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Gold 201 HSA
Health Insurance Plan Details (2025 Plan)
by Ambetter from Sunflower Health Plan
Monthly Premium
EPO
$ubsidy
HSA
Gold
- Deductible
- $3,300 /yr
- Max Out-of-Pocket
- $3,300 /yr
Details
| Deductible (per individual) | $3,300 /yr |
| Deductible (per family) | $6,600 /yr |
| Max Out-of-Pocket (per individual) | $3,300 /yr |
| Max Out-of-Pocket (per family) | $6,600 /yr |
| Drug Deductible (per individual) | |
| Drug Deductible (per family) | |
| Drug Max Out-of-Pocket (per individual) | |
| Drug Max Out-of-Pocket (per family) | |
| Plan Type | EPO |
| Includes Child Dental? | No |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | Not Applicable |
| Specialist Visit | Not Applicable |
| Emergency Room | Not Applicable |
| Inpatient Facility | Not Applicable |
| Inpatient Physician | Not Applicable |
| Generic Drugs | Not Applicable |
| Preferred Brand Drugs | Not Applicable |
| Non-preferred Brand Drugs | Not Applicable |
| Specialty Drugs | Not Applicable |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | n/a |
* 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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