Bronze Plan
HSA Eligible

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No
Participant deductible $8,550
Family deductible $17,100
Participant out-of-pocket $8,550
Family out-of-pocket $17,100
Coinsurance

BCBSWY Pays

Participant Pays

100%

0%

Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay

Subject to the deductible & coinsurance

Prescription Drugs
Tier 1: Generic Drugs
Tier 2: Preferred Brand drugs
 

Subject to the deductible & coinsurance

Subject to the deductible & coinsurance

Summary of Benefits and Coverage (SBC) View SBC »

Cost Assistance

Based on certain income requirements, you may qualify for assistance, through government subsidies, with your monthly premiums.


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Silver Plan Bronze Plan
HSA Eligible

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No No
Participant deductible $3,500 $6,000
Family deductible $7,000 $12,000
Participant out-of-pocket $7,900 $7,900
Family out-of-pocket $15,800 $15,800
Coinsurance

BCBSWY Pays

Participant Pays

80%

20%

80%

20%

Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay

$40 Subject to the deductible & coinsurance

Prescription Drugs
Tier 1: Generic DrugsTier 2: Preferred Brand drugs
$5 copay

$50 copay

$10 copay

$150 copay

Summary of Benefits and Coverage (SBC) View SBC »
View SBC »
Gold Plan Silver Plan
HSA Eligible

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No No
Participant deductible $750 $2,500
Family deductible $1,500 $5,000
Participant out-of-pocket $7,900 $7,900
Family out-of-pocket $15,800 $15,800
Coinsurance

BCBSWY Pays

Participant Pays

75%

25%

60%

40%

Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay
$30 $45
Prescription Drugs
Tier 1: Generic Drugs  $5 copay $5 copay
 Tier 2: Preferred Brand drugs $20 copay $50 copay
Summary of Benefits and Coverage (SBC)
View SBC

View SBC
Bronze Plan
Single Plan Family Plan
HSA Eligible

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Yes Yes
Participant deductible $4,500 NA
Family deductible NA $9,000
Participant out-of-pocket $6,750 $6,750
Family out-of-pocket NA $13,500
Coinsurance

BCBSWY Pays

Participant Pays

50%

50%

50%

50%

Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay

Subject to the deductible

& coinsurance

Subject to the deductible

& coinsurance

Prescription Drugs

Tier 1: Generic Drugs

Tier 2: Preferred Brand drugs

Subject to the deductible

& coinsurance

Subject to the deductible

& coinsurance

Summary of Benefits and Coverage (SBC) View SBC » View SBC »
Gold Plan Silver Plan
HSA Eligible

Learn More

No No
Participant deductible $1,000 $4,000
Family deductible $2,000 $8,000
Participant out-of-pocket $7,900 $7,900
Family out-of-pocket $15,800 $15,800
Coinsurance

BCBSWY Pays

Participant Pays

80%

20%

75%

25%

Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay

$30 $45
Prescription Drugs

Tier 1: Generic Drugs

Tier 2: Preferred Brand drugs

$5/$0 copay

$20/$10 copay

$5/$0 copay

$50/$25 copay

Summary of Benefits and Coverage (SBC) View SBC  View SBC 
 Gold PlanSilver PlanBronze Plan
 Professional
Services
Hospital
Services
Professional
Services
Hospital
Services
Professional
Services
Hospital
Services

HSA Eligible

Learn More

NoNoNo
Participant deductible$500$1,500$1,500$4,500$3,500$7,000
Family deductible$1,000$3,000$3,000$9,000$7,000$14,000
Participant out-of-pocket$7,900$7,900$7,900
Family out-of-pocket$15,800$15,800$15,800
Coinsurance
BCBSWY Pays80%60%75%55%70%50%
Participant Pays20%40%25%45%30%50%
Preventive CarePaid at 100% of maximum allowable amount at appropriate intervals.
Primary Care
Copay$30N/A$40N/ASubject to the deductible & coinsuranceN/A
Prescription Drugs

Tier 1: Generic Drugs

Tier 2: Preferred Brand drugs

$5 copay

$50 copay

$5 copay

$100 copay

Subject to the professional services deductible & coinsurance
Summary of Benefits and Coverage (SBC)
View SBC

View SBC

View SBC
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