* This includes a summary of Gold plans including Kaiser Copay and Coinsurance plans.
Benefits in blue: Subject to a deductible
Benefits in black: Not subject to a deductible
The following benefits are for in-network services only. Before selecting a plan we recommend reviewing the plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) documents for specific costs and out-of-network benefits for PPO plans. There may be variations between plans that are not reflected here.
Individual Deductible
no deductible, no pharmacy deductible
Family Deductible
no deductible, no pharmacy deductible
Preventative Care Copay
no cost
Primary Care Visit Copay
You pay $25
Specialty Care Visit Copay
You pay $55
Urgent Care Visit Copay
You pay $25
Lab Testing Copay
You pay $35
Emergency Room Facility Copay
You pay $325
Hospitalization (and high cost and infrequent services)
HMO: You pay $600 per day, up to 5 daysPPO, EPO, Kaiser Coinsurance:You pay 20%
Tier 1 (most generics) Drug Copay
You pay $15
Tier 2 (preferred brand) Drug Copay
You pay $55
Tier 3 (non-preferred brand) Drug Copay
You pay $75 (except Kaiser, which is $55)
Tier 4 (specialty drugs)
You pay 20%
up to $250 per script
Maximum Out-of-Pocket For One
$6,000
Maximum Out-of-Pocket For Family
$12,000