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Montana Obamacare 2023 Rates

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PacificSource Health Plans

Local: 1-406-442-6589 | Toll Free: 1-877-590-1596

Toc - Plan #1 PacificSource Health Plans
Expanded Bronze

(PPO) Navigator Bronze HSA 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322.00
$366.00
$412.00
$575.00
$874.00
$568.00
$612.00
$658.00
$821.00
$814.00
$858.00
$904.00
$1,067.00
$1,060.00
$1,104.00
$1,150.00
$1,313.00
$246.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$644.00
$732.00
$824.00
$1,150.00
$1,748.00
$890.00
$978.00
$1,070.00
$1,396.00
$1,136.00
$1,224.00
$1,316.00
$1,642.00
$1,382.00
$1,470.00
$1,562.00
$1,888.00
$246.00
Toc - Plan #2 PacificSource Health Plans
Expanded Bronze

(PPO) Navigator Bronze HSA 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322.00
$366.00
$412.00
$575.00
$874.00
$568.00
$612.00
$658.00
$821.00
$814.00
$858.00
$904.00
$1,067.00
$1,060.00
$1,104.00
$1,150.00
$1,313.00
$246.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$644.00
$732.00
$824.00
$1,150.00
$1,748.00
$890.00
$978.00
$1,070.00
$1,396.00
$1,136.00
$1,224.00
$1,316.00
$1,642.00
$1,382.00
$1,470.00
$1,562.00
$1,888.00
$246.00
Toc - Plan #3 PacificSource Health Plans
Silver

(PPO) Navigator Silver HSA 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,700 $13,400 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
$432.00
$490.00
$552.00
$772.00
$1,173.00
$763.00
$821.00
$883.00
$1,103.00
$1,094.00
$1,152.00
$1,214.00
$1,434.00
$1,425.00
$1,483.00
$1,545.00
$1,765.00
$331.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$864.00
$980.00
$1,104.00
$1,544.00
$2,346.00
$1,195.00
$1,311.00
$1,435.00
$1,875.00
$1,526.00
$1,642.00
$1,766.00
$2,206.00
$1,857.00
$1,973.00
$2,097.00
$2,537.00
$331.00
Toc - Plan #4 PacificSource Health Plans
Silver

(PPO) Navigator Silver HSA 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,700 $13,400 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
$432.00
$490.00
$552.00
$772.00
$1,173.00
$763.00
$821.00
$883.00
$1,103.00
$1,094.00
$1,152.00
$1,214.00
$1,434.00
$1,425.00
$1,483.00
$1,545.00
$1,765.00
$331.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$864.00
$980.00
$1,104.00
$1,544.00
$2,346.00
$1,195.00
$1,311.00
$1,435.00
$1,875.00
$1,526.00
$1,642.00
$1,766.00
$2,206.00
$1,857.00
$1,973.00
$2,097.00
$2,537.00
$331.00
Toc - Plan #5 PacificSource Health Plans
Gold

(PPO) Navigator Gold 1500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$473.00
$537.00
$605.00
$845.00
$1,284.00
$835.00
$899.00
$967.00
$1,207.00
$1,197.00
$1,261.00
$1,329.00
$1,569.00
$1,559.00
$1,623.00
$1,691.00
$1,931.00
$362.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$946.00
$1,074.00
$1,210.00
$1,690.00
$2,568.00
$1,308.00
$1,436.00
$1,572.00
$2,052.00
$1,670.00
$1,798.00
$1,934.00
$2,414.00
$2,032.00
$2,160.00
$2,296.00
$2,776.00
$362.00
Toc - Plan #6 PacificSource Health Plans
Gold

(PPO) Navigator Gold 1500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$473.00
$537.00
$605.00
$845.00
$1,284.00
$835.00
$899.00
$967.00
$1,207.00
$1,197.00
$1,261.00
$1,329.00
$1,569.00
$1,559.00
$1,623.00
$1,691.00
$1,931.00
$362.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$946.00
$1,074.00
$1,210.00
$1,690.00
$2,568.00
$1,308.00
$1,436.00
$1,572.00
$2,052.00
$1,670.00
$1,798.00
$1,934.00
$2,414.00
$2,032.00
$2,160.00
$2,296.00
$2,776.00
$362.00
Toc - Plan #7 PacificSource Health Plans
Expanded Bronze

(PPO) Navigator Bronze 7000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

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
$332.00
$376.00
$424.00
$592.00
$900.00
$586.00
$630.00
$678.00
$846.00
$840.00
$884.00
$932.00
$1,100.00
$1,094.00
$1,138.00
$1,186.00
$1,354.00
$254.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.00
$752.00
$848.00
$1,184.00
$1,800.00
$918.00
$1,006.00
$1,102.00
$1,438.00
$1,172.00
$1,260.00
$1,356.00
$1,692.00
$1,426.00
$1,514.00
$1,610.00
$1,946.00
$254.00
Toc - Plan #8 PacificSource Health Plans
Expanded Bronze

(PPO) Navigator Bronze 7000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

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
$332.00
$376.00
$424.00
$592.00
$900.00
$586.00
$630.00
$678.00
$846.00
$840.00
$884.00
$932.00
$1,100.00
$1,094.00
$1,138.00
$1,186.00
$1,354.00
$254.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.00
$752.00
$848.00
$1,184.00
$1,800.00
$918.00
$1,006.00
$1,102.00
$1,438.00
$1,172.00
$1,260.00
$1,356.00
$1,692.00
$1,426.00
$1,514.00
$1,610.00
$1,946.00
$254.00
Toc - Plan #9 PacificSource Health Plans
Silver

(PPO) Navigator Silver 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,600 $15,200 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
$422.00
$479.00
$539.00
$753.00
$1,145.00
$745.00
$802.00
$862.00
$1,076.00
$1,068.00
$1,125.00
$1,185.00
$1,399.00
$1,391.00
$1,448.00
$1,508.00
$1,722.00
$323.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$844.00
$958.00
$1,078.00
$1,506.00
$2,290.00
$1,167.00
$1,281.00
$1,401.00
$1,829.00
$1,490.00
$1,604.00
$1,724.00
$2,152.00
$1,813.00
$1,927.00
$2,047.00
$2,475.00
$323.00
Toc - Plan #10 PacificSource Health Plans
Silver

(PPO) Navigator Silver 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,600 $15,200 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
$422.00
$479.00
$539.00
$753.00
$1,145.00
$745.00
$802.00
$862.00
$1,076.00
$1,068.00
$1,125.00
$1,185.00
$1,399.00
$1,391.00
$1,448.00
$1,508.00
$1,722.00
$323.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$844.00
$958.00
$1,078.00
$1,506.00
$2,290.00
$1,167.00
$1,281.00
$1,401.00
$1,829.00
$1,490.00
$1,604.00
$1,724.00
$2,152.00
$1,813.00
$1,927.00
$2,047.00
$2,475.00
$323.00
Toc - Plan #11 PacificSource Health Plans
Bronze

(PPO) Navigator Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

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
$298.00
$338.00
$381.00
$533.00
$809.00
$526.00
$566.00
$609.00
$761.00
$754.00
$794.00
$837.00
$989.00
$982.00
$1,022.00
$1,065.00
$1,217.00
$228.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.00
$676.00
$762.00
$1,066.00
$1,618.00
$824.00
$904.00
$990.00
$1,294.00
$1,052.00
$1,132.00
$1,218.00
$1,522.00
$1,280.00
$1,360.00
$1,446.00
$1,750.00
$228.00
Toc - Plan #12 PacificSource Health Plans
Bronze

(PPO) Navigator Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

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
$298.00
$338.00
$381.00
$533.00
$809.00
$526.00
$566.00
$609.00
$761.00
$754.00
$794.00
$837.00
$989.00
$982.00
$1,022.00
$1,065.00
$1,217.00
$228.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.00
$676.00
$762.00
$1,066.00
$1,618.00
$824.00
$904.00
$990.00
$1,294.00
$1,052.00
$1,132.00
$1,218.00
$1,522.00
$1,280.00
$1,360.00
$1,446.00
$1,750.00
$228.00
Toc - Plan #13 PacificSource Health Plans
Expanded Bronze

(PPO) Navigator Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

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
$326.00
$370.00
$417.00
$583.00
$886.00
$576.00
$620.00
$667.00
$833.00
$826.00
$870.00
$917.00
$1,083.00
$1,076.00
$1,120.00
$1,167.00
$1,333.00
$250.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$652.00
$740.00
$834.00
$1,166.00
$1,772.00
$902.00
$990.00
$1,084.00
$1,416.00
$1,152.00
$1,240.00
$1,334.00
$1,666.00
$1,402.00
$1,490.00
$1,584.00
$1,916.00
$250.00
Toc - Plan #14 PacificSource Health Plans
Expanded Bronze

(PPO) Navigator Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

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
$326.00
$370.00
$417.00
$583.00
$886.00
$576.00
$620.00
$667.00
$833.00
$826.00
$870.00
$917.00
$1,083.00
$1,076.00
$1,120.00
$1,167.00
$1,333.00
$250.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$652.00
$740.00
$834.00
$1,166.00
$1,772.00
$902.00
$990.00
$1,084.00
$1,416.00
$1,152.00
$1,240.00
$1,334.00
$1,666.00
$1,402.00
$1,490.00
$1,584.00
$1,916.00
$250.00
Toc - Plan #15 PacificSource Health Plans
Silver

(PPO) Navigator Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

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
$416.00
$472.00
$532.00
$743.00
$1,129.00
$734.00
$790.00
$850.00
$1,061.00
$1,052.00
$1,108.00
$1,168.00
$1,379.00
$1,370.00
$1,426.00
$1,486.00
$1,697.00
$318.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.00
$944.00
$1,064.00
$1,486.00
$2,258.00
$1,150.00
$1,262.00
$1,382.00
$1,804.00
$1,468.00
$1,580.00
$1,700.00
$2,122.00
$1,786.00
$1,898.00
$2,018.00
$2,440.00
$318.00
Toc - Plan #16 PacificSource Health Plans
Silver

(PPO) Navigator Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

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
$416.00
$472.00
$532.00
$743.00
$1,129.00
$734.00
$790.00
$850.00
$1,061.00
$1,052.00
$1,108.00
$1,168.00
$1,379.00
$1,370.00
$1,426.00
$1,486.00
$1,697.00
$318.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.00
$944.00
$1,064.00
$1,486.00
$2,258.00
$1,150.00
$1,262.00
$1,382.00
$1,804.00
$1,468.00
$1,580.00
$1,700.00
$2,122.00
$1,786.00
$1,898.00
$2,018.00
$2,440.00
$318.00
Toc - Plan #17 PacificSource Health Plans
Gold

(PPO) Navigator Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.00
$501.00
$564.00
$788.00
$1,197.00
$778.00
$838.00
$901.00
$1,125.00
$1,115.00
$1,175.00
$1,238.00
$1,462.00
$1,452.00
$1,512.00
$1,575.00
$1,799.00
$337.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.00
$1,002.00
$1,128.00
$1,576.00
$2,394.00
$1,219.00
$1,339.00
$1,465.00
$1,913.00
$1,556.00
$1,676.00
$1,802.00
$2,250.00
$1,893.00
$2,013.00
$2,139.00
$2,587.00
$337.00
Toc - Plan #18 PacificSource Health Plans
Gold

(PPO) Navigator Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-590-1596

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.00
$501.00
$564.00
$788.00
$1,197.00
$778.00
$838.00
$901.00
$1,125.00
$1,115.00
$1,175.00
$1,238.00
$1,462.00
$1,452.00
$1,512.00
$1,575.00
$1,799.00
$337.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.00
$1,002.00
$1,128.00
$1,576.00
$2,394.00
$1,219.00
$1,339.00
$1,465.00
$1,913.00
$1,556.00
$1,676.00
$1,802.00
$2,250.00
$1,893.00
$2,013.00
$2,139.00
$2,587.00
$337.00

ADVERTISEMENT

Blue Cross and Blue Shield of Montana

Local: 1-855-258-8471 | Toll Free: 1-855-258-8471 | TTY: 1-406-444-4212

Toc - Plan #19 Blue Cross and Blue Shield of Montana
Gold

(PPO) Blue Preferred Gold PPO? 204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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
$470.13
$533.60
$600.83
$839.66
$1,275.94
$829.78
$893.25
$960.48
$1,199.31
$1,189.43
$1,252.90
$1,320.13
$1,558.96
$1,549.08
$1,612.55
$1,679.78
$1,918.61
$359.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$940.26
$1,067.20
$1,201.66
$1,679.32
$2,551.88
$1,299.91
$1,426.85
$1,561.31
$2,038.97
$1,659.56
$1,786.50
$1,920.96
$2,398.62
$2,019.21
$2,146.15
$2,280.61
$2,758.27
$359.65
Toc - Plan #20 Blue Cross and Blue Shield of Montana
Silver

(PPO) Blue Preferred Silver PPO? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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
$437.43
$496.48
$559.04
$781.25
$1,187.19
$772.06
$831.11
$893.67
$1,115.88
$1,106.69
$1,165.74
$1,228.30
$1,450.51
$1,441.32
$1,500.37
$1,562.93
$1,785.14
$334.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.86
$992.96
$1,118.08
$1,562.50
$2,374.38
$1,209.49
$1,327.59
$1,452.71
$1,897.13
$1,544.12
$1,662.22
$1,787.34
$2,231.76
$1,878.75
$1,996.85
$2,121.97
$2,566.39
$334.63
Toc - Plan #21 Blue Cross and Blue Shield of Montana
Expanded Bronze

(PPO) Blue Preferred Bronze PPO? 201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$332.15
$376.99
$424.49
$593.22
$901.46
$586.25
$631.09
$678.59
$847.32
$840.35
$885.19
$932.69
$1,101.42
$1,094.45
$1,139.29
$1,186.79
$1,355.52
$254.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.30
$753.98
$848.98
$1,186.44
$1,802.92
$918.40
$1,008.08
$1,103.08
$1,440.54
$1,172.50
$1,262.18
$1,357.18
$1,694.64
$1,426.60
$1,516.28
$1,611.28
$1,948.74
$254.10
Toc - Plan #22 Blue Cross and Blue Shield of Montana
Expanded Bronze

(PPO) Blue Preferred Bronze PPO? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.77
$401.53
$452.12
$631.83
$960.13
$624.40
$672.16
$722.75
$902.46
$895.03
$942.79
$993.38
$1,173.09
$1,165.66
$1,213.42
$1,264.01
$1,443.72
$270.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.54
$803.06
$904.24
$1,263.66
$1,920.26
$978.17
$1,073.69
$1,174.87
$1,534.29
$1,248.80
$1,344.32
$1,445.50
$1,804.92
$1,519.43
$1,614.95
$1,716.13
$2,075.55
$270.63
Toc - Plan #23 Blue Cross and Blue Shield of Montana
Catastrophic

(PPO) Blue Preferred Security PPO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$279.48
$317.20
$357.17
$499.14
$758.50
$493.28
$531.00
$570.97
$712.94
$707.08
$744.80
$784.77
$926.74
$920.88
$958.60
$998.57
$1,140.54
$213.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$558.96
$634.40
$714.34
$998.28
$1,517.00
$772.76
$848.20
$928.14
$1,212.08
$986.56
$1,062.00
$1,141.94
$1,425.88
$1,200.36
$1,275.80
$1,355.74
$1,639.68
$213.80
Toc - Plan #24 Blue Cross and Blue Shield of Montana
Silver

(PPO) Blue Preferred Silver PPO? 308

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$418.27
$474.74
$534.55
$747.04
$1,135.19
$738.25
$794.72
$854.53
$1,067.02
$1,058.23
$1,114.70
$1,174.51
$1,387.00
$1,378.21
$1,434.68
$1,494.49
$1,706.98
$319.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.54
$949.48
$1,069.10
$1,494.08
$2,270.38
$1,156.52
$1,269.46
$1,389.08
$1,814.06
$1,476.50
$1,589.44
$1,709.06
$2,134.04
$1,796.48
$1,909.42
$2,029.04
$2,454.02
$319.98
Toc - Plan #25 Blue Cross and Blue Shield of Montana
Bronze

(PPO) Blue Preferred Bronze PPO? 301

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 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
$320.00
$363.20
$408.96
$571.51
$868.47
$564.80
$608.00
$653.76
$816.31
$809.60
$852.80
$898.56
$1,061.11
$1,054.40
$1,097.60
$1,143.36
$1,305.91
$244.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.00
$726.40
$817.92
$1,143.02
$1,736.94
$884.80
$971.20
$1,062.72
$1,387.82
$1,129.60
$1,216.00
$1,307.52
$1,632.62
$1,374.40
$1,460.80
$1,552.32
$1,877.42
$244.80
Toc - Plan #26 Blue Cross and Blue Shield of Montana
Gold

(PPO) Blue Preferred Gold PPO? 704

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$465.99
$528.90
$595.53
$832.25
$1,264.69
$822.47
$885.38
$952.01
$1,188.73
$1,178.95
$1,241.86
$1,308.49
$1,545.21
$1,535.43
$1,598.34
$1,664.97
$1,901.69
$356.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$931.98
$1,057.80
$1,191.06
$1,664.50
$2,529.38
$1,288.46
$1,414.28
$1,547.54
$2,020.98
$1,644.94
$1,770.76
$1,904.02
$2,377.46
$2,001.42
$2,127.24
$2,260.50
$2,733.94
$356.48
Toc - Plan #27 Blue Cross and Blue Shield of Montana
Silver

(PPO) Blue Preferred Silver PPO? 703

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$428.08
$485.87
$547.08
$764.54
$1,161.80
$755.56
$813.35
$874.56
$1,092.02
$1,083.04
$1,140.83
$1,202.04
$1,419.50
$1,410.52
$1,468.31
$1,529.52
$1,746.98
$327.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.16
$971.74
$1,094.16
$1,529.08
$2,323.60
$1,183.64
$1,299.22
$1,421.64
$1,856.56
$1,511.12
$1,626.70
$1,749.12
$2,184.04
$1,838.60
$1,954.18
$2,076.60
$2,511.52
$327.48
Toc - Plan #28 Blue Cross and Blue Shield of Montana
Bronze

(PPO) Blue Preferred Bronze PPO? 701

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$312.73
$354.95
$399.67
$558.53
$848.74
$551.97
$594.19
$638.91
$797.77
$791.21
$833.43
$878.15
$1,037.01
$1,030.45
$1,072.67
$1,117.39
$1,276.25
$239.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625.46
$709.90
$799.34
$1,117.06
$1,697.48
$864.70
$949.14
$1,038.58
$1,356.30
$1,103.94
$1,188.38
$1,277.82
$1,595.54
$1,343.18
$1,427.62
$1,517.06
$1,834.78
$239.24
Toc - Plan #29 Blue Cross and Blue Shield of Montana
Expanded Bronze

(PPO) Blue Preferred Bronze PPO? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$353.75
$401.50
$452.09
$631.80
$960.07
$624.37
$672.12
$722.71
$902.42
$894.99
$942.74
$993.33
$1,173.04
$1,165.61
$1,213.36
$1,263.95
$1,443.66
$270.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.50
$803.00
$904.18
$1,263.60
$1,920.14
$978.12
$1,073.62
$1,174.80
$1,534.22
$1,248.74
$1,344.24
$1,445.42
$1,804.84
$1,519.36
$1,614.86
$1,716.04
$2,075.46
$270.62
Toc - Plan #30 Blue Cross and Blue Shield of Montana
Gold

(HMO) Blue Focus Gold POS? 207

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

Annual Out of Pocket Expenses:

Individual Family
$250 $500 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
$350.33
$397.62
$447.72
$625.69
$950.79
$618.33
$665.62
$715.72
$893.69
$886.33
$933.62
$983.72
$1,161.69
$1,154.33
$1,201.62
$1,251.72
$1,429.69
$268.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700.66
$795.24
$895.44
$1,251.38
$1,901.58
$968.66
$1,063.24
$1,163.44
$1,519.38
$1,236.66
$1,331.24
$1,431.44
$1,787.38
$1,504.66
$1,599.24
$1,699.44
$2,055.38
$268.00
Toc - Plan #31 Blue Cross and Blue Shield of Montana
Silver

(HMO) Blue Focus Silver POS? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 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
$314.42
$356.86
$401.83
$561.55
$853.33
$554.95
$597.39
$642.36
$802.08
$795.48
$837.92
$882.89
$1,042.61
$1,036.01
$1,078.45
$1,123.42
$1,283.14
$240.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$628.84
$713.72
$803.66
$1,123.10
$1,706.66
$869.37
$954.25
$1,044.19
$1,363.63
$1,109.90
$1,194.78
$1,284.72
$1,604.16
$1,350.43
$1,435.31
$1,525.25
$1,844.69
$240.53
Toc - Plan #32 Blue Cross and Blue Shield of Montana
Expanded Bronze

(HMO) Blue Focus Bronze POS? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

Annual Out of Pocket Expenses:

Individual Family
$4,900 $10,200 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
$228.45
$259.30
$291.96
$408.02
$620.03
$403.22
$434.07
$466.73
$582.79
$577.99
$608.84
$641.50
$757.56
$752.76
$783.61
$816.27
$932.33
$174.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$456.90
$518.60
$583.92
$816.04
$1,240.06
$631.67
$693.37
$758.69
$990.81
$806.44
$868.14
$933.46
$1,165.58
$981.21
$1,042.91
$1,108.23
$1,340.35
$174.77
Toc - Plan #33 Blue Cross and Blue Shield of Montana
Gold

(HMO) Blue Focus Gold POS? 707

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$358.82
$407.26
$458.57
$640.85
$973.84
$633.32
$681.76
$733.07
$915.35
$907.82
$956.26
$1,007.57
$1,189.85
$1,182.32
$1,230.76
$1,282.07
$1,464.35
$274.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.64
$814.52
$917.14
$1,281.70
$1,947.68
$992.14
$1,089.02
$1,191.64
$1,556.20
$1,266.64
$1,363.52
$1,466.14
$1,830.70
$1,541.14
$1,638.02
$1,740.64
$2,105.20
$274.50
Toc - Plan #34 Blue Cross and Blue Shield of Montana
Silver

(HMO) Blue Focus Silver POS? 706

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$315.11
$357.65
$402.71
$562.78
$855.20
$556.17
$598.71
$643.77
$803.84
$797.23
$839.77
$884.83
$1,044.90
$1,038.29
$1,080.83
$1,125.89
$1,285.96
$241.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.22
$715.30
$805.42
$1,125.56
$1,710.40
$871.28
$956.36
$1,046.48
$1,366.62
$1,112.34
$1,197.42
$1,287.54
$1,607.68
$1,353.40
$1,438.48
$1,528.60
$1,848.74
$241.06
Toc - Plan #35 Blue Cross and Blue Shield of Montana
Bronze

(HMO) Blue Focus Bronze POS? 705

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$217.67
$247.06
$278.18
$388.76
$590.76
$384.19
$413.58
$444.70
$555.28
$550.71
$580.10
$611.22
$721.80
$717.23
$746.62
$777.74
$888.32
$166.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$435.34
$494.12
$556.36
$777.52
$1,181.52
$601.86
$660.64
$722.88
$944.04
$768.38
$827.16
$889.40
$1,110.56
$934.90
$993.68
$1,055.92
$1,277.08
$166.52
Toc - Plan #36 Blue Cross and Blue Shield of Montana
Expanded Bronze

(HMO) Blue Focus Bronze POS? 708

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-258-8471

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
$257.12
$291.83
$328.60
$459.22
$697.83
$453.82
$488.53
$525.30
$655.92
$650.52
$685.23
$722.00
$852.62
$847.22
$881.93
$918.70
$1,049.32
$196.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$514.24
$583.66
$657.20
$918.44
$1,395.66
$710.94
$780.36
$853.90
$1,115.14
$907.64
$977.06
$1,050.60
$1,311.84
$1,104.34
$1,173.76
$1,247.30
$1,508.54
$196.70

ADVERTISEMENT

Mountain Health CO-OP

Local: 1-406-447-9510 | Toll Free: 1-855-447-2900 | TTY: 1-855-447-2900

Toc - Plan #37 Mountain Health CO-OP
Gold

(PPO) Plus Ind Gold MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.18
$437.18
$492.27
$687.94
$1,045.39
$679.85
$731.85
$786.94
$982.61
$974.52
$1,026.52
$1,081.61
$1,277.28
$1,269.19
$1,321.19
$1,376.28
$1,571.95
$294.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.36
$874.36
$984.54
$1,375.88
$2,090.78
$1,065.03
$1,169.03
$1,279.21
$1,670.55
$1,359.70
$1,463.70
$1,573.88
$1,965.22
$1,654.37
$1,758.37
$1,868.55
$2,259.89
$294.67
Toc - Plan #38 Mountain Health CO-OP
Silver

(PPO) Plus Ind Silver MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$346.86
$393.69
$443.29
$619.50
$941.39
$612.21
$659.04
$708.64
$884.85
$877.56
$924.39
$973.99
$1,150.20
$1,142.91
$1,189.74
$1,239.34
$1,415.55
$265.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.72
$787.38
$886.58
$1,239.00
$1,882.78
$959.07
$1,052.73
$1,151.93
$1,504.35
$1,224.42
$1,318.08
$1,417.28
$1,769.70
$1,489.77
$1,583.43
$1,682.63
$2,035.05
$265.35
Toc - Plan #39 Mountain Health CO-OP
Expanded Bronze

(PPO) Plus Ind Bronze MT Expanded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$260.73
$295.93
$333.22
$465.67
$707.63
$460.19
$495.39
$532.68
$665.13
$659.65
$694.85
$732.14
$864.59
$859.11
$894.31
$931.60
$1,064.05
$199.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$521.46
$591.86
$666.44
$931.34
$1,415.26
$720.92
$791.32
$865.90
$1,130.80
$920.38
$990.78
$1,065.36
$1,330.26
$1,119.84
$1,190.24
$1,264.82
$1,529.72
$199.46
Toc - Plan #40 Mountain Health CO-OP
Expanded Bronze

(PPO) Plus Ind Bronze MT HD

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$268.19
$304.40
$342.75
$478.99
$727.87
$473.36
$509.57
$547.92
$684.16
$678.53
$714.74
$753.09
$889.33
$883.70
$919.91
$958.26
$1,094.50
$205.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$536.38
$608.80
$685.50
$957.98
$1,455.74
$741.55
$813.97
$890.67
$1,163.15
$946.72
$1,019.14
$1,095.84
$1,368.32
$1,151.89
$1,224.31
$1,301.01
$1,573.49
$205.17
Toc - Plan #41 Mountain Health CO-OP
Gold

(PPO) Plus Ind Gold Standard MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$382.63
$434.29
$489.01
$683.39
$1,038.47
$675.35
$727.01
$781.73
$976.11
$968.07
$1,019.73
$1,074.45
$1,268.83
$1,260.79
$1,312.45
$1,367.17
$1,561.55
$292.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.26
$868.58
$978.02
$1,366.78
$2,076.94
$1,057.98
$1,161.30
$1,270.74
$1,659.50
$1,350.70
$1,454.02
$1,563.46
$1,952.22
$1,643.42
$1,746.74
$1,856.18
$2,244.94
$292.72
Toc - Plan #42 Mountain Health CO-OP
Silver

(PPO) Plus Ind Silver Standard MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$354.16
$401.97
$452.61
$632.53
$961.19
$625.09
$672.90
$723.54
$903.46
$896.02
$943.83
$994.47
$1,174.39
$1,166.95
$1,214.76
$1,265.40
$1,445.32
$270.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.32
$803.94
$905.22
$1,265.06
$1,922.38
$979.25
$1,074.87
$1,176.15
$1,535.99
$1,250.18
$1,345.80
$1,447.08
$1,806.92
$1,521.11
$1,616.73
$1,718.01
$2,077.85
$270.93
Toc - Plan #43 Mountain Health CO-OP
Expanded Bronze

(PPO) Plus Ind Bronze Standard MT Expanded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$264.95
$300.71
$338.60
$473.19
$719.06
$467.63
$503.39
$541.28
$675.87
$670.31
$706.07
$743.96
$878.55
$872.99
$908.75
$946.64
$1,081.23
$202.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$529.90
$601.42
$677.20
$946.38
$1,438.12
$732.58
$804.10
$879.88
$1,149.06
$935.26
$1,006.78
$1,082.56
$1,351.74
$1,137.94
$1,209.46
$1,285.24
$1,554.42
$202.68
Toc - Plan #44 Mountain Health CO-OP
Gold

(PPO) Connect Ind Gold MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$422.70
$479.77
$540.22
$754.95
$1,147.22
$746.07
$803.14
$863.59
$1,078.32
$1,069.44
$1,126.51
$1,186.96
$1,401.69
$1,392.81
$1,449.88
$1,510.33
$1,725.06
$323.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.40
$959.54
$1,080.44
$1,509.90
$2,294.44
$1,168.77
$1,282.91
$1,403.81
$1,833.27
$1,492.14
$1,606.28
$1,727.18
$2,156.64
$1,815.51
$1,929.65
$2,050.55
$2,480.01
$323.37
Toc - Plan #45 Mountain Health CO-OP
Silver

(PPO) Connect Ind Silver MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$385.39
$437.42
$492.53
$688.31
$1,045.95
$680.21
$732.24
$787.35
$983.13
$975.03
$1,027.06
$1,082.17
$1,277.95
$1,269.85
$1,321.88
$1,376.99
$1,572.77
$294.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.78
$874.84
$985.06
$1,376.62
$2,091.90
$1,065.60
$1,169.66
$1,279.88
$1,671.44
$1,360.42
$1,464.48
$1,574.70
$1,966.26
$1,655.24
$1,759.30
$1,869.52
$2,261.08
$294.82
Toc - Plan #46 Mountain Health CO-OP
Expanded Bronze

(PPO) Connect Ind Bronze MT Expanded 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,500 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$279.56
$317.30
$357.27
$499.29
$758.72
$493.42
$531.16
$571.13
$713.15
$707.28
$745.02
$784.99
$927.01
$921.14
$958.88
$998.85
$1,140.87
$213.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$559.12
$634.60
$714.54
$998.58
$1,517.44
$772.98
$848.46
$928.40
$1,212.44
$986.84
$1,062.32
$1,142.26
$1,426.30
$1,200.70
$1,276.18
$1,356.12
$1,640.16
$213.86
Toc - Plan #47 Mountain Health CO-OP
Expanded Bronze

(PPO) Connect Ind Bronze MT HD

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$293.53
$333.15
$375.13
$524.24
$796.63
$518.08
$557.70
$599.68
$748.79
$742.63
$782.25
$824.23
$973.34
$967.18
$1,006.80
$1,048.78
$1,197.89
$224.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$587.06
$666.30
$750.26
$1,048.48
$1,593.26
$811.61
$890.85
$974.81
$1,273.03
$1,036.16
$1,115.40
$1,199.36
$1,497.58
$1,260.71
$1,339.95
$1,423.91
$1,722.13
$224.55
Toc - Plan #48 Mountain Health CO-OP
Silver

(PPO) Connect Ind Silver MT Option 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.14
$425.78
$479.43
$670.00
$1,018.13
$662.12
$712.76
$766.41
$956.98
$949.10
$999.74
$1,053.39
$1,243.96
$1,236.08
$1,286.72
$1,340.37
$1,530.94
$286.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.28
$851.56
$958.86
$1,340.00
$2,036.26
$1,037.26
$1,138.54
$1,245.84
$1,626.98
$1,324.24
$1,425.52
$1,532.82
$1,913.96
$1,611.22
$1,712.50
$1,819.80
$2,200.94
$286.98
Toc - Plan #49 Mountain Health CO-OP
Catastrophic

(PPO) Connect Ind Catastrophic MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$191.11
$216.91
$244.24
$341.32
$518.67
$337.31
$363.11
$390.44
$487.52
$483.51
$509.31
$536.64
$633.72
$629.71
$655.51
$682.84
$779.92
$146.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$382.22
$433.82
$488.48
$682.64
$1,037.34
$528.42
$580.02
$634.68
$828.84
$674.62
$726.22
$780.88
$975.04
$820.82
$872.42
$927.08
$1,121.24
$146.20
Toc - Plan #50 Mountain Health CO-OP
Expanded Bronze

(PPO) Connect Ind Bronze MT Expanded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

Individual Family
$8,400 $16,800 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.54
$330.90
$372.59
$520.69
$791.24
$514.57
$553.93
$595.62
$743.72
$737.60
$776.96
$818.65
$966.75
$960.63
$999.99
$1,041.68
$1,189.78
$223.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$583.08
$661.80
$745.18
$1,041.38
$1,582.48
$806.11
$884.83
$968.21
$1,264.41
$1,029.14
$1,107.86
$1,191.24
$1,487.44
$1,252.17
$1,330.89
$1,414.27
$1,710.47
$223.03
Toc - Plan #51 Mountain Health CO-OP
Gold

(PPO) Connect Ind Gold Standard MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$416.32
$472.53
$532.06
$743.56
$1,129.91
$734.81
$791.02
$850.55
$1,062.05
$1,053.30
$1,109.51
$1,169.04
$1,380.54
$1,371.79
$1,428.00
$1,487.53
$1,699.03
$318.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.64
$945.06
$1,064.12
$1,487.12
$2,259.82
$1,151.13
$1,263.55
$1,382.61
$1,805.61
$1,469.62
$1,582.04
$1,701.10
$2,124.10
$1,788.11
$1,900.53
$2,019.59
$2,442.59
$318.49
Toc - Plan #52 Mountain Health CO-OP
Silver

(PPO) Connect Ind Silver Standard MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$386.55
$438.73
$494.01
$690.38
$1,049.09
$682.26
$734.44
$789.72
$986.09
$977.97
$1,030.15
$1,085.43
$1,281.80
$1,273.68
$1,325.86
$1,381.14
$1,577.51
$295.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$773.10
$877.46
$988.02
$1,380.76
$2,098.18
$1,068.81
$1,173.17
$1,283.73
$1,676.47
$1,364.52
$1,468.88
$1,579.44
$1,972.18
$1,660.23
$1,764.59
$1,875.15
$2,267.89
$295.71
Toc - Plan #53 Mountain Health CO-OP
Expanded Bronze

(PPO) Connect Ind Bronze Expanded Standard MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$288.77
$327.75
$369.05
$515.74
$783.72
$509.68
$548.66
$589.96
$736.65
$730.59
$769.57
$810.87
$957.56
$951.50
$990.48
$1,031.78
$1,178.47
$220.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$577.54
$655.50
$738.10
$1,031.48
$1,567.44
$798.45
$876.41
$959.01
$1,252.39
$1,019.36
$1,097.32
$1,179.92
$1,473.30
$1,240.27
$1,318.23
$1,400.83
$1,694.21
$220.91
Toc - Plan #54 Mountain Health CO-OP
Gold

(PPO) Rocky Mountain Ind Gold MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.85
$458.37
$516.12
$721.28
$1,096.05
$712.80
$767.32
$825.07
$1,030.23
$1,021.75
$1,076.27
$1,134.02
$1,339.18
$1,330.70
$1,385.22
$1,442.97
$1,648.13
$308.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$807.70
$916.74
$1,032.24
$1,442.56
$2,192.10
$1,116.65
$1,225.69
$1,341.19
$1,751.51
$1,425.60
$1,534.64
$1,650.14
$2,060.46
$1,734.55
$1,843.59
$1,959.09
$2,369.41
$308.95
Toc - Plan #55 Mountain Health CO-OP
Silver

(PPO) Rocky Mountain Ind Silver MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$361.91
$410.77
$462.52
$646.37
$982.23
$638.77
$687.63
$739.38
$923.23
$915.63
$964.49
$1,016.24
$1,200.09
$1,192.49
$1,241.35
$1,293.10
$1,476.95
$276.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.82
$821.54
$925.04
$1,292.74
$1,964.46
$1,000.68
$1,098.40
$1,201.90
$1,569.60
$1,277.54
$1,375.26
$1,478.76
$1,846.46
$1,554.40
$1,652.12
$1,755.62
$2,123.32
$276.86
Toc - Plan #56 Mountain Health CO-OP
Expanded Bronze

(PPO) Rocky Mountain Ind Bronze MT Expanded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

Annual Out of Pocket Expenses:

Individual Family
$8,400 $16,800 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$278.60
$316.21
$356.05
$497.58
$756.12
$491.73
$529.34
$569.18
$710.71
$704.86
$742.47
$782.31
$923.84
$917.99
$955.60
$995.44
$1,136.97
$213.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$557.20
$632.42
$712.10
$995.16
$1,512.24
$770.33
$845.55
$925.23
$1,208.29
$983.46
$1,058.68
$1,138.36
$1,421.42
$1,196.59
$1,271.81
$1,351.49
$1,634.55
$213.13
Toc - Plan #57 Mountain Health CO-OP
Gold

(PPO) Rocky Mountain Ind Gold Standard MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$397.76
$451.46
$508.34
$710.40
$1,079.52
$702.05
$755.75
$812.63
$1,014.69
$1,006.34
$1,060.04
$1,116.92
$1,318.98
$1,310.63
$1,364.33
$1,421.21
$1,623.27
$304.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.52
$902.92
$1,016.68
$1,420.80
$2,159.04
$1,099.81
$1,207.21
$1,320.97
$1,725.09
$1,404.10
$1,511.50
$1,625.26
$2,029.38
$1,708.39
$1,815.79
$1,929.55
$2,333.67
$304.29
Toc - Plan #58 Mountain Health CO-OP
Silver

(PPO) Rocky Mountain Ind Silver Standard MT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$369.19
$419.03
$471.83
$659.38
$1,001.98
$651.62
$701.46
$754.26
$941.81
$934.05
$983.89
$1,036.69
$1,224.24
$1,216.48
$1,266.32
$1,319.12
$1,506.67
$282.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.38
$838.06
$943.66
$1,318.76
$2,003.96
$1,020.81
$1,120.49
$1,226.09
$1,601.19
$1,303.24
$1,402.92
$1,508.52
$1,883.62
$1,585.67
$1,685.35
$1,790.95
$2,166.05
$282.43
Toc - Plan #59 Mountain Health CO-OP
Expanded Bronze

(PPO) Rocky Mountain Ind Bronze Standard MT Expanded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-447-2900

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
$275.95
$313.21
$352.67
$492.85
$748.94
$487.05
$524.31
$563.77
$703.95
$698.15
$735.41
$774.87
$915.05
$909.25
$946.51
$985.97
$1,126.15
$211.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$551.90
$626.42
$705.34
$985.70
$1,497.88
$763.00
$837.52
$916.44
$1,196.80
$974.10
$1,048.62
$1,127.54
$1,407.90
$1,185.20
$1,259.72
$1,338.64
$1,619.00
$211.10

‡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 Yellowstone County here.

Yellowstone County is in “Rating Area 1” of Montana.

Currently, there are 59 plans offered in Rating Area 1.

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2023 Obamacare Plans for Yellowstone County, MT

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