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
Age
0 -14
15 -15
16 -16
17 -17
18 -18
19 -19
20 -20
21 -21
22 -22
23 -23
24 -24
25 -25
26 -26
27 -27
28 -28
29 -29
30 -30
31 -31
32 -32
33 -33
34 -34
35 -35
36 -36
37 -37
38 -38
39 -39
40 -40
41 -41
42 -42
43 -43
44 -44
45 -45
46 -46
47 -47
48 -48
49 -49
50 -50
51 -51
52 -52
53 -53
54 -54
55 -55
56 -56
57 -57
58 -58
59 -59
60 -60
61 -61
62 -62
63 -63
64 -99
$0
$20/$20
0%
$4,000
No Charge
$50
$5
$30
$50
GATEWAY 20
274.37
298.76
308.09
317.41
327.45
337.50
347.90
358.66
358.66
358.66
358.66
360.09
367.26
375.87
389.86
401.34
407.07
415.68
424.29
429.67
435.41
438.28
441.15
444.02
446.89
452.62
458.36
466.97
475.22
486.70
501.04
517.90
537.98
560.58
586.40
611.87
640.56
668.89
700.10
731.66
765.73
799.80
836.74
874.04
913.86
933.58
973.39
1007.82
1030.42
1058.75
1075.97
$0
$20/$20
30%
$4,000
30%
$50
$5
$30
$50
$2,000 ind; $2,700 ind w/ fam
0% after ded
0%
$2,000 medical/$4,000 with RX (incl ded)
0% after ded
0% after ded
0% after ded
$30 after ded
$50 after ded
Age
0 -14
15 -15
16 -16
17 -17
18 -18
19 -19
20 -20
21 -21
22 -22
23 -23
24 -24
25 -25
26 -26
27 -27
28 -28
29 -29
30 -30
31 -31
32 -32
33 -33
34 -34
35 -35
36 -36
37 -37
38 -38
39 -39
40 -40
41 -41
42 -42
43 -43
44 -44
45 -45
46 -46
47 -47
48 -48
49 -49
50 -50
51 -51
52 -52
53 -53
54 -54
55 -55
56 -56
57 -57
58 -58
59 -59
60 -60
61 -61
62 -62
63 -63
64 -99
GATEWAY 70
255.33
278.03
286.70
295.38
304.73
314.07
323.75
333.76
333.76
333.76
333.76
335.10
341.77
349.78
362.80
373.48
378.82
386.83
394.84
399.85
405.19
407.86
410.53
413.20
415.87
421.21
426.55
434.56
442.24
452.92
466.27
481.96
500.65
521.67
545.70
569.40
596.10
622.47
651.51
680.88
712.59
744.29
778.67
813.38
850.43
868.79
905.84
937.88
958.90
985.27
1001.28
Age
0 -14
15 -15
16 -16
17 -17
18 -18
19 -19
20 -20
21 -21
22 -22
23 -23
24 -24
25 -25
26 -26
27 -27
28 -28
29 -29
30 -30
31 -31
32 -32
33 -33
34 -34
35 -35
36 -36
37 -37
38 -38
39 -39
40 -40
41 -41
42 -42
43 -43
44 -44
45 -45
46 -46
47 -47
48 -48
49 -49
50 -50
51 -51
52 -52
53 -53
54 -54
55 -55
56 -56
57 -57
58 -58
59 -59
60 -60
61 -61
62 -62
63 -63
64 -99
GATEWAY 2000 HSA
221.01
240.66
248.17
255.68
263.77
271.86
280.24
288.90
288.90
288.90
288.90
290.06
295.84
302.77
314.04
323.28
327.91
334.84
341.77
346.11
350.73
353.04
355.35
357.66
359.98
364.60
369.22
376.15
382.80
392.04
403.60
417.18
433.36
451.56
472.36
492.87
515.98
538.81
563.94
589.37
616.81
644.26
674.01
704.06
736.13
752.02
784.09
811.82
830.02
852.85
866.70