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Gold Simple PPO 0/0/25
Health Insurance Plan Details (2025 Plan)
by Capital BlueCross
Monthly Premium
PPO
$ubsidy
Gold
- Deductible
- $0 /yr
- Max Out-of-Pocket
- $8,550 /yr
Details
| Deductible (per individual) | $0 /yr |
| Deductible (per family) | $0 /yr |
| Max Out-of-Pocket (per individual) | $8,550 /yr |
| Max Out-of-Pocket (per family) | $17,100 /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 | PPO |
| Includes Child Dental? | Yes |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $25 Copay |
| Specialist Visit | $50 Copay |
| Emergency Room | $200 Copay |
| Inpatient Facility | $3500 Copay per Stay |
| Inpatient Physician | Not Applicable |
| Generic Drugs | $4 Copay |
| Preferred Brand Drugs | $55 Copay |
| Non-preferred Brand Drugs | $90 Copay |
| Specialty Drugs | 20.00% Coinsurance |
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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