Gold  2018 Small Group Plans, Q2

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 $618.19 $710.94 $650.81  
   Employee and child $1,050.91 $1,208.59 $1,106.37  
   Employee and spouse/domestic partner $1,236.36 $1,421.86 $1,301.60  
   Family $1,761.82 $2,026.16 $1,854.78  
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 $679.40 $649.17 $672.72
   Employee and child $1,154.97 $1,103.58 $1,143.61
   Employee and spouse/domestic partner $1,358.80 $1,298.34 $1,345.42
   Family $1,936.29 $1,850.14 $1,917.24
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 $652.86 $602.95 $622.65
   Employee and child $1,109.86 $1,025.03 $1,058.51
   Employee and spouse/domestic partner $1,305.71 $1,205.92 $1,245.31
   Family $1,860.65 $1,718.44 $1,774.55
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 $746.26 $859.73 $786.16  
   Employee and child $1,268.64 $1,461.55 $1,336.48  
   Employee and spouse/domestic partner $1,492.51 $1,719.46 $1,572.31  
   Family $2,126.83 $2,450.24 $2,240.56  
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 $821.15 $784.17 $812.99
   Employee and child $1,395.95 $1,333.10 $1,382.07
   Employee and spouse/domestic partner $1,642.29 $1,568.34 $1,625.96
   Family $2,340.27 $2,234.89 $2,317.00
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 $788.70 $727.65 $751.72
   Employee and child $1,340.77 $1,237.01 $1,277.92
   Employee and spouse/domestic partner $1,577.38 $1,455.29 $1,503.43
   Family $2,247.77 $2,073.80 $2,142.39
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  EPO Gold Radius Gold EX
Monthly Premium      
   Single $788.70 $727.65 $751.72
   Employee and child $1,340.77 $1,237.01 $1,277.92
   Employee and spouse/domestic partner $1,577.38 $1,455.29 $1,503.43
   Family $2,247.77 $2,073.80 $2,142.39
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 $618.19
   Employee and child $1,050.91
   Employee and spouse/
domestic partner
$1,236.36
   Family $1,761.82
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 $746.26
   Employee and child $1,268.64
   Employee and spouse/
domestic partner
$1,492.51
   Family $2,126.83
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 $710.94
   Employee and child $1,208.59
   Employee and spouse/
domestic partner
$1,421.86
   Family $2,026.16
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 $859.73
   Employee and child $1,461.55
   Employee and spouse/
domestic partner
$1,719.46
   Family $2,450.24
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 Radius high
Region 1  
Monthly Premium  
   Single $650.81
   Employee and child $1,106.37
   Employee and spouse/
domestic partner
$1,301.60
   Family $1,854.78
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 $786.16
   Employee and child $1,336.48
   Employee and spouse/
domestic partner
$1,572.31
   Family $2,240.56
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 $679.40
   Employee and child $1,154.97
   Employee and spouse/
domestic partner
$1,358.80
   Family $1,936.29
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 $821.15
   Employee and child $1,395.95
   Employee and spouse/
domestic partner
$1,642.29
   Family $2,340.27
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 $649.17
   Employee and child $1,103.58
   Employee and spouse/
domestic partner
$1,298.34
   Family $1,850.14
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 $784.17
   Employee and child $1,333.10
   Employee and spouse/
domestic partner
$1,568.34
   Family $2,234.89
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 $672.72
   Employee and child $1,143.61
   Employee and spouse/
domestic partner
$1,345.42
   Family $1,917.24
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 $812.99
   Employee and child $1,382.07
   Employee and spouse/
domestic partner
$1,625.96
   Family $2,317.00
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 $652.86
   Employee and child $1,109.86
   Employee and spouse/
domestic partner
$1,305.71
   Family $1,860.65
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 $788.70
   Employee and child $1,340.77
   Employee and spouse/
domestic partner
$1,557.38
   Family $2,247.77
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 Radius
Region 1  
Monthly Premium  
   Single $602.95
   Employee and child $1,025.03
   Employee and spouse/
domestic partner
$1,205.92
   Family $1,718.44
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 $727.65
   Employee and child $1,237.01
   Employee and spouse/
domestic partner
$1,455.29
   Family $2,073.80
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 $622.65
   Employee and child $1,058.51
   Employee and spouse/
domestic partner
$1,245.31
   Family $1,774.55
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 $751.72
   Employee and child $1,277.92
   Employee and spouse/
domestic partner
$1,503.43
   Family $2,142.39
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 7
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

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Preventive Services

$0 preventive services

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