Individual & Family Plans Plan Details
Essential Gold 2025
Greater provider selection at a lower cost.
ANNUAL DEDUCTIBLE
$800
OUT-OF-POCKET MAX
$7,600
COPAY
Prescription Drug Coverage
Generic Drugs
Coverage
Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
30 Days
per month
Coinsurance
Not Applicable
Copay
$10.00
Preferred Brand Drugs
Coverage
Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
30 Days
per month
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Non-Preferred Brand Drugs
Coverage
Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
30 Days
per month
Coinsurance
40.00% Coinsurance
after deductible
Copay
Not Applicable
Specialty Drugs
Coverage
First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill.
30 Days
per month
Coinsurance
50.00% Coinsurance
after deductible
Copay
Not Applicable
Physician Office Services
Primary Care Visit to Treat an Injury or Illness
Coinsurance
Not Applicable
Copay
$30.00
Specialist Visit
Coinsurance
Not Applicable
Copay
$60.00
Urgent Care and Emergency
Urgent Care Centers or Facilities
Coinsurance
Not Applicable
Copay
$60.00
Emergency Room Services
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Hospital and Surgical Care
Inpatient Hospital Services (e.g., Hospital Stay)
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Outpatient Surgery Physician/Surgical Services
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Inpatient Physician and Surgical Services
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Laboratory Outpatient and Professional Services
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Outpatient Diagnostic Services
Laboratory Outpatient and Professional Services
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
X-rays and Diagnostic Imaging
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Imaging (CT/PET Scans, MRIs)
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Other Benefits
Mental/Behavioral Health Outpatient Services
Coinsurance
Not Applicable
Copay
$60.00
Substance Abuse Disorder Outpatient Services
Coinsurance
Not Applicable
Copay
$60.00
Outpatient Rehabilitation Services
Coverage
25 Visit(s)
per year
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Habilitation Services
Coverage
Coverage for habilitative services is limited to 30-inpatient days/year. Coverage for habilitative services is limited to 25-outpatient visits/year.
30 Visit(s)
per year
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Prenatal and Postnatal Care
Coinsurance
No Charge
Copay
No Charge
Delivery and All Inpatient Services for Maternity Care
Coinsurance
30.00% Coinsurance
after deductible
Copay
Not Applicable
Vision
Routine Eye Exam (Adult)
Not covered
Routine Eye Exam for Children
Coverage
1 Exam(s)
per year
Coinsurance
Not Applicable
Copay
$30.00
Eye Glasses for Children
Coverage
Coverage is limited to one frame and one pair (two lenses)/ calendar year or contacts (in lieu of glasses).
1 Item(s)
per year
Coinsurance
No Charge
Copay
No Charge
Adult Dental Coverage
Routine Dental Services (Adult)
Not covered
Basic Dental Care - Adult
Not covered
Major Dental Care - Adult
Not covered
Orthodontia - Adult
Not covered
Child Dental Coverage
Dental Check-Up for Children
Not covered
Basic Dental Care - Child
Not covered
Major Dental Care - Child
Not covered
Orthodontia - Child
Not covered
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