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

268.57

292.44

301.57

310.69

320.52

330.35

340.53

351.07

351.07

351.07

351.07

352.47

359.49

367.92

381.61

392.84

398.46

406.89

415.31

420.58

426.19

429

431.81

434.62

437.43

443.05

448.66

457.09

465.16

476.4

490.44

506.94

526.6

548.72

573.99

598.92

627

654.74

685.28

716.17

749.53

782.88

819.04

855.55

894.52

913.82

952.79

986.5

1008.61

1036.35

1053.2

$0

$20/$20

30%

$4,000

30%

$50

$5

$30

$50

$2,400 ind; $2,800 ind w/ fam

0% after ded

0%

$4,800 incl ded (Medical Max $2400)

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

249.95

272.17

280.67

289.16

298.31

307.46

316.93

326.74

326.74

326.74

326.74

328.04

334.58

342.42

355.16

365.62

370.85

378.69

386.53

391.43

396.66

399.27

401.89

404.5

407.11

412.34

417.57

425.41

432.93

443.38

456.45

471.81

490.1

510.69

534.21

557.41

583.55

609.36

637.79

666.54

697.58

728.62

762.28

796.26

832.52

850.5

886.76

918.13

938.71

964.53

980.21

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 2400 HSA

218.52

237.94

245.37

252.8

260.8

268.79

277.08

285.65

285.65

285.65

285.65

286.79

292.5

299.36

310.5

319.64

324.21

331.07

337.92

342.21

346.78

349.06

351.35

353.63

355.92

360.49

365.06

371.91

378.48

387.62

399.05

412.48

428.47

446.47

467.03

487.31

510.17

532.73

557.58

582.72

609.86

636.99

666.42

696.12

727.83

743.54

775.25

802.67

820.67

843.23

856.94