| Gold Plan | Silver Plan | Bronze Plan | ||||
|---|---|---|---|---|---|---|
| Professional Services | Hospital Services | Professional Services | Hospital Services | Professional Services | Hospital Services | |
HSA Eligible | No | No | No | |||
| 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 Pays | 80% | 60% | 75% | 55% | 70% | 50% |
| Participant Pays | 20% | 40% | 25% | 45% | 30% | 50% |
| Preventive Care | Paid at 100% of maximum allowable amount at appropriate intervals. | |||||
| Primary Care | ||||||
| Copay | $30 | N/A | $40 | N/A | Subject to the deductible & coinsurance | N/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 | |||
| Gold Plan | Silver Plan | |
|---|---|---|
| HSA Eligible | 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 |
| Bronze Plan | |
|---|---|
| HSA Eligible | 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 » |
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| Silver Plan | Bronze Plan | |
|---|---|---|
| HSA Eligible | 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 | 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 | 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 » |