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| Gold Plan* | Silver Plan* | |
|---|---|---|
| HSA Eligible | No | No |
| Participant deductible | $1,500 | $5,900 |
| Family deductible | $3,000 | $11,800 |
| Participant out-of-pocket | $7,800 | $9,100 |
| Family out-of-pocket | $15,600 | $18,200 |
| Coinsurance BCBSWY Pays Participant Pays | 75% 25% | 60% 40% |
| Preventive Care | Paid at 100% of maximum allowable amount at appropriate intervals when services are rendered by a network provider. | |
| Primary Care Copay | $30 | $40 |
| Prescription Drugs | ||
| Tier 1: Generic Drugs | $15 copay | $20 copay |
| Tier 2: Preferred Brand drugs | $30 copay | $40 copay |
| Summary of Benefits and Coverage (SBC) | View SBC | View SBC |
*This plan does not include kid’s dental coverage.
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.
