Gold  2018 Small Group Plans, Q1

Our Gold plans have a robust level of coverage combined with low cost of sharing. View the plan details below. Please note, all premiums listed represent coverage for dependents up to age 26. 

 

Region 1: Albany, Columbia, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington.

Region 7: Clinton & Essex

 

If you are an existing group with BlueShield of Northeastern New York, visit BlueConnect to enroll. If you are a new group and would like to enroll in a Gold plan, please contact your broker or account executive. 


Region 1 Gold  Standard Gold EPO high
Gold Radius high
Monthly Premium      
   Single $610.25 $701.81 $642.45  
   Employee and child $1,037.42 $1,193.08 $1,092.17  
   Employee and spouse/domestic partner $1,220.50 $1,403.62 $1,284.90  
   Family $1,739.21 $2,000.16 $1,830.98  
Primary Care Doctor/Specialist $25/$40 after deductible $0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
 
Deductible (Single/Family) $600/$1,200 embedded $0 $0

 

Inpatient Hospital (per admission) $1,000 after deductible $500 $750  
Prescription Drugs:        
   Tier 1/2/3 $10/$35/$70  $4/$35/$70  $4/$35/$70   
   Generic Oral Contraceptives Covered in full Covered in full Covered in full  
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply  
 

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

 

 

Region 1 Gold  EX high Gold HMO Gold PPO
Monthly Premium      
   Single $670.68 $640.84 $664.08
   Employee and child $1,140.15 $1,089.42 $1,128.94
   Employee and spouse/domestic partner $1,341.36 $1,281.68 $1,328.16
   Family $1,911.44 $1,826.40 $1,892.63
Primary Care Doctor/Specialist $0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $0 $0 $5,000/$1,000 embedded
Inpatient Hospital (per admission) $500 $1,000 20% after deductible
Prescription Drugs:      
   Tier 1/2/3 $4/$35/$70  $4/$35/$70  $4/$35/$70 
   Generic Oral Contraceptives Covered in full Covered in full Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

Region 1 Gold  EPO Gold Radius Gold EX
Monthly Premium      
   Single $644.48 $595.22 $614.66
   Employee and child $1,095.62 $1,011.88 $1,044.92
   Employee and spouse/domestic partner $1,228.96 $1,190.44 $1,229.32
   Family $1,836.77 $1,696.38 $1,751.78
Primary Care Doctor/Specialist $0 pediatric PCP visits
$25/$50
$0 pediatric PCP visits
$25/$50
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded $500/$1,000 embedded $500/$1,000 embedded
Inpatient Hospital (per admission) 20% after deductible 20% after deductible 20% after deductible
Prescription Drugs:      
   Tier 1/2/3 $4/$35/$70  $4/$35/$70  $4/$35/$70 
   Generic Oral Contraceptives Covered in full Covered in full Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage


Region 7 Gold  Standard Gold EPO high
Gold Radius high
Monthly Premium      
   Single $736.68 $848.70 $776.07  
   Employee and child $1,252.36 $1,442.79 $1,319.32  
   Employee and spouse/domestic partner $1,473.36 $1,697.40 $1,552.14  
   Family $2,099.54 $2,418.80 $2,211.80  
Primary Care Doctor/Specialist $25/$40 after deductible $0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
 
Deductible (Single/Family) $600/$1,200 embedded $0 $0

 

Inpatient Hospital (per admission) $1,000 after deductible $500 $750  
Prescription Drugs:        
   Tier 1/2/3 $10/$35/$70  $4/$35/$70  $4/$35/$70   
   Generic Oral Contraceptives Covered in full Covered in full Covered in full  
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply  
 

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

 

Region 7 Gold  EX high Gold HMO Gold PPO
Monthly Premium      
   Single $810.61 $774.11 $802.55
   Employee and child $1,378.03 $1,315.99 $1,364.34
   Employee and spouse/domestic partner $1,621.22 $1,548.22 $1,605.10
   Family $2,310.24 $2,206.21 $2,287.26
Primary Care Doctor/Specialist $0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
$25/$50
Deductible (Single/Family) $0 $0 $5,000/$1,000 embedded
Inpatient Hospital (per admission) $500 $1,000 20% after deductible
Prescription Drugs:      
   Tier 1/2/3 $4/$35/$70  $4/$35/$70  $4/$35/$70 
   Generic Oral Contraceptives Covered in full Covered in full Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

Region 7 Gold  EPO Gold Radius Gold EX
Monthly Premium      
   Single $778.57 $718.31 $742.07
   Employee and child $1,323.57 $1,221.13 $1,261.52
   Employee and spouse/domestic partner $1,557.14 $1,436.62 $1,484.14
   Family $2,218.92 $2,047.18 $2,114.90
Primary Care Doctor/Specialist $0 pediatric PCP visits
$25/$50
$0 pediatric PCP visits
$25/$50
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded $500/$1,000 embedded $500/$1,000 embedded
Inpatient Hospital (per admission) 20% after deductible 20% after deductible 20% after deductible
Prescription Drugs:      
   Tier 1/2/3 $4/$35/$70  $4/$35/$70  $4/$35/$70 
   Generic Oral Contraceptives Covered in full Covered in full Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

Gold Standard
Region 1  
Monthly Premium  
   Single $610.25
   Employee and child $1,037.42
   Employee and spouse/
domestic partner
$1,220.50
   Family $1,739.21
Primary Care
Doctor/Specialist
$25/$40 after deductible
Deductible (Single/Family) $600/$1,200 embedded
Inpatient Hospital
(per admission)
$1,000 after deductible
Prescription Drugs:  
   Tier 1/2/3 $10/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold Standard
Region 7  
Monthly Premium  
   Single $736.68
   Employee and child $1,252.36
   Employee and spouse/
domestic partner
$1,473.36
   Family $2,099.54
Primary Care
Doctor/Specialist
$25/$40 after deductible
Deductible (Single/Family) $600/$1,200 embedded
Inpatient Hospital
(per admission)
$1,000 after deductible
Prescription Drugs:  
   Tier 1/2/3 $10/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EPO High
Region 1  
Monthly Premium  
   Single $701.81
   Employee and child $1,193.08
   Employee and spouse/
domestic partner
$1,403.62
   Family $2,000.16
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
Deductible (Single/Family) N/A
Inpatient Hospital
(per admission)
$500
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EPO High
Region 7  
Monthly Premium  
   Single $848.70
   Employee and child $1,442.79
   Employee and spouse/
domestic partner
$1,697.40
   Family $2,418.80
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
Deductible (Single/Family) N/A
Inpatient Hospital
(per admission)
$500
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold Radius high
Region 1  
Monthly Premium  
   Single $642.45
   Employee and child $1,092.17
   Employee and spouse/
domestic partner
$1,284.90
   Family $1,830.98
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
Deductible (Single/Family) N/A
Inpatient Hospital
(per admission)
$750
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold Radius high
Region 7  
Monthly Premium  
   Single $776.07
   Employee and child $1,319.32
   Employee and spouse/
domestic partner
$1,552.14
   Family $2,211.80
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
Deductible (Single/Family) N/A
Inpatient Hospital
(per admission)
$750
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EX high
Region 1  
Monthly Premium  
   Single $670.68
   Employee and child $1,140.15
   Employee and spouse/
domestic partner
$1,341.36
   Family $1,911.44
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
Deductible (Single/Family) N/A
Inpatient Hospital
(per admission)
$500
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EX high
Region 7  
Monthly Premium  
   Single $810.61
   Employee and child $1,378.03
   Employee and spouse/
domestic partner
$1,621.22
   Family $2,310.24
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
Deductible (Single/Family) N/A
Inpatient Hospital
(per admission)
$500
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  HMO
Region 1  
Monthly Premium  
   Single $640.84
   Employee and child $1,089.42
   Employee and spouse/
domestic partner
$1,281.68
   Family $1,826.40
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/40
Deductible (Single/Family) N/A
Inpatient Hospital
(per admission)
$1,000
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  HMO
Region 7  
Monthly Premium  
   Single $774.11
   Employee and child $1,315.99
   Employee and spouse/
domestic partner
$1,548.22
   Family $2,206.21
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$0 for first three adult PCP visits
$25/$40
Deductible (Single/Family) N/A
Inpatient Hospital
(per admission)
$1,000
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold PPO
Region 1  
Monthly Premium  
   Single $664.08
   Employee and child $1,128.94
   Employee and spouse/
domestic partner
$1,328.16
   Family $1,892.63
Primary Care
Doctor/Specialist
$25/$50
Deductible (Single/Family) $500/$1,000 embedded
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold PPO
Region 7  
Monthly Premium  
   Single $802.55
   Employee and child $1,364.34
   Employee and spouse/
domestic partner
$1,605.10
   Family $2,287.26
Primary Care
Doctor/Specialist
$25/$50
Deductible (Single/Family) $500/$1,000 embedded
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold EPO
Region 1  
Monthly Premium  
   Single $644.48
   Employee and child $1,095.62
   Employee and spouse/
domestic partner
$1,288.96
   Family $1,836.77
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold EPO
Region 7  
Monthly Premium  
   Single $778.57
   Employee and child $1,323.57
   Employee and spouse/
domestic partner
$1,557.14
   Family $2,218.92
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold Radius
Region 1  
Monthly Premium  
   Single $595.22
   Employee and child $1,011.88
   Employee and spouse/
domestic partner
$1,190.44
   Family $1,696.38
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold Radius
Region 7  
Monthly Premium  
   Single $718.31
   Employee and child $1,221.13
   Employee and spouse/
domestic partner
$1,436.62
   Family $2,047.18
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EX
Region 1  
Monthly Premium    
   Single $614.66
   Employee and child $1,044.92
   Employee and spouse/
domestic partner
$1,229.32
   Family $1,751.78
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EX
Region 7  
Monthly Premium  
   Single $742.07
   Employee and child $1,261.52
   Employee and spouse/
domestic partner
$1,484.14
   Family $2,114.90
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Visit BlueConnect to enroll. If you are a new group and would like to enroll in a Gold plan, please contact your broker or account executive.

 

Region 1 Gold Standard Gold Radius*

Gold EPO Gold PPO Gold EX
Monthly Premium          
   Single $576.05 $564.46 $632.90 $649.65 $593.47
   Employee and child $979.29 $959.58 $1,075.93 $1,104.41 $1,008.90
   Employee and spouse/domestic partner $1,152.10 $1,128.92 $1,265.80 $1,299.30 $1,186.94
   Family $1,641.74 $1,608.71 $1,803.77 $1,851.50 $1,691.39
Primary Care Doctor/Specialist $25/$40
after deductible 
$0 pediatric PCP vists
$25/$50
$0 pediatric PCP visits
$25/$50

$0 pediartic PCP visits
$25/$50

$0 pediatric PCP visits
$25/$50, preferred

$25/$50, participating

Deductible (Single/Family) $600/$1,200 
$500/$1,000
$500/$1,000 $500/$1,000
$500/$1,000
Inpatient Hospital (per admission) $1,000 after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Prescription Drugs:          
   Tier 1/2/3 $10/$35/$70  $4/$35/$70  $4/$35/$70 $4/$35/$70  $4/$35/$70
   Generic Oral Contraceptives Covered in full Covered in full Covered in full Covered in full Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

 
Region 7 Gold Standard Gold Radius*

Gold EPO Gold PPO Gold EX
Monthly Premium          
   Single $687.78 $673.56 $757.58 $778.13 $704.88
   Employee and child $1,169.23 $1,145.05 $1,287.89 $1,322.82 $1,198.30
   Employee and spouse/domestic partner $1,375.56 $1,347.12 $1,515.16 $1,556.26 $1,409.76
   Family $1,960.17 $1919.65 $2,159.10 $2,217.67 $2,008.91
Primary Care Doctor/Specialist $25/$40
after deductible 
$0 pediatric PCP vists
$25/$50
$0 pediatric PCP visits
$25/$50

$0 pediartic PCP visits
$25/$50

$0 pediatric PCP visits
$25/$50, preferred

$25/$50, participating

Deductible (Single/Family) $600/$1,200 
$500/$1,000
$500/$1,000 $500/$1,000
$500/$1,000
Inpatient Hospital (per admission) $1,000 after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Prescription Drugs:          
   Tier 1/2/3 $10/$35/$70  $4/$35/$70  $4/$35/$70 $4/$35/$70  $4/$35/$70
   Generic Oral Contraceptives Covered in full Covered in full Covered in full Covered in full Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

 
Gold  Standard 
Region 1
Monthly Premium
 
   Single $576.05
   Employee and child $979.29
   Employee and spouse/
domestic partner
$1,152.10
   Family $1,641.74
Primary Care
Doctor/Specialist
$25/$40 after deductible
Deductible (Single/Family) $600/$1,200
Inpatient Hospital
(per admission)
$1,000 after deductible
Prescription Drugs:  
   Tier 1/2/3 $10/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  Standard 
Region 7
Monthly Premium
 
   Single $687.78
   Employee and child $1,169.23
   Employee and spouse/
domestic partner
$1,375.56
   Family $1,960.17
Primary Care
Doctor/Specialist
$25/$40 after deductible
Deductible (Single/Family) $600/$1,200 
Inpatient Hospital
(per admission)
$1,000 after deductible
Prescription Drugs:  
   Tier 1/2/3 $10/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  Radius
Region 1
Monthly Premium
 
   Single $564.46
   Employee and child $959.58
   Employee and spouse/
domestic partner
$1,128.92
   Family $1,608.71
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  Radius
Region 7
Monthly Premium
 
   Single $673.56
   Employee and child $1,145.05
   Employee and spouse/
domestic partner
$1,347.12
   Family $1,919.65
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EPO
Region 1
Monthly Premium
 
   Single $632.90
   Employee and child $1,075.93
   Employee and spouse/
domestic partner
$1,265.80
   Family $1,803.77
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EPO
Region 7
Monthly Premium
 
   Single $757.58
   Employee and child $1,287.89
   Employee and spouse/
domestic partner
$1,515.16
   Family $2,159.10
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  PPO
Region 1
Monthly Premium
 
   Single $649.65
   Employee and child $1,104.41
   Employee and spouse/
domestic partner
$1,299.30
   Family $1,851.50
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded deductible
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  PPO
Region 7
Monthly Premium
 
   Single $778.13
   Employee and child $1,322.82
   Employee and spouse/
domestic partner
$1,556.26
   Family $2,217.67
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50
Deductible (Single/Family) $500/$1,000 embedded deductible
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EX
Region 1
Monthly Premium
 
   Single $593.47
   Employee and child $1,008.90
   Employee and spouse/
domestic partner
$1,186.94
   Family $1,691.39
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50, preferred

$25/$50, participating
Deductible (Single/Family) $500/$1,000
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  EX
Region 1
Monthly Premium
 
   Single $704.88
   Employee and child $1,198.30
   Employee and spouse/
domestic partner
$1,409.76
   Family $2,008.91
Primary Care
Doctor/Specialist
$0 pediatric PCP visits
$25/$50, preferred

$25/$50, participating
Deductible (Single/Family) $500/$1,000
Inpatient Hospital
(per admission)
20% after deductible
Prescription Drugs:  
   Tier 1/2/3 $4/$35/$70 
   Generic Oral
Contraceptives
Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits of Blue

BlueConnect

A comprehensive online benefits solution

Wellness Card

 

Offered with every small group plan

Preventive Services

$0 preventive services

HealthyLife Rewards

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