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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 		$228.61
$259.47
$292.16
$408.30
$620.45 		$403.50
$434.36
$467.05
$583.19 		$578.39
$609.25
$641.94
$758.08 		$753.28
$784.14
$816.83
$932.97 		$174.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$457.22
$518.94
$584.32
$816.60
$1,240.90 		$632.11
$693.83
$759.21
$991.49 		$807.00
$868.72
$934.10
$1,166.38 		$981.89
$1,043.61
$1,108.99
$1,341.27 		$174.89
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 		$304.48
$345.58
$389.13
$543.80
$826.36 		$537.41
$578.51
$622.06
$776.73 		$770.34
$811.44
$854.99
$1,009.66 		$1,003.27
$1,044.37
$1,087.92
$1,242.59 		$232.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.96
$691.16
$778.26
$1,087.60
$1,652.72 		$841.89
$924.09
$1,011.19
$1,320.53 		$1,074.82
$1,157.02
$1,244.12
$1,553.46 		$1,307.75
$1,389.95
$1,477.05
$1,786.39 		$232.93
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 		$412.06
$467.69
$526.61
$735.94
$1,118.33 		$727.29
$782.92
$841.84
$1,051.17 		$1,042.52
$1,098.15
$1,157.07
$1,366.40 		$1,357.75
$1,413.38
$1,472.30
$1,681.63 		$315.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.12
$935.38
$1,053.22
$1,471.88
$2,236.66 		$1,139.35
$1,250.61
$1,368.45
$1,787.11 		$1,454.58
$1,565.84
$1,683.68
$2,102.34 		$1,769.81
$1,881.07
$1,998.91
$2,417.57 		$315.23
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 		$505.61
$573.87
$646.17
$903.02
$1,372.23 		$892.40
$960.66
$1,032.96
$1,289.81 		$1,279.19
$1,347.45
$1,419.75
$1,676.60 		$1,665.98
$1,734.24
$1,806.54
$2,063.39 		$386.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,011.22
$1,147.74
$1,292.34
$1,806.04
$2,744.46 		$1,398.01
$1,534.53
$1,679.13
$2,192.83 		$1,784.80
$1,921.32
$2,065.92
$2,579.62 		$2,171.59
$2,308.11
$2,452.71
$2,966.41 		$386.79
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 		$280.76
$318.66
$358.81
$501.44
$761.98 		$495.54
$533.44
$573.59
$716.22 		$710.32
$748.22
$788.37
$931.00 		$925.10
$963.00
$1,003.15
$1,145.78 		$214.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.52
$637.32
$717.62
$1,002.88
$1,523.96 		$776.30
$852.10
$932.40
$1,217.66 		$991.08
$1,066.88
$1,147.18
$1,432.44 		$1,205.86
$1,281.66
$1,361.96
$1,647.22 		$214.78
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 		$412.13
$467.77
$526.70
$736.06
$1,118.52 		$727.41
$783.05
$841.98
$1,051.34 		$1,042.69
$1,098.33
$1,157.26
$1,366.62 		$1,357.97
$1,413.61
$1,472.54
$1,681.90 		$315.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.26
$935.54
$1,053.40
$1,472.12
$2,237.04 		$1,139.54
$1,250.82
$1,368.68
$1,787.40 		$1,454.82
$1,566.10
$1,683.96
$2,102.68 		$1,770.10
$1,881.38
$1,999.24
$2,417.96 		$315.28
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 		$318.95
$362.01
$407.62
$569.64
$865.63 		$562.95
$606.01
$651.62
$813.64 		$806.95
$850.01
$895.62
$1,057.64 		$1,050.95
$1,094.01
$1,139.62
$1,301.64 		$244.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637.90
$724.02
$815.24
$1,139.28
$1,731.26 		$881.90
$968.02
$1,059.24
$1,383.28 		$1,125.90
$1,212.02
$1,303.24
$1,627.28 		$1,369.90
$1,456.02
$1,547.24
$1,871.28 		$244.00
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 		$438.08
$497.22
$559.87
$782.41
$1,188.95 		$773.21
$832.35
$895.00
$1,117.54 		$1,108.34
$1,167.48
$1,230.13
$1,452.67 		$1,443.47
$1,502.61
$1,565.26
$1,787.80 		$335.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$876.16
$994.44
$1,119.74
$1,564.82
$2,377.90 		$1,211.29
$1,329.57
$1,454.87
$1,899.95 		$1,546.42
$1,664.70
$1,790.00
$2,235.08 		$1,881.55
$1,999.83
$2,125.13
$2,570.21 		$335.13
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 		$550.45
$624.76
$703.48
$983.10
$1,493.92 		$971.54
$1,045.85
$1,124.57
$1,404.19 		$1,392.63
$1,466.94
$1,545.66
$1,825.28 		$1,813.72
$1,888.03
$1,966.75
$2,246.37 		$421.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,100.90
$1,249.52
$1,406.96
$1,966.20
$2,987.84 		$1,521.99
$1,670.61
$1,828.05
$2,387.29 		$1,943.08
$2,091.70
$2,249.14
$2,808.38 		$2,364.17
$2,512.79
$2,670.23
$3,229.47 		$421.09

ADVERTISEMENT

Priority Health

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

(HMO) MyPriority Gold Copay+ - Beaumont Health Network

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$405.41
$460.14
$518.11
$724.06
$1,100.28 		$715.55
$770.28
$828.25
$1,034.20 		$1,025.69
$1,080.42
$1,138.39
$1,344.34 		$1,335.83
$1,390.56
$1,448.53
$1,654.48 		$310.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.82
$920.28
$1,036.22
$1,448.12
$2,200.56 		$1,120.96
$1,230.42
$1,346.36
$1,758.26 		$1,431.10
$1,540.56
$1,656.50
$2,068.40 		$1,741.24
$1,850.70
$1,966.64
$2,378.54 		$310.14
Toc - Plan #11 Priority Health
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$392.80
$445.83
$502.00
$701.54
$1,066.06 		$693.29
$746.32
$802.49
$1,002.03 		$993.78
$1,046.81
$1,102.98
$1,302.52 		$1,294.27
$1,347.30
$1,403.47
$1,603.01 		$300.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.60
$891.66
$1,004.00
$1,403.08
$2,132.12 		$1,086.09
$1,192.15
$1,304.49
$1,703.57 		$1,386.58
$1,492.64
$1,604.98
$2,004.06 		$1,687.07
$1,793.13
$1,905.47
$2,304.55 		$300.49
Toc - Plan #12 Priority Health
Gold

(HMO) MyPriority Gold Copay+ - Trinity Health East Network

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$398.20
$451.96
$508.90
$711.19
$1,080.71 		$702.82
$756.58
$813.52
$1,015.81 		$1,007.44
$1,061.20
$1,118.14
$1,320.43 		$1,312.06
$1,365.82
$1,422.76
$1,625.05 		$304.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.40
$903.92
$1,017.80
$1,422.38
$2,161.42 		$1,101.02
$1,208.54
$1,322.42
$1,727.00 		$1,405.64
$1,513.16
$1,627.04
$2,031.62 		$1,710.26
$1,817.78
$1,931.66
$2,336.24 		$304.62
Toc - Plan #13 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 		$255.07
$289.50
$325.98
$455.56
$692.26 		$450.20
$484.63
$521.11
$650.69 		$645.33
$679.76
$716.24
$845.82 		$840.46
$874.89
$911.37
$1,040.95 		$195.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$510.14
$579.00
$651.96
$911.12
$1,384.52 		$705.27
$774.13
$847.09
$1,106.25 		$900.40
$969.26
$1,042.22
$1,301.38 		$1,095.53
$1,164.39
$1,237.35
$1,496.51 		$195.13
Toc - Plan #14 Priority Health
Expanded Bronze

(HMO) MyPriority HSA Bronze 7100 - Beaumont Health Network

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 		$229.57
$260.56
$293.39
$410.01
$623.05 		$405.19
$436.18
$469.01
$585.63 		$580.81
$611.80
$644.63
$761.25 		$756.43
$787.42
$820.25
$936.87 		$175.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$459.14
$521.12
$586.78
$820.02
$1,246.10 		$634.76
$696.74
$762.40
$995.64 		$810.38
$872.36
$938.02
$1,171.26 		$986.00
$1,047.98
$1,113.64
$1,346.88 		$175.62
Toc - Plan #15 Priority Health
Expanded Bronze

(HMO) MyPriority HSA Bronze 7100 - Ascension St. John Providence Network

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

Annual Out of Pocket Expenses:

Individual Family
$7,100 $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 		$222.42
$252.45
$284.25
$397.24
$603.65 		$392.57
$422.60
$454.40
$567.39 		$562.72
$592.75
$624.55
$737.54 		$732.87
$762.90
$794.70
$907.69 		$170.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$444.84
$504.90
$568.50
$794.48
$1,207.30 		$614.99
$675.05
$738.65
$964.63 		$785.14
$845.20
$908.80
$1,134.78 		$955.29
$1,015.35
$1,078.95
$1,304.93 		$170.15
Toc - Plan #16 Priority Health
Expanded Bronze

(HMO) MyPriority HSA Bronze 7100 - Trinity Health East Network

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 		$225.49
$255.93
$288.18
$402.73
$611.98 		$397.99
$428.43
$460.68
$575.23 		$570.49
$600.93
$633.18
$747.73 		$742.99
$773.43
$805.68
$920.23 		$172.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$450.98
$511.86
$576.36
$805.46
$1,223.96 		$623.48
$684.36
$748.86
$977.96 		$795.98
$856.86
$921.36
$1,150.46 		$968.48
$1,029.36
$1,093.86
$1,322.96 		$172.50
Toc - Plan #17 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 		$233.09
$264.56
$297.89
$416.30
$632.61 		$411.40
$442.87
$476.20
$594.61 		$589.71
$621.18
$654.51
$772.92 		$768.02
$799.49
$832.82
$951.23 		$178.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$466.18
$529.12
$595.78
$832.60
$1,265.22 		$644.49
$707.43
$774.09
$1,010.91 		$822.80
$885.74
$952.40
$1,189.22 		$1,001.11
$1,064.05
$1,130.71
$1,367.53 		$178.31
Toc - Plan #18 Priority Health
Expanded Bronze

(HMO) MyPriority Bronze 9100 - Beaumont Health Network

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 		$209.78
$238.10
$268.10
$374.67
$569.34 		$370.26
$398.58
$428.58
$535.15 		$530.74
$559.06
$589.06
$695.63 		$691.22
$719.54
$749.54
$856.11 		$160.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$419.56
$476.20
$536.20
$749.34
$1,138.68 		$580.04
$636.68
$696.68
$909.82 		$740.52
$797.16
$857.16
$1,070.30 		$901.00
$957.64
$1,017.64
$1,230.78 		$160.48
Toc - Plan #19 Priority Health
Expanded Bronze

(HMO) MyPriority Bronze 9100 - Ascension St. John Providence Network

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$203.26
$230.70
$259.77
$363.02
$551.65 		$358.75
$386.19
$415.26
$518.51 		$514.24
$541.68
$570.75
$674.00 		$669.73
$697.17
$726.24
$829.49 		$155.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$406.52
$461.40
$519.54
$726.04
$1,103.30 		$562.01
$616.89
$675.03
$881.53 		$717.50
$772.38
$830.52
$1,037.02 		$872.99
$927.87
$986.01
$1,192.51 		$155.49
Toc - Plan #20 Priority Health
Expanded Bronze

(HMO) MyPriority Bronze 9100 - Trinity Health East Network

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 		$206.05
$233.87
$263.33
$368.01
$559.22 		$363.68
$391.50
$420.96
$525.64 		$521.31
$549.13
$578.59
$683.27 		$678.94
$706.76
$736.22
$840.90 		$157.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$412.10
$467.74
$526.66
$736.02
$1,118.44 		$569.73
$625.37
$684.29
$893.65 		$727.36
$783.00
$841.92
$1,051.28 		$884.99
$940.63
$999.55
$1,208.91 		$157.63
Toc - Plan #21 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 		$220.27
$250.01
$281.51
$393.40
$597.81 		$388.78
$418.52
$450.02
$561.91 		$557.29
$587.03
$618.53
$730.42 		$725.80
$755.54
$787.04
$898.93 		$168.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$440.54
$500.02
$563.02
$786.80
$1,195.62 		$609.05
$668.53
$731.53
$955.31 		$777.56
$837.04
$900.04
$1,123.82 		$946.07
$1,005.55
$1,068.55
$1,292.33 		$168.51
Toc - Plan #22 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 		$268.05
$304.24
$342.57
$478.74
$727.49 		$473.11
$509.30
$547.63
$683.80 		$678.17
$714.36
$752.69
$888.86 		$883.23
$919.42
$957.75
$1,093.92 		$205.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.10
$608.48
$685.14
$957.48
$1,454.98 		$741.16
$813.54
$890.20
$1,162.54 		$946.22
$1,018.60
$1,095.26
$1,367.60 		$1,151.28
$1,223.66
$1,300.32
$1,572.66 		$205.06
Toc - Plan #23 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 		$318.22
$361.18
$406.69
$568.34
$863.65 		$561.66
$604.62
$650.13
$811.78 		$805.10
$848.06
$893.57
$1,055.22 		$1,048.54
$1,091.50
$1,137.01
$1,298.66 		$243.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.44
$722.36
$813.38
$1,136.68
$1,727.30 		$879.88
$965.80
$1,056.82
$1,380.12 		$1,123.32
$1,209.24
$1,300.26
$1,623.56 		$1,366.76
$1,452.68
$1,543.70
$1,867.00 		$243.44
Toc - Plan #24 Priority Health
Silver

(HMO) MyPriority Silver 3600 - Beaumont Health Network

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 		$286.40
$325.06
$366.02
$511.51
$777.29 		$505.50
$544.16
$585.12
$730.61 		$724.60
$763.26
$804.22
$949.71 		$943.70
$982.36
$1,023.32
$1,168.81 		$219.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.80
$650.12
$732.04
$1,023.02
$1,554.58 		$791.90
$869.22
$951.14
$1,242.12 		$1,011.00
$1,088.32
$1,170.24
$1,461.22 		$1,230.10
$1,307.42
$1,389.34
$1,680.32 		$219.10
Toc - Plan #25 Priority Health
Silver

(HMO) MyPriority Silver 3600 - Ascension St. John Providence Network

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

Annual Out of Pocket Expenses:

Individual Family
$3,600 $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 		$277.49
$314.95
$354.63
$495.60
$753.11 		$489.77
$527.23
$566.91
$707.88 		$702.05
$739.51
$779.19
$920.16 		$914.33
$951.79
$991.47
$1,132.44 		$212.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.98
$629.90
$709.26
$991.20
$1,506.22 		$767.26
$842.18
$921.54
$1,203.48 		$979.54
$1,054.46
$1,133.82
$1,415.76 		$1,191.82
$1,266.74
$1,346.10
$1,628.04 		$212.28
Toc - Plan #26 Priority Health
Silver

(HMO) MyPriority Silver 3600 - Trinity Health East Network

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 		$281.30
$319.28
$359.50
$502.40
$763.45 		$496.49
$534.47
$574.69
$717.59 		$711.68
$749.66
$789.88
$932.78 		$926.87
$964.85
$1,005.07
$1,147.97 		$215.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.60
$638.56
$719.00
$1,004.80
$1,526.90 		$777.79
$853.75
$934.19
$1,219.99 		$992.98
$1,068.94
$1,149.38
$1,435.18 		$1,208.17
$1,284.13
$1,364.57
$1,650.37 		$215.19
Toc - Plan #27 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 		$307.64
$349.17
$393.16
$549.45
$834.93 		$542.98
$584.51
$628.50
$784.79 		$778.32
$819.85
$863.84
$1,020.13 		$1,013.66
$1,055.19
$1,099.18
$1,255.47 		$235.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.28
$698.34
$786.32
$1,098.90
$1,669.86 		$850.62
$933.68
$1,021.66
$1,334.24 		$1,085.96
$1,169.02
$1,257.00
$1,569.58 		$1,321.30
$1,404.36
$1,492.34
$1,804.92 		$235.34
Toc - Plan #28 Priority Health
Silver

(HMO) MyPriority Silver 5500 - Beaumont Health Network

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$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 		$276.87
$314.25
$353.84
$494.49
$751.43 		$488.68
$526.06
$565.65
$706.30 		$700.49
$737.87
$777.46
$918.11 		$912.30
$949.68
$989.27
$1,129.92 		$211.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.74
$628.50
$707.68
$988.98
$1,502.86 		$765.55
$840.31
$919.49
$1,200.79 		$977.36
$1,052.12
$1,131.30
$1,412.60 		$1,189.17
$1,263.93
$1,343.11
$1,624.41 		$211.81
Toc - Plan #29 Priority Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$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 		$268.26
$304.48
$342.84
$479.11
$728.06 		$473.48
$509.70
$548.06
$684.33 		$678.70
$714.92
$753.28
$889.55 		$883.92
$920.14
$958.50
$1,094.77 		$205.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.52
$608.96
$685.68
$958.22
$1,456.12 		$741.74
$814.18
$890.90
$1,163.44 		$946.96
$1,019.40
$1,096.12
$1,368.66 		$1,152.18
$1,224.62
$1,301.34
$1,573.88 		$205.22
Toc - Plan #30 Priority Health
Silver

(HMO) MyPriority Silver 5500 - Trinity Health East Network

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$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 		$271.95
$308.66
$347.55
$485.70
$738.07 		$479.99
$516.70
$555.59
$693.74 		$688.03
$724.74
$763.63
$901.78 		$896.07
$932.78
$971.67
$1,109.82 		$208.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543.90
$617.32
$695.10
$971.40
$1,476.14 		$751.94
$825.36
$903.14
$1,179.44 		$959.98
$1,033.40
$1,111.18
$1,387.48 		$1,168.02
$1,241.44
$1,319.22
$1,595.52 		$208.04
Toc - Plan #31 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 		$290.71
$329.96
$371.53
$519.21
$788.99 		$513.10
$552.35
$593.92
$741.60 		$735.49
$774.74
$816.31
$963.99 		$957.88
$997.13
$1,038.70
$1,186.38 		$222.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.42
$659.92
$743.06
$1,038.42
$1,577.98 		$803.81
$882.31
$965.45
$1,260.81 		$1,026.20
$1,104.70
$1,187.84
$1,483.20 		$1,248.59
$1,327.09
$1,410.23
$1,705.59 		$222.39
Toc - Plan #32 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 		$369.16
$419.00
$471.79
$659.32
$1,001.90 		$651.57
$701.41
$754.20
$941.73 		$933.98
$983.82
$1,036.61
$1,224.14 		$1,216.39
$1,266.23
$1,319.02
$1,506.55 		$282.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.32
$838.00
$943.58
$1,318.64
$2,003.80 		$1,020.73
$1,120.41
$1,225.99
$1,601.05 		$1,303.14
$1,402.82
$1,508.40
$1,883.46 		$1,585.55
$1,685.23
$1,790.81
$2,165.87 		$282.41
Toc - Plan #33 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 		$235.14
$266.88
$300.51
$419.96
$638.17 		$415.02
$446.76
$480.39
$599.84 		$594.90
$626.64
$660.27
$779.72 		$774.78
$806.52
$840.15
$959.60 		$179.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$470.28
$533.76
$601.02
$839.92
$1,276.34 		$650.16
$713.64
$780.90
$1,019.80 		$830.04
$893.52
$960.78
$1,199.68 		$1,009.92
$1,073.40
$1,140.66
$1,379.56 		$179.88
Toc - Plan #34 Priority Health
Expanded Bronze

(HMO) MyPriority Standard Bronze 7500 - Beaumont Health Network

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 		$211.62
$240.19
$270.45
$377.95
$574.34 		$373.51
$402.08
$432.34
$539.84 		$535.40
$563.97
$594.23
$701.73 		$697.29
$725.86
$756.12
$863.62 		$161.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$423.24
$480.38
$540.90
$755.90
$1,148.68 		$585.13
$642.27
$702.79
$917.79 		$747.02
$804.16
$864.68
$1,079.68 		$908.91
$966.05
$1,026.57
$1,241.57 		$161.89
Toc - Plan #35 Priority Health
Expanded Bronze

(HMO) MyPriority Standard Bronze 7500 - Ascension St. John Providence Network

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $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 		$205.04
$232.72
$262.04
$366.20
$556.48 		$361.90
$389.58
$418.90
$523.06 		$518.76
$546.44
$575.76
$679.92 		$675.62
$703.30
$732.62
$836.78 		$156.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$410.08
$465.44
$524.08
$732.40
$1,112.96 		$566.94
$622.30
$680.94
$889.26 		$723.80
$779.16
$837.80
$1,046.12 		$880.66
$936.02
$994.66
$1,202.98 		$156.86
Toc - Plan #36 Priority Health
Expanded Bronze

(HMO) MyPriority Standard Bronze 7500 - Trinity Health East Network

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 		$207.86
$235.92
$265.65
$371.24
$564.13 		$366.87
$394.93
$424.66
$530.25 		$525.88
$553.94
$583.67
$689.26 		$684.89
$712.95
$742.68
$848.27 		$159.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$415.72
$471.84
$531.30
$742.48
$1,128.26 		$574.73
$630.85
$690.31
$901.49 		$733.74
$789.86
$849.32
$1,060.50 		$892.75
$948.87
$1,008.33
$1,219.51 		$159.01
Toc - Plan #37 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 		$328.19
$372.50
$419.43
$586.15
$890.71 		$579.26
$623.57
$670.50
$837.22 		$830.33
$874.64
$921.57
$1,088.29 		$1,081.40
$1,125.71
$1,172.64
$1,339.36 		$251.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$656.38
$745.00
$838.86
$1,172.30
$1,781.42 		$907.45
$996.07
$1,089.93
$1,423.37 		$1,158.52
$1,247.14
$1,341.00
$1,674.44 		$1,409.59
$1,498.21
$1,592.07
$1,925.51 		$251.07
Toc - Plan #38 Priority Health
Silver

(HMO) MyPriority Standard Silver 5800 - Beaumont Health Network

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 		$295.37
$335.24
$377.48
$527.53
$801.63 		$521.33
$561.20
$603.44
$753.49 		$747.29
$787.16
$829.40
$979.45 		$973.25
$1,013.12
$1,055.36
$1,205.41 		$225.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$590.74
$670.48
$754.96
$1,055.06
$1,603.26 		$816.70
$896.44
$980.92
$1,281.02 		$1,042.66
$1,122.40
$1,206.88
$1,506.98 		$1,268.62
$1,348.36
$1,432.84
$1,732.94 		$225.96
Toc - Plan #39 Priority Health
Silver

(HMO) MyPriority Standard Silver 5800 - Ascension St. John Providence Network

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $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 		$286.18
$324.81
$365.74
$511.12
$776.69 		$505.11
$543.74
$584.67
$730.05 		$724.04
$762.67
$803.60
$948.98 		$942.97
$981.60
$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
$649.62
$731.48
$1,022.24
$1,553.38 		$791.29
$868.55
$950.41
$1,241.17 		$1,010.22
$1,087.48
$1,169.34
$1,460.10 		$1,229.15
$1,306.41
$1,388.27
$1,679.03 		$218.93
Toc - Plan #40 Priority Health
Silver

(HMO) MyPriority Standard Silver 5800 - Trinity Health East Network

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 		$290.12
$329.29
$370.77
$518.15
$787.39 		$512.06
$551.23
$592.71
$740.09 		$734.00
$773.17
$814.65
$962.03 		$955.94
$995.11
$1,036.59
$1,183.97 		$221.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.24
$658.58
$741.54
$1,036.30
$1,574.78 		$802.18
$880.52
$963.48
$1,258.24 		$1,024.12
$1,102.46
$1,185.42
$1,480.18 		$1,246.06
$1,324.40
$1,407.36
$1,702.12 		$221.94
Toc - Plan #41 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 		$432.22
$490.57
$552.38
$771.94
$1,173.05 		$762.87
$821.22
$883.03
$1,102.59 		$1,093.52
$1,151.87
$1,213.68
$1,433.24 		$1,424.17
$1,482.52
$1,544.33
$1,763.89 		$330.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$864.44
$981.14
$1,104.76
$1,543.88
$2,346.10 		$1,195.09
$1,311.79
$1,435.41
$1,874.53 		$1,525.74
$1,642.44
$1,766.06
$2,205.18 		$1,856.39
$1,973.09
$2,096.71
$2,535.83 		$330.65
Toc - Plan #42 Priority Health
Gold

(HMO) MyPriority Standard Gold 2000 - Beaumont Health Network

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 		$389.00
$441.52
$497.14
$694.75
$1,055.75 		$686.59
$739.11
$794.73
$992.34 		$984.18
$1,036.70
$1,092.32
$1,289.93 		$1,281.77
$1,334.29
$1,389.91
$1,587.52 		$297.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.00
$883.04
$994.28
$1,389.50
$2,111.50 		$1,075.59
$1,180.63
$1,291.87
$1,687.09 		$1,373.18
$1,478.22
$1,589.46
$1,984.68 		$1,670.77
$1,775.81
$1,887.05
$2,282.27 		$297.59
Toc - Plan #43 Priority Health
Gold

(HMO) MyPriority Standard Gold 2000 - Ascension St. John Providence Network

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $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 		$376.90
$427.78
$481.68
$673.14
$1,022.91 		$665.23
$716.11
$770.01
$961.47 		$953.56
$1,004.44
$1,058.34
$1,249.80 		$1,241.89
$1,292.77
$1,346.67
$1,538.13 		$288.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.80
$855.56
$963.36
$1,346.28
$2,045.82 		$1,042.13
$1,143.89
$1,251.69
$1,634.61 		$1,330.46
$1,432.22
$1,540.02
$1,922.94 		$1,618.79
$1,720.55
$1,828.35
$2,211.27 		$288.33
Toc - Plan #44 Priority Health
Gold

(HMO) MyPriority Standard Gold 2000 - Trinity Health East Network

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 		$382.08
$433.66
$488.30
$682.39
$1,036.97 		$674.37
$725.95
$780.59
$974.68 		$966.66
$1,018.24
$1,072.88
$1,266.97 		$1,258.95
$1,310.53
$1,365.17
$1,559.26 		$292.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.16
$867.32
$976.60
$1,364.78
$2,073.94 		$1,056.45
$1,159.61
$1,268.89
$1,657.07 		$1,348.74
$1,451.90
$1,561.18
$1,949.36 		$1,641.03
$1,744.19
$1,853.47
$2,241.65 		$292.29

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-4087 | Toll Free: 1-888-560-4087 | TTY: 1-888-665-4629
Toc - Plan #45 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 		$270.73
$307.28
$346.00
$483.53
$734.77 		$477.84
$514.39
$553.11
$690.64 		$684.95
$721.50
$760.22
$897.75 		$892.06
$928.61
$967.33
$1,104.86 		$207.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541.46
$614.56
$692.00
$967.06
$1,469.54 		$748.57
$821.67
$899.11
$1,174.17 		$955.68
$1,028.78
$1,106.22
$1,381.28 		$1,162.79
$1,235.89
$1,313.33
$1,588.39 		$207.11
Toc - Plan #46 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 		$267.74
$303.89
$342.18
$478.19
$726.66 		$472.56
$508.71
$547.00
$683.01 		$677.38
$713.53
$751.82
$887.83 		$882.20
$918.35
$956.64
$1,092.65 		$204.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$535.48
$607.78
$684.36
$956.38
$1,453.32 		$740.30
$812.60
$889.18
$1,161.20 		$945.12
$1,017.42
$1,094.00
$1,366.02 		$1,149.94
$1,222.24
$1,298.82
$1,570.84 		$204.82
Toc - Plan #47 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 		$270.71
$307.25
$345.96
$483.48
$734.69 		$477.80
$514.34
$553.05
$690.57 		$684.89
$721.43
$760.14
$897.66 		$891.98
$928.52
$967.23
$1,104.75 		$207.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541.42
$614.50
$691.92
$966.96
$1,469.38 		$748.51
$821.59
$899.01
$1,174.05 		$955.60
$1,028.68
$1,106.10
$1,381.14 		$1,162.69
$1,235.77
$1,313.19
$1,588.23 		$207.09
Toc - Plan #48 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 		$265.71
$301.58
$339.58
$474.56
$721.14 		$468.98
$504.85
$542.85
$677.83 		$672.25
$708.12
$746.12
$881.10 		$875.52
$911.39
$949.39
$1,084.37 		$203.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$531.42
$603.16
$679.16
$949.12
$1,442.28 		$734.69
$806.43
$882.43
$1,152.39 		$937.96
$1,009.70
$1,085.70
$1,355.66 		$1,141.23
$1,212.97
$1,288.97
$1,558.93 		$203.27
Toc - Plan #49 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 		$275.24
$312.40
$351.76
$491.58
$747.00 		$485.80
$522.96
$562.32
$702.14 		$696.36
$733.52
$772.88
$912.70 		$906.92
$944.08
$983.44
$1,123.26 		$210.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.48
$624.80
$703.52
$983.16
$1,494.00 		$761.04
$835.36
$914.08
$1,193.72 		$971.60
$1,045.92
$1,124.64
$1,404.28 		$1,182.16
$1,256.48
$1,335.20
$1,614.84 		$210.56
Toc - Plan #50 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 		$273.55
$310.48
$349.60
$488.56
$742.42 		$482.82
$519.75
$558.87
$697.83 		$692.09
$729.02
$768.14
$907.10 		$901.36
$938.29
$977.41
$1,116.37 		$209.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$547.10
$620.96
$699.20
$977.12
$1,484.84 		$756.37
$830.23
$908.47
$1,186.39 		$965.64
$1,039.50
$1,117.74
$1,395.66 		$1,174.91
$1,248.77
$1,327.01
$1,604.93 		$209.27

ADVERTISEMENT

Ambetter from Meridian

Local: 1-833-993-2426 | Toll Free: 1-833-993-2426 | TTY: 1-833-993-2426
Toc - Plan #51 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 		$192.62
$218.61
$246.15
$343.99
$522.73 		$339.96
$365.95
$393.49
$491.33 		$487.30
$513.29
$540.83
$638.67 		$634.64
$660.63
$688.17
$786.01 		$147.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$385.24
$437.22
$492.30
$687.98
$1,045.46 		$532.58
$584.56
$639.64
$835.32 		$679.92
$731.90
$786.98
$982.66 		$827.26
$879.24
$934.32
$1,130.00 		$147.34
Toc - Plan #52 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 		$209.86
$238.18
$268.19
$374.80
$569.54 		$370.40
$398.72
$428.73
$535.34 		$530.94
$559.26
$589.27
$695.88 		$691.48
$719.80
$749.81
$856.42 		$160.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$419.72
$476.36
$536.38
$749.60
$1,139.08 		$580.26
$636.90
$696.92
$910.14 		$740.80
$797.44
$857.46
$1,070.68 		$901.34
$957.98
$1,018.00
$1,231.22 		$160.54
Toc - Plan #53 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 		$254.01
$288.29
$324.61
$453.64
$689.35 		$448.32
$482.60
$518.92
$647.95 		$642.63
$676.91
$713.23
$842.26 		$836.94
$871.22
$907.54
$1,036.57 		$194.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$508.02
$576.58
$649.22
$907.28
$1,378.70 		$702.33
$770.89
$843.53
$1,101.59 		$896.64
$965.20
$1,037.84
$1,295.90 		$1,090.95
$1,159.51
$1,232.15
$1,490.21 		$194.31
Toc - Plan #54 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 		$284.36
$322.74
$363.40
$507.85
$771.73 		$501.89
$540.27
$580.93
$725.38 		$719.42
$757.80
$798.46
$942.91 		$936.95
$975.33
$1,015.99
$1,160.44 		$217.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$568.72
$645.48
$726.80
$1,015.70
$1,543.46 		$786.25
$863.01
$944.33
$1,233.23 		$1,003.78
$1,080.54
$1,161.86
$1,450.76 		$1,221.31
$1,298.07
$1,379.39
$1,668.29 		$217.53
Toc - Plan #55 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 		$210.04
$238.38
$268.42
$375.11
$570.02 		$370.71
$399.05
$429.09
$535.78 		$531.38
$559.72
$589.76
$696.45 		$692.05
$720.39
$750.43
$857.12 		$160.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$420.08
$476.76
$536.84
$750.22
$1,140.04 		$580.75
$637.43
$697.51
$910.89 		$741.42
$798.10
$858.18
$1,071.56 		$902.09
$958.77
$1,018.85
$1,232.23 		$160.67
Toc - Plan #56 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 		$239.05
$271.31
$305.49
$426.92
$648.75 		$421.91
$454.17
$488.35
$609.78 		$604.77
$637.03
$671.21
$792.64 		$787.63
$819.89
$854.07
$975.50 		$182.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$478.10
$542.62
$610.98
$853.84
$1,297.50 		$660.96
$725.48
$793.84
$1,036.70 		$843.82
$908.34
$976.70
$1,219.56 		$1,026.68
$1,091.20
$1,159.56
$1,402.42 		$182.86
Toc - Plan #57 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 		$244.79
$277.82
$312.83
$437.17
$664.33 		$432.04
$465.07
$500.08
$624.42 		$619.29
$652.32
$687.33
$811.67 		$806.54
$839.57
$874.58
$998.92 		$187.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$489.58
$555.64
$625.66
$874.34
$1,328.66 		$676.83
$742.89
$812.91
$1,061.59 		$864.08
$930.14
$1,000.16
$1,248.84 		$1,051.33
$1,117.39
$1,187.41
$1,436.09 		$187.25
Toc - Plan #58 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 		$248.93
$282.52
$318.12
$444.57
$675.56 		$439.35
$472.94
$508.54
$634.99 		$629.77
$663.36
$698.96
$825.41 		$820.19
$853.78
$889.38
$1,015.83 		$190.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$497.86
$565.04
$636.24
$889.14
$1,351.12 		$688.28
$755.46
$826.66
$1,079.56 		$878.70
$945.88
$1,017.08
$1,269.98 		$1,069.12
$1,136.30
$1,207.50
$1,460.40 		$190.42
Toc - Plan #59 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 		$271.58
$308.24
$347.07
$485.03
$737.05 		$479.33
$515.99
$554.82
$692.78 		$687.08
$723.74
$762.57
$900.53 		$894.83
$931.49
$970.32
$1,108.28 		$207.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543.16
$616.48
$694.14
$970.06
$1,474.10 		$750.91
$824.23
$901.89
$1,177.81 		$958.66
$1,031.98
$1,109.64
$1,385.56 		$1,166.41
$1,239.73
$1,317.39
$1,593.31 		$207.75
Toc - Plan #60 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 		$315.02
$357.53
$402.58
$562.60
$854.93 		$556.00
$598.51
$643.56
$803.58 		$796.98
$839.49
$884.54
$1,044.56 		$1,037.96
$1,080.47
$1,125.52
$1,285.54 		$240.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.04
$715.06
$805.16
$1,125.20
$1,709.86 		$871.02
$956.04
$1,046.14
$1,366.18 		$1,112.00
$1,197.02
$1,287.12
$1,607.16 		$1,352.98
$1,438.00
$1,528.10
$1,848.14 		$240.98
Toc - Plan #61 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 		$182.46
$207.08
$233.17
$325.85
$495.16 		$322.03
$346.65
$372.74
$465.42 		$461.60
$486.22
$512.31
$604.99 		$601.17
$625.79
$651.88
$744.56 		$139.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$364.92
$414.16
$466.34
$651.70
$990.32 		$504.49
$553.73
$605.91
$791.27 		$644.06
$693.30
$745.48
$930.84 		$783.63
$832.87
$885.05
$1,070.41 		$139.57
Toc - Plan #62 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 		$205.01
$232.68
$261.99
$366.13
$556.37 		$361.84
$389.51
$418.82
$522.96 		$518.67
$546.34
$575.65
$679.79 		$675.50
$703.17
$732.48
$836.62 		$156.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$410.02
$465.36
$523.98
$732.26
$1,112.74 		$566.85
$622.19
$680.81
$889.09 		$723.68
$779.02
$837.64
$1,045.92 		$880.51
$935.85
$994.47
$1,202.75 		$156.83
Toc - Plan #63 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 		$247.15
$280.50
$315.84
$441.39
$670.74 		$436.21
$469.56
$504.90
$630.45 		$625.27
$658.62
$693.96
$819.51 		$814.33
$847.68
$883.02
$1,008.57 		$189.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494.30
$561.00
$631.68
$882.78
$1,341.48 		$683.36
$750.06
$820.74
$1,071.84 		$872.42
$939.12
$1,009.80
$1,260.90 		$1,061.48
$1,128.18
$1,198.86
$1,449.96 		$189.06
Toc - Plan #64 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 		$268.08
$304.26
$342.59
$478.77
$727.54 		$473.15
$509.33
$547.66
$683.84 		$678.22
$714.40
$752.73
$888.91 		$883.29
$919.47
$957.80
$1,093.98 		$205.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.16
$608.52
$685.18
$957.54
$1,455.08 		$741.23
$813.59
$890.25
$1,162.61 		$946.30
$1,018.66
$1,095.32
$1,367.68 		$1,151.37
$1,223.73
$1,300.39
$1,572.75 		$205.07
Toc - Plan #65 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 		$204.00
$231.53
$260.70
$364.32
$553.62 		$360.05
$387.58
$416.75
$520.37 		$516.10
$543.63
$572.80
$676.42 		$672.15
$699.68
$728.85
$832.47 		$156.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$408.00
$463.06
$521.40
$728.64
$1,107.24 		$564.05
$619.11
$677.45
$884.69 		$720.10
$775.16
$833.50
$1,040.74 		$876.15
$931.21
$989.55
$1,196.79 		$156.05
Toc - Plan #66 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 		$222.26
$252.26
$284.04
$396.94
$603.19 		$392.28
$422.28
$454.06
$566.96 		$562.30
$592.30
$624.08
$736.98 		$732.32
$762.32
$794.10
$907.00 		$170.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$444.52
$504.52
$568.08
$793.88
$1,206.38 		$614.54
$674.54
$738.10
$963.90 		$784.56
$844.56
$908.12
$1,133.92 		$954.58
$1,014.58
$1,078.14
$1,303.94 		$170.02
Toc - Plan #67 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 		$269.02
$305.32
$343.79
$480.44
$730.08 		$474.81
$511.11
$549.58
$686.23 		$680.60
$716.90
$755.37
$892.02 		$886.39
$922.69
$961.16
$1,097.81 		$205.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538.04
$610.64
$687.58
$960.88
$1,460.16 		$743.83
$816.43
$893.37
$1,166.67 		$949.62
$1,022.22
$1,099.16
$1,372.46 		$1,155.41
$1,228.01
$1,304.95
$1,578.25 		$205.79
Toc - Plan #68 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 		$301.16
$341.81
$384.87
$537.86
$817.33 		$531.54
$572.19
$615.25
$768.24 		$761.92
$802.57
$845.63
$998.62 		$992.30
$1,032.95
$1,076.01
$1,229.00 		$230.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.32
$683.62
$769.74
$1,075.72
$1,634.66 		$832.70
$914.00
$1,000.12
$1,306.10 		$1,063.08
$1,144.38
$1,230.50
$1,536.48 		$1,293.46
$1,374.76
$1,460.88
$1,766.86 		$230.38
Toc - Plan #69 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 		$222.45
$252.47
$284.28
$397.28
$603.71 		$392.62
$422.64
$454.45
$567.45 		$562.79
$592.81
$624.62
$737.62 		$732.96
$762.98
$794.79
$907.79 		$170.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$444.90
$504.94
$568.56
$794.56
$1,207.42 		$615.07
$675.11
$738.73
$964.73 		$785.24
$845.28
$908.90
$1,134.90 		$955.41
$1,015.45
$1,079.07
$1,305.07 		$170.17
Toc - Plan #70 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 		$253.17
$287.34
$323.54
$452.15
$687.08 		$446.84
$481.01
$517.21
$645.82 		$640.51
$674.68
$710.88
$839.49 		$834.18
$868.35
$904.55
$1,033.16 		$193.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$506.34
$574.68
$647.08
$904.30
$1,374.16 		$700.01
$768.35
$840.75
$1,097.97 		$893.68
$962.02
$1,034.42
$1,291.64 		$1,087.35
$1,155.69
$1,228.09
$1,485.31 		$193.67
Toc - Plan #71 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 		$263.64
$299.22
$336.91
$470.84
$715.48 		$465.31
$500.89
$538.58
$672.51 		$666.98
$702.56
$740.25
$874.18 		$868.65
$904.23
$941.92
$1,075.85 		$201.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$527.28
$598.44
$673.82
$941.68
$1,430.96 		$728.95
$800.11
$875.49
$1,143.35 		$930.62
$1,001.78
$1,077.16
$1,345.02 		$1,132.29
$1,203.45
$1,278.83
$1,546.69 		$201.67
Toc - Plan #72 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 		$287.63
$326.45
$367.58
$513.69
$780.60 		$507.66
$546.48
$587.61
$733.72 		$727.69
$766.51
$807.64
$953.75 		$947.72
$986.54
$1,027.67
$1,173.78 		$220.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.26
$652.90
$735.16
$1,027.38
$1,561.20 		$795.29
$872.93
$955.19
$1,247.41 		$1,015.32
$1,092.96
$1,175.22
$1,467.44 		$1,235.35
$1,312.99
$1,395.25
$1,687.47 		$220.03
Toc - Plan #73 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 		$259.25
$294.24
$331.31
$463.00
$703.58 		$457.57
$492.56
$529.63
$661.32 		$655.89
$690.88
$727.95
$859.64 		$854.21
$889.20
$926.27
$1,057.96 		$198.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$518.50
$588.48
$662.62
$926.00
$1,407.16 		$716.82
$786.80
$860.94
$1,124.32 		$915.14
$985.12
$1,059.26
$1,322.64 		$1,113.46
$1,183.44
$1,257.58
$1,520.96 		$198.32
Toc - Plan #74 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 		$333.63
$378.66
$426.37
$595.85
$905.45 		$588.85
$633.88
$681.59
$851.07 		$844.07
$889.10
$936.81
$1,106.29 		$1,099.29
$1,144.32
$1,192.03
$1,361.51 		$255.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.26
$757.32
$852.74
$1,191.70
$1,810.90 		$922.48
$1,012.54
$1,107.96
$1,446.92 		$1,177.70
$1,267.76
$1,363.18
$1,702.14 		$1,432.92
$1,522.98
$1,618.40
$1,957.36 		$255.22
Toc - Plan #75 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 		$203.13
$230.54
$259.59
$362.78
$551.27 		$358.52
$385.93
$414.98
$518.17 		$513.91
$541.32
$570.37
$673.56 		$669.30
$696.71
$725.76
$828.95 		$155.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$406.26
$461.08
$519.18
$725.56
$1,102.54 		$561.65
$616.47
$674.57
$880.95 		$717.04
$771.86
$829.96
$1,036.34 		$872.43
$927.25
$985.35
$1,191.73 		$155.39
Toc - Plan #76 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 		$243.64
$276.53
$311.36
$435.13
$661.22 		$430.02
$462.91
$497.74
$621.51 		$616.40
$649.29
$684.12
$807.89 		$802.78
$835.67
$870.50
$994.27 		$186.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$487.28
$553.06
$622.72
$870.26
$1,322.44 		$673.66
$739.44
$809.10
$1,056.64 		$860.04
$925.82
$995.48
$1,243.02 		$1,046.42
$1,112.20
$1,181.86
$1,429.40 		$186.38
Toc - Plan #77 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 		$276.59
$313.92
$353.47
$493.97
$750.63 		$488.17
$525.50
$565.05
$705.55 		$699.75
$737.08
$776.63
$917.13 		$911.33
$948.66
$988.21
$1,128.71 		$211.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.18
$627.84
$706.94
$987.94
$1,501.26 		$764.76
$839.42
$918.52
$1,199.52 		$976.34
$1,051.00
$1,130.10
$1,411.10 		$1,187.92
$1,262.58
$1,341.68
$1,622.68 		$211.58

ADVERTISEMENT

US Health and Life

Local: 1-833-600-1311 | Toll Free: 

Toc - Plan #78 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 		$197.49
$224.15
$252.39
$352.71
$535.98 		$348.57
$375.23
$403.47
$503.79 		$499.65
$526.31
$554.55
$654.87 		$650.73
$677.39
$705.63
$805.95 		$151.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$394.98
$448.30
$504.78
$705.42
$1,071.96 		$546.06
$599.38
$655.86
$856.50 		$697.14
$750.46
$806.94
$1,007.58 		$848.22
$901.54
$958.02
$1,158.66 		$151.08
Toc - Plan #79 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 		$195.17
$221.52
$249.43
$348.57
$529.69 		$344.48
$370.83
$398.74
$497.88 		$493.79
$520.14
$548.05
$647.19 		$643.10
$669.45
$697.36
$796.50 		$149.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$390.34
$443.04
$498.86
$697.14
$1,059.38 		$539.65
$592.35
$648.17
$846.45 		$688.96
$741.66
$797.48
$995.76 		$838.27
$890.97
$946.79
$1,145.07 		$149.31
Toc - Plan #80 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 		$225.06
$255.44
$287.62
$401.95
$610.80 		$397.23
$427.61
$459.79
$574.12 		$569.40
$599.78
$631.96
$746.29 		$741.57
$771.95
$804.13
$918.46 		$172.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$450.12
$510.88
$575.24
$803.90
$1,221.60 		$622.29
$683.05
$747.41
$976.07 		$794.46
$855.22
$919.58
$1,148.24 		$966.63
$1,027.39
$1,091.75
$1,320.41 		$172.17
Toc - Plan #81 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 		$284.17
$322.54
$363.17
$507.53
$771.25 		$501.56
$539.93
$580.56
$724.92 		$718.95
$757.32
$797.95
$942.31 		$936.34
$974.71
$1,015.34
$1,159.70 		$217.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$568.34
$645.08
$726.34
$1,015.06
$1,542.50 		$785.73
$862.47
$943.73
$1,232.45 		$1,003.12
$1,079.86
$1,161.12
$1,449.84 		$1,220.51
$1,297.25
$1,378.51
$1,667.23 		$217.39
Toc - Plan #82 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 		$285.09
$323.58
$364.35
$509.17
$773.74 		$503.18
$541.67
$582.44
$727.26 		$721.27
$759.76
$800.53
$945.35 		$939.36
$977.85
$1,018.62
$1,163.44 		$218.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.18
$647.16
$728.70
$1,018.34
$1,547.48 		$788.27
$865.25
$946.79
$1,236.43 		$1,006.36
$1,083.34
$1,164.88
$1,454.52 		$1,224.45
$1,301.43
$1,382.97
$1,672.61 		$218.09
Toc - Plan #83 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 		$262.24
$297.65
$335.15
$468.37
$711.73 		$462.86
$498.27
$535.77
$668.99 		$663.48
$698.89
$736.39
$869.61 		$864.10
$899.51
$937.01
$1,070.23 		$200.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524.48
$595.30
$670.30
$936.74
$1,423.46 		$725.10
$795.92
$870.92
$1,137.36 		$925.72
$996.54
$1,071.54
$1,337.98 		$1,126.34
$1,197.16
$1,272.16
$1,538.60 		$200.62
Toc - Plan #84 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 		$199.73
$226.69
$255.25
$356.71
$542.06 		$352.52
$379.48
$408.04
$509.50 		$505.31
$532.27
$560.83
$662.29 		$658.10
$685.06
$713.62
$815.08 		$152.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$399.46
$453.38
$510.50
$713.42
$1,084.12 		$552.25
$606.17
$663.29
$866.21 		$705.04
$758.96
$816.08
$1,019.00 		$857.83
$911.75
$968.87
$1,171.79 		$152.79
Toc - Plan #85 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 		$264.05
$299.69
$337.45
$471.59
$716.62 		$466.05
$501.69
$539.45
$673.59 		$668.05
$703.69
$741.45
$875.59 		$870.05
$905.69
$943.45
$1,077.59 		$202.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$528.10
$599.38
$674.90
$943.18
$1,433.24 		$730.10
$801.38
$876.90
$1,145.18 		$932.10
$1,003.38
$1,078.90
$1,347.18 		$1,134.10
$1,205.38
$1,280.90
$1,549.18 		$202.00
Toc - Plan #86 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 		$322.79
$366.36
$412.52
$576.50
$876.05 		$569.72
$613.29
$659.45
$823.43 		$816.65
$860.22
$906.38
$1,070.36 		$1,063.58
$1,107.15
$1,153.31
$1,317.29 		$246.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.58
$732.72
$825.04
$1,153.00
$1,752.10 		$892.51
$979.65
$1,071.97
$1,399.93 		$1,139.44
$1,226.58
$1,318.90
$1,646.86 		$1,386.37
$1,473.51
$1,565.83
$1,893.79 		$246.93

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0324 | Toll Free: 1-888-200-0324 | TTY: 1-888-200-0324
Toc - Plan #87 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 		$227.87
$258.63
$291.22
$406.98
$618.45 		$402.19
$432.95
$465.54
$581.30 		$576.51
$607.27
$639.86
$755.62 		$750.83
$781.59
$814.18
$929.94 		$174.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$455.74
$517.26
$582.44
$813.96
$1,236.90 		$630.06
$691.58
$756.76
$988.28 		$804.38
$865.90
$931.08
$1,162.60 		$978.70
$1,040.22
$1,105.40
$1,336.92 		$174.32
Toc - Plan #88 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 		$232.17
$263.51
$296.71
$414.65
$630.11 		$409.78
$441.12
$474.32
$592.26 		$587.39
$618.73
$651.93
$769.87 		$765.00
$796.34
$829.54
$947.48 		$177.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$464.34
$527.02
$593.42
$829.30
$1,260.22 		$641.95
$704.63
$771.03
$1,006.91 		$819.56
$882.24
$948.64
$1,184.52 		$997.17
$1,059.85
$1,126.25
$1,362.13 		$177.61
Toc - Plan #89 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 		$228.21
$259.01
$291.65
$407.58
$619.35 		$402.79
$433.59
$466.23
$582.16 		$577.37
$608.17
$640.81
$756.74 		$751.95
$782.75
$815.39
$931.32 		$174.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$456.42
$518.02
$583.30
$815.16
$1,238.70 		$631.00
$692.60
$757.88
$989.74 		$805.58
$867.18
$932.46
$1,164.32 		$980.16
$1,041.76
$1,107.04
$1,338.90 		$174.58
Toc - Plan #90 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 		$326.33
$370.39
$417.05
$582.83
$885.67 		$575.97
$620.03
$666.69
$832.47 		$825.61
$869.67
$916.33
$1,082.11 		$1,075.25
$1,119.31
$1,165.97
$1,331.75 		$249.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.66
$740.78
$834.10
$1,165.66
$1,771.34 		$902.30
$990.42
$1,083.74
$1,415.30 		$1,151.94
$1,240.06
$1,333.38
$1,664.94 		$1,401.58
$1,489.70
$1,583.02
$1,914.58 		$249.64
Toc - Plan #91 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 		$344.84
$391.39
$440.71
$615.89
$935.90 		$608.64
$655.19
$704.51
$879.69 		$872.44
$918.99
$968.31
$1,143.49 		$1,136.24
$1,182.79
$1,232.11
$1,407.29 		$263.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689.68
$782.78
$881.42
$1,231.78
$1,871.80 		$953.48
$1,046.58
$1,145.22
$1,495.58 		$1,217.28
$1,310.38
$1,409.02
$1,759.38 		$1,481.08
$1,574.18
$1,672.82
$2,023.18 		$263.80
Toc - Plan #92 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 		$323.25
$366.89
$413.12
$577.33
$877.31 		$570.54
$614.18
$660.41
$824.62 		$817.83
$861.47
$907.70
$1,071.91 		$1,065.12
$1,108.76
$1,154.99
$1,319.20 		$247.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.50
$733.78
$826.24
$1,154.66
$1,754.62 		$893.79
$981.07
$1,073.53
$1,401.95 		$1,141.08
$1,228.36
$1,320.82
$1,649.24 		$1,388.37
$1,475.65
$1,568.11
$1,896.53 		$247.29
Toc - Plan #93 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 		$273.18
$310.06
$349.12
$487.89
$741.40 		$482.16
$519.04
$558.10
$696.87 		$691.14
$728.02
$767.08
$905.85 		$900.12
$937.00
$976.06
$1,114.83 		$208.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.36
$620.12
$698.24
$975.78
$1,482.80 		$755.34
$829.10
$907.22
$1,184.76 		$964.32
$1,038.08
$1,116.20
$1,393.74 		$1,173.30
$1,247.06
$1,325.18
$1,602.72 		$208.98
Toc - Plan #94 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 		$286.73
$325.43
$366.44
$512.09
$778.17 		$506.08
$544.78
$585.79
$731.44 		$725.43
$764.13
$805.14
$950.79 		$944.78
$983.48
$1,024.49
$1,170.14 		$219.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.46
$650.86
$732.88
$1,024.18
$1,556.34 		$792.81
$870.21
$952.23
$1,243.53 		$1,012.16
$1,089.56
$1,171.58
$1,462.88 		$1,231.51
$1,308.91
$1,390.93
$1,682.23 		$219.35
Toc - Plan #95 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 		$216.34
$245.55
$276.49
$386.39
$587.15 		$381.84
$411.05
$441.99
$551.89 		$547.34
$576.55
$607.49
$717.39 		$712.84
$742.05
$772.99
$882.89 		$165.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$432.68
$491.10
$552.98
$772.78
$1,174.30 		$598.18
$656.60
$718.48
$938.28 		$763.68
$822.10
$883.98
$1,103.78 		$929.18
$987.60
$1,049.48
$1,269.28 		$165.50
Toc - Plan #96 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 		$227.05
$257.71
$290.17
$405.52
$616.22 		$400.75
$431.41
$463.87
$579.22 		$574.45
$605.11
$637.57
$752.92 		$748.15
$778.81
$811.27
$926.62 		$173.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$454.10
$515.42
$580.34
$811.04
$1,232.44 		$627.80
$689.12
$754.04
$984.74 		$801.50
$862.82
$927.74
$1,158.44 		$975.20
$1,036.52
$1,101.44
$1,332.14 		$173.70
Toc - Plan #97 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 		$216.03
$245.20
$276.09
$385.84
$586.32 		$381.30
$410.47
$441.36
$551.11 		$546.57
$575.74
$606.63
$716.38 		$711.84
$741.01
$771.90
$881.65 		$165.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$432.06
$490.40
$552.18
$771.68
$1,172.64 		$597.33
$655.67
$717.45
$936.95 		$762.60
$820.94
$882.72
$1,102.22 		$927.87
$986.21
$1,047.99
$1,267.49 		$165.27
Toc - Plan #98 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 		$315.50
$358.09
$403.21
$563.48
$856.27 		$556.86
$599.45
$644.57
$804.84 		$798.22
$840.81
$885.93
$1,046.20 		$1,039.58
$1,082.17
$1,127.29
$1,287.56 		$241.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.00
$716.18
$806.42
$1,126.96
$1,712.54 		$872.36
$957.54
$1,047.78
$1,368.32 		$1,113.72
$1,198.90
$1,289.14
$1,609.68 		$1,355.08
$1,440.26
$1,530.50
$1,851.04 		$241.36
Toc - Plan #99 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 		$286.43
$325.10
$366.06
$511.56
$777.37 		$505.55
$544.22
$585.18
$730.68 		$724.67
$763.34
$804.30
$949.80 		$943.79
$982.46
$1,023.42
$1,168.92 		$219.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.86
$650.20
$732.12
$1,023.12
$1,554.74 		$791.98
$869.32
$951.24
$1,242.24 		$1,011.10
$1,088.44
$1,170.36
$1,461.36 		$1,230.22
$1,307.56
$1,389.48
$1,680.48 		$219.12
Toc - Plan #100 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 		$285.87
$324.46
$365.34
$510.57
$775.86 		$504.56
$543.15
$584.03
$729.26 		$723.25
$761.84
$802.72
$947.95 		$941.94
$980.53
$1,021.41
$1,166.64 		$218.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.74
$648.92
$730.68
$1,021.14
$1,551.72 		$790.43
$867.61
$949.37
$1,239.83 		$1,009.12
$1,086.30
$1,168.06
$1,458.52 		$1,227.81
$1,304.99
$1,386.75
$1,677.21 		$218.69
Toc - Plan #101 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 		$280.74
$318.64
$358.79
$501.41
$761.94 		$495.51
$533.41
$573.56
$716.18 		$710.28
$748.18
$788.33
$930.95 		$925.05
$962.95
$1,003.10
$1,145.72 		$214.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.48
$637.28
$717.58
$1,002.82
$1,523.88 		$776.25
$852.05
$932.35
$1,217.59 		$991.02
$1,066.82
$1,147.12
$1,432.36 		$1,205.79
$1,281.59
$1,361.89
$1,647.13 		$214.77
Toc - Plan #102 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 		$299.24
$339.64
$382.43
$534.44
$812.14 		$528.16
$568.56
$611.35
$763.36 		$757.08
$797.48
$840.27
$992.28 		$986.00
$1,026.40
$1,069.19
$1,221.20 		$228.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.48
$679.28
$764.86
$1,068.88
$1,624.28 		$827.40
$908.20
$993.78
$1,297.80 		$1,056.32
$1,137.12
$1,222.70
$1,526.72 		$1,285.24
$1,366.04
$1,451.62
$1,755.64 		$228.92
Toc - Plan #103 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 		$223.32
$253.47
$285.41
$398.86
$606.10 		$394.16
$424.31
$456.25
$569.70 		$565.00
$595.15
$627.09
$740.54 		$735.84
$765.99
$797.93
$911.38 		$170.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$446.64
$506.94
$570.82
$797.72
$1,212.20 		$617.48
$677.78
$741.66
$968.56 		$788.32
$848.62
$912.50
$1,139.40 		$959.16
$1,019.46
$1,083.34
$1,310.24 		$170.84

ADVERTISEMENT

McLaren Health Plan Community

Local: 1-888-327-0671 | Toll Free: 1-888-327-0671 | TTY: 1-800-356-3232
Toc - Plan #104 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 		$276.34
$313.65
$353.17
$493.55
$750.00 		$487.74
$525.05
$564.57
$704.95 		$699.14
$736.45
$775.97
$916.35 		$910.54
$947.85
$987.37
$1,127.75 		$211.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552.68
$627.30
$706.34
$987.10
$1,500.00 		$764.08
$838.70
$917.74
$1,198.50 		$975.48
$1,050.10
$1,129.14
$1,409.90 		$1,186.88
$1,261.50
$1,340.54
$1,621.30 		$211.40
Toc - Plan #105 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 		$488.98
$554.99
$624.92
$873.32
$1,327.10 		$863.05
$929.06
$998.99
$1,247.39 		$1,237.12
$1,303.13
$1,373.06
$1,621.46 		$1,611.19
$1,677.20
$1,747.13
$1,995.53 		$374.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$977.96
$1,109.98
$1,249.84
$1,746.64
$2,654.20 		$1,352.03
$1,484.05
$1,623.91
$2,120.71 		$1,726.10
$1,858.12
$1,997.98
$2,494.78 		$2,100.17
$2,232.19
$2,372.05
$2,868.85 		$374.07
Toc - Plan #106 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 		$474.63
$538.71
$606.58
$847.70
$1,288.16 		$837.72
$901.80
$969.67
$1,210.79 		$1,200.81
$1,264.89
$1,332.76
$1,573.88 		$1,563.90
$1,627.98
$1,695.85
$1,936.97 		$363.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$949.26
$1,077.42
$1,213.16
$1,695.40
$2,576.32 		$1,312.35
$1,440.51
$1,576.25
$2,058.49 		$1,675.44
$1,803.60
$1,939.34
$2,421.58 		$2,038.53
$2,166.69
$2,302.43
$2,784.67 		$363.09
Toc - Plan #107 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 		$305.61
$346.87
$390.57
$545.83
$829.43 		$539.40
$580.66
$624.36
$779.62 		$773.19
$814.45
$858.15
$1,013.41 		$1,006.98
$1,048.24
$1,091.94
$1,247.20 		$233.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.22
$693.74
$781.14
$1,091.66
$1,658.86 		$845.01
$927.53
$1,014.93
$1,325.45 		$1,078.80
$1,161.32
$1,248.72
$1,559.24 		$1,312.59
$1,395.11
$1,482.51
$1,793.03 		$233.79
Toc - Plan #108 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 		$336.60
$382.05
$430.18
$601.18
$913.55 		$594.10
$639.55
$687.68
$858.68 		$851.60
$897.05
$945.18
$1,116.18 		$1,109.10
$1,154.55
$1,202.68
$1,373.68 		$257.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$673.20
$764.10
$860.36
$1,202.36
$1,827.10 		$930.70
$1,021.60
$1,117.86
$1,459.86 		$1,188.20
$1,279.10
$1,375.36
$1,717.36 		$1,445.70
$1,536.60
$1,632.86
$1,974.86 		$257.50
Toc - Plan #109 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 		$476.20
$540.49
$608.59
$850.50
$1,292.41 		$840.49
$904.78
$972.88
$1,214.79 		$1,204.78
$1,269.07
$1,337.17
$1,579.08 		$1,569.07
$1,633.36
$1,701.46
$1,943.37 		$364.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952.40
$1,080.98
$1,217.18
$1,701.00
$2,584.82 		$1,316.69
$1,445.27
$1,581.47
$2,065.29 		$1,680.98
$1,809.56
$1,945.76
$2,429.58 		$2,045.27
$2,173.85
$2,310.05
$2,793.87 		$364.29
Toc - Plan #110 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 		$472.25
$536.00
$603.53
$843.44
$1,281.68 		$833.52
$897.27
$964.80
$1,204.71 		$1,194.79
$1,258.54
$1,326.07
$1,565.98 		$1,556.06
$1,619.81
$1,687.34
$1,927.25 		$361.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$944.50
$1,072.00
$1,207.06
$1,686.88
$2,563.36 		$1,305.77
$1,433.27
$1,568.33
$2,048.15 		$1,667.04
$1,794.54
$1,929.60
$2,409.42 		$2,028.31
$2,155.81
$2,290.87
$2,770.69 		$361.27
Toc - Plan #111 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 		$487.21
$552.98
$622.65
$870.16
$1,322.28 		$859.92
$925.69
$995.36
$1,242.87 		$1,232.63
$1,298.40
$1,368.07
$1,615.58 		$1,605.34
$1,671.11
$1,740.78
$1,988.29 		$372.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$974.42
$1,105.96
$1,245.30
$1,740.32
$2,644.56 		$1,347.13
$1,478.67
$1,618.01
$2,113.03 		$1,719.84
$1,851.38
$1,990.72
$2,485.74 		$2,092.55
$2,224.09
$2,363.43
$2,858.45 		$372.71
Toc - Plan #112 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 		$306.28
$347.63
$391.43
$547.02
$831.25 		$540.58
$581.93
$625.73
$781.32 		$774.88
$816.23
$860.03
$1,015.62 		$1,009.18
$1,050.53
$1,094.33
$1,249.92 		$234.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.56
$695.26
$782.86
$1,094.04
$1,662.50 		$846.86
$929.56
$1,017.16
$1,328.34 		$1,081.16
$1,163.86
$1,251.46
$1,562.64 		$1,315.46
$1,398.16
$1,485.76
$1,796.94 		$234.30
Toc - Plan #113 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 		$326.67
$370.77
$417.49
$583.44
$886.59 		$576.57
$620.67
$667.39
$833.34 		$826.47
$870.57
$917.29
$1,083.24 		$1,076.37
$1,120.47
$1,167.19
$1,333.14 		$249.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.34
$741.54
$834.98
$1,166.88
$1,773.18 		$903.24
$991.44
$1,084.88
$1,416.78 		$1,153.14
$1,241.34
$1,334.78
$1,666.68 		$1,403.04
$1,491.24
$1,584.68
$1,916.58 		$249.90

ADVERTISEMENT

Blue Care Network of Michigan

Local: 1-888-227-2345 | Toll Free: 1-888-227-2345 | TTY: 1-800-257-9980
Toc - Plan #114 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 		$194.06
$220.26
$248.01
$346.59
$526.68 		$342.52
$368.72
$396.47
$495.05 		$490.98
$517.18
$544.93
$643.51 		$639.44
$665.64
$693.39
$791.97 		$148.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$388.12
$440.52
$496.02
$693.18
$1,053.36 		$536.58
$588.98
$644.48
$841.64 		$685.04
$737.44
$792.94
$990.10 		$833.50
$885.90
$941.40
$1,138.56 		$148.46
Toc - Plan #115 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 		$336.45
$381.87
$429.98
$600.90
$913.13 		$593.83
$639.25
$687.36
$858.28 		$851.21
$896.63
$944.74
$1,115.66 		$1,108.59
$1,154.01
$1,202.12
$1,373.04 		$257.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.90
$763.74
$859.96
$1,201.80
$1,826.26 		$930.28
$1,021.12
$1,117.34
$1,459.18 		$1,187.66
$1,278.50
$1,374.72
$1,716.56 		$1,445.04
$1,535.88
$1,632.10
$1,973.94 		$257.38
Toc - Plan #116 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 		$369.68
$419.59
$472.45
$660.25
$1,003.31 		$652.49
$702.40
$755.26
$943.06 		$935.30
$985.21
$1,038.07
$1,225.87 		$1,218.11
$1,268.02
$1,320.88
$1,508.68 		$282.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.36
$839.18
$944.90
$1,320.50
$2,006.62 		$1,022.17
$1,121.99
$1,227.71
$1,603.31 		$1,304.98
$1,404.80
$1,510.52
$1,886.12 		$1,587.79
$1,687.61
$1,793.33
$2,168.93 		$282.81
Toc - Plan #117 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 		$415.93
$472.08
$531.56
$742.85
$1,128.83 		$734.12
$790.27
$849.75
$1,061.04 		$1,052.31
$1,108.46
$1,167.94
$1,379.23 		$1,370.50
$1,426.65
$1,486.13
$1,697.42 		$318.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.86
$944.16
$1,063.12
$1,485.70
$2,257.66 		$1,150.05
$1,262.35
$1,381.31
$1,803.89 		$1,468.24
$1,580.54
$1,699.50
$2,122.08 		$1,786.43
$1,898.73
$2,017.69
$2,440.27 		$318.19
Toc - Plan #118 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Metro Detroit HMO Silver

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$326.10
$370.12
$416.76
$582.41
$885.04 		$575.57
$619.59
$666.23
$831.88 		$825.04
$869.06
$915.70
$1,081.35 		$1,074.51
$1,118.53
$1,165.17
$1,330.82 		$249.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.20
$740.24
$833.52
$1,164.82
$1,770.08 		$901.67
$989.71
$1,082.99
$1,414.29 		$1,151.14
$1,239.18
$1,332.46
$1,663.76 		$1,400.61
$1,488.65
$1,581.93
$1,913.23 		$249.47
Toc - Plan #119 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 		$301.52
$342.23
$385.34
$538.51
$818.33 		$532.18
$572.89
$616.00
$769.17 		$762.84
$803.55
$846.66
$999.83 		$993.50
$1,034.21
$1,077.32
$1,230.49 		$230.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.04
$684.46
$770.68
$1,077.02
$1,636.66 		$833.70
$915.12
$1,001.34
$1,307.68 		$1,064.36
$1,145.78
$1,232.00
$1,538.34 		$1,295.02
$1,376.44
$1,462.66
$1,769.00 		$230.66
Toc - Plan #120 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Metro Detroit HMO Silver Saver

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$292.24
$331.69
$373.48
$521.94
$793.14 		$515.80
$555.25
$597.04
$745.50 		$739.36
$778.81
$820.60
$969.06 		$962.92
$1,002.37
$1,044.16
$1,192.62 		$223.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.48
$663.38
$746.96
$1,043.88
$1,586.28 		$808.04
$886.94
$970.52
$1,267.44 		$1,031.60
$1,110.50
$1,194.08
$1,491.00 		$1,255.16
$1,334.06
$1,417.64
$1,714.56 		$223.56
Toc - Plan #121 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 		$331.30
$376.03
$423.40
$591.70
$899.15 		$584.74
$629.47
$676.84
$845.14 		$838.18
$882.91
$930.28
$1,098.58 		$1,091.62
$1,136.35
$1,183.72
$1,352.02 		$253.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662.60
$752.06
$846.80
$1,183.40
$1,798.30 		$916.04
$1,005.50
$1,100.24
$1,436.84 		$1,169.48
$1,258.94
$1,353.68
$1,690.28 		$1,422.92
$1,512.38
$1,607.12
$1,943.72 		$253.44
Toc - Plan #122 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Local 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 		$306.84
$348.26
$392.14
$548.02
$832.76 		$541.57
$582.99
$626.87
$782.75 		$776.30
$817.72
$861.60
$1,017.48 		$1,011.03
$1,052.45
$1,096.33
$1,252.21 		$234.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.68
$696.52
$784.28
$1,096.04
$1,665.52 		$848.41
$931.25
$1,019.01
$1,330.77 		$1,083.14
$1,165.98
$1,253.74
$1,565.50 		$1,317.87
$1,400.71
$1,488.47
$1,800.23 		$234.73
Toc - Plan #123 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Local 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 		$274.99
$312.11
$351.44
$491.13
$746.32 		$485.36
$522.48
$561.81
$701.50 		$695.73
$732.85
$772.18
$911.87 		$906.10
$943.22
$982.55
$1,122.24 		$210.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.98
$624.22
$702.88
$982.26
$1,492.64 		$760.35
$834.59
$913.25
$1,192.63 		$970.72
$1,044.96
$1,123.62
$1,403.00 		$1,181.09
$1,255.33
$1,333.99
$1,613.37 		$210.37
Toc - Plan #124 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 		$236.56
$268.50
$302.32
$422.50
$642.02 		$417.53
$449.47
$483.29
$603.47 		$598.50
$630.44
$664.26
$784.44 		$779.47
$811.41
$845.23
$965.41 		$180.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$473.12
$537.00
$604.64
$845.00
$1,284.04 		$654.09
$717.97
$785.61
$1,025.97 		$835.06
$898.94
$966.58
$1,206.94 		$1,016.03
$1,079.91
$1,147.55
$1,387.91 		$180.97
Toc - Plan #125 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Metro Detroit HMO Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$229.24
$260.19
$292.97
$409.42
$622.16 		$404.61
$435.56
$468.34
$584.79 		$579.98
$610.93
$643.71
$760.16 		$755.35
$786.30
$819.08
$935.53 		$175.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$458.48
$520.38
$585.94
$818.84
$1,244.32 		$633.85
$695.75
$761.31
$994.21 		$809.22
$871.12
$936.68
$1,169.58 		$984.59
$1,046.49
$1,112.05
$1,344.95 		$175.37
Toc - Plan #126 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 		$240.37
$272.82
$307.19
$429.30
$652.36 		$424.25
$456.70
$491.07
$613.18 		$608.13
$640.58
$674.95
$797.06 		$792.01
$824.46
$858.83
$980.94 		$183.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$480.74
$545.64
$614.38
$858.60
$1,304.72 		$664.62
$729.52
$798.26
$1,042.48 		$848.50
$913.40
$982.14
$1,226.36 		$1,032.38
$1,097.28
$1,166.02
$1,410.24 		$183.88
Toc - Plan #127 Blue Care Network of Michigan
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $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 		$231.42
$262.66
$295.75
$413.32
$628.07 		$408.46
$439.70
$472.79
$590.36 		$585.50
$616.74
$649.83
$767.40 		$762.54
$793.78
$826.87
$944.44 		$177.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$462.84
$525.32
$591.50
$826.64
$1,256.14 		$639.88
$702.36
$768.54
$1,003.68 		$816.92
$879.40
$945.58
$1,180.72 		$993.96
$1,056.44
$1,122.62
$1,357.76 		$177.04
Toc - Plan #128 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 		$264.10
$299.75
$337.52
$471.68
$716.77 		$466.14
$501.79
$539.56
$673.72 		$668.18
$703.83
$741.60
$875.76 		$870.22
$905.87
$943.64
$1,077.80 		$202.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$528.20
$599.50
$675.04
$943.36
$1,433.54 		$730.24
$801.54
$877.08
$1,145.40 		$932.28
$1,003.58
$1,079.12
$1,347.44 		$1,134.32
$1,205.62
$1,281.16
$1,549.48 		$202.04
Toc - Plan #129 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 		$259.92
$295.01
$332.18
$464.22
$705.42 		$458.76
$493.85
$531.02
$663.06 		$657.60
$692.69
$729.86
$861.90 		$856.44
$891.53
$928.70
$1,060.74 		$198.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519.84
$590.02
$664.36
$928.44
$1,410.84 		$718.68
$788.86
$863.20
$1,127.28 		$917.52
$987.70
$1,062.04
$1,326.12 		$1,116.36
$1,186.54
$1,260.88
$1,524.96 		$198.84
Toc - Plan #130 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Local 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 		$215.76
$244.89
$275.74
$385.35
$585.57 		$380.82
$409.95
$440.80
$550.41 		$545.88
$575.01
$605.86
$715.47 		$710.94
$740.07
$770.92
$880.53 		$165.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$431.52
$489.78
$551.48
$770.70
$1,171.14 		$596.58
$654.84
$716.54
$935.76 		$761.64
$819.90
$881.60
$1,100.82 		$926.70
$984.96
$1,046.66
$1,265.88 		$165.06
Toc - Plan #131 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Local 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 		$219.22
$248.81
$280.16
$391.53
$594.96 		$386.92
$416.51
$447.86
$559.23 		$554.62
$584.21
$615.56
$726.93 		$722.32
$751.91
$783.26
$894.63 		$167.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$438.44
$497.62
$560.32
$783.06
$1,189.92 		$606.14
$665.32
$728.02
$950.76 		$773.84
$833.02
$895.72
$1,118.46 		$941.54
$1,000.72
$1,063.42
$1,286.16 		$167.70
Toc - Plan #132 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 		$353.36
$401.06
$451.59
$631.10
$959.02 		$623.68
$671.38
$721.91
$901.42 		$894.00
$941.70
$992.23
$1,171.74 		$1,164.32
$1,212.02
$1,262.55
$1,442.06 		$270.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.72
$802.12
$903.18
$1,262.20
$1,918.04 		$977.04
$1,072.44
$1,173.50
$1,532.52 		$1,247.36
$1,342.76
$1,443.82
$1,802.84 		$1,517.68
$1,613.08
$1,714.14
$2,073.16 		$270.32
Toc - Plan #133 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 		$388.26
$440.68
$496.20
$693.43
$1,053.74 		$685.28
$737.70
$793.22
$990.45 		$982.30
$1,034.72
$1,090.24
$1,287.47 		$1,279.32
$1,331.74
$1,387.26
$1,584.49 		$297.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.52
$881.36
$992.40
$1,386.86
$2,107.48 		$1,073.54
$1,178.38
$1,289.42
$1,683.88 		$1,370.56
$1,475.40
$1,586.44
$1,980.90 		$1,667.58
$1,772.42
$1,883.46
$2,277.92 		$297.02
Toc - Plan #134 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Metro Detroit HMO Silver Extra

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $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 		$342.49
$388.73
$437.70
$611.69
$929.52 		$604.49
$650.73
$699.70
$873.69 		$866.49
$912.73
$961.70
$1,135.69 		$1,128.49
$1,174.73
$1,223.70
$1,397.69 		$262.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.98
$777.46
$875.40
$1,223.38
$1,859.04 		$946.98
$1,039.46
$1,137.40
$1,485.38 		$1,208.98
$1,301.46
$1,399.40
$1,747.38 		$1,470.98
$1,563.46
$1,661.40
$2,009.38 		$262.00
Toc - Plan #135 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 		$418.73
$475.26
$535.14
$747.85
$1,136.43 		$739.06
$795.59
$855.47
$1,068.18 		$1,059.39
$1,115.92
$1,175.80
$1,388.51 		$1,379.72
$1,436.25
$1,496.13
$1,708.84 		$320.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.46
$950.52
$1,070.28
$1,495.70
$2,272.86 		$1,157.79
$1,270.85
$1,390.61
$1,816.03 		$1,478.12
$1,591.18
$1,710.94
$2,136.36 		$1,798.45
$1,911.51
$2,031.27
$2,456.69 		$320.33
Toc - Plan #136 Blue Care Network of Michigan
Silver

(HMO) Blue Cross® Local 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 		$322.26
$365.77
$411.85
$575.56
$874.61 		$568.79
$612.30
$658.38
$822.09 		$815.32
$858.83
$904.91
$1,068.62 		$1,061.85
$1,105.36
$1,151.44
$1,315.15 		$246.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.52
$731.54
$823.70
$1,151.12
$1,749.22 		$891.05
$978.07
$1,070.23
$1,397.65 		$1,137.58
$1,224.60
$1,316.76
$1,644.18 		$1,384.11
$1,471.13
$1,563.29
$1,890.71 		$246.53
Toc - Plan #137 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 		$227.66
$258.39
$290.95
$406.60
$617.87 		$401.82
$432.55
$465.11
$580.76 		$575.98
$606.71
$639.27
$754.92 		$750.14
$780.87
$813.43
$929.08 		$174.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$455.32
$516.78
$581.90
$813.20
$1,235.74 		$629.48
$690.94
$756.06
$987.36 		$803.64
$865.10
$930.22
$1,161.52 		$977.80
$1,039.26
$1,104.38
$1,335.68 		$174.16
Toc - Plan #138 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Metro Detroit 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 		$220.61
$250.39
$281.94
$394.01
$598.74 		$389.38
$419.16
$450.71
$562.78 		$558.15
$587.93
$619.48
$731.55 		$726.92
$756.70
$788.25
$900.32 		$168.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$441.22
$500.78
$563.88
$788.02
$1,197.48 		$609.99
$669.55
$732.65
$956.79 		$778.76
$838.32
$901.42
$1,125.56 		$947.53
$1,007.09
$1,070.19
$1,294.33 		$168.77
Toc - Plan #139 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 		$250.13
$283.90
$319.67
$446.73
$678.85 		$441.48
$475.25
$511.02
$638.08 		$632.83
$666.60
$702.37
$829.43 		$824.18
$857.95
$893.72
$1,020.78 		$191.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$500.26
$567.80
$639.34
$893.46
$1,357.70 		$691.61
$759.15
$830.69
$1,084.81 		$882.96
$950.50
$1,022.04
$1,276.16 		$1,074.31
$1,141.85
$1,213.39
$1,467.51 		$191.35
Toc - Plan #140 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross® Local 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 		$207.63
$235.66
$265.35
$370.83
$563.51 		$366.47
$394.50
$424.19
$529.67 		$525.31
$553.34
$583.03
$688.51 		$684.15
$712.18
$741.87
$847.35 		$158.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$415.26
$471.32
$530.70
$741.66
$1,127.02 		$574.10
$630.16
$689.54
$900.50 		$732.94
$789.00
$848.38
$1,059.34 		$891.78
$947.84
$1,007.22
$1,218.18 		$158.84
Toc - Plan #141 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 		$202.57
$229.92
$258.88
$361.79
$549.77 		$357.54
$384.89
$413.85
$516.76 		$512.51
$539.86
$568.82
$671.73 		$667.48
$694.83
$723.79
$826.70 		$154.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$405.14
$459.84
$517.76
$723.58
$1,099.54 		$560.11
$614.81
$672.73
$878.55 		$715.08
$769.78
$827.70
$1,033.52 		$870.05
$924.75
$982.67
$1,188.49 		$154.97
Toc - Plan #142 Blue Care Network of Michigan
Bronze

(HMO) Blue Cross® Metro Detroit 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 		$196.31
$222.81
$250.88
$350.61
$532.79 		$346.49
$372.99
$401.06
$500.79 		$496.67
$523.17
$551.24
$650.97 		$646.85
$673.35
$701.42
$801.15 		$150.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$392.62
$445.62
$501.76
$701.22
$1,065.58 		$542.80
$595.80
$651.94
$851.40 		$692.98
$745.98
$802.12
$1,001.58 		$843.16
$896.16
$952.30
$1,151.76 		$150.18
Toc - Plan #143 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 		$222.57
$252.62
$284.44
$397.51
$604.05 		$392.84
$422.89
$454.71
$567.78 		$563.11
$593.16
$624.98
$738.05 		$733.38
$763.43
$795.25
$908.32 		$170.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$445.14
$505.24
$568.88
$795.02
$1,208.10 		$615.41
$675.51
$739.15
$965.29 		$785.68
$845.78
$909.42
$1,135.56 		$955.95
$1,016.05
$1,079.69
$1,305.83 		$170.27
Toc - Plan #144 Blue Care Network of Michigan
Bronze

(HMO) Blue Cross® Local 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 		$184.76
$209.70
$236.12
$329.98
$501.44 		$326.10
$351.04
$377.46
$471.32 		$467.44
$492.38
$518.80
$612.66 		$608.78
$633.72
$660.14
$754.00 		$141.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$369.52
$419.40
$472.24
$659.96
$1,002.88 		$510.86
$560.74
$613.58
$801.30 		$652.20
$702.08
$754.92
$942.64 		$793.54
$843.42
$896.26
$1,083.98 		$141.34
Toc - Plan #145 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 		$239.73
$272.09
$306.37
$428.16
$650.63 		$423.12
$455.48
$489.76
$611.55 		$606.51
$638.87
$673.15
$794.94 		$789.90
$822.26
$856.54
$978.33 		$183.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$479.46
$544.18
$612.74
$856.32
$1,301.26 		$662.85
$727.57
$796.13
$1,039.71 		$846.24
$910.96
$979.52
$1,223.10 		$1,029.63
$1,094.35
$1,162.91
$1,406.49 		$183.39
Toc - Plan #146 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 		$336.44
$381.86
$429.97
$600.88
$913.10 		$593.82
$639.24
$687.35
$858.26 		$851.20
$896.62
$944.73
$1,115.64 		$1,108.58
$1,154.00
$1,202.11
$1,373.02 		$257.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.88
$763.72
$859.94
$1,201.76
$1,826.20 		$930.26
$1,021.10
$1,117.32
$1,459.14 		$1,187.64
$1,278.48
$1,374.70
$1,716.52 		$1,445.02
$1,535.86
$1,632.08
$1,973.90 		$257.38

‡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 Wayne County here.

Wayne County is in “Rating Area 1” of Michigan.

Currently, there are 146 plans offered in Rating Area 1.

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2023 Obamacare Plans for Wayne County, MI

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