.68
$774.10
$914.14 		$908.35
$945.57
$984.99
$1,125.03 		$210.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.36
$625.80
$704.64
$984.72
$1,496.38 		$762.25
$836.69
$915.53
$1,195.61 		$973.14
$1,047.58
$1,126.42
$1,406.50 		$1,184.03
$1,258.47
$1,337.31
$1,617.39 		$210.89
Toc - Plan #78 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$293.84
$333.51
$375.53
$524.80
$797.49 		$518.63
$558.30
$600.32
$749.59 		$743.42
$783.09
$825.11
$974.38 		$968.21
$1,007.88
$1,049.90
$1,199.17 		$224.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.68
$667.02
$751.06
$1,049.60
$1,594.98 		$812.47
$891.81
$975.85
$1,274.39 		$1,037.26
$1,116.60
$1,200.64
$1,499.18 		$1,262.05
$1,341.39
$1,425.43
$1,723.97 		$224.79
Toc - Plan #79 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $9,100 Deductible ($3 T1 Preferred Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$219.29
$248.90
$280.26
$391.66
$595.17 		$387.05
$416.66
$448.02
$559.42 		$554.81
$584.42
$615.78
$727.18 		$722.57
$752.18
$783.54
$894.94 		$167.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$438.58
$497.80
$560.52
$783.32
$1,190.34 		$606.34
$665.56
$728.28
$951.08 		$774.10
$833.32
$896.04
$1,118.84 		$941.86
$1,001.08
$1,063.80
$1,286.60 		$167.76

ADVERTISEMENT

McLaren Health Plan Community

Local: 1-888-327-0671 | Toll Free: 1-888-327-0671 | TTY: 1-800-356-3232
Toc - Plan #80 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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$206.89
$234.82
$264.41
$369.51
$561.50 		$365.16
$393.09
$422.68
$527.78 		$523.43
$551.36
$580.95
$686.05 		$681.70
$709.63
$739.22
$844.32 		$158.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$413.78
$469.64
$528.82
$739.02
$1,123.00 		$572.05
$627.91
$687.09
$897.29 		$730.32
$786.18
$845.36
$1,055.56 		$888.59
$944.45
$1,003.63
$1,213.83 		$158.27
Toc - Plan #81 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
$3,800 $7,600 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.09
$415.51
$467.86
$653.83
$993.56 		$646.15
$695.57
$747.92
$933.89 		$926.21
$975.63
$1,027.98
$1,213.95 		$1,206.27
$1,255.69
$1,308.04
$1,494.01 		$280.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.18
$831.02
$935.72
$1,307.66
$1,987.12 		$1,012.24
$1,111.08
$1,215.78
$1,587.72 		$1,292.30
$1,391.14
$1,495.84
$1,867.78 		$1,572.36
$1,671.20
$1,775.90
$2,147.84 		$280.06
Toc - Plan #82 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
$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 		$355.34
$403.32
$454.13
$634.65
$964.41 		$627.18
$675.16
$725.97
$906.49 		$899.02
$947.00
$997.81
$1,178.33 		$1,170.86
$1,218.84
$1,269.65
$1,450.17 		$271.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.68
$806.64
$908.26
$1,269.30
$1,928.82 		$982.52
$1,078.48
$1,180.10
$1,541.14 		$1,254.36
$1,350.32
$1,451.94
$1,812.98 		$1,526.20
$1,622.16
$1,723.78
$2,084.82 		$271.84
Toc - Plan #83 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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$228.80
$259.69
$292.41
$408.64
$620.97 		$403.83
$434.72
$467.44
$583.67 		$578.86
$609.75
$642.47
$758.70 		$753.89
$784.78
$817.50
$933.73 		$175.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$457.60
$519.38
$584.82
$817.28
$1,241.94 		$632.63
$694.41
$759.85
$992.31 		$807.66
$869.44
$934.88
$1,167.34 		$982.69
$1,044.47
$1,109.91
$1,342.37 		$175.03
Toc - Plan #84 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
$7,100 $14,200 Annual Deductible
$7,100 $14,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$252.01
$286.03
$322.06
$450.08
$683.95 		$444.79
$478.81
$514.84
$642.86 		$637.57
$671.59
$707.62
$835.64 		$830.35
$864.37
$900.40
$1,028.42 		$192.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.02
$572.06
$644.12
$900.16
$1,367.90 		$696.80
$764.84
$836.90
$1,092.94 		$889.58
$957.62
$1,029.68
$1,285.72 		$1,082.36
$1,150.40
$1,222.46
$1,478.50 		$192.78
Toc - Plan #85 McLaren Health Plan Community
Silver

(HMO) McLaren Silver VCP

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

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.41
$386.37
$435.04
$607.97
$923.87 		$600.82
$646.78
$695.45
$868.38 		$861.23
$907.19
$955.86
$1,128.79 		$1,121.64
$1,167.60
$1,216.27
$1,389.20 		$260.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.82
$772.74
$870.08
$1,215.94
$1,847.74 		$941.23
$1,033.15
$1,130.49
$1,476.35 		$1,201.64
$1,293.56
$1,390.90
$1,736.76 		$1,462.05
$1,553.97
$1,651.31
$1,997.17 		$260.41
Toc - Plan #86 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
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$217.63
$247.01
$278.13
$388.69
$590.66 		$384.12
$413.50
$444.62
$555.18 		$550.61
$579.99
$611.11
$721.67 		$717.10
$746.48
$777.60
$888.16 		$166.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$435.26
$494.02
$556.26
$777.38
$1,181.32 		$601.75
$660.51
$722.75
$943.87 		$768.24
$827.00
$889.24
$1,110.36 		$934.73
$993.49
$1,055.73
$1,276.85 		$166.49
Toc - Plan #87 McLaren Health Plan Community
Gold

(HMO) McLaren Gold 1400 VCP

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

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 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 		$337.85
$383.46
$431.77
$603.39
$916.92 		$596.30
$641.91
$690.22
$861.84 		$854.75
$900.36
$948.67
$1,120.29 		$1,113.20
$1,158.81
$1,207.12
$1,378.74 		$258.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.70
$766.92
$863.54
$1,206.78
$1,833.84 		$934.15
$1,025.37
$1,121.99
$1,465.23 		$1,192.60
$1,283.82
$1,380.44
$1,723.68 		$1,451.05
$1,542.27
$1,638.89
$1,982.13 		$258.45
Toc - Plan #88 McLaren Health Plan Community
Silver

(HMO) McLaren Silver Exchange Rewards

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$356.52
$404.65
$455.63
$636.74
$967.59 		$629.26
$677.39
$728.37
$909.48 		$902.00
$950.13
$1,001.11
$1,182.22 		$1,174.74
$1,222.87
$1,273.85
$1,454.96 		$272.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.04
$809.30
$911.26
$1,273.48
$1,935.18 		$985.78
$1,082.04
$1,184.00
$1,546.22 		$1,258.52
$1,354.78
$1,456.74
$1,818.96 		$1,531.26
$1,627.52
$1,729.48
$2,091.70 		$272.74
Toc - Plan #89 McLaren Health Plan Community
Gold

(HMO) McLaren Gold Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$353.56
$401.29
$451.85
$631.46
$959.56 		$624.03
$671.76
$722.32
$901.93 		$894.50
$942.23
$992.79
$1,172.40 		$1,164.97
$1,212.70
$1,263.26
$1,442.87 		$270.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.12
$802.58
$903.70
$1,262.92
$1,919.12 		$977.59
$1,073.05
$1,174.17
$1,533.39 		$1,248.06
$1,343.52
$1,444.64
$1,803.86 		$1,518.53
$1,613.99
$1,715.11
$2,074.33 		$270.47
Toc - Plan #90 McLaren Health Plan Community
Silver

(HMO) McLaren Silver Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.76
$414.00
$466.16
$651.46
$989.96 		$643.80
$693.04
$745.20
$930.50 		$922.84
$972.08
$1,024.24
$1,209.54 		$1,201.88
$1,251.12
$1,303.28
$1,488.58 		$279.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.52
$828.00
$932.32
$1,302.92
$1,979.92 		$1,008.56
$1,107.04
$1,211.36
$1,581.96 		$1,287.60
$1,386.08
$1,490.40
$1,861.00 		$1,566.64
$1,665.12
$1,769.44
$2,140.04 		$279.04
Toc - Plan #91 McLaren Health Plan Community
Bronze

(HMO) McLaren Bronze Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$229.30
$260.26
$293.05
$409.54
$622.33 		$404.72
$435.68
$468.47
$584.96 		$580.14
$611.10
$643.89
$760.38 		$755.56
$786.52
$819.31
$935.80 		$175.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$458.60
$520.52
$586.10
$819.08
$1,244.66 		$634.02
$695.94
$761.52
$994.50 		$809.44
$871.36
$936.94
$1,169.92 		$984.86
$1,046.78
$1,112.36
$1,345.34 		$175.42
Toc - Plan #92 McLaren Health Plan Community
Expanded Bronze

(HMO) McLaren Expanded Bronze Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$244.57
$277.59
$312.56
$436.80
$663.76 		$431.67
$464.69
$499.66
$623.90 		$618.77
$651.79
$686.76
$811.00 		$805.87
$838.89
$873.86
$998.10 		$187.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$489.14
$555.18
$625.12
$873.60
$1,327.52 		$676.24
$742.28
$812.22
$1,060.70 		$863.34
$929.38
$999.32
$1,247.80 		$1,050.44
$1,116.48
$1,186.42
$1,434.90 		$187.10

ADVERTISEMENT

Blue Care Network of Michigan

Local: 1-888-227-2345 | Toll Free: 1-888-227-2345 | TTY: 1-800-257-9980
Toc - Plan #93 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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$204.68
$232.31
$261.58
$365.56
$555.50 		$361.26
$388.89
$418.16
$522.14 		$517.84
$545.47
$574.74
$678.72 		$674.42
$702.05
$731.32
$835.30 		$156.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$409.36
$464.62
$523.16
$731.12
$1,111.00 		$565.94
$621.20
$679.74
$887.70 		$722.52
$777.78
$836.32
$1,044.28 		$879.10
$934.36
$992.90
$1,200.86 		$156.58
Toc - Plan #94 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
$4,650 $9,300 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.87
$402.78
$453.52
$633.80
$963.12 		$626.35
$674.26
$725.00
$905.28 		$897.83
$945.74
$996.48
$1,176.76 		$1,169.31
$1,217.22
$1,267.96
$1,448.24 		$271.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.74
$805.56
$907.04
$1,267.60
$1,926.24 		$981.22
$1,077.04
$1,178.52
$1,539.08 		$1,252.70
$1,348.52
$1,450.00
$1,810.56 		$1,524.18
$1,620.00
$1,721.48
$2,082.04 		$271.48
Toc - Plan #95 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
$4,650 $9,300 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.92
$442.56
$498.32
$696.40
$1,058.24 		$688.21
$740.85
$796.61
$994.69 		$986.50
$1,039.14
$1,094.90
$1,292.98 		$1,284.79
$1,337.43
$1,393.19
$1,591.27 		$298.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.84
$885.12
$996.64
$1,392.80
$2,116.48 		$1,078.13
$1,183.41
$1,294.93
$1,691.09 		$1,376.42
$1,481.70
$1,593.22
$1,989.38 		$1,674.71
$1,779.99
$1,891.51
$2,287.67 		$298.29
Toc - Plan #96 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
$1,600 $3,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$438.69
$497.91
$560.65
$783.50
$1,190.60 		$774.29
$833.51
$896.25
$1,119.10 		$1,109.89
$1,169.11
$1,231.85
$1,454.70 		$1,445.49
$1,504.71
$1,567.45
$1,790.30 		$335.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$877.38
$995.82
$1,121.30
$1,567.00
$2,381.20 		$1,212.98
$1,331.42
$1,456.90
$1,902.60 		$1,548.58
$1,667.02
$1,792.50
$2,238.20 		$1,884.18
$2,002.62
$2,128.10
$2,573.80 		$335.60
Toc - Plan #97 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
$5,500 $11,000 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 		$318.03
$360.96
$406.44
$568.00
$863.13 		$561.32
$604.25
$649.73
$811.29 		$804.61
$847.54
$893.02
$1,054.58 		$1,047.90
$1,090.83
$1,136.31
$1,297.87 		$243.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.06
$721.92
$812.88
$1,136.00
$1,726.26 		$879.35
$965.21
$1,056.17
$1,379.29 		$1,122.64
$1,208.50
$1,299.46
$1,622.58 		$1,365.93
$1,451.79
$1,542.75
$1,865.87 		$243.29
Toc - Plan #98 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
$5,500 $11,000 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 		$349.43
$396.60
$446.57
$624.08
$948.35 		$616.74
$663.91
$713.88
$891.39 		$884.05
$931.22
$981.19
$1,158.70 		$1,151.36
$1,198.53
$1,248.50
$1,426.01 		$267.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.86
$793.20
$893.14
$1,248.16
$1,896.70 		$966.17
$1,060.51
$1,160.45
$1,515.47 		$1,233.48
$1,327.82
$1,427.76
$1,782.78 		$1,500.79
$1,595.13
$1,695.07
$2,050.09 		$267.31
Toc - Plan #99 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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$249.51
$283.19
$318.87
$445.62
$677.17 		$440.39
$474.07
$509.75
$636.50 		$631.27
$664.95
$700.63
$827.38 		$822.15
$855.83
$891.51
$1,018.26 		$190.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499.02
$566.38
$637.74
$891.24
$1,354.34 		$689.90
$757.26
$828.62
$1,082.12 		$880.78
$948.14
$1,019.50
$1,273.00 		$1,071.66
$1,139.02
$1,210.38
$1,463.88 		$190.88
Toc - Plan #100 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
$7,500 $15,000 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 		$253.53
$287.76
$324.01
$452.80
$688.08 		$447.48
$481.71
$517.96
$646.75 		$641.43
$675.66
$711.91
$840.70 		$835.38
$869.61
$905.86
$1,034.65 		$193.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$507.06
$575.52
$648.02
$905.60
$1,376.16 		$701.01
$769.47
$841.97
$1,099.55 		$894.96
$963.42
$1,035.92
$1,293.50 		$1,088.91
$1,157.37
$1,229.87
$1,487.45 		$193.95
Toc - Plan #101 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
$7,500 $15,000 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 		$278.56
$316.17
$356.00
$497.51
$756.01 		$491.66
$529.27
$569.10
$710.61 		$704.76
$742.37
$782.20
$923.71 		$917.86
$955.47
$995.30
$1,136.81 		$213.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.12
$632.34
$712.00
$995.02
$1,512.02 		$770.22
$845.44
$925.10
$1,208.12 		$983.32
$1,058.54
$1,138.20
$1,421.22 		$1,196.42
$1,271.64
$1,351.30
$1,634.32 		$213.10
Toc - Plan #102 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
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$274.15
$311.16
$350.36
$489.63
$744.04 		$483.87
$520.88
$560.08
$699.35 		$693.59
$730.60
$769.80
$909.07 		$903.31
$940.32
$979.52
$1,118.79 		$209.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.30
$622.32
$700.72
$979.26
$1,488.08 		$758.02
$832.04
$910.44
$1,188.98 		$967.74
$1,041.76
$1,120.16
$1,398.70 		$1,177.46
$1,251.48
$1,329.88
$1,608.42 		$209.72
Toc - Plan #103 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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.70
$423.01
$476.31
$665.64
$1,011.51 		$657.82
$708.13
$761.43
$950.76 		$942.94
$993.25
$1,046.55
$1,235.88 		$1,228.06
$1,278.37
$1,331.67
$1,521.00 		$285.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.40
$846.02
$952.62
$1,331.28
$2,023.02 		$1,030.52
$1,131.14
$1,237.74
$1,616.40 		$1,315.64
$1,416.26
$1,522.86
$1,901.52 		$1,600.76
$1,701.38
$1,807.98
$2,186.64 		$285.12
Toc - Plan #104 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
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.51
$464.79
$523.35
$731.38
$1,111.41 		$722.79
$778.07
$836.63
$1,044.66 		$1,036.07
$1,091.35
$1,149.91
$1,357.94 		$1,349.35
$1,404.63
$1,463.19
$1,671.22 		$313.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.02
$929.58
$1,046.70
$1,462.76
$2,222.82 		$1,132.30
$1,242.86
$1,359.98
$1,776.04 		$1,445.58
$1,556.14
$1,673.26
$2,089.32 		$1,758.86
$1,869.42
$1,986.54
$2,402.60 		$313.28
Toc - Plan #105 Blue Care Network of Michigan
Gold

(HMO) Blue Cross® Preferred HMO Gold Extra

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$441.65
$501.27
$564.43
$788.79
$1,198.64 		$779.51
$839.13
$902.29
$1,126.65 		$1,117.37
$1,176.99
$1,240.15
$1,464.51 		$1,455.23
$1,514.85
$1,578.01
$1,802.37 		$337.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.30
$1,002.54
$1,128.86
$1,577.58
$2,397.28 		$1,221.16
$1,340.40
$1,466.72
$1,915.44 		$1,559.02
$1,678.26
$1,804.58
$2,253.30 		$1,896.88
$2,016.12
$2,142.44
$2,591.16 		$337.86
Toc - Plan #106 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Select HMO Bronze Extra

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$240.12
$272.54
$306.87
$428.85
$651.69 		$423.81
$456.23
$490.56
$612.54 		$607.50
$639.92
$674.25
$796.23 		$791.19
$823.61
$857.94
$979.92 		$183.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$480.24
$545.08
$613.74
$857.70
$1,303.38 		$663.93
$728.77
$797.43
$1,041.39 		$847.62
$912.46
$981.12
$1,225.08 		$1,031.31
$1,096.15
$1,164.81
$1,408.77 		$183.69
Toc - Plan #107 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Preferred HMO Bronze Extra

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$263.82
$299.44
$337.16
$471.18
$716.01 		$465.64
$501.26
$538.98
$673.00 		$667.46
$703.08
$740.80
$874.82 		$869.28
$904.90
$942.62
$1,076.64 		$201.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$527.64
$598.88
$674.32
$942.36
$1,432.02 		$729.46
$800.70
$876.14
$1,144.18 		$931.28
$1,002.52
$1,077.96
$1,346.00 		$1,133.10
$1,204.34
$1,279.78
$1,547.82 		$201.82
Toc - Plan #108 Blue Care Network of Michigan
Bronze

(HMO) Blue Cross® Select HMO Bronze Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$213.66
$242.50
$273.06
$381.60
$579.87 		$377.11
$405.95
$436.51
$545.05 		$540.56
$569.40
$599.96
$708.50 		$704.01
$732.85
$763.41
$871.95 		$163.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$427.32
$485.00
$546.12
$763.20
$1,159.74 		$590.77
$648.45
$709.57
$926.65 		$754.22
$811.90
$873.02
$1,090.10 		$917.67
$975.35
$1,036.47
$1,253.55 		$163.45
Toc - Plan #109 Blue Care Network of Michigan
Bronze

(HMO) Blue Cross® Preferred HMO Bronze Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$234.75
$266.44
$300.01
$419.26
$637.11 		$414.33
$446.02
$479.59
$598.84 		$593.91
$625.60
$659.17
$778.42 		$773.49
$805.18
$838.75
$958.00 		$179.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$469.50
$532.88
$600.02
$838.52
$1,274.22 		$649.08
$712.46
$779.60
$1,018.10 		$828.66
$892.04
$959.18
$1,197.68 		$1,008.24
$1,071.62
$1,138.76
$1,377.26 		$179.58
Toc - Plan #110 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Preferred HMO Virtual Primary Care Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$252.85
$286.98
$323.14
$451.59
$686.23 		$446.28
$480.41
$516.57
$645.02 		$639.71
$673.84
$710.00
$838.45 		$833.14
$867.27
$903.43
$1,031.88 		$193.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$505.70
$573.96
$646.28
$903.18
$1,372.46 		$699.13
$767.39
$839.71
$1,096.61 		$892.56
$960.82
$1,033.14
$1,290.04 		$1,085.99
$1,154.25
$1,226.57
$1,483.47 		$193.43
Toc - Plan #111 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Preferred HMO Virtual Primary Care Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,050 $12,100 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.86
$402.77
$453.51
$633.78
$963.09 		$626.33
$674.24
$724.98
$905.25 		$897.80
$945.71
$996.45
$1,176.72 		$1,169.27
$1,217.18
$1,267.92
$1,448.19 		$271.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.72
$805.54
$907.02
$1,267.56
$1,926.18 		$981.19
$1,077.01
$1,178.49
$1,539.03 		$1,252.66
$1,348.48
$1,449.96
$1,810.50 		$1,524.13
$1,619.95
$1,721.43
$2,081.97 		$271.47

‡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 Genesee County here.

Genesee County is in “Rating Area 5” of Michigan.

Currently, there are 111 plans offered in Rating Area 5.

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2023 Obamacare Plans for Genesee County, MI

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