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Off exchange Gold 80 Plan Details

* 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.

Standard Benefits for Individuals

Key benefits
Gold 80
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
X-Ray Copay
You pay $55
Emergency Room Facility Copay
You pay $325
High cost and infrequent services (e.g. Hospital Stay)
HMO: You pay $600 per day, up to 5 days
PPO, 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