| 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 |
| 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 » |


