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
$2,400 ind; $2,800 ind w/ fam
0% after ded
0%
$4,800 incl ded (M. Max $2400)
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
$273.93
$298.28
$307.59
$316.90
$326.93
$336.96
$347.34
$358.08
$359.52
$366.68
$375.27
$389.24
$400.70
$406.42
$415.02
$423.61
$428.98
$434.71
$437.58
$440.44
$443.31
$446.17
$451.90
$457.63
$466.22
$474.46
$485.92
$500.24
$517.07
$537.13
$559.68
$585.47
$610.89
$639.54
$667.83
$698.98
$730.49
$764.51
$798.53
$835.41
$872.65
$912.40
$932.09
$971.84
$1,006.21
$1,028.77
$1,057.06
$1,074.25
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
$254.95
$277.61
$286.28
$291.94
$304.28
$313.61
$323.27
$333.27
$334.60
$341.27
$349.27
$362.26
$372.93
$378.26
$386.26
$394.26
$399.26
$404.59
$407.26
$409.92
$412.59
$415.25
$420.59
$425.92
$433.92
$441.58
$452.25
$465.58
$481.24
$499.91
$520.90
$544.90
$568.56
$595.22
$621.55
$650.54
$679.87
$711.53
$743.19
$777.52
$812.18
$849.17
$867.50
$904.50
$936.49
$957.49
$983.81
$999.81
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
$222.88
$242.70
$250.27
$257.85
$266.00
$274.16
$282.61
$291.35
$292.52
$298.34
$305.34
$316.70
$326.02
$330.69
$337.68
$344.67
$349.02
$353.70
$356.03
$358.36
$360.69
$363.03
$367.69
$372.35
$379.34
$386.04
$395.37
$407.02
$420.71
$437.03
$455.38
$476.36
$497.05
$520.36
$543.37
$568.72
$594.36
$622.04
$649.72
$679.73
$710.03
$742.37
$758.39
$790.73
$818.70
$837.06
$860.07
$874.06