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
$ 289.81
$ 315.57
$ 325.42
$ 335.27
$ 345.88
$ 356.49
$ 367.48
$ 378.84
$ 380.36
$ 387.93
$ 397.02
$ 411.80
$ 423.92
$ 429.98
$ 439.08
$ 448.17
$ 453.85
$ 459.91
$ 462.94
$ 465.97
$ 469.00
$ 472.03
$ 478.10
$ 484.16
$ 493.25
$ 501.96
$ 514.09
$ 529.24
$ 547.05
$ 568.26
$ 592.13
$ 619.40
$ 646.30
$ 676.61
$ 706.54
$ 739.50
$ 772.83
$ 808.82
$ 844.81
$ 883.83
$ 923.23
$ 965.28
$ 986.12
$ 1,028.17
$ 1,064.54
$ 1,088.41
$ 1,118.34
$ 1,136.52
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
$ 278.68
$ 303.46
$ 312.93
$ 322.40
$ 332.60
$ 342.80
$ 353.36
$ 364.29
$ 365.75
$ 373.03
$ 381.78
$ 395.99
$ 407.64
$ 413.47
$ 422.21
$ 430.96
$ 436.42
$ 442.25
$ 445.16
$ 448.08
$ 450.99
$ 453.91
$ 459.74
$ 465.56
$ 474.31
$ 482.69
$ 494.34
$ 508.92
$ 526.04
$ 546.44
$ 569.39
$ 595.62
$ 621.48
$ 650.63
$ 679.40
$ 711.10
$ 743.16
$ 777.76
$ 812.37
$ 849.89
$ 887.78
$ 928.22
$ 948.25
$ 988.69
$ 1,023.66
$ 1,046.61
$ 1,075.39
$ 1,092.88
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
$ 243.33
$ 264.96
$ 273.23
$ 281.50
$ 290.41
$ 299.31
$ 308.54
$ 318.08
$ 319.35
$ 325.71
$ 333.35
$ 345.75
$ 355.93
$ 361.02
$ 368.66
$ 376.29
$ 381.06
$ 386.15
$ 388.69
$ 391.24
$ 393.78
$ 396.33
$ 401.42
$ 406.51
$ 414.14
$ 421.46
$ 431.64
$ 444.36
$ 459.31
$ 477.12
$ 497.16
$ 520.06
$ 542.65
$ 568.09
$ 593.22
$ 620.89
$ 648.88
$ 679.10
$ 709.32
$ 742.08
$ 775.16
$ 810.47
$ 827.96
$ 863.27
$ 893.81
$ 913.85
$ 938.97
$ 954.24