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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