Gold  2018 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 your clients are an existing group with BlueShield of Northeastern New York, visit BlueConnect to enroll or contact the appropriate account executive. If your clients 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 $626.23 $720.19 $659.27  
   Employee and child $1,064.57 $1,224.30 $1,120.75  
   Employee and spouse/domestic partner $1,252.43 $1,440.34 $1,318.52  
   Family $1,784.72 $2,052.50 $1,878.89  
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 $688.23 $657.61 $681.46
   Employee and child $1,169.99 $1,117.92 $1,158.48
   Employee and spouse/domestic partner $1,376.47 $1,315.22 $1,362.91
   Family $1,936.29 $1,874.19 $1,942.16
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 $661.35 $610.79 $630.74
   Employee and child $1,124.29 $1,038.35 $1,072.27
   Employee and spouse/domestic partner $1,322.68 $1,221.60 $1,261.50
   Family $1,884.84 $1,740.78 $1,797.62
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 $755.97 $870.91 $796.38  
   Employee and child $1,285.13 $1,480.55 $1,353.86  
   Employee and spouse/domestic partner $1,511.91 $1,741.81 $1,592.75  
   Family $2,154.48 $2,482.09 $2,269.68  
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 $831.83 $794.36 $823.56
   Employee and child $1,663.64 $1,350.43 $1,400.04
   Employee and spouse/domestic partner $1,414.09 $1,588.73 $1,647.10
   Family $2,370.69 $2,263.95 $2,347.12
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 $798.95 $737.10 $761.49
   Employee and child $1,358.20 $1,474.21 $1,294.53
   Employee and spouse/domestic partner $1,597.89 $1,253.09 $1,522.97
   Family $2,276.99 $2,100.76 $2,170.24
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 $626.23
   Employee and child $1,064.57
   Employee and spouse/
domestic partner
$1,252.43
   Family $1,784.72
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 $755.97
   Employee and child $1,285.13
   Employee and spouse/
domestic partner
$1,511.91
   Family $2,154.48
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 $720.19
   Employee and child $1,224.30
   Employee and spouse/
domestic partner
$1,440.34
   Family $2,052.50
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 $870.91
   Employee and child $1,480.55
   Employee and spouse/
domestic partner
$1,741.81
   Family $2,482.09
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 $659.27
   Employee and child $1,120.75
   Employee and spouse/
domestic partner
$1,318.52
   Family $1,878.89
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)
$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 $796.38
   Employee and child $1,353.86
   Employee and spouse/
domestic partner
$1,592.75
   Family $2,269.68
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 $688.23
   Employee and child $1,169.99
   Employee and spouse/
domestic partner
$1,376.47
   Family $1,961.46
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 $831.83
   Employee and child $1,414.09
   Employee and spouse/
domestic partner
$1,663.64
   Family $2,370.69
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 $657.61
   Employee and child $1,117.92
   Employee and spouse/
domestic partner
$1,315.22
   Family $1,874.19
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 $794.36
   Employee and child $1,350.43
   Employee and spouse/
domestic partner
$1,588.73
   Family $2,263.95
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 $681.46
   Employee and child $1,158.48
   Employee and spouse/
domestic partner
$1,362.91
   Family $1,942.16
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 $823.56
   Employee and child $1,400.04
   Employee and spouse/
domestic partner
$1,647.10
   Family $2,347.12
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 $661.35
   Employee and child $1,124.29
   Employee and spouse/
domestic partner
$1,322.68
   Family $1,884.84
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 $798.95
   Employee and child $1,358.20
   Employee and spouse/
domestic partner
$1,597.89
   Family $2,276.99
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 $610.79
   Employee and child $1,038.35
   Employee and spouse/
domestic partner
$1,221.60
   Family $1,740.78
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 Radius
Region 7  
Monthly Premium  
   Single $737.10
   Employee and child $1,253.09
   Employee and spouse/
domestic partner
$1,474.21
   Family $2,100.76
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 $630.74
   Employee and child $1,072.27
   Employee and spouse/
domestic partner
$1,261.50
   Family $1,797.62
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 $761.49
   Employee and child $1,294.53
   Employee and spouse/
domestic partner
$1,522.97
   Family $2,170.24
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

>>Select preventive drugs are a $0 cost-share; not subject to deductible on the following plans: Gold Complete, Gold align, Gold focus, Gold POS 7100, Gold POS 7100EX, Gold PPO 7100
 

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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