Gold Gold 80
Premium plan with 80% actuarial value
Cost Overview
Annual Deductible
$0
Out-of-Pocket Maximum
$8,700
Standardized Benefits
| Service | You Pay | Notes |
|---|---|---|
| Deductibles | ||
| Individual Deductible (Medical) | $0 | |
| Individual Deductible (Pharmacy) | $0 | |
| Family Deductible (Medical) | $0 | |
| Family Deductible (Pharmacy) | $0 | |
| Care Visits | ||
| Preventive Care | no charge | |
| Primary Care Visit | $35 | |
| Urgent Care Visit | $35 | |
| Specialty Care Visit | $65 | |
| Mental/Behavioral Health Visit | $35 | |
| Tests & Therapy | ||
| Other Therapy (PT/OT/Speech) | $35 | |
| Lab Testing | $40 | |
| X-rays & Diagnostic Imaging | $75 | |
| Advanced Imaging (CT/MRI) | $75 or 25% | |
| Hospital & Emergency | ||
| Outpatient Surgery | $190 or 30% | |
| Emergency Room | $330 | |
| Emergency Transport | $250 | |
| Prenatal/Postnatal Care | no charge | |
| Inpatient Hospital Stay | $350 per day up to 5 days or 30% | |
| Hospital Physician | $0 or 30% | |
| Prescription Drugs | ||
| Generic Drugs (Tier 1) | $15 | |
| Preferred Brand Drugs (Tier 2) | $60 | |
| Non-Preferred Brand Drugs (Tier 3) | $85 | |
| Specialty Drugs (Tier 4) | 20% up to $250 | |
| Out of Pocket Maximums | ||
| Maximum Out of Pocket (Individual) | $8,700 | |
| Maximum Out of Pocket (Family) | $17,400 | |
Understanding Deductibles and Benefit Costs
Benefits in Orange are Subject to the Annual Deductible amounts listed above. You will pay the full cost for these services until the Deductible is met. Then you will pay the specified amount that is shown until the Annual Maximum Out-of-Pocket is met. The deductible counts toward the Maximum Out-Of-Pocket.
Copays in Black are NOT Subject to any Deductible and count towards the Annual Maximum Out-Of-Pocket. The Annual Out-Of-Pocket Maximum and Deductible amounts are always based on the Individual amount listed even under a family plan. Two or more people in the family have to reach the family amounts listed above in order for them to apply to the entire family.
Understanding Your Benefits
- Copay: A fixed amount you pay for a covered service.
- Coinsurance: Your share of costs after meeting your deductible (shown as a percentage).
- Deductible: The amount you pay before your insurance starts covering costs.
- Out-of-Pocket Maximum: The most you'll pay in a year for covered services.