Gold  2018 Small Group Plans, Q1

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

If your clients are part of an existing group with BlueCross BlueShield of Western 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 the appropriate new sales representative.

  Gold Standard* Gold Aqua
First Dollar $500/$1,000
Gold Complete
Gold POS 7100
Monthly Premium        
  Single $539.14 $476.62 $500.87 $505.21
  Employee & Child(ren) $916.53 $810.25 $851.48 $858.86
  Employee & spouse/domestic partner $1,078.28 $953.24 $1,001.74 $1,010.42
  Family $1,536.55 $1,358.37 $1,427.48 $1,439.84
Primary Care Doctor/Specialist $25/$40 after deductible 25% after first dollar
and deductible
0% after deductible  $20/$40 after deductible 
Deductible (Single/Family) $600/$1,200 embedded $1,010/$2,020 embedded
$2,500/$5,000 embedded  $1,350/ $2,700 true family 
Inpatient Hospital Stay (per admission) $1,000 after deductible  25% after first dollar
0% after deductible $500 after deductible 
Prescription Drugs:        
   Tier 1/2/3 $10/$35/$70  $15/$50/50% 0% after deductible $5/$30/50% after deductible
   Generic Oral Contraceptives 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
 

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

Benefits & Coverage

*Available on SHOP

  Gold POS 7100EX Gold PPO 7100
Gold align*
Gold focus*
 
Monthly Premium        
   Single $526.25 $603.13 $480.56  
   Employee & Child(ren) $894.63 $1,025.32 $816.96  
   Employee & spouse/domestic partner $1,052.50 $1,206.26 $961.12  
   Family $1,499.81 $1,718.92 $1,369.59  
Primary Care Doctor/Specialist $20/$40 after deductible  $20/$40  after deductible     $20/$40  after deductible, Optimum
50% after deductible, Flexible
 
Deductible (Single/Family) $1,350/$2,700 embedded  $1,350/$2,670 true family, Optimum/Preferred
$1,350/$2,700 true family, Flexible/Participating
$1,350/$2,700 true family
 
Inpatient Hospital Stay (per admission)  $500 after deductible $500 after deductible $500 after deductible, Optimum
50% after deductible, Flexible
 
Prescription Drugs:        
   Tier 1/2/3 $5/$30/50%  after deductible $5/$30/50% after deductible $5/$30/$50 after deductible  
   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, align

Benefits & Coverage, focus

 


**Available in Erie and Niagara counties only

Gold Standard*
   
Monthly Premium  
   Single $539.14
   Employee & Child(ren) $916.53
   Employee and spouse/domestic partner  $1,078.28
   Family $1,536.55
Primary Care Doctor/Specialist $25/$40  after deductible
Deductible (Single/Family) $600/$1,200 embedded 
Inpatient Hospital Stay (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

*Available on SHOP

Gold Aqua
   
Monthly Premium  
   Single $476.62
   Employee & Child(ren) $810.25
    Employee and spouse/domestic partner $953.24
   Family $1,358.37
Primary Care Doctor/Specialist 25% after first dollar and deductible 
Deductible (Single/Family) $1,010/$2,020 embedded 
Inpatient Hospital Stay (per admission)  25% after first dollar 
Prescription Drugs:  
   Tier 1/2/3 $15/$50/50% 
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold Complete
   
Monthly Premium  
   Single $500.87
   Employee & Child(ren) $851.48
   Employee & spouse/domestic partner  $1,001.74
   Family $1,427.48
Primary Care Doctor/Specialist 0% after deductible
Deductible (Single/Family) $2,500/$5,000 true family 
Inpatient Hospital Stay (per admission)  0% after deductible
Prescription Drugs:  
   Tier 1/2/3 0% after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold POS 7100
   
Monthly Premium  
   Single $505.21
   Employee & Child $858.86
   Employee & spouse/domestic partner  $1,010.42
   Family $1,439.84
Primary Care Doctor/Specialist $20/$40 after deductible
Deductible (Single/Family) $1,350/$2,700 embedded 
Inpatient Hospital Stay (per admission) $500 after deductible
Prescription Drugs:  
   Tier 1/2/3 $5/$30/50% after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold POS 7100EX
   
Monthly Premium  
   Single $526.25
   Employee & Child(ren) $894.63
   Employee & spouse/domestic partner  $1,052.50
   Family $1,499.81
Primary Care Doctor/Specialist $20/$40 after deductible 
Deductible (Single/Family) $1,350/$2,700 true family 
Inpatient Hospital Stay (per admission)  $500 after deductible 
Prescription Drugs:  
   Tier 1/2/3 $5/$30/50% after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold PPO 7100
   
Monthly Premium  
   Single $603.13
   Employee & Child(ren) $1,025.32
   Employee & spouse/domestic partner  $1,206.26
   Family $1,718.92
Primary Care Doctor/Specialist $20/$40 after deductible
Deductible (Single/Family) $1,350/$2,700 true family 
Inpatient Hospital Stay (per admission)  $500 after deductible
Prescription Drugs:  
   Tier 1/2/3 $5/$30/50% after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold  align* *& Gold  focus**
   
Monthly Premium  
   Single $480.56
   Employee & Child(ren) $816.98
   Employee and spouse/domestic partner  $961.12
   Family $1,369.59
Primary Care Doctor/Specialist $20/$40 after deductible, Optimum
50% after deductible, Flexible
Deductible (Single/Family) $1,350/$2,670 true family, Optimum/Preferred
$1,350/$2,700 true family, Flexible/Participating
Inpatient Hospital Stay (per admission) $500 after deductible, Optimum
50% after deductible, Flexible
Prescription Drugs:  
   Tier 1/2/3 $5/$30/$50 after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage, Align

 

Benefits & Coverage, Focus

**Available in Erie & Niagara counties only

If you are already part of a group, visit BlueConnect to enroll or contact the appropriate account executive. If your client is a new group and would like to enroll in a Gold plan, please contact the appropriate new sales representative.

Fourth Quarter Gold Standard* Gold align**
Gold focus**
Gold Aqua
First Dollar $500/$1,000
Gold Complete
Monthly Premium        
   Single $515.95 $467.55 $485.31 $469.72
   Employee & Child(ren) $877.12 $794.83 $825.03 $798.53
   Employee and spouse/domestic partner $1,031.90 $936.10 $970.62 $939.44
   Family $1,470.46 $1,332.52 $1,383.14 $1,338.70
Primary Care Doctor/Specialist $25/$40 after deductible $20/$40 after deductible, Optimum
$20/40% after deductible, Flexible
20% after first dollar
and deductible 
0%  after deductible 
Deductible (Single/Family) $600/$1,200 embedded  $1,300/$2,600 true family $1,000/$2,000 embedded  $2,500/$5,000 true family  
Inpatient Hospital Stay (per admission) $1,000 after deductible  $500 after deductible, Optimum
40% after deductible, Flexible 
20% after first dollar  0% after deductible 
Prescription Drugs:        
   Tier 1/2/3 $10/$35/$70 $5/$30/$50 after deductible $15/$50/50% 0% after deductible
   Generic Oral Contraceptives 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
 

Benefits & Coverage

Benefits & Coverage, align

Benefits & Coverage, focus

Benefits & Coverage

Benefits & Coverage

*Available on SHOP
**Available in Erie and Niagara counties only

Fourth Quarter Gold POS 7100 NQ Gold POS 7100
Gold POS 7100EX
Gold PPO 7100
Monthly Premium        
   Single $497.96 $493.05 $518.42 $584.09
   Employee & Child(ren) $846.53 $838.19 $881.31 $992.95
   Employee and spouse/domestic partner $995.92 $986.10 $1,036.84 $1,168.18
   Family $1,419.18 $1,405.19 $1,477.50 $1,664.66
Primary Care Doctor/Specialist $20/$40 after deductible $20/$40 after deductible
$20/$40 after deductible
$20/$40 after deductible 
Deductible (Single/Family) $1,300/$2,600 embedded  $1,300/$2,600 true family $1,300/$2,600 true family
$1,300/$2,600 true family  
Inpatient Hospital Stay (per admission) $500 after deductible  $500 after deductible
$500 after deductible $500 after deductible
Prescription Drugs:        
   Tier 1/2/3 $5/$30/$50 $5/$30/$50 after deductible $5/$30/$50 after deductible $5/$30/$50 after deductible
   Generic Oral Contraceptives 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
 

Benefits & Coverage

Benefits & Coverage

 

Benefits & Coverage

Benefits & Coverage

Gold Standard*
Fourth Quarter   
Monthly Premium  
   Single $515.95
   Employee & Child $877.12
   Employee and spouse/domestic partner  $1,031.90
   Family $1,470.46
Primary Care Doctor/Specialist $25/$40  after deductible
Deductible (Single/Family) $600/$1,200 embedded 
Inpatient Hospital Stay (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

*Available on SHOP

Gold align** & Gold focus**
Fourth Quarter   
Monthly Premium  
   Single $467.55
   Employee & Child $794.83
   Employee and spouse/domestic partner  $935.10
   Family $1,332.52
Primary Care Doctor/Specialist $20/$40  after deductible, Optimum
$20/40% after deductible, Flexible 
Deductible (Single/Family) $1,300/$2,600 true family 
Inpatient Hospital Stay (per admission)  $500 after deductible, Optimum
40% after deductible, Flexible 
Prescription Drugs:  
   Tier 1/2/3 $5/$30/$50 after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage, align

Benefits & Coverage, focus

**Available in Erie and Niagara counties only

Gold Aqua
Fourth Quarter   
Monthly Premium  
   Single $485.31
   Employee & Child $825.03
   Employee and spouse/domestic partner  $970.62
   Family $1,383.14
Primary Care Doctor/Specialist 20% after first dollar and deductible 
Deductible (Single/Family) $1,000/$2,000 embedded 
Inpatient Hospital Stay (per admission)  20% after first dollar 
Prescription Drugs:  
   Tier 1/2/3 $15/$50/50%
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold Complete
Fourth Quarter   
Monthly Premium  
   Single $469.72
   Employee & Child $798.53
   Employee and spouse/domestic partner  $939.44
   Family $1,338.70
Primary Care Doctor/Specialist 0%  after deductible
Deductible (Single/Family) $2,500/$5,000 true family 
Inpatient Hospital Stay (per admission)  0% after deductible 
Prescription Drugs:  
   Tier 1/2/3 0% after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold POS 7100 NQ
Fourth Quarter   
Monthly Premium  
   Single $497.96
   Employee & Child $846.53
   Employee and spouse/domestic partner  $995.92
   Family $1,419.18
Primary Care Doctor/Specialist $20/$40  after deductible
Deductible (Single/Family) $1,300/$2,600 embedded
Inpatient Hospital Stay (per admission)  $500 after deductible 
Prescription Drugs:  
   Tier 1/2/3 $5/$30/$50 after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold POS 7100
Fourth Quarter   
Monthly Premium  
   Single $493.05
   Employee & Child $838.19
   Employee and spouse/domestic partner  $986.10
   Family $1,405.19
Primary Care Doctor/Specialist $20/$40  after deductible
Deductible (Single/Family) $1,300/$2,600 true family  
Inpatient Hospital Stay (per admission)  $500 after deductible 
Prescription Drugs:  
   Tier 1/2/3 $5/$30/$50 after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold POS 7100 EX
Fourth Quarter   
Monthly Premium  
   Single $518.42
   Employee & Child $881.31
   Employee and spouse/domestic partner  $1,036.84
   Family $1,477.50
Primary Care Doctor/Specialist $20/$40  after deductible
Deductible (Single/Family) $1,300/$2,600 true family  
Inpatient Hospital Stay (per admission)  $500 after deductible 
Prescription Drugs:  
   Tier 1/2/3 $5/$30/$50 after deductible
   Generic Oral Contraceptives Covered in full
   Mail Order Drugs 2.5 Copays/90-day supply
 

Benefits & Coverage

Gold PPO 7100
Fourth Quarter   
Monthly Premium  
   Single $584.09
   Employee & Child $992.95
   Employee and spouse/domestic partner  $1,168.18
   Family $1,664.66
Primary Care Doctor/Specialist $20/$40  after deductible
Deductible (Single/Family) $1,300/$2,600 true family  
Inpatient Hospital Stay (per admission)  $500 after deductible 
Prescription Drugs:  
   Tier 1/2/3 $5/$30/$50 after deductible
   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

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