Gold 1 with Adult Vision Services

Health Insurance Plan Details (2025 Plan)

SBC doc

doctor lookup

drug list

HMO

Gold

Deductible (per individual)	$1,640 /yr
Deductible (per family)	$3,280 /yr
Max Out-of-Pocket (per individual)	$8,100 /yr
Max Out-of-Pocket (per family)	$16,200 /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	$20 Copay
Specialist Visit	$50 Copay
Emergency Room	25% Coinsurance after deductible
Inpatient Facility	25% Coinsurance after deductible
Inpatient Physician	25% Coinsurance after deductible

Drug Costs
Generic Drugs	$15 Copay
Preferred Brand Drugs	$50 Copay after deductible
Non-preferred Brand Drugs	30% Coinsurance after deductible
Specialty Drugs	30% Coinsurance after deductible

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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