Sacramento County Bar
Benefits Program
Medical Benefits Provided by Western Health Advantage
Deductible
PC/Specialist
Co-Insurance
OOP Limit
Inpatient Hosp
Urgent Care
Rx Generic
Rx Preferred
Rx Non Preferred
$0
$20/$20
0%
$4,000
No Charge
$50
$5
$30
$50
$0
$20/$20
30%
$4,000
30%
$50
$5
$30
$50
$2,600 ind; $3,200 ind w/ fam
0% after ded
0%
$4,800 incl ded (M. Max $2600)
0% after ded
0% after ded
0% after ded
$30 after ded
$50 after ded
AGE
0-14
15
16
17
18
19
20
21-24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64+
GATEWAY 20
$ 316.79
$ 344.95
$ 355.71
$ 366.48
$ 378.07
$ 389.67
$ 401.68
$ 414.10
$ 415.76
$ 424.04
$ 433.98
$ 450.13
$ 463.38
$ 470.00
$ 479.94
$ 489.88
$ 496.09
$ 502.72
$ 506.03
$ 509.34
$ 512.66
$ 515.97
$ 522.59
$ 529.22
$ 539.16
$ 548.68
$ 561.93
$ 578.50
$ 597.96
$ 621.15
$ 647.24
$ 677.05
$ 706.46
$ 739.58
$ 772.30
$ 808.32
$ 844.76
$ 884.10
$ 923.44
$ 966.10
$ 1,009.16
$ 1,055.13
$ 1,077.90
$ 1,123.87
$ 1,163.62
$ 1,189.71
$ 1,222.42
$ 1,242.30
AGE
0-14
15
16
17
18
19
20
21-24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64+
GATEWAY 70
$ 304.84
$ 331.94
$ 342.30
$ 352.66
$ 363.81
$ 374.97
$ 386.53
$ 398.48
$ 400.05
$ 408.05
$ 417.61
$ 433.15
$ 445.90
$ 452.28
$ 461.84
$ 471.40
$ 477.38
$ 483.76
$ 486.95
$ 490.13
$ 493.32
$ 496.51
$ 502.88
$ 509.26
$ 518.82
$ 527.99
$ 540.74
$ 556.68
$ 575.41
$ 597.72
$ 622.83
$ 651.52
$ 679.81
$ 711.69
$ 743.17
$ 777.84
$ 812.90
$ 850.76
$ 888.61
$ 929.66
$ 971.10
$ 1,015.33
$ 1,037.25
$ 1,081.48
$ 1,119.73
$ 1,144.84
$ 1,176.32
$ 1,195.45
AGE
0-14
15
16
17
18
19
20
21-24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64+
GATEWAY 2400
$ 262.87
$ 286.24
$ 295.17
$ 304.10
$ 313.73
$ 323.35
$ 333.31
$ 343.62
$ 345.00
$ 351.87
$ 360.11
$ 373.52
$ 384.51
$ 390.01
$ 398.26
$ 406.50
$ 411.66
$ 417.16
$ 419.90
$ 422.65
$ 425.40
$ 428.15
$ 433.65
$ 439.15
$ 447.39
$ 455.30
$ 466.29
$ 480.04
$ 496.19
$ 515.43
$ 537.08
$ 561.82
$ 586.22
$ 613.71
$ 640.85
$ 670.75
$ 700.99
$ 733.63
$ 766.27
$ 801.67
$ 837.40
$ 875.55
$ 894.45
$ 932.59
$ 965.58
$ 987.22
$ 1,014.37
$ 1,030.86