Obamacare 2021 Rates for Macomb County

Obamacare > Rates > Michigan > Macomb County

Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Macomb County, MI.

The health insurance rates listed below are for calendar year 2021.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 88 Plans and 2021 Rates for Macomb County, Michigan

Below, you’ll find a summary of the 88 plans for Macomb County, Michigan and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Blue Cross Blue Shield of Michigan Mutual Insurance Company

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

(PPO) Blue Cross¨ Premier PPO Value

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$222,16
$252,15
$283,92
$396,78
$602,94 		$392,11
$422,10
$453,87
$566,73 		$562,06
$592,05
$623,82
$736,68 		$732,01
$762,00
$793,77
$906,63 		$169,95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$444,32
$504,30
$567,84
$793,56
$1 205,88 		$614,27
$674,25
$737,79
$963,51 		$784,22
$844,20
$907,74
$1 133,46 		$954,17
$1 014,15
$1 077,69
$1 303,41 		$169,95
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
$6,950 $13,900 Annual Deductible
$6,950 $13,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301,31
$341,99
$385,07
$538,14
$817,76 		$531,81
$572,49
$615,57
$768,64 		$762,31
$802,99
$846,07
$999,14 		$992,81
$1 033,49
$1 076,57
$1 229,64 		$230,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602,62
$683,98
$770,14
$1 076,28
$1 635,52 		$833,12
$914,48
$1 000,64
$1 306,78 		$1 063,62
$1 144,98
$1 231,14
$1 537,28 		$1 294,12
$1 375,48
$1 461,64
$1 767,78 		$230,50
Toc - Plan #3 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Silver

(PPO) Blue Cross¨ Premier PPO Silver

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,500 $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 		$407,24
$462,22
$520,45
$727,33
$1 105,25 		$718,78
$773,76
$831,99
$1 038,87 		$1 030,32
$1 085,30
$1 143,53
$1 350,41 		$1 341,86
$1 396,84
$1 455,07
$1 661,95 		$311,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814,48
$924,44
$1 040,90
$1 454,66
$2 210,50 		$1 126,02
$1 235,98
$1 352,44
$1 766,20 		$1 437,56
$1 547,52
$1 663,98
$2 077,74 		$1 749,10
$1 859,06
$1 975,52
$2 389,28 		$311,54
Toc - Plan #4 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Gold

(PPO) Blue Cross¨ Premier PPO Gold

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

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$509,00
$577,72
$650,50
$909,07
$1 381,43 		$898,39
$967,11
$1 039,89
$1 298,46 		$1 287,78
$1 356,50
$1 429,28
$1 687,85 		$1 677,17
$1 745,89
$1 818,67
$2 077,24 		$389,39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 018,00
$1 155,44
$1 301,00
$1 818,14
$2 762,86 		$1 407,39
$1 544,83
$1 690,39
$2 207,53 		$1 796,78
$1 934,22
$2 079,78
$2 596,92 		$2 186,17
$2 323,61
$2 469,17
$2 986,31 		$389,39
Toc - Plan #5 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Bronze

(PPO) Blue Cross¨ Premier PPO Bronze Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279,71
$317,47
$357,47
$499,56
$759,13 		$493,69
$531,45
$571,45
$713,54 		$707,67
$745,43
$785,43
$927,52 		$921,65
$959,41
$999,41
$1 141,50 		$213,98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559,42
$634,94
$714,94
$999,12
$1 518,26 		$773,40
$848,92
$928,92
$1 213,10 		$987,38
$1 062,90
$1 142,90
$1 427,08 		$1 201,36
$1 276,88
$1 356,88
$1 641,06 		$213,98
Toc - Plan #6 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Silver

(PPO) Blue Cross¨ Premier PPO Silver Saver HSA

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,950 $13,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$390,20
$442,88
$498,68
$696,90
$1 059,00 		$688,70
$741,38
$797,18
$995,40 		$987,20
$1 039,88
$1 095,68
$1 293,90 		$1 285,70
$1 338,38
$1 394,18
$1 592,40 		$298,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780,40
$885,76
$997,36
$1 393,80
$2 118,00 		$1 078,90
$1 184,26
$1 295,86
$1 692,30 		$1 377,40
$1 482,76
$1 594,36
$1 990,80 		$1 675,90
$1 781,26
$1 892,86
$2 289,30 		$298,50
Toc - Plan #7 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Expanded Bronze

(PPO) Blue Cross¨ Premier PPO Bronze Extra

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,500 $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 		$308,66
$350,33
$394,47
$551,27
$837,70 		$544,78
$586,45
$630,59
$787,39 		$780,90
$822,57
$866,71
$1 023,51 		$1 017,02
$1 058,69
$1 102,83
$1 259,63 		$236,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617,32
$700,66
$788,94
$1 102,54
$1 675,40 		$853,44
$936,78
$1 025,06
$1 338,66 		$1 089,56
$1 172,90
$1 261,18
$1 574,78 		$1 325,68
$1 409,02
$1 497,30
$1 810,90 		$236,12
Toc - Plan #8 Blue Cross Blue Shield of Michigan Mutual Insurance Company
Silver

(PPO) Blue Cross¨ Premier PPO Silver Extra

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

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$8,500 $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 		$445,56
$505,71
$569,43
$795,77
$1 209,25 		$786,41
$846,56
$910,28
$1 136,62 		$1 127,26
$1 187,41
$1 251,13
$1 477,47 		$1 468,11
$1 528,26
$1 591,98
$1 818,32 		$340,85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$891,12
$1 011,42
$1 138,86
$1 591,54
$2 418,50 		$1 231,97
$1 352,27
$1 479,71
$1 932,39 		$1 572,82
$1 693,12
$1 820,56
$2 273,24 		$1 913,67
$2 033,97
$2 161,41
$2 614,09 		$340,85

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Priority Health

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

(HMO) MyPriority HMO Gold 1100

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

Annual Out of Pocket Expenses:

Individual Family
$1,100 $2,200 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383,07
$434,78
$489,56
$684,16
$1 039,65 		$676,12
$727,83
$782,61
$977,21 		$969,17
$1 020,88
$1 075,66
$1 270,26 		$1 262,22
$1 313,93
$1 368,71
$1 563,31 		$293,05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766,14
$869,56
$979,12
$1 368,32
$2 079,30 		$1 059,19
$1 162,61
$1 272,17
$1 661,37 		$1 352,24
$1 455,66
$1 565,22
$1 954,42 		$1 645,29
$1 748,71
$1 858,27
$2 247,47 		$293,05
Toc - Plan #10 Priority Health
Expanded Bronze

(HMO) MyPriority HMO HSA Bronze 7000

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

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 		$216,23
$245,42
$276,34
$386,19
$586,85 		$381,65
$410,84
$441,76
$551,61 		$547,07
$576,26
$607,18
$717,03 		$712,49
$741,68
$772,60
$882,45 		$165,42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$432,46
$490,84
$552,68
$772,38
$1 173,70 		$597,88
$656,26
$718,10
$937,80 		$763,30
$821,68
$883,52
$1 103,22 		$928,72
$987,10
$1 048,94
$1 268,64 		$165,42
Toc - Plan #11 Priority Health
Expanded Bronze

(HMO) MyPriority HMO HSA Bronze 7000 - Beaumont Health Network

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

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 		$194,60
$220,87
$248,70
$347,56
$528,14 		$343,47
$369,74
$397,57
$496,43 		$492,34
$518,61
$546,44
$645,30 		$641,21
$667,48
$695,31
$794,17 		$148,87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$389,20
$441,74
$497,40
$695,12
$1 056,28 		$538,07
$590,61
$646,27
$843,99 		$686,94
$739,48
$795,14
$992,86 		$835,81
$888,35
$944,01
$1 141,73 		$148,87
Toc - Plan #12 Priority Health
Expanded Bronze

(HMO) MyPriority HMO HSA Bronze 7000 - St. John Providence Network

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $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 		$187,69
$213,03
$239,87
$335,21
$509,39 		$331,27
$356,61
$383,45
$478,79 		$474,85
$500,19
$527,03
$622,37 		$618,43
$643,77
$670,61
$765,95 		$143,58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$375,38
$426,06
$479,74
$670,42
$1 018,78 		$518,96
$569,64
$623,32
$814,00 		$662,54
$713,22
$766,90
$957,58 		$806,12
$856,80
$910,48
$1 101,16 		$143,58
Toc - Plan #13 Priority Health
Expanded Bronze

(HMO) MyPriority HMO HSA Bronze 7000 - St. Joseph Mercy Health System Network

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $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 		$195,04
$221,37
$249,26
$348,34
$529,34 		$344,25
$370,58
$398,47
$497,55 		$493,46
$519,79
$547,68
$646,76 		$642,67
$669,00
$696,89
$795,97 		$149,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$390,08
$442,74
$498,52
$696,68
$1 058,68 		$539,29
$591,95
$647,73
$845,89 		$688,50
$741,16
$796,94
$995,10 		$837,71
$890,37
$946,15
$1 144,31 		$149,21
Toc - Plan #14 Priority Health
Expanded Bronze

(HMO) MyPriority HMO Bronze 8550

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$208,06
$236,15
$265,90
$371,60
$564,67 		$367,23
$395,32
$425,07
$530,77 		$526,40
$554,49
$584,24
$689,94 		$685,57
$713,66
$743,41
$849,11 		$159,17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$416,12
$472,30
$531,80
$743,20
$1 129,34 		$575,29
$631,47
$690,97
$902,37 		$734,46
$790,64
$850,14
$1 061,54 		$893,63
$949,81
$1 009,31
$1 220,71 		$159,17
Toc - Plan #15 Priority Health
Expanded Bronze

(HMO) MyPriority HMO Bronze 8550 - Beaumont Health Network

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$187,25
$212,53
$239,31
$334,43
$508,20 		$330,50
$355,78
$382,56
$477,68 		$473,75
$499,03
$525,81
$620,93 		$617,00
$642,28
$669,06
$764,18 		$143,25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$374,50
$425,06
$478,62
$668,86
$1 016,40 		$517,75
$568,31
$621,87
$812,11 		$661,00
$711,56
$765,12
$955,36 		$804,25
$854,81
$908,37
$1 098,61 		$143,25
Toc - Plan #16 Priority Health
Expanded Bronze

(HMO) MyPriority HMO Bronze 8550 - St. John Providence Network

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$180,59
$204,97
$230,79
$322,53
$490,12 		$318,74
$343,12
$368,94
$460,68 		$456,89
$481,27
$507,09
$598,83 		$595,04
$619,42
$645,24
$736,98 		$138,15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$361,18
$409,94
$461,58
$645,06
$980,24 		$499,33
$548,09
$599,73
$783,21 		$637,48
$686,24
$737,88
$921,36 		$775,63
$824,39
$876,03
$1 059,51 		$138,15
Toc - Plan #17 Priority Health
Expanded Bronze

(HMO) MyPriority HMO Bronze 8550 - St. Joseph Mercy Health System Network

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$187,66
$212,99
$239,83
$335,16
$509,31 		$331,22
$356,55
$383,39
$478,72 		$474,78
$500,11
$526,95
$622,28 		$618,34
$643,67
$670,51
$765,84 		$143,56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$375,32
$425,98
$479,66
$670,32
$1 018,62 		$518,88
$569,54
$623,22
$813,88 		$662,44
$713,10
$766,78
$957,44 		$806,00
$856,66
$910,34
$1 101,00 		$143,56
Toc - Plan #18 Priority Health
Expanded Bronze

(HMO) MyPriority HMO Bronze 8550 - Telehealth PCP

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$195,56
$221,96
$249,93
$349,27
$530,75 		$345,16
$371,56
$399,53
$498,87 		$494,76
$521,16
$549,13
$648,47 		$644,36
$670,76
$698,73
$798,07 		$149,60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$391,12
$443,92
$499,86
$698,54
$1 061,50 		$540,72
$593,52
$649,46
$848,14 		$690,32
$743,12
$799,06
$997,74 		$839,92
$892,72
$948,66
$1 147,34 		$149,60
Toc - Plan #19 Priority Health
Silver

(HMO) MyPriority HMO Silver 3400

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

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 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 		$288,24
$327,15
$368,37
$514,80
$782,28 		$508,74
$547,65
$588,87
$735,30 		$729,24
$768,15
$809,37
$955,80 		$949,74
$988,65
$1 029,87
$1 176,30 		$220,50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576,48
$654,30
$736,74
$1 029,60
$1 564,56 		$796,98
$874,80
$957,24
$1 250,10 		$1 017,48
$1 095,30
$1 177,74
$1 470,60 		$1 237,98
$1 315,80
$1 398,24
$1 691,10 		$220,50
Toc - Plan #20 Priority Health
Silver

(HMO) MyPriority HMO Silver 3400 - Beaumont Health Network

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

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 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 		$259,41
$294,43
$331,53
$463,31
$704,04 		$457,86
$492,88
$529,98
$661,76 		$656,31
$691,33
$728,43
$860,21 		$854,76
$889,78
$926,88
$1 058,66 		$198,45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$518,82
$588,86
$663,06
$926,62
$1 408,08 		$717,27
$787,31
$861,51
$1 125,07 		$915,72
$985,76
$1 059,96
$1 323,52 		$1 114,17
$1 184,21
$1 258,41
$1 521,97 		$198,45
Toc - Plan #21 Priority Health
Silver

(HMO) MyPriority HMO Silver 3400 - St. John Providence Network

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

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 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 		$250,19
$283,97
$319,74
$446,84
$679,02 		$441,59
$475,37
$511,14
$638,24 		$632,99
$666,77
$702,54
$829,64 		$824,39
$858,17
$893,94
$1 021,04 		$191,40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$500,38
$567,94
$639,48
$893,68
$1 358,04 		$691,78
$759,34
$830,88
$1 085,08 		$883,18
$950,74
$1 022,28
$1 276,48 		$1 074,58
$1 142,14
$1 213,68
$1 467,88 		$191,40
Toc - Plan #22 Priority Health
Silver

(HMO) MyPriority HMO Silver 3400 - St. Joseph Mercy Health System Network

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

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 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 		$259,99
$295,09
$332,27
$464,34
$705,61 		$458,88
$493,98
$531,16
$663,23 		$657,77
$692,87
$730,05
$862,12 		$856,66
$891,76
$928,94
$1 061,01 		$198,89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519,98
$590,18
$664,54
$928,68
$1 411,22 		$718,87
$789,07
$863,43
$1 127,57 		$917,76
$987,96
$1 062,32
$1 326,46 		$1 116,65
$1 186,85
$1 261,21
$1 525,35 		$198,89
Toc - Plan #23 Priority Health
Silver

(HMO) MyPriority HMO Silver 2400 50+

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

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 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 		$301,13
$341,78
$384,84
$537,82
$817,27 		$531,49
$572,14
$615,20
$768,18 		$761,85
$802,50
$845,56
$998,54 		$992,21
$1 032,86
$1 075,92
$1 228,90 		$230,36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602,26
$683,56
$769,68
$1 075,64
$1 634,54 		$832,62
$913,92
$1 000,04
$1 306,00 		$1 062,98
$1 144,28
$1 230,40
$1 536,36 		$1 293,34
$1 374,64
$1 460,76
$1 766,72 		$230,36
Toc - Plan #24 Priority Health
Silver

(HMO) MyPriority HMO Silver 2400 50+ - Beaumont Health Network

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

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 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 		$271,02
$307,61
$346,36
$484,04
$735,55 		$478,35
$514,94
$553,69
$691,37 		$685,68
$722,27
$761,02
$898,70 		$893,01
$929,60
$968,35
$1 106,03 		$207,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$542,04
$615,22
$692,72
$968,08
$1 471,10 		$749,37
$822,55
$900,05
$1 175,41 		$956,70
$1 029,88
$1 107,38
$1 382,74 		$1 164,03
$1 237,21
$1 314,71
$1 590,07 		$207,33
Toc - Plan #25 Priority Health
Silver

(HMO) MyPriority HMO Silver 2400 50+ - St. John Providence Network

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

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 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 		$261,38
$296,67
$334,04
$466,82
$709,39 		$461,34
$496,63
$534,00
$666,78 		$661,30
$696,59
$733,96
$866,74 		$861,26
$896,55
$933,92
$1 066,70 		$199,96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$522,76
$593,34
$668,08
$933,64
$1 418,78 		$722,72
$793,30
$868,04
$1 133,60 		$922,68
$993,26
$1 068,00
$1 333,56 		$1 122,64
$1 193,22
$1 267,96
$1 533,52 		$199,96
Toc - Plan #26 Priority Health
Silver

(HMO) MyPriority HMO Silver 2400 50+ - St. Joseph Mercy Health System Network

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

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 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 		$271,62
$308,29
$347,13
$485,11
$737,18 		$479,41
$516,08
$554,92
$692,90 		$687,20
$723,87
$762,71
$900,69 		$894,99
$931,66
$970,50
$1 108,48 		$207,79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543,24
$616,58
$694,26
$970,22
$1 474,36 		$751,03
$824,37
$902,05
$1 178,01 		$958,82
$1 032,16
$1 109,84
$1 385,80 		$1 166,61
$1 239,95
$1 317,63
$1 593,59 		$207,79
Toc - Plan #27 Priority Health
Silver

(HMO) MyPriority HMO Silver 5500

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,550 $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 		$274,68
$311,76
$351,04
$490,58
$745,48 		$484,81
$521,89
$561,17
$700,71 		$694,94
$732,02
$771,30
$910,84 		$905,07
$942,15
$981,43
$1 120,97 		$210,13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549,36
$623,52
$702,08
$981,16
$1 490,96 		$759,49
$833,65
$912,21
$1 191,29 		$969,62
$1 043,78
$1 122,34
$1 401,42 		$1 179,75
$1 253,91
$1 332,47
$1 611,55 		$210,13
Toc - Plan #28 Priority Health
Silver

(HMO) MyPriority HMO Silver 5500 - Beaumont Health Network

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,550 $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 		$247,21
$280,58
$315,93
$441,52
$670,93 		$436,33
$469,70
$505,05
$630,64 		$625,45
$658,82
$694,17
$819,76 		$814,57
$847,94
$883,29
$1 008,88 		$189,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494,42
$561,16
$631,86
$883,04
$1 341,86 		$683,54
$750,28
$820,98
$1 072,16 		$872,66
$939,40
$1 010,10
$1 261,28 		$1 061,78
$1 128,52
$1 199,22
$1 450,40 		$189,12
Toc - Plan #29 Priority Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$238,42
$270,61
$304,70
$425,82
$647,07 		$420,81
$453,00
$487,09
$608,21 		$603,20
$635,39
$669,48
$790,60 		$785,59
$817,78
$851,87
$972,99 		$182,39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$476,84
$541,22
$609,40
$851,64
$1 294,14 		$659,23
$723,61
$791,79
$1 034,03 		$841,62
$906,00
$974,18
$1 216,42 		$1 024,01
$1 088,39
$1 156,57
$1 398,81 		$182,39
Toc - Plan #30 Priority Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,550 $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 		$247,76
$281,21
$316,64
$442,50
$672,42 		$437,30
$470,75
$506,18
$632,04 		$626,84
$660,29
$695,72
$821,58 		$816,38
$849,83
$885,26
$1 011,12 		$189,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$495,52
$562,42
$633,28
$885,00
$1 344,84 		$685,06
$751,96
$822,82
$1 074,54 		$874,60
$941,50
$1 012,36
$1 264,08 		$1 064,14
$1 131,04
$1 201,90
$1 453,62 		$189,54
Toc - Plan #31 Priority Health
Silver

(HMO) MyPriority HMO Silver 5500 - Telehealth PCP

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,550 $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 		$258,19
$293,05
$329,97
$461,13
$700,73 		$455,71
$490,57
$527,49
$658,65 		$653,23
$688,09
$725,01
$856,17 		$850,75
$885,61
$922,53
$1 053,69 		$197,52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$516,38
$586,10
$659,94
$922,26
$1 401,46 		$713,90
$783,62
$857,46
$1 119,78 		$911,42
$981,14
$1 054,98
$1 317,30 		$1 108,94
$1 178,66
$1 252,50
$1 514,82 		$197,52
Toc - Plan #32 Priority Health
Gold

(HMO) MyPriority HMO Gold Copay+ - Beaumont Health Network

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $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 		$343,54
$389,92
$439,04
$613,56
$932,37 		$606,35
$652,73
$701,85
$876,37 		$869,16
$915,54
$964,66
$1 139,18 		$1 131,97
$1 178,35
$1 227,47
$1 401,99 		$262,81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687,08
$779,84
$878,08
$1 227,12
$1 864,74 		$949,89
$1 042,65
$1 140,89
$1 489,93 		$1 212,70
$1 305,46
$1 403,70
$1 752,74 		$1 475,51
$1 568,27
$1 666,51
$2 015,55 		$262,81
Toc - Plan #33 Priority Health
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $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 		$331,32
$376,05
$423,43
$591,74
$899,20 		$584,78
$629,51
$676,89
$845,20 		$838,24
$882,97
$930,35
$1 098,66 		$1 091,70
$1 136,43
$1 183,81
$1 352,12 		$253,46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662,64
$752,10
$846,86
$1 183,48
$1 798,40 		$916,10
$1 005,56
$1 100,32
$1 436,94 		$1 169,56
$1 259,02
$1 353,78
$1 690,40 		$1 423,02
$1 512,48
$1 607,24
$1 943,86 		$253,46
Toc - Plan #34 Priority Health
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $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 		$344,30
$390,78
$440,02
$614,92
$934,43 		$607,69
$654,17
$703,41
$878,31 		$871,08
$917,56
$966,80
$1 141,70 		$1 134,47
$1 180,95
$1 230,19
$1 405,09 		$263,39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688,60
$781,56
$880,04
$1 229,84
$1 868,86 		$951,99
$1 044,95
$1 143,43
$1 493,23 		$1 215,38
$1 308,34
$1 406,82
$1 756,62 		$1 478,77
$1 571,73
$1 670,21
$2 020,01 		$263,39

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-4087 | Toll Free: 1-888-560-4087 | TTY: 1-888-665-4629
Toc - Plan #35 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

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

Annual Out of Pocket Expenses:

Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282,62
$320,78
$361,19
$504,76
$767,04 		$498,83
$536,99
$577,40
$720,97 		$715,04
$753,20
$793,61
$937,18 		$931,25
$969,41
$1 009,82
$1 153,39 		$216,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565,24
$641,56
$722,38
$1 009,52
$1 534,08 		$781,45
$857,77
$938,59
$1 225,73 		$997,66
$1 073,98
$1 154,80
$1 441,94 		$1 213,87
$1 290,19
$1 371,01
$1 658,15 		$216,21
Toc - Plan #36 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$252,75
$286,88
$323,02
$451,42
$685,98 		$446,11
$480,24
$516,38
$644,78 		$639,47
$673,60
$709,74
$838,14 		$832,83
$866,96
$903,10
$1 031,50 		$193,36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$505,50
$573,76
$646,04
$902,84
$1 371,96 		$698,86
$767,12
$839,40
$1 096,20 		$892,22
$960,48
$1 032,76
$1 289,56 		$1 085,58
$1 153,84
$1 226,12
$1 482,92 		$193,36
Toc - Plan #37 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$210,02
$238,37
$268,41
$375,10
$570,00 		$370,69
$399,04
$429,08
$535,77 		$531,36
$559,71
$589,75
$696,44 		$692,03
$720,38
$750,42
$857,11 		$160,67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$420,04
$476,74
$536,82
$750,20
$1 140,00 		$580,71
$637,41
$697,49
$910,87 		$741,38
$798,08
$858,16
$1 071,54 		$902,05
$958,75
$1 018,83
$1 232,21 		$160,67
Toc - Plan #38 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

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

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$250,21
$283,98
$319,76
$446,87
$679,06 		$441,62
$475,39
$511,17
$638,28 		$633,03
$666,80
$702,58
$829,69 		$824,44
$858,21
$893,99
$1 021,10 		$191,41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$500,42
$567,96
$639,52
$893,74
$1 358,12 		$691,83
$759,37
$830,93
$1 085,15 		$883,24
$950,78
$1 022,34
$1 276,56 		$1 074,65
$1 142,19
$1 213,75
$1 467,97 		$191,41
Toc - Plan #39 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$219,84
$249,52
$280,96
$392,64
$596,66 		$388,02
$417,70
$449,14
$560,82 		$556,20
$585,88
$617,32
$729,00 		$724,38
$754,06
$785,50
$897,18 		$168,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$439,68
$499,04
$561,92
$785,28
$1 193,32 		$607,86
$667,22
$730,10
$953,46 		$776,04
$835,40
$898,28
$1 121,64 		$944,22
$1 003,58
$1 066,46
$1 289,82 		$168,18
Toc - Plan #40 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 5

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$213,84
$242,71
$273,29
$381,92
$580,36 		$377,43
$406,30
$436,88
$545,51 		$541,02
$569,89
$600,47
$709,10 		$704,61
$733,48
$764,06
$872,69 		$163,59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$427,68
$485,42
$546,58
$763,84
$1 160,72 		$591,27
$649,01
$710,17
$927,43 		$754,86
$812,60
$873,76
$1 091,02 		$918,45
$976,19
$1 037,35
$1 254,61 		$163,59
Toc - Plan #41 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$2,925 $5,850 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$286,06
$324,68
$365,59
$510,91
$776,37 		$504,90
$543,52
$584,43
$729,75 		$723,74
$762,36
$803,27
$948,59 		$942,58
$981,20
$1 022,11
$1 167,43 		$218,84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572,12
$649,36
$731,18
$1 021,82
$1 552,74 		$790,96
$868,20
$950,02
$1 240,66 		$1 009,80
$1 087,04
$1 168,86
$1 459,50 		$1 228,64
$1 305,88
$1 387,70
$1 678,34 		$218,84
Toc - Plan #42 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$256,19
$290,78
$327,42
$457,56
$695,31 		$452,18
$486,77
$523,41
$653,55 		$648,17
$682,76
$719,40
$849,54 		$844,16
$878,75
$915,39
$1 045,53 		$195,99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$512,38
$581,56
$654,84
$915,12
$1 390,62 		$708,37
$777,55
$850,83
$1 111,11 		$904,36
$973,54
$1 046,82
$1 307,10 		$1 100,35
$1 169,53
$1 242,81
$1 503,09 		$195,99
Toc - Plan #43 Molina Healthcare
Bronze

(HMO) Core Care Bronze 1 + Vision

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$213,46
$242,28
$272,80
$381,24
$579,33 		$376,76
$405,58
$436,10
$544,54 		$540,06
$568,88
$599,40
$707,84 		$703,36
$732,18
$762,70
$871,14 		$163,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$426,92
$484,56
$545,60
$762,48
$1 158,66 		$590,22
$647,86
$708,90
$925,78 		$753,52
$811,16
$872,20
$1 089,08 		$916,82
$974,46
$1 035,50
$1 252,38 		$163,30
Toc - Plan #44 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

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

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$252,52
$286,62
$322,73
$451,01
$685,35 		$445,70
$479,80
$515,91
$644,19 		$638,88
$672,98
$709,09
$837,37 		$832,06
$866,16
$902,27
$1 030,55 		$193,18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$505,04
$573,24
$645,46
$902,02
$1 370,70 		$698,22
$766,42
$838,64
$1 095,20 		$891,40
$959,60
$1 031,82
$1 288,38 		$1 084,58
$1 152,78
$1 225,00
$1 481,56 		$193,18
Toc - Plan #45 Molina Healthcare
Bronze

(HMO) Core Care Bronze 2

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$208,19
$236,30
$266,07
$371,83
$565,04 		$367,46
$395,57
$425,34
$531,10 		$526,73
$554,84
$584,61
$690,37 		$686,00
$714,11
$743,88
$849,64 		$159,27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$416,38
$472,60
$532,14
$743,66
$1 130,08 		$575,65
$631,87
$691,41
$902,93 		$734,92
$791,14
$850,68
$1 062,20 		$894,19
$950,41
$1 009,95
$1 221,47 		$159,27

ADVERTISEMENT

Ambetter from Meridian

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

Toc - Plan #46 Ambetter from Meridian
Bronze

(HMO) Ambetter Essential Care 1 (2021)

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
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$190,56
$216,27
$243,52
$340,32
$517,14 		$336,33
$362,04
$389,29
$486,09 		$482,10
$507,81
$535,06
$631,86 		$627,87
$653,58
$680,83
$777,63 		$145,77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$381,12
$432,54
$487,04
$680,64
$1 034,28 		$526,89
$578,31
$632,81
$826,41 		$672,66
$724,08
$778,58
$972,18 		$818,43
$869,85
$924,35
$1 117,95 		$145,77
Toc - Plan #47 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA (2021)

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 		$205,58
$233,32
$262,71
$367,14
$557,90 		$362,84
$390,58
$419,97
$524,40 		$520,10
$547,84
$577,23
$681,66 		$677,36
$705,10
$734,49
$838,92 		$157,26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$411,16
$466,64
$525,42
$734,28
$1 115,80 		$568,42
$623,90
$682,68
$891,54 		$725,68
$781,16
$839,94
$1 048,80 		$882,94
$938,42
$997,20
$1 206,06 		$157,26
Toc - Plan #48 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 25 HSA (2021)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$262,37
$297,77
$335,29
$468,57
$712,04 		$463,07
$498,47
$535,99
$669,27 		$663,77
$699,17
$736,69
$869,97 		$864,47
$899,87
$937,39
$1 070,67 		$200,70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524,74
$595,54
$670,58
$937,14
$1 424,08 		$725,44
$796,24
$871,28
$1 137,84 		$926,14
$996,94
$1 071,98
$1 338,54 		$1 126,84
$1 197,64
$1 272,68
$1 539,24 		$200,70
Toc - Plan #49 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 11 (2021)

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 		$253,76
$288,00
$324,29
$453,19
$688,67 		$447,88
$482,12
$518,41
$647,31 		$642,00
$676,24
$712,53
$841,43 		$836,12
$870,36
$906,65
$1 035,55 		$194,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$507,52
$576,00
$648,58
$906,38
$1 377,34 		$701,64
$770,12
$842,70
$1 100,50 		$895,76
$964,24
$1 036,82
$1 294,62 		$1 089,88
$1 158,36
$1 230,94
$1 488,74 		$194,12
Toc - Plan #50 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 12 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$249,44
$283,11
$318,78
$445,49
$676,96 		$440,26
$473,93
$509,60
$636,31 		$631,08
$664,75
$700,42
$827,13 		$821,90
$855,57
$891,24
$1 017,95 		$190,82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$498,88
$566,22
$637,56
$890,98
$1 353,92 		$689,70
$757,04
$828,38
$1 081,80 		$880,52
$947,86
$1 019,20
$1 272,62 		$1 071,34
$1 138,68
$1 210,02
$1 463,44 		$190,82
Toc - Plan #51 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 21 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$252,45
$286,52
$322,62
$450,87
$685,13 		$445,57
$479,64
$515,74
$643,99 		$638,69
$672,76
$708,86
$837,11 		$831,81
$865,88
$901,98
$1 030,23 		$193,12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504,90
$573,04
$645,24
$901,74
$1 370,26 		$698,02
$766,16
$838,36
$1 094,86 		$891,14
$959,28
$1 031,48
$1 287,98 		$1 084,26
$1 152,40
$1 224,60
$1 481,10 		$193,12
Toc - Plan #52 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 22 (2021)

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
$7,900 $15,800 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 		$255,28
$289,73
$326,23
$455,91
$692,79 		$450,56
$485,01
$521,51
$651,19 		$645,84
$680,29
$716,79
$846,47 		$841,12
$875,57
$912,07
$1 041,75 		$195,28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$510,56
$579,46
$652,46
$911,82
$1 385,58 		$705,84
$774,74
$847,74
$1 107,10 		$901,12
$970,02
$1 043,02
$1 302,38 		$1 096,40
$1 165,30
$1 238,30
$1 497,66 		$195,28
Toc - Plan #53 Ambetter from Meridian
Gold

(HMO) Ambetter Secure Care 5 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$262,19
$297,57
$335,06
$468,25
$711,55 		$462,76
$498,14
$535,63
$668,82 		$663,33
$698,71
$736,20
$869,39 		$863,90
$899,28
$936,77
$1 069,96 		$200,57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524,38
$595,14
$670,12
$936,50
$1 423,10 		$724,95
$795,71
$870,69
$1 137,07 		$925,52
$996,28
$1 071,26
$1 337,64 		$1 126,09
$1 196,85
$1 271,83
$1 538,21 		$200,57
Toc - Plan #54 Ambetter from Meridian
Gold

(HMO) Ambetter Base Gold (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$256,12
$290,68
$327,31
$457,41
$695,07 		$452,04
$486,60
$523,23
$653,33 		$647,96
$682,52
$719,15
$849,25 		$843,88
$878,44
$915,07
$1 045,17 		$195,92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$512,24
$581,36
$654,62
$914,82
$1 390,14 		$708,16
$777,28
$850,54
$1 110,74 		$904,08
$973,20
$1 046,46
$1 306,66 		$1 100,00
$1 169,12
$1 242,38
$1 502,58 		$195,92
Toc - Plan #55 Ambetter from Meridian
Bronze

(HMO) Ambetter Essential Care 1 (2021) + 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
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$217,81
$247,20
$278,35
$388,99
$591,11 		$384,43
$413,82
$444,97
$555,61 		$551,05
$580,44
$611,59
$722,23 		$717,67
$747,06
$778,21
$888,85 		$166,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$435,62
$494,40
$556,70
$777,98
$1 182,22 		$602,24
$661,02
$723,32
$944,60 		$768,86
$827,64
$889,94
$1 111,22 		$935,48
$994,26
$1 056,56
$1 277,84 		$166,62
Toc - Plan #56 Ambetter from Meridian
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA (2021) + 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 		$232,84
$264,26
$297,55
$415,83
$631,90 		$410,95
$442,37
$475,66
$593,94 		$589,06
$620,48
$653,77
$772,05 		$767,17
$798,59
$831,88
$950,16 		$178,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$465,68
$528,52
$595,10
$831,66
$1 263,80 		$643,79
$706,63
$773,21
$1 009,77 		$821,90
$884,74
$951,32
$1 187,88 		$1 000,01
$1 062,85
$1 129,43
$1 365,99 		$178,11
Toc - Plan #57 Ambetter from Meridian
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$287,60
$326,41
$367,54
$513,64
$780,52 		$507,61
$546,42
$587,55
$733,65 		$727,62
$766,43
$807,56
$953,66 		$947,63
$986,44
$1 027,57
$1 173,67 		$220,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575,20
$652,82
$735,08
$1 027,28
$1 561,04 		$795,21
$872,83
$955,09
$1 247,29 		$1 015,22
$1 092,84
$1 175,10
$1 467,30 		$1 235,23
$1 312,85
$1 395,11
$1 687,31 		$220,01
Toc - Plan #58 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 11 (2021) + 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 		$279,00
$316,65
$356,55
$498,28
$757,18 		$492,43
$530,08
$569,98
$711,71 		$705,86
$743,51
$783,41
$925,14 		$919,29
$956,94
$996,84
$1 138,57 		$213,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558,00
$633,30
$713,10
$996,56
$1 514,36 		$771,43
$846,73
$926,53
$1 209,99 		$984,86
$1 060,16
$1 139,96
$1 423,42 		$1 198,29
$1 273,59
$1 353,39
$1 636,85 		$213,43
Toc - Plan #59 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 21 (2021) + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$277,70
$315,17
$354,88
$495,95
$753,64 		$490,13
$527,60
$567,31
$708,38 		$702,56
$740,03
$779,74
$920,81 		$914,99
$952,46
$992,17
$1 133,24 		$212,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555,40
$630,34
$709,76
$991,90
$1 507,28 		$767,83
$842,77
$922,19
$1 204,33 		$980,26
$1 055,20
$1 134,62
$1 416,76 		$1 192,69
$1 267,63
$1 347,05
$1 629,19 		$212,43
Toc - Plan #60 Ambetter from Meridian
Silver

(HMO) Ambetter Balanced Care 22 (2021) + 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
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$280,51
$318,37
$358,48
$500,97
$761,28 		$495,09
$532,95
$573,06
$715,55 		$709,67
$747,53
$787,64
$930,13 		$924,25
$962,11
$1 002,22
$1 144,71 		$214,58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561,02
$636,74
$716,96
$1 001,94
$1 522,56 		$775,60
$851,32
$931,54
$1 216,52 		$990,18
$1 065,90
$1 146,12
$1 431,10 		$1 204,76
$1 280,48
$1 360,70
$1 645,68 		$214,58
Toc - Plan #61 Ambetter from Meridian
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$287,43
$326,22
$367,32
$513,33
$780,06 		$507,31
$546,10
$587,20
$733,21 		$727,19
$765,98
$807,08
$953,09 		$947,07
$985,86
$1 026,96
$1 172,97 		$219,88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574,86
$652,44
$734,64
$1 026,66
$1 560,12 		$794,74
$872,32
$954,52
$1 246,54 		$1 014,62
$1 092,20
$1 174,40
$1 466,42 		$1 234,50
$1 312,08
$1 394,28
$1 686,30 		$219,88

ADVERTISEMENT

Total Health Care USA, Inc.

Local: 1-313-871-2000x350 | Toll Free: 1-800-826-2862 | TTY: 1-800-649-3777
Toc - Plan #62 Total Health Care USA, Inc.
Gold

(HMO) Total HMO Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-826-2862

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 		$265,88
$301,77
$339,79
$474,86
$721,60 		$469,28
$505,17
$543,19
$678,26 		$672,68
$708,57
$746,59
$881,66 		$876,08
$911,97
$949,99
$1 085,06 		$203,40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$531,76
$603,54
$679,58
$949,72
$1 443,20 		$735,16
$806,94
$882,98
$1 153,12 		$938,56
$1 010,34
$1 086,38
$1 356,52 		$1 141,96
$1 213,74
$1 289,78
$1 559,92 		$203,40
Toc - Plan #63 Total Health Care USA, Inc.
Silver

(HMO) Totally You

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-826-2862

Annual Out of Pocket Expenses:

Individual Family
$4,450 $8,900 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 		$274,51
$311,57
$350,82
$490,27
$745,02 		$484,51
$521,57
$560,82
$700,27 		$694,51
$731,57
$770,82
$910,27 		$904,51
$941,57
$980,82
$1 120,27 		$210,00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549,02
$623,14
$701,64
$980,54
$1 490,04 		$759,02
$833,14
$911,64
$1 190,54 		$969,02
$1 043,14
$1 121,64
$1 400,54 		$1 179,02
$1 253,14
$1 331,64
$1 610,54 		$210,00
Toc - Plan #64 Total Health Care USA, Inc.
Expanded Bronze

(HMO) Total Saver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-826-2862

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$187,87
$213,23
$240,10
$335,54
$509,88 		$331,59
$356,95
$383,82
$479,26 		$475,31
$500,67
$527,54
$622,98 		$619,03
$644,39
$671,26
$766,70 		$143,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$375,74
$426,46
$480,20
$671,08
$1 019,76 		$519,46
$570,18
$623,92
$814,80 		$663,18
$713,90
$767,64
$958,52 		$806,90
$857,62
$911,36
$1 102,24 		$143,72
Toc - Plan #65 Total Health Care USA, Inc.
Expanded Bronze

(HMO) Total Saver Complete

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-826-2862

Annual Out of Pocket Expenses:

Individual Family
$7,850 $15,700 Annual Deductible
$7,850 $15,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$195,82
$222,26
$250,26
$349,73
$531,46 		$345,62
$372,06
$400,06
$499,53 		$495,42
$521,86
$549,86
$649,33 		$645,22
$671,66
$699,66
$799,13 		$149,80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$391,64
$444,52
$500,52
$699,46
$1 062,92 		$541,44
$594,32
$650,32
$849,26 		$691,24
$744,12
$800,12
$999,06 		$841,04
$893,92
$949,92
$1 148,86 		$149,80
Toc - Plan #66 Total Health Care USA, Inc.
Silver

(HMO) Totally You - Value

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-826-2862

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,900 $15,800 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 		$238,34
$270,52
$304,60
$425,68
$646,85 		$420,67
$452,85
$486,93
$608,01 		$603,00
$635,18
$669,26
$790,34 		$785,33
$817,51
$851,59
$972,67 		$182,33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$476,68
$541,04
$609,20
$851,36
$1 293,70 		$659,01
$723,37
$791,53
$1 033,69 		$841,34
$905,70
$973,86
$1 216,02 		$1 023,67
$1 088,03
$1 156,19
$1 398,35 		$182,33

ADVERTISEMENT

McLaren Health Plan Community

Local: 1-888-327-0671 | Toll Free: 1-888-327-0671 | TTY: 1-800-356-3232
Toc - Plan #67 McLaren Health Plan Community
Catastrophic

(HMO) McLaren Young Adult/Catastrophic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$190,12
$215,78
$242,97
$339,55
$515,98 		$335,56
$361,22
$388,41
$484,99 		$481,00
$506,66
$533,85
$630,43 		$626,44
$652,10
$679,29
$775,87 		$145,44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$380,24
$431,56
$485,94
$679,10
$1 031,96 		$525,68
$577,00
$631,38
$824,54 		$671,12
$722,44
$776,82
$969,98 		$816,56
$867,88
$922,26
$1 115,42 		$145,44
Toc - Plan #68 McLaren Health Plan Community
Silver

(HMO) McLaren Silver Exchange

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

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321,24
$364,61
$410,54
$573,73
$871,84 		$566,99
$610,36
$656,29
$819,48 		$812,74
$856,11
$902,04
$1 065,23 		$1 058,49
$1 101,86
$1 147,79
$1 310,98 		$245,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642,48
$729,22
$821,08
$1 147,46
$1 743,68 		$888,23
$974,97
$1 066,83
$1 393,21 		$1 133,98
$1 220,72
$1 312,58
$1 638,96 		$1 379,73
$1 466,47
$1 558,33
$1 884,71 		$245,75
Toc - Plan #69 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
$6,750 $13,500 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 		$308,99
$350,71
$394,89
$551,86
$838,61 		$545,37
$587,09
$631,27
$788,24 		$781,75
$823,47
$867,65
$1 024,62 		$1 018,13
$1 059,85
$1 104,03
$1 261,00 		$236,38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617,98
$701,42
$789,78
$1 103,72
$1 677,22 		$854,36
$937,80
$1 026,16
$1 340,10 		$1 090,74
$1 174,18
$1 262,54
$1 576,48 		$1 327,12
$1 410,56
$1 498,92
$1 812,86 		$236,38
Toc - Plan #70 McLaren Health Plan Community
Bronze

(HMO) McLaren Bronze 6500

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,500 $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 		$210,52
$238,93
$269,04
$375,98
$571,34 		$371,56
$399,97
$430,08
$537,02 		$532,60
$561,01
$591,12
$698,06 		$693,64
$722,05
$752,16
$859,10 		$161,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$421,04
$477,86
$538,08
$751,96
$1 142,68 		$582,08
$638,90
$699,12
$913,00 		$743,12
$799,94
$860,16
$1 074,04 		$904,16
$960,98
$1 021,20
$1 235,08 		$161,04
Toc - Plan #71 McLaren Health Plan Community
Expanded Bronze

(HMO) McLaren Bronze Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$219,14
$248,72
$280,06
$391,38
$594,74 		$386,78
$416,36
$447,70
$559,02 		$554,42
$584,00
$615,34
$726,66 		$722,06
$751,64
$782,98
$894,30 		$167,64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$438,28
$497,44
$560,12
$782,76
$1 189,48 		$605,92
$665,08
$727,76
$950,40 		$773,56
$832,72
$895,40
$1 118,04 		$941,20
$1 000,36
$1 063,04
$1 285,68 		$167,64

ADVERTISEMENT

Blue Care Network of Michigan

Local: 1-888-227-2345 | Toll Free: 1-888-227-2345 | TTY: 1-800-257-9980
Toc - Plan #72 Blue Care Network of Michigan
Catastrophic

(HMO) Blue Cross¨ Select HMO Value

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$156,22
$177,31
$199,65
$279,01
$423,98 		$275,73
$296,82
$319,16
$398,52 		$395,24
$416,33
$438,67
$518,03 		$514,75
$535,84
$558,18
$637,54 		$119,51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$312,44
$354,62
$399,30
$558,02
$847,96 		$431,95
$474,13
$518,81
$677,53 		$551,46
$593,64
$638,32
$797,04 		$670,97
$713,15
$757,83
$916,55 		$119,51
Toc - Plan #73 Blue Care Network of Michigan
Silver

(HMO) Blue Cross¨ Select HMO Silver

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$302,58
$343,43
$386,70
$540,41
$821,20 		$534,05
$574,90
$618,17
$771,88 		$765,52
$806,37
$849,64
$1 003,35 		$996,99
$1 037,84
$1 081,11
$1 234,82 		$231,47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605,16
$686,86
$773,40
$1 080,82
$1 642,40 		$836,63
$918,33
$1 004,87
$1 312,29 		$1 068,10
$1 149,80
$1 236,34
$1 543,76 		$1 299,57
$1 381,27
$1 467,81
$1 775,23 		$231,47
Toc - Plan #74 Blue Care Network of Michigan
Silver

(HMO) Blue Cross¨ Preferred HMO Silver

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$328,85
$373,24
$420,27
$587,33
$892,50 		$580,42
$624,81
$671,84
$838,90 		$831,99
$876,38
$923,41
$1 090,47 		$1 083,56
$1 127,95
$1 174,98
$1 342,04 		$251,57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657,70
$746,48
$840,54
$1 174,66
$1 785,00 		$909,27
$998,05
$1 092,11
$1 426,23 		$1 160,84
$1 249,62
$1 343,68
$1 677,80 		$1 412,41
$1 501,19
$1 595,25
$1 929,37 		$251,57
Toc - Plan #75 Blue Care Network of Michigan
Gold

(HMO) Blue Cross¨ Preferred HMO Gold

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

Annual Out of Pocket Expenses:

Individual Family
$850 $1,700 Annual Deductible
$8,500 $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 		$355,68
$403,70
$454,56
$635,24
$965,32 		$627,78
$675,80
$726,66
$907,34 		$899,88
$947,90
$998,76
$1 179,44 		$1 171,98
$1 220,00
$1 270,86
$1 451,54 		$272,10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711,36
$807,40
$909,12
$1 270,48
$1 930,64 		$983,46
$1 079,50
$1 181,22
$1 542,58 		$1 255,56
$1 351,60
$1 453,32
$1 814,68 		$1 527,66
$1 623,70
$1 725,42
$2 086,78 		$272,10
Toc - Plan #76 Blue Care Network of Michigan
Silver

(HMO) Blue Cross¨ Metro Detroit HMO Silver

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$280,44
$318,30
$358,40
$500,87
$761,11 		$494,98
$532,84
$572,94
$715,41 		$709,52
$747,38
$787,48
$929,95 		$924,06
$961,92
$1 002,02
$1 144,49 		$214,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560,88
$636,60
$716,80
$1 001,74
$1 522,22 		$775,42
$851,14
$931,34
$1 216,28 		$989,96
$1 065,68
$1 145,88
$1 430,82 		$1 204,50
$1 280,22
$1 360,42
$1 645,36 		$214,54
Toc - Plan #77 Blue Care Network of Michigan
Silver

(HMO) Blue Cross¨ Select HMO Silver Saver

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$7,500 $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 		$291,13
$330,43
$372,06
$519,96
$790,13 		$513,84
$553,14
$594,77
$742,67 		$736,55
$775,85
$817,48
$965,38 		$959,26
$998,56
$1 040,19
$1 188,09 		$222,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582,26
$660,86
$744,12
$1 039,92
$1 580,26 		$804,97
$883,57
$966,83
$1 262,63 		$1 027,68
$1 106,28
$1 189,54
$1 485,34 		$1 250,39
$1 328,99
$1 412,25
$1 708,05 		$222,71
Toc - Plan #78 Blue Care Network of Michigan
Silver

(HMO) Blue Cross¨ Metro Detroit HMO Silver Saver

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$7,500 $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 		$269,84
$306,27
$344,86
$481,93
$732,35 		$476,27
$512,70
$551,29
$688,36 		$682,70
$719,13
$757,72
$894,79 		$889,13
$925,56
$964,15
$1 101,22 		$206,43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539,68
$612,54
$689,72
$963,86
$1 464,70 		$746,11
$818,97
$896,15
$1 170,29 		$952,54
$1 025,40
$1 102,58
$1 376,72 		$1 158,97
$1 231,83
$1 309,01
$1 583,15 		$206,43
Toc - Plan #79 Blue Care Network of Michigan
Silver

(HMO) Blue Cross¨ Preferred HMO Silver Saver

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316,41
$359,13
$404,37
$565,11
$858,74 		$558,46
$601,18
$646,42
$807,16 		$800,51
$843,23
$888,47
$1 049,21 		$1 042,56
$1 085,28
$1 130,52
$1 291,26 		$242,05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632,82
$718,26
$808,74
$1 130,22
$1 717,48 		$874,87
$960,31
$1 050,79
$1 372,27 		$1 116,92
$1 202,36
$1 292,84
$1 614,32 		$1 358,97
$1 444,41
$1 534,89
$1 856,37 		$242,05
Toc - Plan #80 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross¨ Select HMO Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$196,80
$223,37
$251,51
$351,48
$534,12 		$347,35
$373,92
$402,06
$502,03 		$497,90
$524,47
$552,61
$652,58 		$648,45
$675,02
$703,16
$803,13 		$150,55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$393,60
$446,74
$503,02
$702,96
$1 068,24 		$544,15
$597,29
$653,57
$853,51 		$694,70
$747,84
$804,12
$1 004,06 		$845,25
$898,39
$954,67
$1 154,61 		$150,55
Toc - Plan #81 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross¨ Metro Detroit HMO Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$182,41
$207,04
$233,12
$325,78
$495,06 		$321,95
$346,58
$372,66
$465,32 		$461,49
$486,12
$512,20
$604,86 		$601,03
$625,66
$651,74
$744,40 		$139,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$364,82
$414,08
$466,24
$651,56
$990,12 		$504,36
$553,62
$605,78
$791,10 		$643,90
$693,16
$745,32
$930,64 		$783,44
$832,70
$884,86
$1 070,18 		$139,54
Toc - Plan #82 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
$6,950 $13,900 Annual Deductible
$6,950 $13,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$205,72
$233,49
$262,91
$367,42
$558,32 		$363,10
$390,87
$420,29
$524,80 		$520,48
$548,25
$577,67
$682,18 		$677,86
$705,63
$735,05
$839,56 		$157,38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$411,44
$466,98
$525,82
$734,84
$1 116,64 		$568,82
$624,36
$683,20
$892,22 		$726,20
$781,74
$840,58
$1 049,60 		$883,58
$939,12
$997,96
$1 206,98 		$157,38
Toc - Plan #83 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
$6,950 $13,900 Annual Deductible
$6,950 $13,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$190,68
$216,42
$243,69
$340,55
$517,51 		$336,55
$362,29
$389,56
$486,42 		$482,42
$508,16
$535,43
$632,29 		$628,29
$654,03
$681,30
$778,16 		$145,87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$381,36
$432,84
$487,38
$681,10
$1 035,02 		$527,23
$578,71
$633,25
$826,97 		$673,10
$724,58
$779,12
$972,84 		$818,97
$870,45
$924,99
$1 118,71 		$145,87
Toc - Plan #84 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
$6,950 $13,900 Annual Deductible
$6,950 $13,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$223,58
$253,76
$285,74
$399,31
$606,80 		$394,62
$424,80
$456,78
$570,35 		$565,66
$595,84
$627,82
$741,39 		$736,70
$766,88
$798,86
$912,43 		$171,04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$447,16
$507,52
$571,48
$798,62
$1 213,60 		$618,20
$678,56
$742,52
$969,66 		$789,24
$849,60
$913,56
$1 140,70 		$960,28
$1 020,64
$1 084,60
$1 311,74 		$171,04
Toc - Plan #85 Blue Care Network of Michigan
Expanded Bronze

(HMO) Blue Cross¨ Preferred HMO Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$213,88
$242,75
$273,34
$381,99
$580,47 		$377,50
$406,37
$436,96
$545,61 		$541,12
$569,99
$600,58
$709,23 		$704,74
$733,61
$764,20
$872,85 		$163,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$427,76
$485,50
$546,68
$763,98
$1 160,94 		$591,38
$649,12
$710,30
$927,60 		$755,00
$812,74
$873,92
$1 091,22 		$918,62
$976,36
$1 037,54
$1 254,84 		$163,62
Toc - Plan #86 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
$4,800 $9,600 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 		$316,45
$359,17
$404,42
$565,18
$858,85 		$558,53
$601,25
$646,50
$807,26 		$800,61
$843,33
$888,58
$1 049,34 		$1 042,69
$1 085,41
$1 130,66
$1 291,42 		$242,08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632,90
$718,34
$808,84
$1 130,36
$1 717,70 		$874,98
$960,42
$1 050,92
$1 372,44 		$1 117,06
$1 202,50
$1 293,00
$1 614,52 		$1 359,14
$1 444,58
$1 535,08
$1 856,60 		$242,08
Toc - Plan #87 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
$4,800 $9,600 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 		$343,93
$390,36
$439,54
$614,26
$933,43 		$607,04
$653,47
$702,65
$877,37 		$870,15
$916,58
$965,76
$1 140,48 		$1 133,26
$1 179,69
$1 228,87
$1 403,59 		$263,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687,86
$780,72
$879,08
$1 228,52
$1 866,86 		$950,97
$1 043,83
$1 142,19
$1 491,63 		$1 214,08
$1 306,94
$1 405,30
$1 754,74 		$1 477,19
$1 570,05
$1 668,41
$2 017,85 		$263,11
Toc - Plan #88 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
$4,800 $9,600 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 		$293,30
$332,90
$374,84
$523,83
$796,02 		$517,67
$557,27
$599,21
$748,20 		$742,04
$781,64
$823,58
$972,57 		$966,41
$1 006,01
$1 047,95
$1 196,94 		$224,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586,60
$665,80
$749,68
$1 047,66
$1 592,04 		$810,97
$890,17
$974,05
$1 272,03 		$1 035,34
$1 114,54
$1 198,42
$1 496,40 		$1 259,71
$1 338,91
$1 422,79
$1 720,77 		$224,37

‡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 Macomb County here.

Macomb County is in “Rating Area 2” of Michigan.

Currently, there are 88 plans offered in Rating Area 2.

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2021 Obamacare Plans for Macomb County, MI

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