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| Gold Plan | Silver Plan* | Bronze Plan | ||||
|---|---|---|---|---|---|---|
| Professional Services | Institutional Services | Professional Services | Institutional Services | Professional Services | Institutional Services | |
| HSA Eligible | No | No | No | |||
| Participant deductible | $500 | $1,500 | $1,500 | $4,500 | $4,000 | $8,000 |
| Family deductible | $1,000 | $3,000 | $3,000 | $9,000 | $8,000 | $16,000 |
| Participant out-of-pocket | $9,100 | $9,100 | $9,100 | |||
| Family out-of-pocket | $18,200 | $18,200 | $18,200 | |||
| 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 when services are rendered by a network provider. | |||||
| 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 | |||
* This plan is available with or without kid’s dental coverage through both BCBSWY and the Health Insurance Marketplace.
At-a-Glance is intended to be a condensed overview of some plan benefits and does not cover all benefits or information contained in the Benefit Booklet. Limitations and exclusions do exist. At-a-Glance is not a contract. For exact benefits and limitations, please request a copy of the Benefit Booklet.
Based on certain income requirements, you may qualify for assistance, through government subsidies, with your monthly premiums.
Find important information on your prescriptions, including how to select a pharmacy, request prescription benefits, and more.
