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