Gold  2017 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 Radius
Gold EPO
Monthly Premium      
   Single $557.50 $546.29 $612.52  
   Employee and child $947.75 $928.69 $1,041.29  
   Employee and spouse/domestic partner $1,115.00 $1,092.58 $1,225.04  
   Family $1,588.88 $1,556.93 $1,745.68  
Primary Care Doctor/Specialist $25/$40
after deductible
$25/$50 
$0 pediatric PCP visits 
$25/$50
$0 pediatric PCP visits
 
Deductible (Single/Family) $600/$1,200 $500 / $1,000 $500/$1,000

 

Inpatient Hospital (per admission) $1,000 after deductible 20% after deductible 20% after deductible
 
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  PPO Gold EX
Monthly Premium    
   Single $628.73 $574.36
   Employee and child $1,068.85 $976.42
   Employee and spouse/domestic partner $1,257.46 $1,148.72
   Family $1,791.88 $1,636.93
Primary Care Doctor/Specialist $25/$50 
$0 pediatric PCP visits
$0 pediatric PCP visits
Deductible (Single/Family) $500/$1,000 $500/$1,000
Inpatient Hospital (per admission) 20% after deductible 20% after deductible
Prescription Drugs:    
   Tier 1/2/3 $4/$35/$70  $4/$35/$70 
   Generic Oral Contraceptives Covered in full Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits & Coverage

Region 7 Gold  Standard Gold Radius
Gold EPO  
Monthly Premium        
   Single $665.63 $651.87 $733.08  
   Employee and child $1,131.58 $1,108.18 $1,246.43  
   Employee and spouse/domestic partner $1,331.26 $1,303.74 $1,466.38  
   Family $1,897.05 $1,857.83 $2,089.59  
Primary Care Doctor/Specialist $25/$40 after deductible $25/$50 
$0 pediatric PCP visits 
$25/$50
$0 pediatric PCP visits


Deductible (Single/Family) $600/$1,200 $500/$1,000 $500/$1,000 

 

Inpatient Hospital (per admission) $1,000 after deductible 20% after deductible 20% after deductible
 
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  PPO Gold EX
Monthly Premium    
   Single $753.08 $682.17
   Employee and child $1,208.24 $1,159.69
   Employee and spouse/domestic partner $1,506.16 $1,364.34
   Family $2,146.28 $1,944.19
Primary Care Doctor/Specialist $25/$50 
$0 pediatric PCP visits
$25/$50 
$0 pediatric PCP visits
Deductible (Single/Family) $500/$1,000 $500/$1,000
Inpatient Hospital (per admission) 20% after deductible 20% after deductible
Prescription Drugs:    
   Tier 1/2/3 $4/$35/$70  $4/$35/$70 
   Generic Oral Contraceptives Covered in full Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits & Coverage

Gold Standard
Region 1  
Monthly Premium  
   Single $557.50
   Employee and child $947.75
   Employee and spouse/
domestic partner
$1,115.00
   Family $1,588.88
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 $665.63
   Employee and child $1,131.58
   Employee and spouse/
domestic partner
$1,331.26
   Family $1,897.05
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 $546.29
   Employee and child $928.69
   Employee and spouse/
domestic partner
$1,092.58
   Family $1,556.93
Primary Care
Doctor/Specialist
$25/$50, $0 pediatric PCP visits
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 $651.87
   Employee and child $1,108.18
   Employee and spouse/
domestic partner
$1,303.74
   Family $1,857.83
Primary Care
Doctor/Specialist
$25/$50
$0 pediatric PCP visits
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 $612.52
   Employee and child $1,041.29
   Employee and spouse/
domestic partner
$1,225.04
   Family $1,745.68
Primary Care
Doctor/Specialist
$25/$50
$0 pediatric PCP visits
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 $733.19
   Employee and child $1,246.43
   Employee and spouse/
domestic partner
$1,466.38
   Family $2,089.59
Primary Care
Doctor/Specialist
$25/$50
$0 pediatric PCP visits
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 $628.73
   Employee and child $1,068.85
   Employee and spouse/
domestic partner
$1,257.46
   Family $1,791.88
Primary Care
Doctor/Specialist
$25/$50
$0 pediatric PCP visits
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 7  
Monthly Premium  
   Single $753.08
   Employee and child $1,280.24
   Employee and spouse/
domestic partner
$1,506.16
   Family $2,146.28
Primary Care
Doctor/Specialist
$25/$50
$0 pediatric PCP visits
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 $574.36
   Employee and child $976.42
   Employee and spouse/
domestic partner
$1,148.72
   Family $1,636.93
Primary Care
Doctor/Specialist
$25/$50
$0 pediatric PCP visits
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 $682.17
   Employee and child $1,159.69
   Employee and spouse/
domestic partner
$1,364.34
   Family $1,944.19
Primary Care
Doctor/Specialist
$25/$50
$0 pediatric PCP visits
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

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 Aqua

Gold EPO 5000 Gold Radius Gold EPO 6000
Monthly Premium          
   Single $505.73 $486.54 $584.74 $499.69 $578.32
   Employee and child $859.74 $827.12 $994.06 $849.47 $983.14
   Employee and spouse/domestic partner $1,011.46 $973.08 $1,169.48 $999.38 $1,156.64
   Family $1,441.33 $1,386.64 $1,666.51 $1,424.12 $1,648.22
Primary Care Doctor/Specialist $25/$40
after deductible 
20% after
deductible
$30/$50 adult PCP visits
$0 pediatric PCP visits

$25/$50 adult PCP visits
$0 pediatric PCP visits

$25/$40 adult PCP visits
$0 pediatric PCP visits

Deductible (Single/Family) $600/$1,200 
embedded deductible
$1,500/$3,000
embedded deductible
$500/$1,000
embedded deductible
$500/$1,000
embedded deductible
$2,000/$4,000 
embedded deductible
Inpatient Hospital (per admission) $1,000 after deductible 20% (not subject to deductible) 20% after deductible 20% after deductible 20% after deductible
Prescription Drugs:          
   Tier 1/2/3 $10/$35/$70  $4/$35/$70  $10/$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 Aqua
Monthly Premium    
  Single $599.62 $576.20
  Employee and child $1,019.35 $979.54
  Employee and spouse/domestic partner $1,199.24 $1,152.40
   Family $1,708.92 $1,642.17
Primary Care Doctor/Specialist $25/$40 
after deductible
20% after 
deductible
Deductible (Single/Family) $600/$1,200
embedded deductible
$1,500/$3,000
embedded deductible
Inpatient Hospital (per admission) $1,000 after deductible 20% (not subject to deductible)
Prescription Drugs:    
   Tier 1/2/3 $10/$35/$70  $4/$35/$70
   Generic Oral Contraceptives Covered in full Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply 2.5 Copays/90-day supply
 

Benefits & Coverage

Benefits & Coverage

 
Gold  Standard 
Region 1
Monthly Premium
 
   Single $505.73
   Employee and child $859.74
   Employee and spouse/
domestic partner
$1,011.46
   Family $1,441.33
Primary Care
Doctor/Specialist
$25/$40 after deductible
Deductible (Single/Family) $600/$1,200 embedded deductible
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 $599.62
   Employee and child $1,019.35
   Employee and spouse/
domestic partner
$1,199.24
   Family $1,708.92
Primary Care
Doctor/Specialist
$25/$40 after deductible
Deductible (Single/Family) $600/$1,200 embedded deductible
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  Aqua
Region 1
Monthly Premium
 
   Single $486.54
   Employee and child $827.12
   Employee and spouse/
domestic partner
$973.08
   Family $1,386.64
Primary Care
Doctor/Specialist
20% after deductible
Deductible (Single/Family) $1,500/$3,000
Inpatient Hospital
(per admission)
20% (not subject to 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  Aqua
Region 7
Monthly Premium
 
   Single $576.20
   Employee and child $979.54
   Employee and spouse/
domestic partner
$1,152.40
   Family $1,642.17
Primary Care
Doctor/Specialist
20% after deductible
Deductible (Single/Family) $1,500/$3,000
Inpatient Hospital
(per admission)
20% (not subject to 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 5000
Region 1
Monthly Premium
 
   Single $584.74
   Employee and child $994.06
   Employee and spouse/
domestic partner
$1,169.48
   Family $1,666.51
Primary Care
Doctor/Specialist
$30/$50 adult PCP visits
$0 pediatric PCP visits
Deductible (Single/Family) $500/$1,000 embedded deductible
Inpatient Hospital
(per admission)
20% 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 $499.69
   Employee and child $849.47
   Employee and spouse/
domestic partner
$999.38
   Family $1,424.12
Primary Care
Doctor/Specialist
$25/$50 adult PCP visits
$0 pediatric PCP visits
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  EPO 6000
Region 1
Monthly Premium
 
   Single $578.32
   Employee and child $983.14
   Employee and spouse/
domestic partner
$1,156.64
   Family $1,648.22
Primary Care
Doctor/Specialist
$25/$40 adult PCP visits
$0 pediatric PCP visits
Deductible (Single/Family) $2,000/$4,000 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

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