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 | No deductible |
| Primary Care Visit | $35 | Deductible may apply |
| Urgent Care Visit | $35 | |
| Specialty Care Visit | $65 | Deductible may apply |
| 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% | After deductible |
| Emergency Room | $330 | After deductible |
| Emergency Transport | $250 | |
| Prenatal/Postnatal Care | no charge | |
| Inpatient Hospital Stay | $350 per day up to 5 days or 30% | After deductible |
| 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 | Annual limit |
| Maximum Out of Pocket (Family) | $17,400 | Annual limit |
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.