Gold  2017 Small Group Plans, Q3

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 $566.42 $555.03 $622.32  
   Employee and child $962.92 $943.56 $1,057.94  
   Employee and spouse/domestic partner $1,132.84 $1,110.06 $1,244.64  
   Family $1,614.30 $1,581.83 $1,773.62  
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 $638.79 $583.55
   Employee and child $1,085.94 $992.03
   Employee and spouse/domestic partner $1,277.58 $1,167.10
   Family $1,820.56 $1,663.12
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 $676.28 $662.30 $744.92  
   Employee and child $1,149.37 $1,125.91 $1,266.37  
   Employee and spouse/domestic partner $1,352.56 $1,324.60 $1,489.84  
   Family $1,927.40 $1,887.56 $2,123.02  
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 $765.13 $693.09
   Employee and child $1,300.72 $1,178.25
   Employee and spouse/domestic partner $1,530.26 $1,386.18
   Family $2,180.62 $1,975.31
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 $566.42
   Employee and child $962.92
   Employee and spouse/
domestic partner
$1,132.84
   Family $1,614.30
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 $676.28
   Employee and child $1,149.67
   Employee and spouse/
domestic partner
$1,352.56
   Family $1,927.40
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 $555.03
   Employee and child $943.56
   Employee and spouse/
domestic partner
$1,110.06
   Family $1,581.83
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  Radius
Region 7  
Monthly Premium  
   Single $662.30
   Employee and child $1,1125.91
   Employee and spouse/
domestic partner
$1,324.60
   Family $1,887.56
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 $622.32
   Employee and child $1,057.94
   Employee and spouse/
domestic partner
$1,244.64
   Family $1,773.62
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 $744.92
   Employee and child $1,266.37
   Employee and spouse/
domestic partner
$1,489.84
   Family $2,123.02
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 $638.79
   Employee and child $1,085.94
   Employee and spouse/
domestic partner
$1,277.58
   Family $1,820.56
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 $765.13
   Employee and child $1,300.72
   Employee and spouse/
domestic partner
$1,530.26
   Family $2,180.62
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 $583.55
   Employee and child $992.03
   Employee and spouse/
domestic partner
$1,167.10
   Family $1,663.12
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 $693.09
   Employee and child $1,178.25
   Employee and spouse/
domestic partner
$1,386.18
   Family $1,975.31
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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