Medical Benefits

Deductible
(Individual/Family)

$1,850/$3,700

$1,850/$3,700

Member Coinsurance

10%

40%

Out-of-Pocket Max
(Individual/Family)

$5,000/$10,000

$10,000/$20,000

Physician Visits

Primary Care Visit

Visits 1-4: $25 Copay

Visits 5+: Ded + 10%

Deductible + 40%

Specialist Visit

Visits 1-4: $25 Copay

Visits 5+: Ded + 10%

Deductible + 40%

Virtual Visits

$10 Copay

Deductible + 40%

Preventative Services

No member cost

Deductible + 40%

Hospital Services

Physician Services

Deductible + 10%

Deductible + 40%

Inpatient Hospitalization

Deductible + 10%

Deductible + 40%

Outpatient Surgery

Deductible + 10%

Deductible + 40%

Labs Performed Providers/Urgent Care

No member cost

Deductible + 40%

Urgent Care

Visits 1-4: $25 Copay

Visits 5+: Ded + 10%

Deductible + 40%

Emergency Room

Deductible + 10%

Deductible + 40%

Low Cost Generic

$5 Copay

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Generic

$15 Copay

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Preferred Brand

$65 Copay

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Non-Preferred Brand

20% Coinsurance

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Specialty Generic/Preferred

$65 Copay

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Specialty Non-Preferred

Deductible + 30%

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Age

First Gold PPO Plan

0-14

$102.64

15

$111.76

16

$115.25

17

$118.74

18

$122.49

19

$126.25

20

$130.14

21

$134.17

22

$134.17

23

$134.17

24

$134.17

25

$134.70

26

$134.70

27

$140.61

28

$145.84

29

$150.13

30

$152.28

31

$155.50

32

$158.72

33

$160.73

34

$162.88

35

$163.95

36

$165.03

37

$166.10

38

$167.17

39

$169.32

40

$171.47

41

$174.69

42

$177.77

43

$182.07

44

$187.43

45

$193.74

46

$201.25

47

$209.70

48

$219.36

49

$228.89

50

$239.62

51

$250.22

52

$261.89

53

$273.70

54

$286.45

55

$299.19

56

$313.01

57

$326.97

58

$341.86

59

$349.24

60

$364.13

61

$377.01

62

$385.46

63

$396.06

64-120

$402.50

Deductible
(Individual/Family)

$1,500/$3,000

$3,000/$6,000

Member Coinsurance

20%

40%

Out-of-Pocket Max
(Individual/Family)

$3,500/$7,000

$7,000/$14,000

Physician Visits

Primary Care Visit

Deductible + 20%

Deductible + 40%

Specialist Visit

Deductible + 20%

Deductible + 40%

Virtual Visits

Deductible + 20%

Deductible + 40%

Preventative Services

No member cost

Deductible + 40%

Hospital Services

Inpatient Hospitalization

Deductible + 20%

Deductible + 40%

Outpatient Surgery

Deductible + 20%

Deductible + 40%

Labs Performed Providers/Urgent Care

Deductible + 20%

Deductible + 40%

Urgent Care

Deductible + 20%

Deductible + 40%

Emergency Room

Deductible + 20%

Deductible + 20%

Low Cost Generic

N/A

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Generic

$15 Copay

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Preferred Brand

$65 Copay

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Non-Preferred Brand

20% Coinsurance

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Specialty Generic/Preferred

$65 Copay

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Specialty Non-Preferred

Deductible + 30%

All Rx
(retail and mail order):
Deductible + 50% coinsurance

Age

Saver Gold HSA Plan

0-14

$103.96

15

$113.20

16

$116.73

17

$120.27

18

$124.07

19

$127.88

20

$131.82

21

$135.90

22

$135.90

23

$135.90

24

$135.90

25

$136.44

26

$139.16

27

$142.42

28

$147.72

29

$152.07

30

$154.24

31

$157.50

32

$160.76

33

$162.80

34

$164.98

35

$166.06

36

$167.15

37

$168.24

38

$169.32

39

$171.50

40

$173.67

41

$176.94

42

$180.06

43

$184.41

44

$189.84

45

$196.23

46

$203.84

47

$212.40

48

$222.19

49

$231.84

50

$242.71

51

$253.44

52

$265.27

53

$277.23

54

$290.13

55

$303.05

56

$317.04

57

$331.18

58

$346.26

59

$353.73

60

$368.82

61

$381.87

62

$390.43

63

$401.16

64-120

$407.68