myBlue Gold 1605 ($0 Virtual Visits / $0 Labs / Rewards $$$)

Health Insurance Plan Details (2024 Plan)

Monthly Premium

HMO
$ubsidy
Gold
Deductible
$940 /yr
Max Out-of-Pocket
$4,700 /yr

Details

Deductible (per individual) $940 /yr
Deductible (per family) $1,880 /yr
Max Out-of-Pocket (per individual) $4,700 /yr
Max Out-of-Pocket (per family) $9,400 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit No Charge
Specialist Visit $20 Copay
Emergency Room 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible
Drug Costs
Generic Drugs $15 Copay
Preferred Brand Drugs 15% Coinsurance after deductible
Non-preferred Brand Drugs 50% Coinsurance after deductible
Specialty Drugs 50% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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